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GME Policies Duty Hours

Work hours policies:

CUMC CT Surgery Policy NYPH Policy ACGME Policy

NY State Policy Program Post-Call Policy

CUMC Cardiothoracic Surgery Program Policy

Policy

It is the policy of the program to comply with the NYHP GME Policy, New York State 405 Regulations, and with ACGME policy on work hours for post-graduate trainees.

Applicability

All thoracic surgery residents and fellows.

Procedure

Duty hours are defined as all clinical and academic activities related to the educational program: patient care, both inpatient and outpatient, administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

A duty hour work-week is defined as a maximum of 80 hours averaged over 4 weeks, inclusive of all in-house activities, clinical assignments, and moonlighting activities. (Please refer to the moonlighting policy).

Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours (24 consecutive hour rule). Trainees may remain on duty for up to 3 additional hours of transition time to be used for transfer of patient care, rounds, and grand rounds. No new patient care may be assigned during the 3 hour transition time (total of 27 hours). As a surgical program, there is an exception to the 24 consecutive hour rule above; this must be done under the following conditions: the trainee documents 4-5 hours of sleep, the duty shift is followed by a non-working period of 16 hours, and the maximum shift is 30 hours from start to end of on-call.

Adequate time for rest and personal activities will be provided. This consists of a 10 hour time period between all daily duty periods and after in-house call.

Every trainee must have at least 24 consecutive hours free from all duty, including call from home, each week.

In-house call can be no more frequent than every 3rd night.

NYPH Policy

NYPH House Staff Manual Regulations

NewYork-Presbyterian Hospital, in compliance with the New York State Department of Health Codes, has adopted a policy relating to post-graduate trainee schedules which prescribes the limits on the assigned responsibilities of post-graduate trainees as follows:

Post Graduate Trainees "on-call" duty night shift hours are to be included in the 80-hour limit and the 24-hour limit identified in items (3) and (4) below.

1. Post-Graduate Trainees are limited to no more than 12 consecutive hours per assigned shift in the emergency room.
2. Post-Graduate Trainee work schedules must not exceed 80 hours per week averaged over a 4 week period. Working hours may exceed these limits only when patient care would not be compromised or jeopardized.
3. Post-Graduate Trainees must not be scheduled for more than 24 consecutive hours including education and training time. An additional 3 hours ("turnover time") past a 24-hour shift may be used by non-surgical post-graduate trainees for transferring information, and could occur no more than twice per week and would be included in the weekly hours subject to the 80 hour limit. Working hours may exceed these limits only when patient care would not be compromised or jeopardized.
4. Post-Graduate Trainee rotation schedules must be separated by no less than 8 non-working hours with at least one 24 hour period of non-working time provided for each week. Non-working time is defined as time away from training or patient care activities.
5. "On-call" duty in the hospital during the night shift hours by trainees in surgery shall not be included in the 24 hour limit and the 80 hour limit if:
• The hospital can document that during such night shifts post-graduate trainees are generally resting and that interruptions for patient care are infrequent and limited to patients for whom the post-graduate trainee has continuing responsibility;
• Such duty is scheduled for each trainee no more than every third night;
• A continuous assignment that includes night shift "on-call" duty is followed by a non-working period of no less than 16 hours; and
• Policies and procedures are developed and implemented to immediately relieve a post-graduate trainee from continuing assignment when fatigue due to an unusually active "on-call" period is observed.

The Program Directors of the Graduate Medical Education programs are responsible for ensuring compliance with this policy. They, in turn, are accountable to their Clinical Chief-of-Service. Any questions regarding the above mentioned policy should be directed to the appropriate clinical Chief-of-Service.

ACGME Policy

Resident Duty Hours and the Working Environment

Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education must have priority in the allotment of residents' time and energies. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients.

Supervision of Residents

All patient care must be supervised by qualified faculty. The program director must ensure, direct, and document adequate supervision of residents at all times. Residents must be provided with rapid, reliable systems for communicating with supervising faculty.

Faculty schedules must be structured to provide residents with continuous supervision and consultation.

Faculty and residents must be educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract the potential negative effects.

Duty Hours

Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

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

Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.

Adequate time for rest and personal activities must be provided. This should consist of a 10 hour time period provided between all daily duty periods and after in-house call.

On-Call Activities

The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution.

In-house call must occur no more frequently than every third night, averaged over a 4-week period.

Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements.

No new patients, as defined in Specialty and Subspecialty Program Requirements, may be accepted after 24 hours of continuous duty.

At-home call (pager call) is defined as call taken from outside the assigned institution.

The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period.

When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit.

The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.

Moonlighting

Because residency education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the resident to achieve the goals and objectives of the educational program.

The program director must comply with the sponsoring institution's written policies and procedures regarding moonlighting, in compliance with the Institutional Requirements III. D.1.k.

Moonlighting that occurs within the residency program and/or the sponsoring institution or the non-hospital sponsor's primary clinical site(s), ie, internal moonlighting, must be counted toward the 80-hour weekly limit on duty hours.

Oversight

Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours and the working environment. These policies must be distributed to the residents and the faculty. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service.

Back-up support 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.

Duty Hours Exception

An RRC may grant exceptions for up to 10% of the 80-hour limit, to individual programs based on a sound educational rationale. However, prior permission of the institution's GMEC is required.

NY State Policy

On Working Conditions and Working Hours

405.4(b)(6)

In order that the working conditions and working hours of physicians and postgraduate trainees promote the provision of quality medical care, the hospital shall establish the following limits on working hours for certain members of the medical staff and postgraduate trainees.

In hospitals with over 15,000 unscheduled visits to an emergency service per year, assignment of post-graduate trainees and attending physicians shall be limited to no more than 12 consecutive hours per on-duty assignment in the emergency service. The commissioner may approve alternative schedule limits of up to 15 hours for attending physicians in a hospital emergency service.

Effective July 1, 1989, schedules of postgraduate trainees with inpatient care responsibilities shall meet the following criteria:

• The scheduled work week shall not exceed an average of 80 hours per week over a 4-week period;
• Such trainees shall not be scheduled to work for more than 24 consecutive hours;
• "On-call" duty in the hospital during the night shift hours by trainees in surgery shall not be included in the forementioned 24 limit or the 80-hour limit if:
• The hospital can document that during such night shifts trainees are generally resting and that interruptions for patient care are infrequent and limited to patients for whom that postgraduate trainee has continuing responsibility;
• Such duty is scheduled for each trainee no more often than every third night;
• A continuous assignment that includes night shift "on call" duty is followed by a non-working period of no less than 16 hours; and
• Policies and procedures are developed and implemented to immediately relieve a postgraduate trainee from a continuing assignment when fatigue due to an unusually active "on call" period is observed.

The medical staff shall develop and implement policies relating to post-graduate trainee schedules which prescribe limits on the assigned responsibilities of postgraduate trainees, including but not limited to, assignment to care of new patients, as the duration of daily on-duty assignments progress.

In determining limits on working hours of post-graduate trainees, the medical staff shall require that scheduled on-duty assignments be separated by not less than 8 non-working hours. Postgraduate trainees shall have at least one 24 hour period of scheduled non-working time per week.

Hospitals employing post-graduate trainees shall adopt and enforce specific policies governing dual employment. Such policies shall require (at a minimum), that each trainee notify the hospital of employment outside the hospital and the hours devoted to such employment. Post-graduate trainees, who have worked the maximum number of hours permitted shall be prohibited from working additional hours as physicians providing professional patient care services.

On Ancillary Staff

405.3(b)(5)

Effective July 1, 1989, the provision, at all times, of intravenous services, phlebotomy services, messenger services, transporter services, nurse aides, housekeeping services, and other ancillary support services in a manner sufficient to meet patient care needs and to prevent adverse impact on the delivery of medical and nursing care.

On Support Services in Emergency Services

405.1 9(d)(4)

There shall be sufficient support personnel assigned to the emergency service to perform the following duties on a timely basis: patient registration, reception, messenger service, acquisition of supplies, equipment, delivery and labeling of laboratory specimens, responsible for the timely retrieval of laboratory reports, obtaining records, patient transport, and other services as required.

Program Post-Call Policy

Policy

It is the policy of the program that all trainees comply with the 6 hour transition period immediately following in-house call.

Applicability

All thoracic surgery residents and fellows.

Procedure

Trainees may remain on duty for up to 6 additional hours of transition time, provided that the trainee documents 4-5 hours of sleep, the duty shift is followed by a non-working period of 16 hours, and the maximum shift is 30 hours from start to end of on-call. This time is to be used for transfer of patient care, rounds, and grand rounds. No new patient care may be assigned during the 6 hour transition time (total of 30 hours).

Coverage for each service is described below: