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Supervision and Duty Hours

The University of Iowa Hospitals & Clinics Emergency Medicine Residency Program

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

Addresses all applicable program requirements 

On-call duties are necessary components of UI Hospitals & Clinics 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 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

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 work 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 work hours directly to the program director or associate program director or via rotational evaluations solicited at the end of every rotation.

Specific resident work hour requirements are as follows:

Maximum Hours of Work Per Week:

The work hours of any resident must be limited to 80 hours per week, when averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home and all moonlighting activities. Any time spent at UI Hospitals & Clinics 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 UI Hospitals & Clinics (or outside another institution related to the program’s academic purposes) for academic preparation, reading, and studying.

Maximum Work Period Length:

  • Residents should have eight hours off between scheduled clinical work and education periods.
  • Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call.
  • Residents must be scheduled for a minimum of one day in seven free of clinical work and required education (when averaged over 4 weeks). At-home call cannot be assigned on these free days.
  • Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments.
  • In unusual circumstances, 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 In-house On-call Duties:

In-house call must not be scheduled more frequently than every third night when averaged over a four-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.

Minimum Time Off between Scheduled Duty Periods:

  • Residents should have eight hours off between scheduled clinical work and education periods.
  • Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call.

 

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 one day in seven free of duty, when averaged over four 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. 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.