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Summary
Pages 5-26

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From page 5...
... The committee first reviewed graduate medical training in the United States and the views of various stakeholders toward the current Accreditation Council for Graduate Medical Education (ACGME) duty hour limits (Chapter 1)
From page 6...
... It has concluded that greater attention should be focused on increasing the opportunities for sleep during resident training to prevent fatigue-related errors, rather than on simply reducing total duty hours. The recommended fatigue prevention and mitigation approach preserves options to address individual training program needs to have residents available for patient care at night and to allow for continuity of patient care on admitting days through extended duty periods.
From page 7...
... As the committee examined alternative resident duty hours and schedules, it was aware of the tension between the educational objectives of medical residency and the economic incentives of training institutions. Both society at large and the training institutions benefit from residents' service at relatively low cost.
From page 8...
... Her family charged that her death was due to inadequate care provided by overworked and undersupervised medical residents. A grand jury did not charge any of the residents but concluded that the long duty hours of residents are counterproductive to both patient care and resident learning.
From page 9...
... In assessing the influence of the 2003 duty hour limits to date, the following are five key questions: 1. Have resident duty hours actually been reduced?
From page 10...
... However, studies also suggest that factors beyond duty hours, such as work intensity, contribute to the resident's emotional state. The Next Era of Reform for Better Education and Patient Safety ACGME and its constituent stakeholders adopted the 80-hour workweek in 2003 as a national standard for all graduate medical training in the
From page 11...
... system of care. The past 5 years since the ACGME duty hour rules were implemented have been a period of change and adjustment for training programs in the United States.
From page 12...
... This in-house sleep period during extended duty of 30 hours should count against total duty hours as sleep during night shifts or overnight call periods does now. Table S-1 compares the elements in the committee's recommendations to current ACGME rules.
From page 13...
... off per 1 •  day (24 hours) off per 1 week, averaged over 4 week, no averaging weeks • One 48-hour period off per month Moonlighting Internal moonlighting is •  Internal and external counted against 80-hour moonlighting is counted weekly limit against 80-hour weekly limit •  other duty hour limits All apply to moonlighting in combination with scheduled work Limit on hours for 88 hours for select No change exceptions programs with a sound educational rationale Emergency room limits 12-hour shift limit, at least No change an equivalent period of time off between shifts; 60-hour workweek with additional 12 hours for education
From page 14...
... Recommendation: ACGME should adopt and enforce requirements for residency training that adhere to the following principles: duty hour limits and schedules should promote the prevention of sleep loss and fatigue; additional measures should mitigate fatigue when it is unavoid able (e.g., during night work and extended duty periods) ; and schedules should provide for predictable, protected, and sufficient uninterrupted recovery sleep to relieve acute and chronic sleep loss, promote resident well-being, and balance learning requirements.
From page 15...
... Residency Review Committees should determine at the time of program re-accreditation whether the documented exceptions to scheduled duty hours warrant citation. • The ACGME should develop criteria for granting individual programs waivers from one or more of the above scheduling parameters; such criteria should be formulated only to ac­com­ modate rare, well-documented circumstances in which patient safety and/or educational requirements of specific programs outweigh the advantages of full compliance with the commit tee's recommendations and cannot be addressed by means other than the requested waiver(s)
From page 16...
... Moonlighting outside of residency training would cut into the strategically designed periods for rest and sleep and could reduce residents' readiness for their primary duties. Limits on resident duty hours designed to protect patients and residents should extend to any additional paid healthcare work that residents undertake.
From page 17...
... CMS could conduct or contract for periodic evaluations of adherence to resident duty hours, the effectiveness of ACGME monitoring practices, and the acceptability of program rationales for exceptions to duty hour limits. Similarly, the Joint Commission could integrate duty hour oversight by monitoring the contribution of fatigue to patient safety events in the tracer cases that it reviews during hospital accreditation site visits.
From page 18...
... Optimizing Resident Education for Resident Learning and Patient Safety One of the unintended consequences of the 2003 duty hour limits has been work compression (i.e., residents have to care for the same number of
From page 19...
... Reducing resident duty hours and workload within those hours should not mean that residency training must be lengthened, although some disciplines may choose to do so. Having better ways to identify and assess mastery of a specialty (e.g., use of simulators)
From page 20...
... (See Chapter 4.) Recommendation: To increase patient safety and enhance education for residents, the ACGME should ensure that programs provide adequate, direct, onsite supervision for residents.
From page 21...
... Learning how to conduct better handovers and intercept errors before they reach patients would enhance the performance of all staff, not only residents. Yet because handover frequency increased with the reduction of duty hours in 2003 (and likely with protected sleep periods as well)
From page 22...
... To avoid having residents bear the burden of implementing the duty hour recommendations by increasing their workload again, and increasing the risk to patient safety, additional funds for graduate medical education (GME) are needed from all existing as well as new sources.
From page 23...
... Closing the Gap in Knowledge Gaps in the available evidence base hampered the committee's work. Given concerns that the medical community has expressed about the 2003 changes in duty hours, the committee was disappointed with the lack of any comprehensive attempt to document changes in residency programs and their impact, if any, on educational outcomes and patient safety.
From page 24...
... The issues surrounding residency education and duty hours should be revisited in a few years to assess the changes put in place and their impact. The committee hopes that by spurring more rigorous monitoring and evaluation there will be further identification of best practices that result in improved patient and resident safety.
From page 25...
... 2007a. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.


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