Supervision and Duty Hours
The University of Iowa Hospitals and Clinics Emergency Medicine 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.)
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.
The Emergency Medicine Residency Program demonstrates that the appropriate level of supervision is in place for all patients cared for by all residents. Residents are Directly Supervised at all times in the Emergency Department. Supervision for other clinical areas is as per the individual department and may include a regulated, intermittent period of indirect supervision. 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- I 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- II 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.
Resident work hours are monitored by the Program Director, Associate Program Director and Program Coordinator by means of a work hour record on MedHub, the on-line resident management system, that residents are expected to complete weekly. All residents adhere to duty hour requirements and any educational experience found to be interfering with this requirements will be modified or eliminated.
All residents will report any concerns about resident hours directly to the Program Director or Associate Program Director or via rotational evaluations solicited at the end of every rotation.
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 60 hours when working in the Emergency Department (ED)), 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- I residents– scheduled duty periods must not exceed 16 hours in duration.
- PGY- II 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- II 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- II or above residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
- In unusual circumstances, PGY- II 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).
- All clinical staff, including residents and faculty, personally sign out their active patients in the ED to their relief. In addition, they will document the time and details of this handoff in the ED clinical note.
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. 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- I 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.
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 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. Moonlighting is allowed with prior approval of 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-I residents are not permitted to moonlight.
The Emergency Medicine 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 as well as included in the residency manual that is distributed during Program Orientation. Emergency Medicine 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.