Policy for Child Neurology Resident Supervision and Duty Hours

The University of Iowa Children’s Hospital, Child 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 addresses all applicable program requirements. On-call duties are necessary components of the UIHC Child Neurology educational program.  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 refer to resident and fellow physicians 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 Neurology RRC of the ACGME.  Call-free months are also built into the program.

The University of Iowa Children’s Hospital, Child Neurology Residency Program demonstrates that the appropriate level of supervision is in place for all patients cared for by all residents. Every child neurology patient has an attending neurologist assigned who is responsible to assure the excellence of medical care and to supervise and teach child 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 child neurology faculty member is physically present with the resident and patient.

·         Indirect Supervision  

i) with direct supervision immediately available – The supervising child neurology physician 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 child neurology physician 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.

All residents in the Child Neurology Residency Program at the University of Iowa have already completed at least two years of post-graduate education.  This post-graduate education is typically in pediatrics.  Therefore, when they enter the Child Neurology Residency Program, the residents are, at a minimum, at the PGY 3 level. 

Residents in their first year of training in our program (typically PGY 3) are supervised either directly or indirectly with direct supervision immediately available while they acquire basic knowledge and skills specific to the specialty of neurology. Activities of PGY 4 residents and above are supervised by more senior residents or by faculty, as appropriate to the patient situation and resident 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 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, he or she can contact a more senior resident or the faculty on call.

DUTY HOURS

Residents’ work hours are monitored by the Program Director and Program Coordinator by means of a work hour record on MedHub that residents are expected to complete 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 report any concerns regarding resident hours directly to the Program Director 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, 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 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 that 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:

            As noted above, upon entry into the program, Child Neurology residents are, at a minimum, at the PGY 3 level.  During the first year of the program (typically PGY 3), the resident will have some rotations in which he or she takes in-house night call.  This in-house call occurs exclusively while the resident is rotating on adult neurology services.  After the first training year, the residents no longer take any in-house night call.

·         For all 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 any resident who is post-call from in-house duties accept a new patient (any patient for whom the resident has not previously provided care) during this 4-hour extension period.

·         Residents are never assigned additional clinical responsibilities after 24 hours of continuous in-house duty.

·         In unusual circumstances, PGY 3 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 justification in the institution’s resident management system (i.e. MedHub).

·         The Child Neurology Residency program has minimized the number of handoffs.  Handoffs between residents occur only once per week, at the end of the resident’s one-week period on call.  The resident going off service and the resident going on service meet face-to-face to discuss each patient’s hospital course and management plan.  

3.         Maximum Frequency of Over-Night In-House On-Call Duties:  House staff in the Child Neurology Residency Program take in-house call exclusively while rotating on the adult neurology service.  This in-house call is taken in rotation with the other junior adult neurology residents.  In-house call must not be scheduled more frequently than every third night when averaged over a 4-week period.  Typically, the in-house call occurs no more frequently than every seventh night.

4.         Maximum Frequency of In-House Night Float:  Child Neurology residents do not participate in in-house night float. 

5.         Mandatory Time Free of Duty:  Residents are scheduled for a minimum of one day free of duty every week (when averaged over four weeks).  During this day off, the resident does not have in-house or home call, has no mandatory conferences, and is not required to carry a pager. A day is defined as 24 consecutive hours.

6.         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.  As noted above, all residents in the Child Neurology Residency Program are at the PGY 3 level or above. 

·         Residents in the first year of the program (usually PGY 3) should have 10 hours, and must have 8 hours, between scheduled duty periods. They have at least 14 hours free of duty after 24 continuous hours of in-house duty.

·         Residents in the final two years of the program (usually PGY 4 and PGY 5) 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.

7.         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.  Typically, while rotating on the Child Neurology Service, the Child Neurology resident will have two weeks of home call during a four-week rotation.  Each of these weeks of home call is typically followed by a week free of any call. 

·         Home call activities are never 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.”

8.         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 policy has been established for child neurology residents wishing to moonlight:

A.  Each resident wishing to moonlight must submit a single request in writing to the Pediatric Neurology Program Director and the Pediatrics 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.

B.  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.

C.  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.

D.  Moonlighting is forbidden during the first year of the training program (typically PGY 3) and is limited to the final two years of the training program (typically PGY 4 and PGY 5 years).

E.  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 Neurology 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 PGY 4 and PGY 5 years.

            F.  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 3 residents are not permitted to moonlight.

The Child Neurology Residency program meets the requirements of this policy as well as any applicable standard set by the ACGME and the Neurology RRC.  This policy is distributed by the GME Office to all GME contract holders.  In addition, the Child Neurology Residency Program distributes the policy at the time of interview and orientation. The Child Neurology Residency program monitors resident duty hours with a frequency sufficient to ensure compliance with this policy and the ACGME and Neurology RRC.


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