The ACGME Duty Hour Standards: An update after the first 120 days __________________________________

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The ACGME Duty Hour StandardsAn update after
the first 120 days _____________________________
_________

• SUO/AADO
• Washington, DC
• November 9, 2003
• Ingrid Philibert
• Director, Field Activities, ACGME
• Staff Duty Hour Work Group and Subcommittee

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At the Start A Quotation

• We have taken the most linear instrument that
  exists the clock, and applied it to a complex
  phenomenon resident education.
• - Marvin Dunn, MD

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The lay of the land Duty hours not a new issue

• Effect of sleep loss recognized for the past 30
  years
• Friedman (1971) Post-call residents more errors
• Dependence on cognition, memory, vigilance
• Until recently, little attention to system
  safeguards
• Performance shaping factors not related to
  intelligence, motivation, professionalism
• Patient Safety and imperatives
• Increasing clinical demands, inefficient support
  systems
• Partly framed by political environment OSHA,
  Conyers
• Effect of sleep loss on learning, well-being

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The Standards in Brief

• 80 hours per week averaged over 4 weeks
• 1 day in 7 free from all responsibilities
• Adequate time for rest (should be 10 hours)
• In-house call no more than every third night
• 24-hour limit on continuous duty
• Up to 6 h for didactics, transfer, continuity of
  care
• No new patients after 24 h (RRC defines new)
• In-hospital hours during call from home counted
• Moonlighting approved by program director
• In-house moonlighting counts toward weekly limit
• Effects on performance in program assessed

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Accreditation allows refinements of the standards

• RRCs have refined language in certain areas
• Allowed activities during the 6 hours
• Definition of new patient
• More restrictive standards in some specialties
• IM, EM, Anesthesiology
• Exceptions to the 80-hour limit possible with a
  sound educational rationale
• Future refinements under consideration
• Home call, rest period, use of time post call,
  limits for surgical chief residents

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A few areas that benefit from clarification

• How should programs account for vacation time?
• Take out of numerator and denominator in
  calculating averages
• What standards apply to home call?
• Activity should determine type of call
• Hours spent in house count only toward weekly
  limit
• Some RRCs require 1 day off in 7
• Standards call for monitoring burden of home call
• What sites count as internal moonlighting
• Sponsoring institution and all affiliated sites
  used by program

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A few areas that benefit from clarification (cont)

• What standards apply to research time?
• If part of the accredited years, research or
  combined research/clinical time must comply
• Two situations not subject to standards
  self-directed research, dedicated year (not part
  of accredited program)
• Gray area of combined research and clinical
  care non-compliance, dilution of research
  experience
• How are other program activities counted
  (conferences, committees, applicant interviews)?
• ACGME required or encouraged activities must be
  counted as duty hours

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ACGME Expectations for Monitoring Duty Hours

• ACGME expects monitoring, does not specify
  approach
• How should programs/institutions assess
  compliance?
• Primary aim monitoring of compliance, secondary
  aim inform the accreditation process
• Many data collection systems available
• Paper-based, PDAs, time-keeping systems,
  institutional
• All have advantages/drawbacks
• Involve your residents, are key to compliance
• Consider the needs of the specialty
• Neurosurgery different from dermatology

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Patterns of response to the duty hour standards

• Scheduling, replacement strategies most common
• Adding home call assignments can be problematic
• In-house moonlighting may work, if compliant with
  standards, sensitive to residents needs
• There is both good and bad creativity
• If in doubt, use ACGME and RRCs as resources
• Some programs are revamping their educational
  models and approaches
• ACGME and other organizations are collecting and
  reporting information on innovative practices

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What Will Contribute to Success?

• Supportive leadership
• Involve faculty, residents, nurses in decisions
• Assess compliance, study effect on care, learning
• Resident replacement vs. rethinking clinical care
  
• Assess non-teaching models
• Disengage from the status quo
• Improve residents work environment
• Come to terms with health care as a 24/7 industry
• Disband residents as the glue in the cracks of
  the health care system

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What Will Contribute to Success?

• Change the culture in academic medicine
• Attend to faculty perceptions, faculty buy-in
• Deal proactively with the hidden curriculum,what
  current residents will miss or reduced
  professionalism
• Protect junior faculty, fellows most
  vulnerable
• Address shift-work mentality as part of the
  professionalism curriculum
• But emphasize there is no link between hours
  worked and professionalism

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Three Critical Issues for the Next 24 Months

• Positive effects of duty hour limits
• Assess in context of other performance shaping
  factors
• Potential negative effects
• More frequent hand-offs, we need to get better
• Issue of withdrawing residents from patient care
  at a time of shortage of other health
  professionals
• ? Effect on education in some specialties
• Reduced operative experience, reduced
  longitudinal patient care experience, fractured
  learning
• For all three need for data collection by ACGME
  and the academic community

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• Questions and Answers