Resident Duty Hours Enhancing Sleep, Supervision, and Safety (2009) / Chapter Skim
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3 Adapting the Resident Educational and Work Environment to Duty Hour Limits
3 Adapting the Resident Educational and Work Environment to Duty Hour Limits
Pages 89-124
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From page 89... ...
The Accreditation Council for Graduate Medical Education (ACGME) announced new duty hour limits in February 2003, with a required start date of July 1, 2003 (ACGME, 2003)
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From page 90... ...
. Residency programs and their sponsoring institutions needed to take many workplace factors into account when they redesigned resident work schedules in response to the 2003 limits, and these will remain considerations as additional duty hour adjustments are implemented.
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From page 91... ...
(2006a) reported that the primary admitting resident team covers approximately 47 percent of an average inpatient's 4-day hospitalization on an internal medicine service compared with 70 percent reported prior to the 2003 duty hour limits (Petersen et al., 1998)
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From page 92... ...
, patient factors must be considered when determining what type of resident work schedule will best provide continuity of patient care and Personal communication, Erika Steinmetz and Karen Fisher, Association of American Medical Colleges, April 18, 2008.
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From page 93... ...
Task Factors Noneducational Activities With reduced duty hours, it is critical to assess not only the number of hours that residents spend in the hospital but also the educational value of that time. A review of the literature on how residents spend their time, covering studies from the time of the Bell Commission to 2003, found that residents spent up to 36 percent of their time learning while delivering patient care services, an additional 15 percent was spent in formalized teaching activities (e.g., conferences, grand rounds)
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From page 94... ...
Specialty-specific and rotation-specific workload guidelines should take into account the number and severity of patients as well as the number of procedures required to determine the intensity of the experience and its effect on promoting safe conditions for residents and patients. The contribution of residents' workload to error and patient safety has not received the same investigative or public attention as their duty hours (Parshuram et al., 2004)
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From page 95... ...
. A national survey of ACGME-accredited programs in internal medicine found that only 28 percent reduced the average daily census for interns in response to duty hour limits (Horwitz et al., 2006b)
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From page 96... ...
. Maintenance of the same caseload can affect the time available for conference attendance, educational activities other than direct patient care, adherence to duty hour limits, and on-call sleep (Arora et al., 2008a; Horwitz et al., 2006b)
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From page 97... ...
Even when working in teams, the ultimate responsibility for patient care resides with each individual patient's attending physician. Reducing resident duty hours has meant changing team dynamics and potentially affecting teaching, learning, and performance.
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From page 98... ...
. Work and Learning Environment The philosophy of the sponsoring organization and the residency program director determines whether the balance of resident work is tilted toward service or education. The size and scope of residency programs vary greatly from site to site.
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From page 99... ...
. More information from reports on education after resident duty hours reform is contained in Chapter 4.
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From page 100... ...
. The term microsystem has been applied to "a small, organized patient care unit with a specific clinical purpose, set of patients, technologies and practitioners who work directly with these patients" (e.g., neonatal intensive care, surgical care team, outpatient clinic)
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From page 101... ...
Institutions should, to the extent possible, redesign their systems; for example, if patients can be admitted or discharged earlier in the day and other efficiencies are in place, there will be less pressure for residents to work long into the evenings and nights. REDESIGNING RESIDENT WORK AND WORKLOAD The 2003 reduction of duty hours did not always translate into a reduced caseload for residents because of both perceived educational needs and institutional economic pressures for patient care and "throughput" (e.g., patients transferred and discharged per day)
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From page 102... ...
, sponsoring institutions, and residency programs need to study and rectify the issue of resident workload so that residents are able to comply with desired duty hours. It is possible that a reduction in noneducational work (e.g., the 8 to 30 percent observed in recent studies; Brasel et al., 2004; Dola et al., 2006)
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From page 103... ...
ACGME already has a process in place as part of its accreditation evaluation to collect information on institutions and residency programs through PIFs (program information forms)
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From page 104... ...
on workload, the committee recommends the following: Recommendation 3-1: To ensure that residency programs fulfill their core educational mission, ACGME should require that institutions spon soring residency programs appropriately adjust resident workload by • Providing support services and redesigning healthcare delivery systems to minimize the current level of residents' work that is of limited or no educational value, is extraneous to their graduate medical education program's educational goals and objectives, and can be done well by others; and • Providing residents with adequate time to conduct thorough evaluations of patients and for reflective learning based on their clinical experiences. ACGME should require each Residency Review Committee to define and then require appropriate limits on the caseload (e.g., patient cen sus, number of admissions, number of surgical cases to assist per day, cross-coverage)
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From page 105... ...
They also report that their first attempts did not always achieve their scheduling goal of being in compliance with the duty hour limits (e.g., Ogden et al., 2006; Yoon, 2007)
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From page 106... ...
. The purpose of reviewing these reports on scheduling is to examine the variations used in response to duty hour reform and to determine whether there is consensus on scheduling practices.
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From page 107... ...
Examples of Schedule Changes Many schedule changes represent relatively no-cost strategies to meet duty hour rules. Schedule changes might include having fewer team mem
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From page 108... ...
The effects of night shift work and approaches to minimizing sleep deficit through appropriate scheduling are discussed more fully in Chapter 7. Several studies of limited duration or of small numbers of residents compared shift schedules to those incorporating extended duty periods and assessed compliance with duty hours, and improvements in patient and resident outcomes (Afessa et al., 2005; Goldstein et al., 2004; Landrigan et al., 2004)
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From page 109... ...
However, the limit on duty hours has induced its adoption (Horwitz et al., 2006a,b; Vaughn et al., 2008; Whang et al., 2003)
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From page 110... ...
Based on the collective field experiences of programs adapting to the 2003 duty hour rules, the committee concludes that no single scheduling model appears to fit all training facilities or specialties, or even training programs within a particular program or specialty, and that some flexibility will have to be retained. There are advantages and disadvantages to each approach from the perspective of complying with duty hour limits, patient continuity, and potentially, patient safety.
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From page 111... ...
. To ensure that residents maximize their patient care learning opportunities within their duty hours, the transfer of support service functions will continue to be required.
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From page 112... ...
. These physician extenders, also known as "midlevel" providers, have been hired to relieve residents after overnight call so that they could adhere to duty hour limits, to reduce workload by taking on more routine patients with little educational value for residents, and to prevent excess resident work from shifting to faculty (Abrass et al., 2001; Lundberg et al., 2006; Schneider et al., 2007)
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From page 113... ...
. Duty hour reduction has also meant changes in relationships among institutions; for example, one teaching facility had to withdraw all of its medicine residents from the Department of Veterans Affairs hospital after a 35-year relationship in order to have a sufficient number of residents at its main facility (Daschbach, 2008)
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From page 114... ...
Such help for transition funding had been included in House and Senate legislative proposals to regulate resident duty hours; these proposals have not been called up for a vote in either body (GovTrack.us, 2005a,b)
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From page 115... ...
2007a. The ACGME's approach to limit resident duty hours 2006-07: A summary of achievements for the fourth year under the common requirements.
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2004. The effect of the Ac creditation Council for Graduate Medical Education duty hours policy on plastic surgery resident education and patient care: An outcomes study.
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2005. Resident duty hours reform: Results of a national survey of the program directors and residents in neurosurgery training programs.
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From page 118... ...
2008. IOM panel: Resident duty hours cost impact estimates 2003-2008.
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From page 119... ...
2008. The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety: A study of resident experiences and perceptions before and after hours reductions.
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From page 120... ...
Pre sentation to the Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, March 4, 2008, Irvine, CA.
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From page 121... ...
2006. Complying with ACGME resident duty hours restrictions: Restructuring the 80 hour workweek to enhance education and patient safety at Texas A & M Scott & White Memorial Hospital.
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2006. Training on the clock: Family medicine residency directors' responses to resident duty hours reform.
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2006. Effects of critical care nurses' work hours on vigilance and patients' safety.
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From page 124... ...
2008. A delicate balance: Physician work hours, patient safety, and organiza tional efficiency.
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