An update to the Accreditation Council on Graduate Medical Education's (ACGME) 2003 resident duty-hour guidelines identifies additional areas critical to both patient safety and resident education that had not been previously addressed — some of which may force the restructuring of some neurology residency programs once again.
The proposed guidelines — released to the public on June 23 with a 45-day comment period — underscore the importance of duty hour limits, as well as resident supervision, graduated responsibility, fatigue mitigation, and patient-care handovers, said Susan Day, MD, co-chair of the ACGME Task Force on Quality Care and Professionalism. (See “ACGME 2010 Guideline Recommendations.”)
The 16-member task force “sought to improve [residents'] learning environment in order to educate residents…in a manner that held patient safety foremost,” said Dr. Day, also chair of the ACGME board of directors and chair of the Department of Ophthalmology at California Pacific Medical Center in San Francisco.
If accepted by the ACGME board in September, the recommendations would be effective in July 2011.
“The ACGME arrived at these guidelines after an exhaustive review of the literature and after considerable input from many stakeholders (including Congress and the AMA) in graduate medical education,” said John Engstrom, MD, professor of clinical neurology and director of the Neurology Residency Program at the University of California-San Francisco (UCSF). “It makes more sense to have physicians and educators at the ACGME draft the duty hour and supervision guidelines than to have a mandate from Congress,” he said.
Dr. Engstrom — who chairs the Neurology Review Committee for the ACGME and the AAN-sponsored National Consortium of Neurology Program Directors, and is a member of the AAN Graduate Medical Education Subcommittee — said: “The training debate is shifting from duty hours to adequate supervision as a result of these guidelines. The total maximum number of hours worked per week will not change — it is still 80 hours — but the way the time is spent will be different.”
The guidelines emphasize “that patient safety is not served by having the most junior person (an intern) on-call without direct, experienced supervision,” he said, in an e-mail to Neurology Today. “One can imagine revisiting the original Libby Zion case and finding that the problem was not a fatigued resident, but a lack of on-site experienced supervision. Most neurology residency programs have no or very limited R1 time anyway. Some medicine programs are going to a model in which hospitalist faculty are in-house so that interns can take on-call duty.”
GRADUATED SUPERVISION, RESPONSIBILITY
Under the proposed guidelines, supervising physicians must be physically present when post-graduate year 1 (PGY1) residents treat patients, and PGY1 residents must have on-site access to the supervising physician at all other times. For PGY2 residents and above, the supervising physician can be available through indirect access, for example, via telephone, or they can simply provide oversight. In addition, senior residents have extended duty hours and may remain longer to ensure continuity of care and also during other unique circumstances.
Although neurology residency programs typically begin in the PGY 2 year, Nicholas E. Johnson, MD, a fourth-year neurology resident at the University of Rochester Medical Center in New York, believes graded responsibilities throughout residency is beneficial for all resident levels. The interns have much stricter guidelines, which may help them become acclimated to their responsibilities, he said. “The guidelines somewhat loosen for chief residents, which may improve their transition to practicing as attendings,” he added.
Additional restrictions on interns makes sense since they are less experienced and know the least about practicing medicine, said Brett Kissela, MD, assistant professor of neurology and residency director at the University of Cincinnati Medical Center. But the only way for programs to be fully in compliance with these new restrictions would be to implement a night-float system, said Dr. Kissela, who is also a member of the ACGME Neurology Residency Review Committee and the AAN Consortium of Neurology Program Directors.
“I can't envision another workable way around the restrictions on interns,” if programs use them on-call, he said. Under the proposed guidelines, interns are limited to 16 continuous duty hours, he pointed out, whereas senior residents can work for 24 hours, with an additional four hours of transition care. Although Dr. Kissela's residency program had planned on a “trial night float,” the system may be adopted to ensure compliance with the guidelines.
“If night float is the solution, then residents must be excused from mandatory educational conferences that fall on the day after they are on-call or on night float,” Dr. Engstrom said. “Many residents will miss formerly ‘mandatory’ educational conferences.”
“It's the ultimate in ‘shift mentality,’” said David J. Capobianco, MD, associate professor of neurology and neurology program director at the Mayo Clinic in Jacksonville, FL. “I am not convinced that the night-float system, which has been enacted by a number of programs takes the learners needs into account.”
Dr. Capobianco cited an abstract presented at this year's AAN annual meeting by Lori Schuh, MD, prior chair of the AAN Consortium of Neurology Program Directors, which showed that residents — because of their schedule during the night-float rotation — spend less time with their own families, which reduces their quality of life.
Still, others argue that night float would, among other benefits, limit the number of fatigue-related errors. “I have found that 24 hours of call is very difficult for some people to manage over a long duration,” said Dr. Johnson. “With these long calls, fatigue can definitely be a factor, with 3 AM being an exceptionally low point.”
He added that at the University of Rochester Medical Center, night float has enabled residents to arrive at work rested and better able to meet their patient responsibilities. To combat the development of a “shift-work” mentality, residents on night float provide the case for morning report and also attend morning rounds.
Another additional benefit of the night float is that it can eliminate the need for “strategic napping,” which the ACGME proposed guidelines endorse, said Dr. Johnson. Residents are encouraged to take a nap after 16 hours of continuous duty, especially between 10 PM and 8 AM. Both Drs. Capobianco and Johnson expressed surprise that the ACGME endorsed napping, which was originally recommended by the Institute of Medicine in its 2008 report, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.” Given their demanding schedules and high-adrenaline state, how could residents “nap on command,” Dr. Capobianco asked.
Additional restrictions on duty hours and the implementation of night float raise another issue: patient errors made with faulty handoffs.
“My fear with our resident trainees is if they're doing shift work and covering for only a couple of hours, there tends to be a reduced level of personal responsibility because they tend to not take ownership of the patient,” said Dr. Kissela. “It becomes even more crucial to train our residents to make good sign outs, and to take ownership of all the time they're working in order not to make mistakes. It's still not known how much damage is done with faulty handoffs.”
Dr. Engstrom noted that the guidelines allow for some flexibility in this area. There may be times when residents need to stay six hours beyond a 24-hour shift, for example, to attend to a patient, and if they request that by letter, they should be fine. But, he added, “if you say all 10 patients need that additional six-hour follow-up, that would not be considered a reasonable argument.”
Although the proposed guidelines outline effective transitions, this area of patient care needs to be addressed further, Dr. Johnson said. As residency programs transition toward an increased number of shifts, it's important to emphasize how to best manage handoffs because patient errors occur at this point as well.
How neurology departments address the supervision issue will likely differ from one institution to the next, Dr. Engstrom said. “There is little doubt that smaller programs will be affected more than larger ones, and we will need to develop creative staffing solutions, possibly through collaboration with other departments.” Dr. Engstrom noted that at UCSF, there has been discussion about coordinating overnight in-house attending coverage with the internal medicine department and hospitalist service.
IMPLEMENTATION COSTS, GUIDANCE
The cost of implementing the guidelines has not yet been determined — a financial impact analysis is expected in September, according to Dr. Day. Dr. Kissela believes the proposed changes will have a financial impact on all residency programs.
Within the last five years residency programs have increased their number of trainees and continue to recruit more trainees and non-physician providers, he noted. And the impending changes in the health care system will make it difficult to predict the financial stability of some hospitals and programs. “As a result, even if the recommendations have only a small incremental cost, it may be devastating to academic centers or other hospitals where training programs exist,” Dr. Kissela said.
“[Residency program directors] accept that change is coming,” he said. “I feel pretty comfortable that program directors as a group are resourceful, talented people who are going to be able to adapt to whatever system is put in place.”
Dr. Capobianco doesn't envision residency programs having major problems complying with the updated guidelines; however, he hopes the ACGME and AAN provide resources and tools to make compliance easier. “This may be an opportunity for the AAN to develop online teaching modules that can supplement institutional initiatives to help meet the new program standards.”
ARTICLE IN BRIEF
Neurology residency program directors and residents weigh in on proposed new guidelines from the Accreditation Council for Graduate Medical Education.
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