It is the policy of the Graduate Medical Education Committee to follow guidelines established by the ACGME regarding duty hours for residents in accredited training programs. Duty hours are defined as all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.
Effective July 1, 2011, the following requirements apply to all residency training programs. Specific details can be found at the ACGME website, acgme.org.
1. Residents are responsible for accurately reporting their duty hours, including all time spent in Internal and External Moonlighting, per program requirements.
2. Program Directors are responsible for monitoring and enforcing compliance with duty hour guidelines.
3. If specialty/subspecialty-specific program duty hour requirements as defined by an individual RRC for that specialty/subspecialty are more restrictive than the above requirements, then the duty hour requirements of that RRC will be included in the policy of that specialty/subspecialty program and will supersede the institutional requirements.
4. Concerns regarding duty hours may be reported to the Associate or Assistant Dean for GME or through the Confidential Helpline1-888-594-5874. Concerns may be reported anonymously.
Maximum Hours of Work per Week
5. Duty hours must be limited to 80 hours, averaged over a four-week period per rotation or a four-week period within a rotation excluding vacation or approved leave. Any requests for exceptions to the maximum weekly limit on duty hours must be presented by the Program Director to the GMEC for review and approval. Any exceptions must conform to the Policy and Procedures for Resident Weekly Duty Hour Limit Exceptions.
6. Time spent in Internal and External Moonlighting will be counted toward the eighty-hour maximum weekly hour limit on duty hours as outlined in #5 above.
Mandatory Time Free of Duty
7. Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). “Duty” includes all clinical and academic activities related to the program as described above. At-home call cannot be assigned on these free days.
Maximum Duty Period Length
8. Duty hour periods of PGY-1 residents must not exceed 16 hours in duration.
9. PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Residents may be allowed to remain on site for an additional 4 hours to ensure effective transitions in care; however, they may not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
10. ESOM encourages residents to use alertness management strategies, including strategic napping, in the context of patient care responsibilities, especially after 16 hours of continuous duty and between the hours of 10pm and 8am.
11. In unusual circumstances and on their own initiative, PGY-2 residents and above may remain beyond their scheduled period of duty to continue to provide care to a single patient. Under such circumstances - which only include continuity of care for a severely ill or unstable patient, a transpiring event of unusual academic importance, or humanistic attention to the needs of a patient or family – the resident must appropriately hand over the care of all other patients responsible for their continuing care and document the reasons for remaining to care for the patient in question. Such documentation must be submitted to the Program Director in every circumstance. The Program Director is responsible for tracking both individual resident and program-wide episodes of additional duty.
Minimum Time Off Between Scheduled Duty Periods
12. PGY-1 residents should have 10 hours and must have 8 hours free of duty between scheduled duty periods.
13. Intermediate level residents as defined by the respective Residency Review Committees should have 10 hours free of duty, must have 8 hours between scheduled duty periods, and must have at least 14 hours free of duty after 24 hours of in-house duty. Individual residency programs must construct their own duty hour policies in compliance with their individual program’s requirements.
14. Residents in the final years of education must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods. 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 when these house officers must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. Individual programs must construct their own duty hour policies in compliance with their individual program’s requirements as to the definition of “final years of education” and the circumstances where house officers may have less than 8 hours free between duty periods. In all instances, such circumstances must be monitored by the Program Director.
Maximum Frequency of In-House Night Float
15. Residents must not be scheduled for more than 6 consecutive nights of night float. Individual residency programs must construct their own duty hour policies in compliance with their individual program’s requirements defining maximum consecutive weeks of night float and maximum number of months of night float per year.
Maximum In-House On-Call Frequency
16. In-house call will occur no more frequently than every third night, averaged over a four-week period.
17. At-home call, or “pager call,” is defined as call taken from outside the assigned site.
18. When residents are called into the hospital from home, they may care for new or established patients and the hours spent in-house, exclusive of travel time, are counted toward the eighty-hour limit. Such episodes will not initiate a new “off-duty period.”
19. At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.
20. At-home call may not be scheduled on the resident’s one free day per week (averaged over four weeks). Any concerns or questions concerning the duty hour guidelines must be directed to the Associate or Assistant Dean for GME.
All programs must have policies for duty hours that at a minimum meet the ACGME’s institutional and program requirements. Programs must monitor in-house and from-home duty hours on an ongoing basis in a way that provides accurate data. The Duty Hour Subcommittee has establish reporting requirements. Each monitoring period must be 4 weeks in length, not a moving average or extrapolated from a shorter length of time. With GMEC oversight, the DIO and the Chair of the GMEC Duty Hour Subcommittee will review program data resulting from internal reviews, annual administrative processing sessions, random audits and other times as determined by the DIO, the GMEC or by the Duty Hour Subcommittee of the GMEC. If a program has received approval from the ACGME to extend the 80-hour rule, if the program received a duty hour citation or if an internal review reveals a duty hour issue, then these training programs must send reports to the sub-committee at a minimum of every other month.
Program Directors must monitor call-from-home duty hours in terms of frequency and characteristics to assure that residents and fellows are following basic guidelines established by the ACGME.
Program Directors must provide information to residents, fellows, and faculty members regarding effects of loss of sleep and chronic fatigue. Currently, the GMEC recommends the using SAFER program available from the GME Office, the Dinges presentation found at the ACGME website, and askng faculty members of Emory University School of Medicine who have expertise in this area.
REPORTING STRUCTURE FOR OFF-SERVICE ROTATIONS
It is the intention of this section of the Duty Hour Policy to establish a process that will address duty hour compliance in a rapid and timely manner when a resident is rotating off serivce. Problems regarding compliance with duty hour guidelines should be reported to the Chief Resident of the accepting training program. If that Chief Resident does not respond to the report of noncompliance, then the resident should report to the Program Director of the sending program. The Program Directors of the two programs must address the issues that led to the violation of the guidelines. The resident may notify the GME Office at any time. The Associate Dean for GME will report to the Chairs of the two training programs and has the option of reporting to the Dean if the issues are not settled on an immediate basis.
The GME office maintains a direct phone line to receive confidential complaints about all issues including duty hours. This phone number 1-888-594-5874, is private and secure. The Associate Dean and DIO will respond to the recorded messages as appropriate.