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Appendix D: Duty Hour and Moonlighting

D. Moonlighting Request Forms

To moonlight at Emory Healthcare facilities, download request form here

To moonlight outside Emory Healthcare, download request form here

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D.1 2011 ACGME CPR Duty Hour Requirements:

Maximum Hours of Work per Week

1. Duty hours must be limited to 80 hours, averaged over a four-week period per rotation or a four-week period within a rotation excluding vacation or approved leave. Any requests for exceptions to the maximum weekly limit on duty hours must be presented by the Program Director to the GMEC for review and approval. Any exceptions must conform to the Policy and Procedures for Resident Weekly Duty Hour Limit Exceptions.

2. Time spent in Internal and External Moonlighting will be counted toward the 80-hour maximum weekly hour limit on duty hours as outlined in #5 above.

Mandatory Time Free of Duty

 Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). “Duty” includes all clinical and academic activities related to the program as described above. At-home call cannot be assigned on these free days.

Maximum Duty Period Length

1. Duty hour periods of PGY-1 residents must not exceed 16 hours in duration.

2. PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Residents may be allowed to remain on site for an additional 4 hours to ensure effective transitions in care; however, they may not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.

3. ESOM encourages residents to use alertness management strategies, including strategic napping, in the context of patient care responsibilities, especially after 16 hours of continuous duty and between the hours of 10pm and 8am.

4. In unusual circumstances and on their own initiative, PGY-2 residents and above may remain beyond their scheduled period of duty to continue to provide care to a single patient. Under such circumstances - which only include continuity of care for a severely ill or unstable patient, a transpiring event of unusual academic importance or humanistic attention to the needs of a patient or family – the resident must:
appropriately hand over the care of all other patients responsible for their continuing care and document the reasons for remaining to care for the patient in question. Such documentation must be submitted to the Program Director in every circumstance. The Program Director is responsible for tracking both individual resident and program-wide episodes of additional duty. 

Minimum Time Off Between Scheduled Duty Periods

1. PGY-1 residents should have 10 hours and must have 8 hours free of duty between scheduled duty periods.

2. Intermediate level residents as defined by the respective Residency Review Committees should have 10 hours free of duty, must have 8 hours between scheduled duty periods, and must have at least 14 hours free of duty after 24 hours of in-house duty. Individual residency programs must construct their own duty hour policies in compliance with their individual program’s requirements.

3. Residents in the final years of education must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods. While it is desirable that residents in their final years of education have 8t hours free of duty between scheduled duty periods, there may be circumstances when these house officers must stay on duty to care for their patients or return to the hospital with fewer than 8t hours free of duty. Individual programs must construct their own duty hour policies in compliance with their individual program’s requirements as to the definition of “final years of education” and the circumstances where house officers may have less than 8 hours free between duty periods. In all instances, such circumstances must be monitored by the Program Director.

Maximum Frequency of In-House Night Float

 Residents must not be scheduled for more than 6 consecutive nights of night float. Individual residency programs must construct their own duty hour policies in compliance with their individual program’s requirements defining maximum consecutive weeks of night float and maximum number of months of night float per year.

Maximum In-House On-Call Frequency

 In-house call will occur no more frequently than every third night, averaged over a four-week period.

At Home Call

1. At-home call, or “pager call,” is defined as call taken from outside the assigned site.

2. When residents are called into the hospital from home, they may care for new or established patients and the hours spent in-house, exclusive of travel time, are counted toward the eighty-hour limit. Such episodes will not initiate a new “off-duty period.”

3. At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.

4. At-home call may not be scheduled on the resident’s one free day per week (averaged over four weeks).

D.2 Code of Federal Regulations:  

§ 415.208 Services of moonlighting residents.

(a) Definition. 

For purposes of this section, the term services of moon-lighting residents refers to services that licensed residents perform that are outside the scope of an approved GME program.

(b) Services in GME program hospitals.

(1) The services of residents to inpatients of hospitals in which the residents have their approved GME program are not covered as physician services and are payable under § 413.86 regarding direct GME payments.

(2) Services of residents that are not related to their approved GME programs and are performed in an out-patient department or emergency department of a hospital in which they have their training program are covered as physician services and payable under the physician fee schedule if all of the following criteria are met:

(i) The services are identifiable physician services and meet the conditions for payment of physician services to beneficiaries in providers in § 415.102(a).

(ii) The resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed.

(iii) The services performed can be separately identified from those services that are required as part of the approved GME program.

(3) If the criteria specified in paragraph (b)(2) of this section are met, the services of the moonlighting resident are considered to have been furnished by the individual in his or her capacity as a physician, rather than in the capacity of a resident. The carrier must review the contracts and agreements for these services to ensure compliance with the criteria specified in paragraph (b)(2) of this section.

(4) No payment is made for services of a ‘‘teaching physician’’ associated with moonlighting services, and the time spent furnishing these services is not included in the teaching hospital’s full-time equivalency count for the indirect GME payment (§ 412.105 of this chapter) and for the direct GME payment (§ 413.86 of this chapter).

(c) Other settings.

Moonlighting services of a licensed resident in an approved GME program furnished outside the scope of that program in a hospital or other setting that does not participate in the approved GME program are payable under the physician fee schedule as set forth in § 415.206(b)(1).