Resident Duty Hours in the Learning and Working Environment
STATEMENT OF POLICY
Residents’ duty hours must reflect and reinforce the physician’s obligation for adequate, continuous patient care while at the same time recognizing that prolonged and difficult hospital duties detract from this obligation. It is further recognized that adequate leisure time is important for the resident’s personal development and health.
For specialty-specific duty hour definitions, please refer to this link: https://www.acgme.org/acgmeweb/Portals/0/PDFs/DH_Definitions.pdf
1.a.) All Residents are required to report their duty hours using the E*Value system. Residents must log their duty hours a minimum of once every fifteen days. If fifteen days pass without a resident logging his/her duty hours, an E*Value-generated email will be sent to the Program Director, Coordinator, affected Resident(s) and the GME Office. The Program Director will be expected to contact his/her affected Resident(s) and instruct the Resident(s) to post past due duty hours immediately. A follow up email will be sent from the GME Office notifying the Program Director and Coordinator of the Residents who have violated the policy and how many days they are past due and that they have 24 hours to log their past due duty hours. The next business day (excluding State holidays), a status check will be done to verify the residents have logged their past due hours. The appropriate Program Director and Coordinator will be notified if any of their Residents remain on the past due list. The Program Director will be asked to pull any affected Resident from duty immediately to be sent home using a vacation day so that s/he may immediately log delinquent duty hours. (Note: Falsification of duty hours will result in suspension and/or termination from the residency program.)
First Infraction: The Program Director is to issue a verbal warning and review the GME Duty Hour Policy with the Resident.
Second Infraction: A written warning is to be given to the Resident by the Program Director. It is to be documented that the Program Director has discussed the GME Duty Hour Policy with the Resident and strongly stressed to him/her that another infraction of noncompliance with regard to duty hours will be in violation of the Professionalism competency and will lead to formal remediation via the GME Office.
The term of the remediation plan will begin on the day the plan is presented to the Resident and will continue through the remainder of the Resident's academic year. (Note: The end date of the plan will vary relative to off-cycle Residents.) At that point, the Resident must log duty hours weekly (every seven days) for the remainder of the remediation plan (remainder of the applicable academic year). If, at any time, the Resident fails to log his/her duty hours on a weekly basis while on remediation, the Resident may be terminated. (The GME Office will monitor the Resident's duty hour logging requirement of every seven days though it is expected the Program Director will also monitor his/her remediated Resident(s) to ensure compliance with the terms of the remediation plan.)
1.b.) Residents are expected to log their duty hours before they leave for vacation/leave of absence. If a resident appears on the "Delinquent Duty Hour" list but is on vacation/leave of absence, it is the Program Director's responsibility to ensure the past due hours are logged before the resident may return to duty. Once the hours are logged, the GME Office is to be notified by the Program Director or the Coordinator. Once the GME Office has confirmed the past due duty hours have been logged, the Program Director and Coordinator will be notified the resident has been reinstated and can return to duty. (If a Resident is scheduled to return to duty, from vacation/leave of absence, outside of business hours but has logged his/her delinquent duty hours and needs to be reinstated, the Program Director or the Coordinator will need to contact the GME Office on the next business day during office hours - Monday - Friday 8:30 a.m. - 5:00 p.m. (excluding State holidays) to have the Resident's duty hours verified. Once they are, the GME Office will notify the Program Director and Coordinator to inform them the Resident has been reinstated to duty.)
Residents are prohibited from logging future work hours. However, it is permissible to log future vacation/leave of absence (as described above), "day off," or annual leave hours.
1.c.) Each Tuesday morning, Residents, Program Directors, Program Coordinators and E*Value Administrators within the GME Office will receive a RIDeR (Report Identifying Delinquent Residents) Report via email (residents via email and pager) detailing which individual ACGME residents are within 24 hours of violating the Duty Hour policy. This early warning gives the residents one last chance to bring their hours current before the Wednesday morning Duty Hour Report is generated.
2.) Residents who encounter problems or difficulty complying with the ACGME duty hours requirements should resolve this matter with his/her Program Director. If the matter cannot be resolved with the Program Director or if the resident encounters violations, s/he should contact the Designated Institutional Official for GME.
ACGME Standards - Duty Hours
A. Professionalism, Personal Responsibility, and Patient Safety
Programs and sponsoring institutions must educate residents and faculty members concerning the professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients.
The program must be committed to and responsible for promoting patient safety and resident well-being in a supportive educational environment.
The program director must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.
The learning objectives of the program must:
The program director and institution must ensure a culture of professionalism that supports patient safety and personal responsibility.
Residents and faculty members must demonstrate an understanding and acceptance of their personal role in the following:
- assurance of the safety and welfare of patients entrusted to their care;
- provision of patient- and family-centered care;
- assurance of their fitness for duty;
- management of their time before, during, and after clinical assignments;
- recognition of impairment, including illness and fatigue, in themselves and in their peers;
- attention to lifelong learning;
- the monitoring of their patient care performance improvement indicators; and,
- honest and accurate reporting of duty hours, patient outcomes, and clinical experience data.
All residents and faculty members must demonstrate responsiveness to patient needs that supersedes self-interest. Physicians must recognize that under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider.
B. Transitions of Care
Programs must design clinical assignments to minimize the number of transitions in patient care.
Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety.
Programs must ensure that residents are competent in communicating with team members in the hand-over process.
The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient’s care.
C. Alertness Management/Fatigue Mitigation
The program must:
- educate all faculty members and residents to recognize the signs of fatigue and sleep deprivation;
- educate all faculty members and residents in alertness management and fatigue mitigation processes; and,
- adopt fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, such as naps or back-up call schedules.
Each program must have a process to ensure continuity of patient care in the event that a resident may be unable to perform his/her patient care duties.
The sponsoring institution must provide adequate sleep facilities and/or safe transportation options for residents who may be too fatigued to safely return home.
D. Supervision of Residents
In the clinical learning environment, each patient must have an identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient’s care.
- This information should be available to residents, faculty members, and patients.
- Residents and faculty members should inform patients of their respective roles in each patient’s care.
The program must demonstrate that the appropriate level of supervision is in place for all residents who care for patients. Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. For many aspects of patient care, the supervising physician may be a more advanced resident or fellow. Other portions of care provided by the resident can be adequately supervised by the immediate availability of the supervising faculty member or resident physician, either in the institution, or by means of telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc review of resident delivered care with feedback as to the appropriateness of that care.
Levels of Supervision
To ensure oversight of resident supervision and graded authority and responsibility, the program must use the following classification of supervision:
- Direct Supervision – the supervising physician is physically present with the resident and patient.
- Indirect Supervision:
- with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.
- with direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision.
Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members.
- The program director must evaluate each resident’s abilities based on specific criteria. When available, evaluation should be guided by specific national standards-based criteria.
- Faculty members functioning as supervising physicians should delegate portions of care to residents, based on the needs of the patient and the skills of the residents.
- Senior residents or fellows should serve in a supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow.
Programs must set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members, such as the transfer of a patient to an intensive care unit, or end-of-life decisions.
- Each resident must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence.
- In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. [Each Review Committee will describe the achieved competencies under which PGY-1 residents progress to be supervised indirectly, with direct supervision available.]
Faculty supervision assignments should be of sufficient duration to
assess the knowledge and skills of each resident and delegate to him/her
the appropriate level of patient care authority and responsibility.
E. Clinical Responsibilities
The clinical responsibilities for each resident must be based on PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services. [Optimal clinical workload will be further specified by each Review Committee.]
Residents must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty.
Each Review Committee will define the elements that must be present in each specialty.
G. Exemptions to the Policy
An increase in duty hours, up to 10% of the 80-hour per week limit, can be granted only when there is a legitimate educational justification for the added hours. The expectation is that all hours in the extended week contribute to resident education. Programs may ask for an extension that is less than the maximum of eight additional weekly hours, and for a subgroup of the residents/fellows in the program (e.g. the chief resident year) or for individual rotations or experiences.
Programs must submit their request in writing to the GME Office two weeks prior to the GMEC meeting where the issue will be discussed. The program must document clear evidence that the exception is necessary for educational reasons. The GMEC will consider the following documentation before granting approval/disapproval:
- Patient Safety - Information must be submitted that describes how the program and institution will monitor, evaluate, and ensure patient safety with extended Resident work hours.
- Educational Rationale - The request must be based on a sound educational rationale, which should be described in relation to the program's stated goals and objectives for the particular assignments, rotations, and level(s) of training for which the increase is requested. Blanket exceptions for the entire educational program should be considered the exception, not the rule.
- Moonlighting Policy - Specific information regarding the program's moonlighting policies for the periods in question must be included.
- Call Schedules - Specific information regarding Resident call schedules during the times specified for the exception must be provided.
- Faculty Monitoring - Evidence of faculty development activities regarding the effects of Resident fatigue and sleep deprivation must be appended.
Because nine Review Committees categorically do not permit programs to use the duty hour exception, the GMEC will not consider requests from: Anesthesiology, Emergency Medicine, Internal Medicine, Neurology, Nuclear Medicine, Pediatrics, and Diagnostic Radiology. (The remaining two programs are Family Medicine and Transitional Year which are not sponsored by MUSC.)
If a program has an exception and wishes to continue it, the DIO and the GMEC shall re-evaluate, both, patient safety and the educational rationale for the exception prior to each site visit and review and may append the findings to the program's request to the RRC for a continued exception. The RRC may continue, deny or modify the exception.
- be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events; and,
- not be compromised by excessive reliance on residents to fulfill non-physician service obligations.
Resident Duty Hours
Maximum Hours of Work per Week
Duty hours must be limited to 80 hours per week, averaged over a four week period, inclusive of all in-house call activities and all moonlighting.
Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program.
- Time spent by residents in Internal and External Moonlighting (as defined in the ACGME Glossary of Terms) must be counted towards the 80-hour Maximum Weekly Hour Limit.
- PGY-1 residents are not permitted to moonlight.
Mandatory Time Free of Duty
Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). At-home call cannot be assigned on these free days.
Maximum Duty Period Length
Duty periods of PGY-1 residents must not exceed 16 hours in duration.
- Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.
- Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested.
- It is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours.
- Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
- In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.
Under those circumstances, the resident must:
1. appropriately hand over the care of all other patients to the team responsible for their continuing care; and,
2. document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director.
The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty.
Minimum Time Off between Scheduled Duty Periods
PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods.
- Intermediate-level residents [as defined by the Review Committee]
- should have 10 hours free of duty, and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty.
- Residents in the final years of education [as defined by the Review Committee] must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods.
- This preparation must occur within the context of the 80-hour, maximum duty period length, and one-day-off-in seven standards. While it is desirable that residents in their final years of education have eight hours free of duty between scheduled duty periods, there may be circumstances [as defined by the Review Committee] when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty.
Circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by residents in their final years of education must be monitored by the program director.
Maximum Frequency of In-House Night Float
Residents must not be scheduled for more than six consecutive nights of night float. [The maximum number of consecutive weeks of night float, and maximum number of months of night float per year may be further specified by the Review Committee.]
Maximum In-House On-Call Frequency
PGY-2 residents and above must be scheduled for in-house call no more frequently than every-third-night (when averaged over a four-week period).
Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty, when averaged over four weeks.
- At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.
- Residents are permitted to return to the hospital while on at-home call to care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period”.