ACGME Proposes New Recommendations on Resident Duty Hours

Laurie Barclay, MD

July 12, 2010

October 14, 2010 — Editor's note: ACGME's final medical resident duty hour limits and supervision standards are now available .

July 12, 2010 ( updated with table July 13, 2010 ) — The Accreditation Council for Graduate Medical Education (ACGME) has released draft standards regarding resident training intended to promote quality patient care in teaching hospitals. The standards are summarized in an article published online June 23 in the New England Journal of Medicine.

The new guidelines, which take into consideration residents' levels of experience and emerging competencies, propose updating current resident work hour limits and adding new requirements for resident supervision and handovers of patient care at hospital shift change.

"Enhanced patient safety and an excellent, humanistic learning environment are the ACGME's twin prime objectives," Thomas Nasca, MD, MACP, chief executive officer of ACGME and vice chair of the Task Force on Quality Care and Professionalism, told Medscape Medical News. "The short-term benefit for patients is enhanced quality of care today."

As the independent nonprofit organization responsible for setting standards and monitoring and accrediting medical residency programs throughout the United States, ACGME conducts periodic reviews of the graduate medical learning environment, including duty hours, professionalism, and supervision of residents, and issues new standards as needed. In 2003, the ACGME implemented a new set of common duty hours standards and planned to revise them as needed in 5 years, after residents beginning training in 2003 had completed training under the new standards.

In March 2009, the ACGME sponsored an International Symposium on Resident Duty Hours and the Learning Environment and formed an independent, 16-member task force to systematically review current evidence, as well as recommendations issued by the Institute of Medicine (IOM) in 2008. For nearly a year, their comprehensive review evaluated duty hour standards, resident supervision, compliance monitoring, and related issues.

"After hearing from nearly 100 individuals, receiving the written formal positions of more than 100 medical organizations, and commissioning and receiving 3 external reviews of the past 20 years of literature on patient safety and resident duty hours, patient handovers, and other relevant issues, the task force determined that new standards revising requirements for supervision and duty hours were needed to better match residents' level of experience and emerging competencies," Dr. Nasca said.

"The task force recognized, based on the available information gleaned from literature reviews, testimony from the profession, patient safety experts, sleep scientists, educators, and the public that safety for patients in the teaching environment is about much more than resident duty hours," Dr. Nasca pointed out. "The standards that are proposed are a cohesive package aimed to ensure patient safety for patients today in the teaching setting, to ensure patient safety of the patients cared for 10 years from now by today's residents, and to ensure the humanistic educational environment for residents that teach professionalism and effacement of self-interest."

The proposed resident training standards on the ACGME Website will be available for public comment for 45 days so that the task force can review the feedback and consider modifications to the draft standards. The Committee on Requirements of the ACGME Board will review the final version, and if the guidelines are approved by the committee, the entire board will consider them for approval in September 2010 and implementation in July 2011.

Specific Standards Endorsed by the ACGME

Specific standards endorsed by the ACGME regarding resident duty now include the following (see Table at end of article for all changes):

  • providing more detailed directives for levels of supervision needed for first-year residents vs residents in subsequent years of training;

  • limiting duty periods for first-year residents to no more than 16 hours per 24 hours, which would include all medical moonlighting; and

  • imposing stricter requirements for duty hour exceptions.

"Dimensions of these standards, and their difference from those implemented in 2003, include [that] the task force recognized that 'one size doesn't fit all' and proposed stratified standards that take into consideration residents' experience and emerging competencies," Dr. Nasca explained to Medscape Medical News.

"While proposing that the recommended maximum weekly work hours stay the same as the ACGME's current standard of 80 hours per week average over 4 weeks — as per the IOM's recommendations — the draft standards do propose significant changes to resident training," Dr. Nasca pointed out. "For instance, while there is limited research on the connection between fatigue and medical errors for the entire resident community, there is data that indicates that fatigue has an influence on the frequency of errors by first-year residents, who are the least experienced and appear the most vulnerable."

Evidence considered by the task force suggested that reducing duty hours was not necessarily linked to lower incidence of medical errors, or even increased average sleep time for residents. A comprehensive review of independent research on quality care issues also showed no association between inpatient mortality and morbidity and resident duty hours.

The proposed ACGME standards also established new categories of standards for teamwork, clinical responsibilities, communication, professionalism, personal responsibility, and healthcare transitions. These include:

  • establishing graduated requirements for minimum time off between scheduled duty shifts;

  • increasing requirements at the program and institutional levels for handovers of patient care; and

  • detailing specific requirements for strategies to improve alertness and reduce the effects of fatigue, so that continuity of patient care and resident safety can be optimized.

"Heightening supervision standards ensures that patients in teaching hospitals are receiving the dual benefit of many more eyes watching their progress due to the involvement of medical students, residents, and fellows, yet ensuring the benefit of oversight of their care by some of the most knowledgeable and capable attending physicians in their specialties," Dr. Nasca said.

"It is this combination of the learner and the teacher at the bedside that provides the excellent clinical outcomes documented to be present in America's teaching hospitals. Enhancing standards regarding transitions in care (also called handovers) will reduce the most common cause of errors in all hospitals — communication errors — and redundant supervision systems minimize the likelihood of an error reaching the patient."

Based on literature evidence that handovers of patient care from one physician to another could cause medical errors because of the potential for miscommunication, the draft training standards minimize the number of patient handovers by structuring duty hours so that transitions in care occur only twice a day.

The ACGME has commissioned a University of California–Los Angeles Rand team, which reviewed the 2008 recommendations, to study the proposed revisions and develop an economic impact analysis, with a report anticipated in September.

"Better supervision early in training, and graded authority and responsibility as the resident progresses through training under circumstances mimicking the actual independent practice of medicine, will permit residents to enter the unsupervised practice of medicine — after graduation from residency — better prepared to meet the rigors of service to the public," Dr. Nasca concluded. "In practice, physicians are called upon to provide care at all hours of the day and night. They must be prepared to deal with, and function well, when fatigued. These standards make that progressive training possible."

Residents Should Take Some Responsibility

When asked for independent comment, Ian Komenaka, MD, FACS, from Maricopa Medical Center Department of Surgery, in Phoenix, Arizona, told Medscape Medical News that "the new recommendations will have little effect on improving patient safety and physician training."

"I feel that some responsibility must be given to the residents," said Dr. Komenaka, who trained at a community program, did his fellowship at a university program, and was a faculty member at a university program and now at a community program. "With an 80-hour work week limitation, there is no reason for any resident to show up with signs of sleep deprivation. It is a privilege to be a physician, and at least some responsibility must be shouldered by the residents."

Dr. Komenaka noted his surprise that the proposed recommendations have many pages devoted to what the institution and the program "must do" to facilitate resident learning and even to ensure the resident shows up for work rested by being able "to recognize signs of sleep deprivation." He also expressed concerns about the different limitations for a first-year resident compared with those for second-year residents and above, and about the single exception allowing residents to return to duty in less than 8 hours.

"While hours may be limited in residency training, once a physician becomes independent, hours cannot be controlled, particularly if the physician is a solo practitioner," Dr. Komenaka said. "Patients getting sick is a random event, and if a physician has a sick patient, particularly as a solo practitioner, he or she will have to care for that patient for 24, 48, [or even] 72 hours — however many hours are required. You cannot simply say, 'OK, hold everything for 8 hours until I get some sleep.' "

Because only 6 to 7 years have elapsed since resident work hour limitations were implemented, Dr. Komenaka believes it is premature to evaluate the effects of these limitations.

"The ultimate evaluation of the success or failure of work hour limitations will be on patient outcomes," he said. "Physicians trained in 'this era' have only been in practice for 1 to 2 (surgery) or 3 to 4 (other) years. Only in another 5 to 10 years will we possibly see changes in outcomes due to these limitations."

Committee of Interns and Residents Responds

On June 23, Committee of Interns and Residents (CIR) National President Farbod Raiszadeh, MD, PhD, released a statement indicating that the new training rules are inadequate to protect patients and residents, based on the scientific literature demonstrating that marathon shifts exceeding 16 hours can have a detrimental effect on a physician's abilities and judgment. The statement suggests that the shift limitation to no more than 16 consecutive hours for first-year residents should also apply to residents in subsequent years of training.

"The [CIR] has long stressed that work and medical education re-design is essential to improving patient care and physician training," the statement reads. "It is not just about hours worked — it is about what residents do in those hours, [yet] so many of our senior medical leaders refuse to recognize the evidence that fatigue leads to an increase in preventable medical errors."

The CIR statement points out that fatigued residents are at greater risk for car crashes and occupational injury from needlesticks when they are sleep-deprived. Although the IOM report recommended that hospitals provide residents with safe transportation home, the ACGME standards do not address this proposal.

"The IOM report called for rigorous oversight on the part of the ACGME, including unannounced visits, strengthened complaint procedures, and confidential, protected reporting of hours by teaching hospitals," the CIR statement noted. "We know that residents often do not accurately report their hours because they are afraid of retribution. Additionally, the penalty for violating work hours limits — putting a program on probation or losing its accreditation — hurts the residents themselves."

The CIR therefore supports the IOM's recommendation that both the Centers for Medicare and Medicaid Services and the Joint Commission play a role in holding ACGME more accountable for the quality of care and for resident training conditions.

"While the ACGME's new plan is more rigorous, it still relies on residents blowing the whistle and the penalty still hurts residents, so we should not expect any better results," the CIR statement concluded. "Although we commend the ACGME for thinking seriously about these issues, we remain alarmed that the end result will perpetuate working conditions that are fundamentally unsafe both for resident physicians and our patients."

Table 1. Comparison of Selected Sections of the Proposed ACGME Requirements with the 2003 Standards and the IOM Recommendations*

Category ACGME 2003 Requirements IOM 2008 Recommendations Proposed 2010 ACGME Requirements
Supervision Programs must ensure that qualified faculty provide appropriate supervision Residency review committee should establish measurable standards of supervision according to specialty and level of training
Residents in first yr must have immediate access to in-house supervision
Residents and attendings should inform patients of their role in the care of each patient
Supervising faculty should delegate portions of care to residents
Senior residents or fellows should serve in a supervisory role for junior residents
Progressive responsibility for care must be assigned by the program director and faculty
Residents are responsible for knowing the limits of their scope of authority
Programs must set guidelines as to when residents are expected to communicate with supervisors
Faculty assignments should be of sufficient duration to assess residents' knowledge and skills
Programs must observe the following three classifications of supervision: level 1 — direct supervision (the supervising physician is physically present with the resident and patient); level 2 — indirect supervision; level 2a — supervising physician is on site and available to provide direct supervision; level 2b — supervising physician is available by phone and available to provide direct supervision; level 3 — oversight (the supervising physician reviews procedures and encounters after care is delivered)
During the postgraduate yr 1, residents must have supervision level 1 or 2a
Workload Learning objectives must not be compromised by excessive reliance on residents to fulfill service obligations
Assignments must recognize that faculty and residents collectively are responsible for patient safety and welfare
Resident workload should be adjusted and work that is of limited or no educational value limited
Residents should be provided with adequate time for patient care and reflection
Appropriate limits on caseload should be set, taking into consideration complexity of illness and resident's competency
The workload for each resident must be based on level of training, patient safety, resident education, severity, and complexity of patient illness, and available support services (specialty-specific guidelines to be enumerated by each specialty review committee
The learning objectives of the program must not be compromised by excessive reliance on residents to fulfill nonphysician service obligations
Maximum hr/wk 80/wk, averaged over 4 wk 80/wk, averaged over 4 wk 80/wk, averaged over 4 wk
Maximum length of duty period Continuous on-site duty, including in-house call, must not exceed 24 consecutive hr
Residents may remain on duty up to 6 additional hr to participate in didactic activities, transfer care of patients, conduct outpatient clinics, or maintain continuity of medical and surgical care
No new patients may be excepted after 24 hr of continuous duty
Extended duty must not exceed 16 hr, unless a 5-hr nap is provided; 5-hr nap must be included in 80-hr limit; after 5-hr nap, resident may continue for 9 more hr for a total of 30 hr
No new patients after 16 hr
Extended duty (e.g., 30 hr with 5-hr nap) must not occur more frequently than every third night; averaging is not allowed
Duty periods of residents in postgraduate year 1 must not exceed 16 hr
Intermediate-level and senior residents (postgraduate yr 2 and above) may be scheduled for a maximum of 24 hr of continuous duty; programs must encourage residents, as professionals, to use alertness-management strategies to maintain alertness in the context of patient care responsibilities; strategic napping, especially after 16 hr of continuous duty and between 10 p.m. and 8 a.m. is strongly suggested
Residents may remain on site for periods of no longer than an additional 4 hr to provide for the transfer of care and may not attend continuity clinics after 24 hr of duty
In unusual circumstances, residents may remain beyond scheduled hr to continue to provide care for a single patient; justifications are limited to required continuity of care for a patient who is severely ill or whose condition is unstable, academic importance, or humanistic attention to the needs of a patient or family; residents cannot be compelled to spend these additional hr
In-hospital on-call frequency Every third night, on average Every third night; no averaging Intermediate-level and senior residents (postgraduate yr 2 and above) — every third night (no averaging)
Minimum time off between scheduled duty periods Adequate time for rest and personal activities must be provided, consisting of 10 hr off between all daily duty periods and after in-house call Time off must be provided as follows:
10 hr off after regular daytime duty period
12 hr off after night duty
14 hr off after an extended duty period, and must not return before 6 a.m. the next day
Residents in postgraduate yr 1 should have 10 hr off and must have 8 hr free of duty between scheduled duty periods
Intermediate-level residents should have 10 hr off and must have 8 hr between duty periods and 14 hr free of duty after 24 hr of in-hospital duty
Residents in the final yr of training should have 10 hr free of duty and must have 8 hr between scheduled duty periods; review committees may create standards that allow residents to return to work in less than 8 hr under the monitoring of the program director
Maximum frequency of in-hospital duty Specialty-specific requirements apply Night duty must not exceed 4 consecutive nights and be followed by a minimum of 48 consecutive hr off (after 3 or 4 consecutive nights) Residents must not be scheduled for more than 6 consecutive night of night duty (night float) (the maximum no. of consecutive wk of night float and maximum no. of mo of night float per yr may be further specified by the specialty review committee)
Mandatory off-duty time 24 hr off per 7-day period, averaged over 4 wk, inclusive of call 24 hr off per 7-day period; no averaging; one golden weekend per mo† 24 hr off per 7-day period (when averaged over 4 wk); home call cannot be assigned on these free days
Moonlighting Moonlighting must not interfere with residents' ability to achieve the goals and objectives of the educational program
Internal moonlighting must be considered part of the 80-hr limit
Internal and external moonlighting count as part of 80-hr limit
Residents must receive permission from program director to moonlight, and resident performance will be monitored to ensure no adverse effects from moonlighting
Internal and external moonlighting are to be included in 80-hr limit
Residents in postgraduate year 1 must not be permitted to moonlight, internally or externally
Duty-hr exceptions Review committee may grant exceptions for up to 10%, or a maximum of 88 hr, for individual programs based on a sound educational rationale Review committee may grant exceptions for up to 10%, or a maximum of 88 hr, for individual programs based on a sound educational rationale Duty-hr exceptions to 88 hr per week averaged are permissible for select programs with a sound educational rationale; before submitting the request to the review committee, the program director must obtain permission from the designated institutional official and the Graduate Medical Education Committee
Home call The frequency of home call is not subject to the every-third-night, or 24+6, limitation, but home call must not be so frequent as to preclude provision for rest and reasonable personal time
Residents on home call must have 1 day in 7 free from all responsibilities, averaged over 4 wk
Hr logged when residents are called into the hospital are counted toward the 80-hr limit
  Time on home call spent by residents in hospital must count toward the 80-hr maximum weekly limit; frequency of home call is not subject to the every third night limitation; at-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident
Residents are permitted to return to the hospital while on home call to care for new or established patients; each episode of this type of care, although it must be included in the 80-hr weekly maximum, will not initiate a new off-duty period

*Information on four categories of the proposed requirement that are not listed in the table (teamwork; professionalism, personal responsibility, and patient safety; transitions of care; and alertness management) is available with the full text of this article at NEJM.org. ACGME denotes Accreditation Council for Graduate Medical Education, and IOM Institute of Medicine.
†Golden weekends are weekends entirely free of responsibility for patient care.
Reprinted with permission from the New England Journal of Medicine.

More information on the new standards is available on the ACGME Web site.

N Engl J Med. Published online June 23, 2010.

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