Policy for Pediatric Resident Supervision and Duty Hours

June 13, 2011

The University of Iowa Children’s Hospital, Pediatric 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 addresses 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 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 Pediatric RRC of the ACGME. Call-free months are also built into the program.

The following guidelines have been established to assure the appropriate supervision of house staff:

1. Inpatient Pediatric Service

All patients admitted to a pediatric inpatient service are assigned an attending general or subspecialty pediatrician. The assignment to this pediatrician is made at the time of admission, regardless of the time of day. The house staff is instructed to notify the attending pediatrician of every admission to the service and make the attending physician aware of the condition of all seriously ill children on the service. Attending pediatricians are notified of the admission of stable patients soon after the residents develop a working diagnosis and treatment plan to encourage the residents' independent diagnostic and management plans. The timeliness of the notification of the attending depends upon the unit and the urgency of the problem.

Daily attending rounds are made by the faculty who remains actively involved in directing patient care. The residents are given progressively increasing responsibility, while continuously maintained under faculty supervision. The first-year resident typically carries several in-patients, a minimum of 5 as suggested by the Pediatric RRC, and the supervising resident typically does not exceed the 30 patients also suggested by the RRC. Residents transition over to this supervisory capacity, with 1 such month in the second year, and 2 months in the third year. There is an attending general or subspecialty pediatrician available 24 hours a day for consultation and is physically present when required. The resident on call for a particular service knows exactly which general or subspecialty pediatrician is on call for that service via SmartWeb and can contact them at any time via the pager system.

2. Outpatient Pediatric Service

Faculty members from the General Pediatrics Division are assigned to staff the pediatric outpatient clinic on a daily basis. Scheduled patients or walk-ins seen in the pediatric clinic are evaluated initially by pediatric residents and then are staffed by the faculty from the General Pediatrics Division. The subspecialty clinics function in the same manner with every patient being seen in consultation with a faculty member. Each resident is assigned a panel of patients that he or she follows in a continuity fashion for well-child care (Continuity Clinic) for one to two half-days a week for their 3 years of training. Residents have one rotation in a community practice. The care of patients is supervised by faculty in all of these settings.

3. Pediatric Emergency Medicine Rotations

Each PGY-3 has a rotation through the Emergency Department at the University of Iowa Hospitals and Clinics. In addition, each PGY-2 has a rotation at the Blank Children's Hospital in Des Moines through an affiliation agreement for education. The evaluation and treatment of trauma patients in the ETC is directly supervised by the Emergency Medicine faculty; if necessary, a pediatric staff subspecialist is available for consultation. If it is deemed necessary for a pediatric staff subspecialist to evaluate the patient, then that individual comes to the ETC and directly supervises the pediatric resident involved in the care of the patient. At Blank Children's Hospital, this supervision is provided directly by pediatric emergency room physicians.

The Pediatric Residency program demonstrates that the appropriate level of supervision is in place for all patients cared for by all residents. Every pediatric patient has an attending pediatrician assigned who is responsible to assure the excellence of medical care and to supervise and teach pediatric 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

Residents work hours are monitored by the Program Director/Associate Program Directors, Chief Residents 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 1100 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.

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

Specific duty hour requirements are as follows:

1. 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, counts toward the weekly maximum. Additionally, the weekly maximum includes 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.

2 Maximum Duty Period Length:

  • PGY-1 residents– scheduled duty periods must not exceed 16 hours in duration.
  • PGY-2 and above residents – no schedule exceeds 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 does 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).
  • The Pediatric residency program has minimized the number of handoffs, and has created a hand off template to ensure the best possible patient care. The handoff template is located in EPIC, titled Peds Check Out Tool.
     

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 does not include home call nor is 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 pediatric residents wishing to moonlight:

  1. Each resident wishing to moonlight must submit a single request in writing to the Program Director and the Department Head. The request will set forth the circumstances necessitating moonlighting. The form for making such a request may be obtained from the Program Director. The PD and Head will evaluate and respond to such requests on an individual resident basis. Approval can be for no longer than one year and may be revoked during the course of the year pursuant to the program's policy.
  2. 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.
  3. 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 of 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.
  4. Moonlighting is limited to the PGY-3 year.
  5. Moonlighting is allowed in a pediatric setting only. (Chief Residents are technically faculty or fellows and, as such, may also request permission to moonlight.)
  6. Total hours worked, including those hours worked as part of the training program and those hours devoted to moonlighting, must not exceed the standard set by the Pediatric Residency Review Committee/ACGME. These standards state that each resident should have a monthly average of one day out of seven without clinical responsibilities and work no more than 80 hours per week on average, when averaged over four weeks. Moonlighting at UIHC counts toward the 80 hour work week. Because of this requirement, moonlighting is allowed only during elective rotations in the PL3 year.
  7. Any resident wishing to moonlight must have obtained scores on the American Board of Pediatrics In-Training Examination which indicate the likelihood of passing the board exam after training is completed (currently: PL2 exam score ≥ 300; PL3 exam score ≥ 360).
  8. Any resident wishing to moonlight should discuss the pros and cons with his/her faculty preceptor prior to initiating a formal request to the Program Director.

It should be noted:

  • 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-1and -2 residents are not permitted to moonlight.
     

The Pediatric 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 to all GME contract holders. The Pediatric Residency also distributes this policy at the time of interview and orientation. The Pediatric 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.

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