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ACGME work group sets medical resident duty hours By this time next year, recommendations of a work group of the Accreditation Council for Graduate Medical Education (ACGME) that would regulate resident duty hours among U.S. medical schools should be in force, according to an ACGME report. The work group recommends mechanisms to achieve three goals to include: A set of common requirements that define a minimum standard that must be met by all accredited programs; Enhanced requirements for institutional oversight and support; and Strengthening the system for compliance. In September 2001, the ACGME appointed the Work Group on Resident Duty Hours and the Learning Environment in response to changes in health care delivery and concerns that restricted sleep could have a detrimental effect on patient safety and well-being. The work group sought to emphasize the responsibilities of programs, sponsoring institutions and the accrediting body relating to safe patient care and an appropriate learning environment for residents. The common accreditation standards recommend “placing appropriate limits on duty hours,” namely limiting scheduling residents for no more than 80 hours per week on a four-week average.  MUSC’s J. David Osguthorpe, M.D., who chairs the ACGME’s Residency Review Committee (RRC) for Oto-larygology, said a provision that eases this hour limitation a bit allows individual programs to apply to their sponsoring institution’s Graduate Medical Education Committee for an increase of up to 10 percent (i.e., 88 hours per week) if the training program director can provide a sound educational rationale. The expectation is that most GMEC’s will be relatively accommodating of such requests for at least the next few years as programs struggle to implement the new work hour rules. Residents must be free of patient care responsibilities one day in seven on average over a four-week period. They should be on call no more than every third night averaged over a four-week period.  The recommendations place a 24-hour limit on “in house” on-call duty, with an added period of up to 6 hours for inpatient and outpatient continuity and transfer of care, educational debriefing and didactic activities; no new patients can be accepted after 24 hours. A 10-hour minimum rest period should be provided between “in house” duty periods. When residents take call from home and are called into the hospital, the time spent in the hospital must be counted hour for hour toward the weekly duty hour limit. Osguthorpe pointed out one recommendation that medical students and residents seeking regulation of duty hours may not have anticipated. Residents will be required to obtain permission from program directors for patient care activities outside of the educational program.  Such “moonlighting” will count toward the 80 hour per week work limitation; the ACGME would not place a distinction on the location of work, i.e., in a training institution versus  “moonlighting” at an ER – all can contribute to fatigue that affects performance and patient care. Other recommended standards affecting accreditation would strengthen institutional oversight and require sound education justification of any departure from ACGME policies. The recommendations reflect a shift of emphasis toward high-quality education and safe and effective patient care, and away from “service” duties. The recommendations of the work group also include strengthening the compliance program and are based on three principles:  Increasing the amount of information collected related to resident duty hours; Shortening the ACGME’s response time in cases of alleged non-compliance with the standards; and Fostering accountability on the part of the programs, sponsoring institutions and the accrediting body for consistent compliance with the duty hour standards. Previously, the ACGME has principally held individual residency programs responsible for compliance with the council’s standards, although the host institutions were also notified of violations and, if widespread among an institution’s training programs, would result in sanctions. Osguthorpe states that as part of tightening accountability, the council will now hold the sponsoring institution immediately and directly responsible for each residency’s violations, putting the residency program and the host institution in joint jeopardy of their accreditation. Also, progress reports at six-month intervals will be requested from training programs that have been cited, rather than the previous one-year minimum intervals.  The work group recommended: “A significantly shortened process will be used for withdrawing accreditation from programs that fail to address the duty hours citation.” Consideration was offered  for sub-specialties with educational needs that may require more than the 80-hours limit. A specialty Residency Review Committee may petition the ACGME for a specialtywide exemption that could increase resident duty hours in that specialty beyond the 80 hours plus 10 percent currently feasible.  Though such is not expected to be a common request, some specialties are considering requests for a “phase-in” period of work hour limitation over a period of years, rather than full implementation in July 1. Osguthorpe said that concerns were raised at the work group meeting regarding the “tough times” currently experienced by the health care industry in the U.S., and such concerns were not just confined to the financial challenges faced by many teaching hospitals. It was stated by an American Hospital Association representative that there were currently 144,000 open FTE’s for nurses in U.S. hospitals, so increased use of nurses to cover care given by residents would be difficult to attain in the near term.  In addition, physician assistant programs are still many years from being able to supply the numbers of trainees that would be required for a major impact on resident or advanced nursing burdens.  Also, some resident programs may choose to lengthen the number of years required to complete training, Osguthorpe said.   For instance, one surgical RRC (residency review committee) has delayed, until the impact of the new work-hour rules on resident training can be assessed, consideration of a proposal to decrease by one year their required length of post-graduate training. Wrote the work group, “The demands of patient safety and resident well-being require that the new standards be implemented without delay, while giving residency programs and sponsoring institutions time to make needed changes. To accommodate these objectives, the recommendations call for the new standards to be implemented July 1. Prior to this there will be a period of ‘initial response,’ during which RRCs will provide constructive feedback on duty hours, but will not take adverse accreditation action.” The work group acknowledged that the recommendations may require additional resources and changes in systems and procedures, and that “...the new requirements will necessitate a change in culture. “The only way residency programs and their sponsoring institutions can achieve a true ‘education’ program as well as provide high quality clinical care is by attending to the issue of resident duty hours and by placing a higher value on resident education and safe patient care than on meeting service demands.” The pdf report of the ACGME Work Group on Resident Duty Hours  can be found at http://www.acgme.org/.