UNIVERSITY OF IOWA HOSPITALS AND CLINICS POLICY FOR PEDIATRIC CRITICAL CARE MEDICINE
FELLOW SUPERVISION AND DUTY HOURS 2013-14
The Pediatric Critical Care Medicine Fellowship Program ensures that it provides appropriate supervision for all fellows, 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 clinical activities of all fellows are supervised by an attending physician in such a way as to ensure that fellows assume progressively increasing responsibility according to each fellow’s level of education, ability and experience. The attending physician determines the level of responsibility accorded to each fellow. On-call schedules for attending physicians are structured to ensure supervision is readily available to those on duty.
Every PICU patient will have an attending pediatrician assigned who is responsible to assure the excellence of medical care and to supervise and teach Pediatric Critical Care fellows involved in the care of that patient. The PICU service will be continuously covered by a faculty member who is accessible at any time by means of the pager system. All fellows in the Division of Pediatric Critical Care at the University of Iowa Hospitals and Clinics are supervised by faculty.
The Pediatric Critical Care Medicine Fellowship Program demonstrates that the appropriate level of supervision is in place for all patients cared for by all fellows. Fellows are given guidelines for supervision and are expected to discuss this with the program director at any time there is a need to deviate from these policies. Fellows are given increasing reponsibility for patient care as they progress through the 3 years of fellowship training. These levels of supervision include:
- Direct Supervision – The supervising physician is physically present with the fellow and patient.
- Indirect Supervision
i) with direct supervision immediately available – The supervising physician is physically present within the hospital and is immediately available to provide direct supervision.
ii) with direct supervision available – The supervising physician is not physically present within the hospital, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide direct supervision. Fellows are able to immediately reach a faculty member by pager at any time that they have a question regarding patient care, and every patient seen by a fellow is also seen by a faculty physician in the division. The program director has a meeting with each fellow every six months that provides an opportunity to address problems with supervision.
Fellows also provide supervision of pediatric residents rotating in the PICU. PICU attendings are present to oversee this supervision and to provide direct supervision to pediatric residents. Fellows are given increasing responsibility with respect to supervision of pediatric residents as they progress through the 3 years of fellowship training, however, faculty members in the Division of Pediatric Critical Care always participate in patient care and supervision of pediatric residents.
Activities of all PICU fellows are supervised by the level of supervision appropriate to the patient situation and fellow capability. Supervision does not equate merely to the presence of more senior physicians nor with the absence of independent decision making on the part of fellows. These supervision standards encompass the concepts of graded authority, responsibility and conditional independence that are the foundation of delegation of authority to fellows. All fellows in the Division of Pediatric Critical Care at the University of Iowa Hospitals and Clinics are supervised by faculty.
The Division of Pediatric Critical Care policy on fellow work hours follows the guidelines set by UIHC and by the Residency Review Committee of Pediatrics and Pediatric Critical Care. This policy applies to all Pediatric Critical Care Fellows. Specific mandated guidelines include: at least one day out of seven when averaged over four weeks without assigned duties; a maximum of 80 hours/week when averaged over four weeks; at least 10 hours off between shifts, and call no more frequently than every third night. Call free months are also built into the program. Fellows are instructed to log all hours worked into an electronic file which is monitored regularly by the program director. The duty hour policies below are presented to and reviewed with the fellows at their original orientation to the program. We have designed a schedule that complies with these rules on all rotations. The faculty is aware of the expected work hours for the fellows while rotating in the PICU and on other rotations. The program director meets semi-annually with each fellow and at this time the program director will directly solicit any concerns about meeting duty hour guidelines. The program director will discuss any apparent issues with meeting duty hour requirements with the fellow(s) when/if these conflicts occur. The program director will also independently spot check both hours worked by fellows and the recording of these hours.
Specific duty hour requirements are as follows:
1. Maximum Hours of Work per Week:
The duty hours of any PICU fellow are limited to 80 hours per week when averaged over a 4-week period, inclusive of all in-house call activities and any moonlighting activities. Any time spent in the UIHC related to the fellowship program, both inpatient and research, 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 fellow 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:
- In unusual circumstances fellows, 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. Fellows must appropriately hand over the care of all other patients to the team responsible for their continuing care.
- Any fellow exceeding maximum duty period lengths will document their justification in the institution’s fellow management system (i.e. MedHub). The program director will discuss any apparent issues with meeting duty hour requirements with the fellow(s) when/if these conflicts occur.
3. Maximum Frequency of Over-Night In-AHouse On-Call Duties:
In-house call must not be scheduled more frequently than every third night when averaged over a 4-week period. Currently fellows are assigned to take in-house call twice weekly during their rotations in the PICU. They leave the hospital on post call days by 11 am and do not return until the next morning at 7am. They also take call from home 1-2 weekends/month during their rotations in the PICU. During the weekend of home call, if the fellow returns to the hospital after 9pm they are relieved of their duties the next day at 12 noon, and do not return until the following morning. Fellows have access to on-call facilities when their call duties require in hospital overnight stay, and on any night that they are required to remain in the hospital for patient care, they must leave the hospital directly following rounds the next day (less than 28 hours continuously worked). During research months, anesthesia rotation, CV surgery, and other elective rotations fellows take in-house call one weeknight/week and are on call either from home one weekend/month or for scheduled 24 hour weekend shifts. All of the above described guidelines for duty hours apply during these rotations as well.
4. Mandatory Time Free of Duty:
Fellows 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 fellow be required to carry a pager. A day is defined as 24 consecutive hours.
5. Minimum Time Off between Scheduled Duty Periods:
All PICU fellows should have 10 hours, and must have 8 hours, free of duty between scheduled duty periods.
- All PICU fellows, according to their ability as assessed by the attending physician, may 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 fellows have 8 hours free of duty between scheduled duty periods, but there may be circumstances where fellows 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.
6. Home call:
Fellows 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 fellow.
- Fellows 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.”
- PICU Fellows take call from home 1-2 weekends/month during their rotations in the PICU depending on their year of training. During the weekend(s) of home call, if the fellow returns to the hospital after 9pm they are relieved of their duties the next day at 12 noon, and do not return until the following morning.
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. Currently, moonlighting is allowed by our program.It should be noted:
- Moonlighting is never required and must not interfere with the ability of the fellow to achieve the goals and objectives of the educational program.
- The fellow 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 fellows 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 fellows are not permitted to moonlight.
Every fellow has the opportunity to evaluate each rotation and all supervising faculty that they work with via MedHub. This includes the opportunity to comment on the hours being worked on that rotation. In addition, the program director will monitor fellow stress, fatigue and work hours. If problems are noted, the program director will then immediately investigate the issue.
The Pediatric Critical Care Medicine Fellowship 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 as well as to all fellows at original orientation and all faculty members at the start of their appointment, and to all PICU faculty and fellows as updates/changes are made. The Pediatric Critical Care Medicine Fellowship Program monitors fellow duty hours with a frequency sufficient to ensure compliance with this policy and the ACGME/RRC/other accrediting or certifying body’s rules.