COTTAGE HEALTH SYSTEM POLICY

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SUBJECT:

RESIDENT DUTY HOURS AND THE WORKING ENVIRONMENT

 

DEPT: MEDICAL EDUCATION
POLICY #: 8240.10

 

GOAL
To provide an Institutional Statement regarding resident duty hours and the working environment in compliance with ACGME requirements.

 

POLICY

patient safety and resident well-being and to providing a supportive educational environment.  The learning objectives of the program must not be compromised by excessive reliance on residents to fulfill service obligations.  Didactic and clinical education must have priority in the allotment of residents' time and energy.  Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients.

 

PROCEDURE

Each program must develop and implement a written policy regarding resident duty hours and the working environment and submit this policy to the GMEC for approval.  This policy will be communicated to the residents and faculty annually.

 

These policies will apply to all participating Institutions where residents are trained.

 

Program directors and faculty must adopt policies to prevent and counteract effects of fatigue.  Back-up systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.  (See Resident Fatigue Policy)

 

At least quarterly, each program must have residents log their duty hours for a 28-day period and submit a program report to the GMEC.  The GMEC may, at its discretion or in response to resident request, ask that such surveys be conducted more frequently.  The results of each survey will be reviewed by the GMEC at its next scheduled meeting.

 

Each Program Director should regularly monitor resident duty hours, rotation and call schedules for compliance with this Institutional Policy and the Common Program Requirements.

 

In addition to quarterly duty hour reports, the GMEC shall monitor compliance with this policy through:

a)    Internal Review Reports / Process
b)    Rotation Evaluations completed by residents
c)    Random call schedule monitoring by Education Specialist

 

Falsification of duty hours data or pressure to cause the falsification of such data is considered egregious behavior for residents and can result in disciplinary action to include dismissal.

a)    Residents must notify their Program Director of requests or pressure to work in excess of duty hours authorized by this policy.

 

Santa Barbara Cottage Hospital fully supports the Residents Work Hours policy established by the Accreditation Council for Graduate Medical Education (ACGME), which sets forth the following requirements:

 

Maximum Hours of Work per Week

1.    Duty hours must be limited to 80 hours per week, averaged over a 4-week period, inclusive of all in-house call activities and all moonlighting.

a)   Duty Hours Exceptions: An RRC may grant exceptions for up to 10% or a maximum of 88 hours to individual programs based on a sound educational rationale.
    i.  In preparing a request for an exception the Program Director must follow the duty hour exception policy from the ACGME Manual on Policies and Procedures.
    ii.  Prior to submitting the request to the Review Committee, the program director must obtain approval of the institution's GMEC and DIO
    iii.  The GMEC will review exemption requests described in #1 above with the program director in attendance; then discuss the request in the absence of the program director but with the participation of the resident member of the GMEC from the program.
    iv.  If the GMEC endorses the request, a letter of support from the Designated Institutional Official will be generated to accompany the request to the RRC.  If the GMEC does not endorse the request, it may not be submitted to the RRC.

2.    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.
3.    Maximum Duty Period Length

a)   Duty periods of PGY-1 residents must not exceed 16 hours in duration.
b)   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.

VI.G.4.b).(1)   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.
VI.G.4.b).(2)   Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
VI.G.4.b).(3)   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.

VI.G.4.b).(3).(a) Under those circumstances, the resident must:
 (i)   appropriately hand over the care of all other patients to the team responsible for their continuing care; and,
 (ii)   document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director.
VI.G.4.b).(3).(b)    The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty.

VI.G.5. Minimum Time Off between Scheduled Duty Periods

VI.G.5.a)   PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods.
VI.G.5.b)   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.
VI.G.5.c)   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.

(1) 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.
  (a) 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.

VI.G.6. 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.]
VI.G.7. 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).
VI.G.8 At-Home Call

VI.G.8.a)   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.

(1)   At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.

VI.G.8.b)   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".

 

7/11

 


COTTAGE HEALTH SYSTEM POLICY

RECOMMENDED BY: R Reid, M.D. DATE: 5/04

ORIGINAL POLICY EFFECTIVE DATE: 5/04

APPROVED BY: R.Werft DATE: 5/ 04

DATE REVISED: 5/07, 5/11 DATE REVIEWED: 3/00, 4/01