EMRA’s 2011 ACGME Duty Hours Summary and Analysis of Potential Impact on Emergency Medicine Residencies

The new ACGME Duty Hour Rules will be implemented on July 1, 2011. At the crux of the new recommendations is increased supervision, decreased work hours (especially for 1st year residents) and increased emphasis on the safe transfer of patient care during sign out. At stake are ACGME residency accreditation and the funds that hospital systems receive from the federal government for training each resident. This short article aims to summarize the new ACGME duty hour requirements then analyze the potential impact they will have on EM residencies across the country.   

Summary of the ACGME Duty Hour Changes 1, 2

Regulations that will remain the same in 2011

- Maximum Hours of Work Week has remains 80hr/week averaged over a four week period with exceptions for 88 hours/week based on “sound educational rationale”.

- EM specific work week hours have not yet been revised and remain unchanged.

o   Shifts cannot exceed 12 hours and there must be at least an equivalent period of continuous time off between scheduled work periods

o   Work duties should not exceed 60 hours/week in the emergency department and should not exceed more than 72 duty hours/week.

Regulations that have been revised or written for 2011

- Moonlighting – Two changes were made here.

  1. Internal and external moonlighting must be counted toward the 80-hour work week, where-as before only internal moonlighting counted.
  2. PGY-1’s are no longer permitted to moonlight.

- Maximum Duty Period Length – has been markedly decreased for interns, for all residents the amount of time to stay and check-out patients has decreased.

o   PGY-1 must not exceed 16 hours

o   PGY-2 and above have a maximum of 24 straight work duty hours. Residents may remain onsite for 4 additional hours to transition care of patients (down from 6 hours). Under unusual circumstances and “on their own initiative” resident can remain beyond duty hours to care for a single patient who is unstable or for academic or humanistic attention to patient or family. However, the resident must document the reasons for remaining and those must be submitted to your PD.

- Minimum time off between Scheduled Duty Periods – has been stratified by year and mandated. Before, there was a recommendation that residents “should have 10 hours off between all daily duty periods and in-house call”. Now it has changed to the following:

o   PGY-1 must have 8 hours free of duty between scheduled duty hours.

o   “Intermediate-level residents” must have 8 hours free of duty and at least 14 hours free of duty after 24-hours of in house duty.

o   Senior or “Residents in the final years of education” may have “irregular or extended work periods” and hence may stay on duty to care for their patients or return with less than 8 hours free of duty.

- Maximum Frequency of In-House Night Float–There was no regulation on this before, but in 2011 residents must not be scheduled for more than six consecutive nights of night float.

- Maximum In-House On-Call Frequency - PGY-2 residents and above must be scheduled for in-house call no more frequently than every-third-night (averaged over a four-week period). There is no language on interns.

§  At-Home Call: Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit.

o   At-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty, when averaged over four weeks.

o   Residents are permitted to return to the hospital while on at-home call to care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period”.

 

How this will Effect EM Residents:

  1. Off Service Rotations
    The effects of these changes will be obvious as surgery, internal medicine, ICU and OB rotations, common to most EM residencies, will have to adhere to these new regulations. Interns may work less and upper level residents may have to take on more clinical responsibilities with longer hours.
      
  1. External Rotators
    With the new duty hours, some specialties will struggle to adequately staff their services.  In particular the American College of Surgeons has opposed the new duty hours, stating “…16-hour shifts could compromise the education of the residents and possibly affect the continuity of patient care that is essential to ensuring that all surgical patients receive safe, effective, and high-quality care before, during, and after surgical procedures.”3 With this stance in mind, there is the possibility that some surgery departments and other departments will withdraw their residents from ED rotations to staff their services.
  1. Mid-Level Providers
    Two things may result in increased staffing of physician’s assistants and nurse practitioners in the ED. First, regulations on no intern moonlighting may create a dilemma for programs that provide interns with moonlighting opportunities and use these interns to staff the lower acuity areas of their ED, especially during weekends. Second, if other services pull their residents from ED rotations (see above), there will be a staffing void created in many programs. As programs adjust, there is speculation that more will turn toward hiring PA’s and NP’s to fill the gaps.  
      

Want to learn more, check out these following ACGME resources:
- To Read the current ACGME Duty Hours visit their official website below: http://www.acgme.org/acWebsite/navPages/nav_residents.asp#ResidentDutyHoursDocuments
- A great summary of the differences in duty hours, check this PDF published by the ACGME: http://www.acgme.org/acWebsite/dutyHours/dh-ComparisonTable2003v2011.pdf

Written By:
Donald Stader, EMRA President Elect, Carolinas Medical Center
November 5, 2010

Citations: 
1. ACGME 2011 Common Program Requirements, www.acgme.org/acWebsite/home/Common_Program_Requirements_07012011.pdf
2. ACGME 2007 Common Program Requirements,  www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf
3. America College of Surgeon’s, American College of Surgeons Comments on Institute of Medicine Report on Resident Duty Hours, December 3, 2008. http://www.facs.org/news/residencyhours.html
4. New England Journal of Medicine,  http://www.nejm.org/doi/pdf/10.1056/NEJMsb1005800

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