Supervision and Duty Hour Policy
The University of Iowa Hospitals and Clinics (UIHC) ensures that their GME programs provide appropriate supervision for all residents, as well as a duty hour schedule and a work environment, that is consistent with proper patient care, the educational needs of residents, and the applicable Program Requirements. On-call requirements are essential for an optimal educational environment and to ensure continuity of patient care. The number of residents and faculty are monitored to prevent excessive frequency and length of on-call duty. The scheduling of on-call duty considers that clinical events do take place at any time. Safe, effective patient care, and a good learning environment require adequate periods of rest.
The UIHC requires that residents are appropriately supervised. Residents are supervised by teaching staff 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 are structured to ensure that supervision is readily available to residents on duty. The UIHC, through its Graduate Medical Education Committee (GMEC), its GME staff, and its internal review process, provides institutional oversight to assure that residents are appropriately supervised.
The policies of UIHC regarding supervision and duty hours must apply to all institutions to which a resident rotates. The educational goals and the learning objectives of the program are not to be compromised by excessive reliance on residents to fulfill institutional service obligations. Duty hours do reflect the fact that responsibilities for continuing patient care are not automatically discharged at specific times. The structuring of schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident.
Hours worked are constantly monitored by the residents and the program director and coordinator through maintenance of work logs by the residents, which are submitted monthly to the program coordinator.
Summary of duty hours
- Shall not exceed 80 hours per week when averaged over 4 weeks
- At least 4 days per month free of all work and on-call assignments
- 10-hour rest period between duty period and after house call
- 3 a.m. rule: junior residents on duty without rest will pass off primary call to senior resident
- Chief resident should contact faculty on call to determine/provide coverage should Chief resident become fatigued
- 24/4 rule: residents may work up to 4 hours beyond 24 hours in special circumstances only, to provide essential continuity of care, but may not accept new patients for care
Specific duty hour requirements are as follows:
Weekly limit: The duty hours of any resident shall not exceed 80 hours per week (or other applicable limit as specified by the appropriate RRC), when averaged over a 4-week period. 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 in-house moonlighting, administrative duties related to patient care, the transfer of patient care, in-house call, 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 preparation, reading, home call or external moonlighting.
Call: PGY2 and PGY4 residents take home call 7-8 times per month, including 2 weekend days. The PGY 5 residents take backup call 2-3 weekdays per week and 1-2 weekends per month (2-4 weekend days). Chief residents at UIHC take backup call 1 night per week, 2 weekend days per month, and Chief backup call every weekday for emergencies and surgeries. Residents take call from home, but a private call room with attached bathroom is available for the use of the on-call resident who may need to spend the night in the hospital.
The senior resident on second call takes call from home, as does the UIHC chief resident. The Chief resident on the Cedar Rapids rotation takes call from home every night, but only for surgical cases, which occur infrequently. The Cedar Rapids Chief Resident takes no call on Sundays, thus guaranteeing one day per week with no clinical duties whatsoever. The senior resident (Uro-3) in Mason City is on call from home every night, but has 4 weekend days per month free. The on-call duties of this resident are relatively light, and he/she is backed by the staff urologist on-call. The Uro-2 and Chief residents at the Iowa City VAMC take call from home, with the Uro-2 resident on first call daily, except for alternate weekends, and the Chief Resident on second call each night and alternate weekends.
The Chief Residents at UIHC and at the Iowa City VAMC alternate weekends on call, with the resident on call taking responsibility for call at both hospitals. This ensures that each of these chief residents has 4 weekend days per month free of call duties.
Day Off: Each resident has at least 4 days per month free of all work and on-call assignments.
10-Hour Rest Period: Each resident should have a 10-hour rest period between duty periods and after in-house call. Although the resident may take home call during this rest period, the requirement to return to the hospital during this time shall not be so frequent as to preclude rest and reasonable personal time for each resident. In rare situations where home call has been continuous until 3 a.m., junior resident will pass primary call to senior resident and return home to rest.
Continuous On-site Duty: We enforce the 24-hour continuous work limit.
Exception: The resident may exceed this 24-hour limit for a maximum of 4 additional hours to attend didactic activities; to maintain continuity of medical and surgical care; to transfer patient care; or to conduct outpatient clinics. In no event shall the resident accept a new patient (any patient for whom the resident has not previously provided care) during this 4-hour extension period.
Each GME training program at the UIHC shall meet the requirements of this policy as well as any applicable standard set by the ACGME, the appropriate RRC, or other accrediting or certifying body. The UIHC requires that each residency Program Director establishes a formal written policy on resident duty hours and supervision to foster resident education and to facilitate patient care. Individual Program Directors at UIHC must submit their policy to the GME Office and also distribute it to the residents and faculty, must monitor resident duty hours with a frequency sufficient to ensure compliance with this policy and the ACGME/RRC rules, and must adjust schedules as necessary to mitigate excessive services demands and/or fatigue that result from either in-house schedules or at-home call. Program Directors must monitor the need for back-up support when patient care responsibilities are unusually difficult or prolonged. Faculty and residents must be educated to recognize the signs of fatigue and sleep deprivation so as to counteract the potential negative effects on patient care and learning.