Dartmouth-Hitchcock

Duty Hours Policy

Scope

The policy applies to all Dartmouth-Hitchcock residents, fellows (hereafter referred to as residents), and their respective training programs.

Purpose

DHMC is committed to the provision of a high-quality resident training environment, balancing time for educational experiences with patient care responsibilities. We supervise and promote resident physicians' health and well-being while they learn to deliver safe, effective patient care. We have instituted and we support limits on resident work hours, while assuming responsibility for addressing the impact of compliance with the ACGME Duty Hours requirements on our delivery of care and our resident physicians' educational experience.

Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours.

Definition

Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education has priority in the allotment of residents' time and energies. Duty hour assignments shall recognize that faculty and residents have collective responsibility for the safety and welfare of patients. The institution shall adhere to the resident duty hour rules as defined by the ACGME.

Duty Hours

1. Duty hours must be limited to 80 hours per week averaged over 28 days or the length of the block, whichever is shorter. Duty hours are defined as all clinical and academic activities related to the residency program.
   1. The following must be included when reporting resident duty hours:
      • Patient care (both inpatient and outpatient);
      • Administrative duties related to patient care;
      • The provision for transfer of patient care / signouts;
      • Time spent in-house during call activities;
      • Scheduled academic activities such as conferences;
      • Research;
      • Hours spent on activities that are required by the accreditation standards, such as membership on a hospital committee, or that are accepted practice in residency programs, such as residents’ participation in interviewing residency candidates;
      • Any of the above duties, when performed at home or outside the clinical workplace, including EMR note writing and preparation of discharge summaries;
      • Time spent at regional / national conferences / meetings when attendance at the meeting is required by the program, or when the resident is acting as a representative of the program (i.e. presenting a paper or poster). Only actual meeting time counts towards duty hours, travel and non-conference time is excluded;
   2. The following should not be included when reporting duty hours:
      • Reading and study time spent away from the duty site;
      • Academic preparation time, such as time spent preparing for presentations or journal club.
2. Residents must be scheduled for a minimum of one day free of duty every week, when averaged over four weeks.
   1. At-home call cannot be assigned on these free days.
   2. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
   3. It is not permissible to have the day off regularly or frequently scheduled on a resident’s post-call day, but in smaller programs it may occasionally be necessary to have the day off fall on the post-call day.
3. PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods. Intermediate level residents [as defined by the Review Committee] should have 10 hours free of duty, and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty. While it is desirable that residents in their final year of training [as defined by the Review Committee] have eight hours free of duty between scheduled duty periods, there may be circumstances [as defined by the Review Committee] when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. Circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by residents in their final years of education must be monitored by the program director.
4. Rotations shorter than 28 days must be fully compliant with the 80 hour and 1 day off in 7 rules. Averaging shorter blocks of high intensity and low intensity rotations is not allowed.
5. When vacation is taken during a block, the remainder of the block must be compliant with all duty hour rules.

Call / Extended Duty Periods

The objective of on-call activities is to provide residents with continuity of patient care experiences throughout an extended period. In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution.

1. In-House Call:
   1. Duty periods of PGY-1 residents must not exceed 16 hours in duration.
   2. Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.
      • Extended duty hour shifts / call may not be more frequent than every third night, averaged over 28 days with the following qualifications:
        • Scheduled duty shifts (usually 8, 10, or 12 hours long) such as those worked in the ICU, on Emergency Medicine rotations, or on Night Float are exempt from this requirement;
        • Residents can be assigned to a maximum of four call nights in any seven-day period. This can only be done one week per month;
        • Residents must not take night call for two consecutive nights.
      • Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty, to include:
        • The care of new patients in any clinical setting;
        • Continuity or outpatient clinics;
        • Participation in new procedures including elective scheduled surgery.
      • Residents may be allowed to remain on site for patient safety or resident education; however, this period of time must be no longer than an additional four hours.
   3. In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. Under those circumstances, the resident must:
      1. appropriately hand over the care of all other patients to the team responsible for their continuing care;
      2. document the reasons for remaining to care for the patient in question, and;
      3. submit that documentation in every circumstance to the program director.
      The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty.
   4. Residents must not be scheduled for more than six consecutive nights of night float.
2. At Home Call:
   1. At-home call (pager call) is defined as call taken from outside the assigned institution.
   2. Time spent in the hospital by residents on at-home call must count towards the 80 hour maximum weekly hour limit. The frequency of 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.
   3. Home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.
   4. Home call is only appropriate if the service intensity and frequency of being called is low.
   5. 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 must be included in the 80-hour weekly maximum but will not initiate a new "off-duty period." The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands or fatigue.
   6. PGY-1 residents are limited to a 16-hour shift and are not allowed to take at-home call.

Moonlighting

1. Because residency education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the resident to achieve the goals and objectives of the educational program.
2. The program director must comply with the DHMC’s written policies and procedures regarding moonlighting.
3. All moonlighting must be counted toward the 80-hour weekly limit on duty hours.
4. PGY-1 residents may not moonlight.

Program-Level Policy

1. DHMC will not accept for review, nor endorse any applications from individual GME training programs seeking exceptions to ACGME duty hour rules and regulations.
2. Each DHMC training program, regardless of ACGME-accreditation status, must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours.
3. Each program must distribute these written policies to residents and faculty.

Education & Orientation

1. Institutional and program leadership must project a clear message to all DHMC faculty and residents regarding the critical importance of adhering to the Institutional and Program Requirements for resident duty hours. The importance of honesty in reporting must be emphasized at every opportunity.
2. The GME staff will incorporate an educational module into the general GME orientation emphasizing the institutional expectations of compliance with duty hour regulations as well as duty hours reporting compliance, and will include didactic material about the effects of sleeplessness and fatigue on physical health, cognitive development, and mental well-being.
3. A review of the rationale for duty hour limitations, expectations regarding reporting compliance, and the importance of honesty in reporting must be provided by a figure of authority (Chair, Section Head or Program Director) to residents in every training program at the beginning of each academic year.

Reporting Procedures

1. DHMC has a standard system for use by all residents to document duty hours. Currently this standard system is a part of the E*Value resident management system. GME Office staff assists with the adaptation of E*Value software for specific program use, as well as the training of program staff in the use of E*Value, as needed. To ensure accuracy and timeliness of the data:
   • Each resident is responsible for direct entry of their own duty hour information into the E-Value system.
   • iThe E-Value system will allow programs the option to establish an automated email announcement to be sent to all residents who have not completed their duty hour calendar for the specified period of time.
   • A global set of duty hour labels are available to all programs to ensure reported data is consistent across programs.
2. The standard definition of "reporting compliance" is that within seven days of a month’s end, each resident completes 80% of that month’s calendar.
3. Programs will have a seven day window, immediately following the seven days provided to residents, for completion of their monthly calendar, to internally audit and confirm duty hours as reported by their residents before the reports are finalized. No changes to the monthly duty hour report should be entered beyond the specified audit window.
4. The GME Office utilizes a standard reporting form across all programs to track data relating to both reporting compliance and duty hour violations. All required data is derived from the E*Value system and may be acquired by GME staff independent of the training program.
5. In order to increase transparency, as well as foster improved compliance, the standard GME-generated data set will be made widely available to all residents, faculty, and administrative members of the DHMC community on a quarterly basis.

Reporting Non-Compliance & Administrative Action

1. A standard threshold for "administrative action" in response to reporting noncompliance exists across all DHMC programs with the following thresholds and administrative actions:
   • Three months of zero compliance in any given academic year will generate a Letter of Concern from the Director of GME to be placed in the resident’s QA file citing a pattern of reporting non-compliance that reflects negatively on the resident physician’s professionalism.
   • Continued reporting non-compliance following receipt of a Letter of Concern will trigger a review by the GME Duty Hours Subcommittee and may result in disciplinary action up to and including dismissal.
2. There are two systems available for confidential reporting: GME Confidential is available for confidential reporting or guidance regarding duty hours, and a confidential telephone hotline is also available. Both systems forward all reports to the Duty Hours Subcommittee. Residents should be educated about confidential reporting by both GME and their own programs.

Duty Hours Subcommittee

1. The GMEC will have a standing Duty Hours Subcommittee. This subcommittee is composed of the GME Office leadership team, one program director, one residency coordinator and six resident representatives, to include one surgery chief resident and one medicine chief resident. The Duty Hours Subcommittee is charged to:
   • review data from the E*Value system at each Subcommittee meeting;
   • annually, in May or June, review/update the DHMC Duty Hours Policy;
   • review all confidential suggestions/concerns submitted through confidential systems at the first available meeting after receiving the concern;
   • report to the GMEC every 6 months (June and December) or more frequently as the need arises;
   • review cases and make decisions regarding disciplinary action for egregious reporting non-compliance, and;
   • arbitrate significant resident/program issues related to duty hours.