ACGME clamps down on hours for residents

New standards set limit of 80 hours per week

The board of directors of the Accreditation Council for Graduate Medical Education (ACGME) in Chicago recently took strong action to impose sweeping new limits on duty hours for participants in 7,800 medical residency-training programs across the country. The ACGME is responding to growing concerns about changes in the health care and educational environment for residents and the possible detrimental effects of sleep restriction on patient safety.

The standards affect residency programs in all health care disciplines in which medical school graduates complete their education by providing care under close supervision at academic medical centers and other institutions. Concerns about residents’ schedules have become more acute as the pressures of shorter hospital stays for patients, more medical procedures to manage, and less support have combined to make balancing education and patient care more difficult, says David Leach, executive director of ACGME.

"Residents have more to do, in less time, with less support than ever before," he says. "As the principal body to ensure quality educational programs in the context of quality patient care, the ACGME has responded with clear standards, strict compliance mechanisms, and strong sanctions for violators."

Because of the need to gain medical experience in a specified period of time, residents must be available to take advantage of opportunities to learn through performance of multiple procedures, Leach says. Residents also help maintain continuity of care for patients and manage the process of transferring care to other residents and attending physicians. These factors combine to require extended duty shifts. The new standards for resident duty hours include these points:

A limit of 80 hours per week, with some flexibility to increase hours up to 10% if the sponsoring institution can show an educational rationale and that the approach will promote safety of both patients and residents.

  • Strengthened limitations on moonlighting to ensure control over total duty hours that residents are working.
  • At least one (24-hour) day out of seven free of patient care duties.
  • On-call duty no more than every third night.
  • Minimum rest period of 10 hours between duty periods.
  • Continuous time on duty limited to 24 hours, with additional time of no more than six hours allowed for patient transfers and educational activities. Residents may not assume responsibility for new patients after 24 hours.

The ACGME convened a Work Group on Duty Hours and the Learning Environment that has been studying these issues for the past year. The new ACGME standards go beyond the issue of duty hours to address supervision and accountability at participating institutions and programs, says Charles Rice, chair-elect of ACGME. "Patient care and resident education is a collective responsibility, requiring close faculty supervision and strong institutional oversight and support," he says. "These standards address the complete context of patient care and medical education. Limiting duty hours is not enough."

Rice says the new standards ensure that faculty are available for residents at all times and make institutions responsible for resident duty hours and faculty schedules. Faculty and program directors must assess residents for signs of sleep loss and fatigue, and institutions are responsible for educating staff and faculty about sleep issues. In addition, participating institutions must give residents adequate backup support, especially for routine activities or when patient care responsibilities are especially difficult or prolonged.

The ACGME has strengthened compliance systems as part of the new standards. The enhanced compliance program shortens the time frame for addressing duty-hour citations, invokes procedures for "Rapid Response to Egregious Accreditation Violations" for resident duty-hour problems, and expedites the process wherein a program can lose accreditation. Loss of accreditation from ACGME is tantamount to a "death sentence" for a residency program and also would result in the loss of Medicare funding for graduate medical education for the violating institution, Rice says. "These sanctions are real and severe. The ACGME is very serious about enforcing these reforms."