Duty Hours andDocumentation

Ash Mansour, M.D., RPVI, FACSProfessor of Surgery

Disclosures

• None

History

• Patient goes to ED with fevers & chills

• Intern prescribes Demerol

• Patient combative• Later patient restrained

1965-1984

Libby Zion Law

ACGME

• 2003: Duty hour restrictions – 80 hours• 2011: More restrictions:

– Minimum time off (10 or 8 hour rule)– Shorten length of shift– Intern supervision

• David Leach, M.D.

ACGME rules

• 80 hours per week (max 88)• Moonlighting not permitted for PGY-1• One day free per week• PGY-1: no more than 16 hours on duty• PGY-2: up to 24 hours• Mandatory naps• At least 8 hours between shifts

ACGME rules

• Nightfloat: – no more than 2 successive months– no more than 4 months per year– Max duration: 8 months for 2-year fellow or 15

months for 5-year residency

• On call:– No more than every third night– Reasonable home call to allow free time

Duty Hour Documentation

• Residents are responsible for log• PD responsible for monitoring• Duty hour violations reported to GMEC• Habitual violations not tolerated (examples

made of well-known programs)• Effect of moonlighting

Duty Hour Violations

• It is understood that exceeding hours can andwill occur from time to time

• Most common violation: not enough rest between shifts

• Some specialties given more latitude?

Resistance to Rules

• No evidence that the 80-hour week improved care or outcomes

• Duty hours created a new problem: hand-offs• Many surgeons voiced concerns about duty

hour problems:– Lack of ownership/continuity– Shift mentality

Resident Duty HoursIt is the ABS position that the three basic requirements: (A) Duty hours limited to 80 hours per week, (B) one day free of duty every week, and (C) in-house call no more often than every third night

(all of the above averaged over 4 weeks) are appropriate and should be maintained for most surgical residents.However, we feel the specific requirements regarding shift lengths and time off are overly rigid, are inappropriate in the context of the professional clinical responsibilities which are necessary for the care of critically ill hospitalized patients, and have contributed significantly to a reduction in the clinical experience of residents and the opportunities for a greater degree of independence and autonomy, particularly in the senior years of residency. The specific requirements we feel are detrimental are:(A) 16-hour Rule and 8-10 hour rest(B) 24-hour shift limit and mandated rest between shifts(C) Night-float limits to 6

SUMMARY

• Duty hours are here to stay• FIRST Trial extension• Violations: headaches for PD & programs• Shift mentality should be discouraged• Aim of training programs is to turn out

responsible surgeons with good judgment