New graduate standards limit residents’ hours
Noncompliance to carry considerable consequences
The Chicago-based Accreditation Council for Graduate Medical Education’s (ACGME) board of directors has approved final standards on resident duty hours. The new standards, approved Feb. 11, 2003, take effect July 1, 2003.
The new standards include provisions affecting the maximum number of resident duty hours per week, rest periods, and days free from resident duties. They generally limit residents to a maximum of 80 duty hours per week, including in-house call, averaged over four weeks. Duty hours are defined as time spent on educational and clinical activities related to the residency program, including patient care, administrative duties related to patient care, and academic activities.
"It’s not that we haven’t had any standards in the past; it’s just that they have not been transparent to other stakeholders who perceived problems around sleep-deprived patient care," explains Ingrid Philibert, ACGME’s director of field activities. In the period of 2000 to 2001, she continues, "There arose a fair amount of interest in having some form of government standards similar to those in the airline, interstate trucking, maritime, and railroad industries."
While ACGME is not a government agency per se, these regulations will have quite a bit of teeth; residency programs that fail to comply with the standards risk adverse accreditation actions, including losing their ACGME accreditation.
"We are a voluntarily accrediting organization, but we do have quasi-regulatory power," Philibert notes. "For example, ACGME accreditation is required for a program to get reimbursement from CMS [the Centers for Medicare & Medicaid Services] for training residents. [A total of $8 billion is issued annually.] Even more powerful, ACGME accreditation is required for individuals who graduate from residencies to sit for board certification," she says. "So, if you were not accredited, you would have a very hard time finding residents who want to train in your program."
The science of sleep is an emerging area of knowledge, Philibert says. "We have better information now than ever before. As far back as 1971, there had been some field studies that looked at residents, and some of the issues related to sleep deprivation. The problem was the samples were relatively small, and there were varying results.
"It was not clear until the late 1980s, when there were much larger populations studied, that there was definitely a decrement in performance if people were sleep-deprived to the extent that residents are," she asserts. "We also learned that chronic sleep restriction (less than seven to eight hours a night) has an effect as well."
The recently passed standards are not entirely new, Philibert says. "Since the late 1980s, it was standard not to have call more than every third night, and to be free one day in seven," she notes.
"Internist programs have had limits of 80 hours per week since 1988. We carefully considered whether those standards would be appropriate for all specialties," she continues. (ACGME has 27 core specialties with varying duty hours.)
Of course, Philibert says, not every residency program requires more than 80 hours a week of duty as a general rule. "Some are much more comfortable. But there are programs where residents work more than 80 hours, and they will have to make changes." Those residencies tend to gather in surgical and procedural specialties, she adds. "In surgical, it tends to apply for almost the entirety of training," Philibert declares.
Once the standards become effective, assessments will begin to see if the programs are in compliance. "We have a total of 7,800 accredited programs, and we survey about 2,000 annually, so the interval ranges between one and five years," she says. "The length [of time between assessments] will depend on the extent to which a program is out of compliance. If a program goes a little bit over, we’ll give them a somewhat longer cycle to correct things — then we’ll come back and re-survey. If the violations are more serious, we’ll use a shorter cycle, see what the program is doing to fix things, and re-survey the residents. If there are pretty grave concerns,’ ACGME will come back within a year," Philibert says.
Once most programs are brought into compliance, the reduction of sleep loss in residents will help boost quality, Philibert predicts. "There is fairly credible evidence that sleep deprivation has a negative effect on mood; you’re grouchier, less professional, and less kind to patients. Beyond that, the incidence [of errors reported] is so rare we do not have good handle on it. But patient satisfaction will definitely be helped," she adds.
ACGME Duty Hours
Duty hours are defined as all clinical and academic activities related to the residency program:
Duty hours do not include reading and preparation time spent away from the duty site.
Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
Residents must be provided with one day in seven free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call.
One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call.
Source: Accreditation Council for Graduate Medical Education, Chicago.
For more information, contact:
• Ingrid Philibert, Director of Field Activities, Accreditation Council for Graduate Medical Education, Chicago. Telephone: (312) 464-4948. Web site: www.acgme.org