Policy for Neurology Resident Supervision and Duty Hours

The University of Iowa Hospitals and Clinics, Neurology Residency Program ensures that it provides appropriate supervision for all residents, as well as a duty hour schedule and a work environment that optimizes quality patient care, fortifies the educational trajectory of house staff members, and address all applicable program requirements. On-call duties are necessary components of the UIHC clinical care systems and educational programs; these duties are managed to ensure adequate periods of rest with appropriate levels of supervision to deliver safe, effective patient care. (The terms “resident” or “house staff member” used in this policy shall refer to resident and fellow physicians and dentists at all house staff levels.)

Supervision

The clinical activities of all residents are supervised by teaching staff and/or a more advanced house staff members in such a way as to ensure that residents assume progressively increasing responsibility according to each resident’s level of education, ability and experience. The teaching staff determines the level of responsibility accorded to each resident. On-call schedules for teaching staff and more advanced house staff members are structured to ensure supervision is readily available to those on duty.

Call is no more frequent than that approved by the Neurology RRC of the ACGME.

The Neurology Residency program demonstrates that the appropriate level of supervision is in place for all patients cared for by all residents. Every neurology patient has an attending neurologist assigned who is responsible to assure the excellence of medical care and to supervise and teach neurology house staff involved in the care of that patient. Each clinical service is continuously covered by a faculty member who is accessible at any time by means of the pager system. These levels of supervision include:

  • Direct Supervision ­- The supervising physician or dentist is physically present with the resident and patient.
  • Indirect Supervision

i) with direct supervision immediately available ­ The supervising physician or dentist is physically present within the hospital or other site of patient care, and is immediately available to provide direct supervision.
ii) with direct supervision available ­ The supervising physician or dentist is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide direct supervision.

PGY 1 residents are supervised either directly or indirectly with direct supervision immediately available while they acquire basic knowledge and skills specific to the specialty. Activities of PGY 2 residents and above are supervised by any level of supervision, as appropriate to the patient situation and resident capability. Supervision does not equate merely to the presence of more senior physicians or dentists nor with the absence of independent decision making on the part of residents. These supervision standards encompass the concepts of graded authority, responsibility and conditional independence that are the foundation of delegation of authority to more senior house staff members. Should a resident ever need further assistance or information, they can contact the senior resident or faculty on call.

Duty Hours

All residents will report any concerns about resident hours directly to the Program Director/Associate Program Directors or via rotational evaluation solicited at the end of every rotation.

Residents work hours are monitored by the Program Director/Associate Program Directors, and Program Coordinator by means of a work hour record on MedHub that residents is expected to be completed weekly. The work hours for day and night duty on all rotations are designed such that hours worked will fall within the ACGME rules for resident work hours: no more than 80 hours per week when averaged over 4 weeks; one day off in seven when averaged over 4 weeks; post call, residents are excused by noon on the post call day if on an in-patient service, and 0730 following check out if on an outpatient rotation unless they have their continuity clinic that morning there is at least a 10 hour period free of clinical duty between shifts.

Specific duty hour requirements are as follows:

Maximum Hours of Work per Week:

  • The duty hours of any resident must be limited to 80 hours per week (or other applicable limit as specified by the appropriate Residency Review Committee (RRC), when averaged over a 4-week period, inclusive of all in-house call activities and any moonlighting activities. Any time spent in the UIHC or at another institution for clinical and academic purposes, related to the residency or fellowship program, both inpatient and outpatient, shall count toward the weekly maximum. Additionally, the weekly maximum shall include time spent for administrative duties related to patient care, the transfer of patient care, scheduled academic activities such as conferences, research related to the program, and any time the resident spends on-site after being called in to the hospital. Not included in the weekly maximum is time spent outside of UIHC (or outside another institution related to the program’s academic purposes) for academic preparation, reading, and studying.

Maximum Duty Period Length:

  • PGY 1 residents­ scheduled duty periods must not exceed 16 hours in duration.
  • PGY 2 and above residents ­ no schedule shall exceed a maximum of 24 hours of continuous duty in the hospital, with no more than 4 additional hours used for any transitional activities (i.e. maintaining continuity of medical and surgical care, transferring patient care, or attending educational sessions).
  • In no event shall the PGY 2 or above resident accept a new patient (any patient for whom the resident has not previously provided care) during this 4-hour extension period.
  • PGY 2 or above residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
  • In unusual circumstances, PGY 2 and above 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. Residents must appropriately hand over the care of all other patients to the team responsible for their continuing care.
  • Any resident exceeding maximum duty period lengths will document their justification in the institution’s resident management system (i.e. MedHub).
  • Neurology residents at the end of the workday who are members of the stroke and 2BT teams (and if necessary, the VA and UIHC consult team, as well) should page you to check out. Sign out should not occur before 5pm on weekdays and should not occur prior to the work being completed on weekends. The ACGME requires that physician handoff be done verbally or in person. The Sign-out feature on Epic allows for a brief amount of information to be entered, both things for the on-call resident to do, and for the on-call resident to let the team know what happened overnight. Significant events should be recorded in a progress note, and conveyed verbally to the team in the morning.

Maximum Frequency of Over-Night In-House On-Call Duties: In-house call must not be scheduled more frequently than every third night when averaged over a 4-week period.

Maximum Frequency of In-House Night Float: Residents must not be scheduled for more than six consecutive nights of night float or as specified further by the program’s RRC, as applicable.

Mandatory Time Free of Duty: Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). This day off shall not include home call nor shall the resident be required to carry a pager. A day is defined as 24 consecutive hours.

Minimum Time Off between Scheduled Duty Periods: Based on the level of the resident, there are identified levels of time off between scheduled duty periods.

  • PGY 1 residents ­ should have 10 hours, and must have 8 hours, free of duty between scheduled duty periods.
  • Intermediate level residents (as defined by the program’s RRC) ­ should have 10 hours, and must have 8 hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 continuous hours of in-house duty.
  • Final year residents (as defined by the program’s RRC) ­ can participate in transition to practice activities when they are preparing to care for patients over irregular or extended periods. It is still desirable that these residents have 8 hours free of duty between scheduled duty periods, but there may be circumstances where residents must stay on duty to care for their patients or return to the hospital after shorter intervals.
  • The Program Director monitors time off between scheduled duty periods.

Home call: Residents returning to the hospital from home call must count their time spent in the hospital towards the 80-hour maximum weekly hour limit. The frequency of home call is not subject to the every-third-night limitation but must satisfy the requirement for 1 day in 7 free of duty, when averaged over 4 weeks.

  • Home call activities must not be so frequent as to preclude rest and reasonable personal time for each resident.
  • Residents are permitted to return to the hospital while on home call to care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period.”

Moonlighting: Moonlighting is governed by the Moonlighting Policy and Procedures for House Staff Physicians and Dentists. All requirements of that policy must also be followed, including visa and license requirements. In order to ensure against any adverse effects on the resident’s educational or clinical program, the following departmental policy has been established for Neurology residents wishing to moonlight:

Moonlighting is never required and must not interfere with the ability of the resident to achieve the goals and objectives of the educational program.

  • The resident must obtain permission of his/her Program Director prior to the beginning of such activities. All approved requests must be filed with the GME Office.
  • Time spent by residents in internal and external moonlighting must be counted toward the 80-hour maximum weekly hour limit. Failure to completely document all time in moonlighting activities will result in suspension of the moonlighting privilege.
  • PGY 1 residents are not permitted to moonlight.
  • Residents must have a permanent physician’s license to moonlight outside of the institution. The “resident physician” license issued by the state is not valid for professional activity outside the training program.
  • Residents must possess adequate professional liability insurance. The professional insurance protection provided by the State Tort Claims Act does not protect the resident when he or she is engaged in clinical practice outside for the scope of the training program The house staff member is responsible for obtaining appropriate medical malpractice/professional liability coverage for moonlighting activities. Evidence of such insurance is required before approval is granted.

The Neurology Residency program meets the requirements of this policy as well as any applicable standard set by the ACGME, the appropriate RRC, or other accrediting or certifying body. This policy is distributed by the GME Office with the GME employment contract. The Neurology Residency also distributes this policy at the time of orientation. The Neurology Residency program monitors resident duty hours with a frequency sufficient to ensure compliance with this policy and the ACGME/RRC/other accrediting or certifying body’s rules.