A Commission of the NY State Department of Health, headed by
Dr. Bertrand Bell, developed regulations regarding the
SUPERVISION of residents and DUTY HOUR LIMITATIONS. These
were first implemented in 1989. Hospitals are subject to
substantial fines for repeatedly violating these
regulations, and all departments of this Hospital strive to
be in compliance, so please let your program director know
if you believe we are not in compliance with the
regulations. Nevertheless, professional conduct by
residents requires that they provide patient care first, and
then discuss any potential violations with the program
director. In fact, residents are asked to fill out
surveys for their program director at least twice a year to
document compliance with the NYS "Bell Commission"
regulations. The ACGME has similar supervision and duty
hour regulations.
A summary of these supervision and duty hour regulations, as
they apply on the medical service, follows:
1) No more than 12 consecutive hours on call in the ER.
This also means that one must not attend conferences or clinics
before or after such 12 hour shifts.) There must be at least
10 hours off between ER shifts (per ACGME).
2) On the inpatient service, no more that 80 hours of work
per week (based on a 4 week average). Some weeks may be somewhat
more than 80 hours, as long as other weeks are less than 80
hours, and the average, over 4 weeks, does not go over 80 hours
work per week. Night call no more often then every 3 days (per ACGME).
Residents must be provided with 1 day in 7 (average over a 4 week period)
off of all call duties (a continuous 24 hour period off of all call).
3) No more than 24 consecutive hours on call (as might
occur on the medical service when there is no Night Float, or in the
ICU when one is on long call), but up to an additional 3 hours
(after the 24) is allowed if it is necessary as "transition time"
for sign out activities (but not work or direct patient care such
as drawing blood, starting IVs, or writing routine progress notes).
[The ACGME would allow up to 6 hours transition, but that would violate
the NYS regulations.] N.B.: Transition time adds to the
allowed average of 80 hours/week and it uses up time from the
24 consecutive hours off.
4) The NYS DOH Bell regulations require that there "must" be at least 8
hours off between shifts on the medical service; starting in July of
2003, the ACGME states that there "should" be at least 10 hours off
between shifts. There must be 10 hours off between shifts in the ER
and the ICU.
5) Moonlighting, if permitted by the Program Director, must
not violate the above regulations. All moonlighting must be
approved in writing by the program director. Note: Sometimes
residents make changes among themselves to cross cover. Since
this can lead to violation of work hour regulations, ALL
changes in the schedules must be approved by the Chief
Residents.
6) Procedures must not be performed on your own unless you
have received written privileges per our credentialling
process.
7) You must be aware of the CHAIN of COMMAND in the area in
which you are working. This is to ensure that you receive
adequate SUPERVISION and than an attending physician is aware of
each patient and can participate in management decisions and
direction of the patient's care.
8) If you observe a colleague who appears over tired, or if
you are over tired, notify your more senior resident so that
action can be taken to find a replacement physician.
9) The "old" ACGME guidelines for the PGY-1 IM continuity clinics
advise no more than 2 new patients and not more than 6 return
patients per 1/2 day session. The 2003 ACGME guidelines require an
average of 3-5 patients per session for PGY-1; an average of 4-6 patients
for PGY-2; and an average of 4 or more patients for PGY-3 per session.
There should be at least 1/2 hour of contact time with the supervising
faculty physician per session and the faculty member should be
responsible for supervising no more than 5 residents at a time (4 for
NYS DPP) during which time the faculty member's primary responsibility
must be supervision and teaching.
On the in-patient medical rotations, a PGY-1 should not care for more
than 12 patients & should not be assigned more than 5 new patients per
admitting day (+ 2 inpatient transfers) and not more than 8 new patients
within a 48 hour period** (twice these numbers for residents supervising
more than one PGY-1 (24;10+4;16)**. (A "res-a-tern" supervising one
PGY-1 can be responsible for a total of no more than 16 patients.)
A PGY-2 Night Float should not admit more than 5 patients per tour of
duty.
Admissions are to be assigned to other PGY-1, 2, or 3 if necessary to
satisfy these guidelines.
Notes:
Residents must spend at least 1/3 of their time on inpatient rotations,
at least 1/3 of their time in ambulatory rotations, at least 36 months of
residency training (of which three are vacation or other leave), 288
continuity clinic sessions [NYS DPP], at least 27 months of attendance at
continuity clinic (ACGME) and not more than one "contiguous" month of
continuity clinic missed because of night float, ICU, etc.; at least 24
months in settings where the resident personally provides or supervises
junior residents who provide direct care (inpatient or the ambulatory
setting) (ACGME).
The Following are Common Requirments of the ACGME (2004)
Resident Duty Hours and the Working Environment
Providing residents with a sound didactic 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 energy. Duty hour assignments must
recognize that faculty and residents collectively have responsibility for
the safety and welfare of patients.
A. Supervision of Residents
1. 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.
2. Faculty schedules must be structured to provide residents with continuous
supervision and consultation.
3. Faculty and residents must be educated to recognize the signs of fatigue,
and adopt and apply policies to prevent and counteract its potential
negative effects.
B. Duty Hours
1. 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 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.
2. Duty hours must be limited to 80 hours per week, averaged over a four week
period, inclusive of all in-house call activities.
3. 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 1 continuous 24-hour period free from all clinical,
educational, and administrative duties.
VI. B. 4. 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.
C. 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.
1. In-house call must occur no more frequently than every third night,
averaged over a 4-week period.
2. 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 further specified by the RRC]
3. No new patients may be accepted after 24 hours of continuous duty.
[as further specified by the RRC]
4. At-home call (or pager call) is defined as a call taken from outside the
assigned institution.
a) The frequency of at-home call is not subject to the every-third-
night limitation. At-home call, however, 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.
b) When residents are called into the hospital from home, the hours
residents spend in-house are counted toward the 80-hour limit.
c) 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.
D. Moonlighting
1. 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.
http://www.newyorkmetro.com/nymetro/health/features/n_9426/
** The "48 hour admission caps" do not apply to night floats.
