ACGME Duty Hours: Where are we and where

Report
ACGME Duty Hours:
Where are we and where are we
going?
George Sarosi Jr. MD
Robert H Hux MD Professor of Surgery
Residency Program Director
Disclosures
• I have no financial conflicts of interest to
disclose.
Disclosure II
• However, those who dislike major change are
likely to find this talk highly unpleasant
• I did not make these rules
• No amount of complaining about this will
cause it to change
A Brief History of Duty Hours Limits
• 1984 Libby Zion case
– Concerns raised about resident fatigue and
supervision
• 1989 New York State sets 80 hour limit
– Applies to 15% of nations residents
• 2003 ACGME Imposes national duty hour
limits
The Current Duty Hours
• Were established in 2003 and represented a
substantial change for surgery training
programs
• Were initially to be reevaluated in 5 years
• Have largely been complied with in most
programs
The Current Duty Hours
• No more than 80 hours per week averaged
over a 4 week rotation
• In house call no more Frequent than 1 in 3
averaged over a 4 week period
• Continuous Duty hours must not exceed 24
hours
– 6 hours after provided for hand-off and didactics
or clinics. NO NEW PATIENTS
Current Duty Hours Cont.
• 10 hours off between duty periods should be
provided.
• 1 day off in 7, averaged over 4 weeks, free from
formal educational and duty assignments
• Internal Moonlighting (but not external) counts
as duty hours
What Have Duty Hour Limits
Accomplished?
• In 1999 in a self reported survey residents in the
US reported average duty hours of
– PGY-1 83 hours/week
– PGY-2 76.2 hours /week
– 49% worked more than 80 hours/ week
• Surgery residents reported working more hours
– PGY-1 103
– PGY-2 105.7
– 89% of PGY-1 and 93% of PGY-2 residents reported
working more than 80 hours/ week
Baldwin Acad Med 2003 78(11)
Effect of Initial Duty Hours Reform
• PGY-1 residents surveyed reported working
fewer hours:
– 2002 70.7 hours/week
– 2003 66.6 hours/ week
– Only 43% of residents nationally reported more
that 80 hours/ week
– 67.2% in General Surgery worked more than 80
hours /week
Landrigan JAMA 96(9) 2006
Other Effects of Duty Hours Reform
• Surgical case volume has shown a small but
statistically significant drop in case numbers of
graduating residents
– 938.9 total and 249.2 chief cases in 2002-3
– 914.2 total and 238.3 chief cases in 2007-8
– No increase in residents failing to meet defined
categories
– Declines in case numbers in areas outside classic
general surgery such as Vascular, Thoracic and
Plastics
Simien Ann Surg 252(2) 2010
Other Effects of Duty Hours Reform
• The majority of Studies show an increase in
resident job satisfaction and personal time.
• The majority of studies show an increase in
resident test performance.
• The majority of studies show a decrease in
attending job satisfaction, satisfaction with
education and quality of life.
Jamal Acad Med 86(1) 2011
Inconclusive Evidence that Duty Hours
Reform has Effected Hospital Mortality
• 2007 JAMA study showed no change in
Medicare hospital mortality in 2004 or 2005
compared to 2000-2003
• A second study showed decrease in mortality
in VA hospitals for medical but not surgical
patients in high intensity teaching VA hospitals
over the same time period
Volpp JAMA 298(9) 2007
2009 IOM Report
• 2007 Congress commissioned the IOM to
examine the relationship between resident duty
hours and patient safety.
• 2009 the IOM released it report “Resident Duty
Hours: Enhancing Sleep, Supervision and Safety”
– At least 5 hours sleep after 16 hours of continuous
duty
– Increased frequency of days off
– Greater supervision especially for PGY-1
– Improved hand offs
Effect of the IOM Report
• Significant Discussion about legislation to
govern resident Duty hours
• Significant criticism of 2003 Duty hours rules
• Raised issues beyond just duty hours such as
supervision
• ACGME commissioned a 16 member task
force to review evidence and draft new
standards.
August 2010: New ACGME Common
Program Requirements
• Announced in NEJM (vol. 363 (2) pp. e3. 2010)
• Have undergone some slight modification
since initial announcement
– Relaxation of strict q3 call to on average
• Focus on three broad areas
– Duty Hours
– Mitigation of Fatigue
– Supervision of residents and transitions of care
• Have level of training specific rules
Total Duty Hours
2003 Rules
• Duty hours must be limited
to 80 hours per week,
averaged over a four‐week
period, inclusive of all
in‐house call activities.
2011 Rules
• VI.G.1. 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.
Maximum Duty Period Length
2003 Rules
• Continuous on‐site duty, including
in‐house call, must not exceed 24
consecutive hours. Residents may
remain on duty for up to six
additional hours to participate in
didactic activities, transfer care of
patients, conduct outpatient
clinics, and maintain continuity of
medical and surgical care.
2011 Rules
• VI.G.4.a) Duty periods of PGY‐1
residents must not exceed 16 hours in
duration.
• VI.G.4.b) Duty periods of PGY‐2
residents and above may be scheduled
to a maximum of 24 hours of
continuous duty in the hospital.
• 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
Some New Flexibility in Duty Hour
Length
• 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
– humanistic attention to the needs of a patient or family.
• VI.G.4.b).(3).(a) Under those circumstances, the resident must:
– appropriately hand over the care of all other patients to the team
responsible for their continuing care
– document the reasons for remaining to care for the patient in question
and submit that documentation in every circumstance to the program
director.
Minimum Time off Between Scheduled
Duty Periods
2003 Rules
• 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.
2011 Rules
• 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 (PGY 2&3) 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.
Minimum Time off Between Scheduled
Duty Periods (Chiefs)
2003 Rules
2011 Rules
• VI.G.5.c) Residents in the final years of
education (PGY 4&5) must be prepared
• Adequate time for rest and
to enter the unsupervised practice of
personal activities must be
medicine and care for patients over
irregular or extended periods.
provided. This should
• VI.G.5.c).(1) This preparation must occur
consist of a 10‐hour time
within the context of the 80‐ hour,
period provided between all
maximum duty period length, and
one‐day‐off‐in‐seven standards. While it
daily duty periods and after
is desirable to have eight hours free of
in‐house call.
duty between scheduled duty periods,
there may be circumstances 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.
• These circumstances must be monitored
by the program director
Minimum Time Between Shifts
Simplified
• Switch from should be 10 hours to must be 8 and should be 10
for all levels
• For 24 hour shifts residents must have 14 hours between shifts
• Chiefs (PGY-4 & 5) can have less time between shifts for
compelling clinical reasons related to continuity of care:
– A patient on whom a resident operated/intervened that day who
needs return to the operating room (OR).
– A patient on whom a resident operated/intervened that day who
requires transfer to the Intensive Care Unit (ICU) from a lower level
of care.
– A patient on whom a resident operated/intervened that day who is
in the ICU and is critically unstable.
– A patient who returns to OR for a complication during the same
admission
• Reasons for return must be documented for PD
Maximum Frequency of In House Call
is Unchanged
2003 Rules
• In‐house call must occur no
more frequently than every
third night, averaged over a
four‐week period.
2011 Rules
• VI.G.7. 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).
Home Call Rules are Largely
Unchanged
2003 Rules
•
•
•
•
The frequency of at‐home call is not
subject to the every‐ third‐night, or
24+6 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 one day in seven
completely free from all educational •
and clinical responsibilities, averaged
over a four‐week period.
•
When residents are called into the
hospital from home, the hours
residents spend in‐house are counted
toward the 80‐ hour limit.
2011 Rules
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.
VI.G.8.a).(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”.
Rules Have Been Added Governing
Night Float Rotations
2003 Rules
2011 Rules
• VI.G.6. Residents must not be
scheduled for more than six
consecutive nights of night
float.
• Night float rotations must not
exceed two months in
duration, and there can be no
more than three months (14
Weeks) of night float per year.
There must be at least two
months between each night
float rotation. (Surgery RRC)
Strong Language on Fatigue Mitigation
Added
2003 Rules
•
2011 Rules
•
Faculty and residents must be •
educated to recognize the
signs of fatigue and sleep
deprivation and must adopt
and apply policies to prevent
and counteract its potential
negative effects on patient
care and learning.
•
•
•
•
•
VI.C.1. The program must:
VI.C.1.a) educate all faculty members and residents to
recognize the signs of fatigue and sleep deprivation
VI.C.1.b) educate all faculty members and residents in
alertness management and fatigue mitigation
processes
VI.C.1.c) 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.
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.C.2. 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.
VI.C.3. The sponsoring institution must provide
adequate sleep facilities and/or safe transportation
options for residents who may be too fatigued to
safely return home.
Significant Changes to Statements
Regarding Resident Supervision
• In 2003 resident supervision:
• “The program must ensure that qualified
faculty provide appropriate supervision of
residents in patient care activities”
Significant Changes to Statements
Regarding Resident Supervision
• In 2011:
• VI.D.1. In the clinical learning environment, each patient must have an
identifiable, appropriately‐credentialed and privileged attending who is
ultimately responsible for that patient’s care.
– VI.D.1.a) This information should be available to residents, faculty members, and
patients.
– VI.D.1.b) Residents and faculty members should inform patients of their respective
roles in each patient’s care.
• VI.D.2. 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 Defined
• VI.D.3. 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:
– (1) 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.
– (2) 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.
Deliberate Assignment of Independence
with Certification will Be Required
• VI.D.4. 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.
• VI.D.4.a) 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.
• VI.D.4.b) 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.
• VI.D.4.c) 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.
• VI.D.5. 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.
• VI.D.5.a) 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.
Strong Focus on PGY-1 Supervision
Direct Supervision
• Direct supervision is required until competency is demonstrated for:
• Patient Management Competencies
– 1. initial evaluation and management of patients in the urgent or
emergent situation, including urgent consultations, trauma, and
emergency department consultations (ATLS required)
– 2. evaluation and management of post-operative complications,
including hypotension, hypertension, oliguria, anuria, cardiac
arrythmias, hypoxemia, change in respiratory rate, change in
neurologic status, and compartment syndromes
– 3. evaluation and management of critcially-ill patients, either
immediately post-operatively or in the intensive care unit, including
the conduct of monitoring, and orders for medications, testing, and
other treatments
– 4. management of patients in cardiac or respiratory arrest (ACLS
required)
Strong Focus on PGY-1 Supervision
Direct Supervision
• Procedural Competencies
– 1. Performance of advanced vascular access procedures,
including central venous catheterization, temporary dialysis
access, and arterial cannulation
– 2. repair of surgical incisions of the skin and soft tissues
– 3. repair of skin and soft tissue lacerations
– 4. excision of lesions of the skin and subcutaneous tissues
– 5. tube thoracostomy
– 6. paracentesis
– 7. endotracheal intubation
– 8. bedside debridement
Strong Focus on PGY-1 Supervision
Indirect Supervision
• Indirect Supervision allowed for:
• Patient Management Competencies
– 1. evaluation and management of a patient admitted to hospital, including initial
history and physical examination, formulation of a plan of therapy, and necessary
orders for therapy and tests
– 2. pre-operative evaluation and management, including history and physical
examination, formulation of a plan of therapy, and specification of necessary tests
– 3. evaluation and management of post-operative patients, including the conduct of
monitoring, and orders for medications, testing, and other treatments
– 4. transfer of patients between hospital units or hospitals
– 5. discharge of patients from the hospital
– 6. interpretation of laboratory results
• Procedural Competencies
– 1. performance of basic venous access procedures, including establishing intravenous
access
– 2. placement and removal of nasogastric tubes and Foley catheters
– 3. arterial puncture for blood gases
New Statements on Transitions of Care
• VI.B.1. Programs must design clinical assignments to
minimize the number of transitions in patient care.
• VI.B.2. Sponsoring institutions and programs must ensure
and monitor effective, structured hand‐over processes to
facilitate both continuity of care and patient safety.
• VI.B.3. Programs must ensure that residents are competent
in communicating with team members in the hand‐over
process.
• VI.B.4. 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.
What does all this mean?
• Fundamental changes in the intern year
–
–
–
–
No more call
Strong incentive to move PGY-1 residents to shift work
Limits on the amount of night work by interns
Delayed maturation of residents?
• More work and more flexibility for upper level
residents
– Likely more in house call for intermediate level
residents
– Much more flexibility for senior residents
What does all this mean II?
• New Focus on supervision and certification of
competence (or at least experience)
– Interns will need to have much more direct
supervision by senior residents and attendings
– A new focus on documentation of competence on the
part of programs and faculty (to allow for expanded
intern independence)
• The changes in supervision are the most radical
changes and likely the hardest to predict
• This may be a very good (but painful) thing
“It's a good idea to obey all the rules when you're
young just so you'll have the strength to break
them when you're old.”
-Mark Twain

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