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Section 6: Duty Hours and Moonlighting Policies

6.01 DUTY HOURS POLICY

It is the policy of the Graduate Medical Education Committee to follow guidelines established by the ACGME regarding duty hours for residents in accredited training programs. Duty hours are defined as all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

General Guidelines

1. Residents are responsible for accurately reporting their duty hours, including all time spent in Internal and External Moonlighting, per program requirements.

2. Program Directors are responsible for monitoring and enforcing compliance with duty hour guidelines.

3. If specialty/subspecialty-specific program duty hour requirements as defined by an individual RRC for that specialty/subspecialty are more restrictive than the above requirements, then the duty hour requirements of that RRC will be included in the policy of that specialty/subspecialty program and will supersede the institutional requirements.

4. Concerns regarding duty hours may be reported to the Associate or Assistant Dean for GME
or
through the Confidential Helpline1-888-594-5874. Concerns may be reported anonymously.

Maximum Hours of Work per Week

5. 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.

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

Mandatory Time Free of Duty

7. 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

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

9. 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.

10. 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.

11. 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

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

13. 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.

14. 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 eight 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 eight 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

15. 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

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

At Home Call

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

18. 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.”

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

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

Any concerns or questions concerning the duty hour guidelines must be directed to the Associate or Assistant Dean for GME.

All programs must have policies for duty hours that at a minimum meet the ACGME's institutional and program requirements. Programs must monitor in-house and from-home duty hours on an ongoing basis in a way that provides accurate data.  The Duty Hour Subcommittee has established reporting requirements.  Each monitoring period must be 4 weeks in length, not a moving average or extrapolated from a shorter length of time.  With GMEC oversight, the DIO and the Chair of the GMEC Duty Hour Subcommittee will review program data resulting from internal reviews, annual administrative processing sessions, random audits and other times as determined by the DIO, the GMEC or by the Duty Hour Sub-committee of the GMEC.  If a program has received approval from the ACGME to extend the 80-hour rule, if the program received a duty hour citation or if an internal review reveals a duty hour issue, then these training programs must send reports to the sub-committee at a minimum of every other month. 

Program Directors must monitor call-from-home duty hours in terms of frequency and characteristics to assure that residents and fellows are following basic guidelines established by the ACGME.    

Program Directors must provide information to residents, fellows and faculty members regarding effects of loss of sleep and chronic fatigue.  Currently, the GMEC recommends using the SAFER program available from the GME office, and the Dinges presentation found at the ACGME website and asking faculty members of Emory University School of Medicine who have expertise in this area.

Transportation Option for Residents Too Fatigued to Return home Safely

For residents/fellows who may be too fatigued to drive home, the GME Office has arranged for residents/fellows' transportation home with a return trip next day through the Checker Cab Company.

Residents can call Checker Cab (404-351-1111) an give their specific pick up location. PLEASE NOTE: 1) The Taxi driver will pick up from any affiliated training site at which residents/fellows are rotating and 2) Checker Cab is authorized to only drop off at a residential address. Resident must indicate they are on the Authorized Caller List and with the GME Account. The GME Office will cover the cost of the transportation (including the tip).

Residents are asked to print name and program name clearly on the voucher provided by the cab driver. The voucher will be used to bill the GME Office. Checker Cab is authorized to provide a return trip the next day to the pickup location. The Program Director or Supervising Attending should be aware if a resident/fellow is too fatigue to drive his/her vehicle and needs transportation.

REPORTING STRUCTURE FOR OFF-SERVICE ROTATIONS

It is the intention of this section of the Duty Hour Policy to establish a process that will address duty hour compliance in a rapid and timely manner when a resident is rotating off service.  Problems regarding compliance with duty hour guidelines should be reported to the Chief Resident of the accepting training program.  If that Chief Resident does not respond to the report of noncompliance, then the resident should report to the Program Director of the sending program.  The Program Directors of the two programs must address the issues that led to the violation of the guidelines.  The resident may notify the GME Office at any time.  The Associate Dean for GME will report to the Chairs of the two training programs and has the option of reporting to the Dean if the issues are not settled on an immediate basis.

The GME office maintains a direct phone line to receive confidential complaints about all issues including duty hours. This phone number 1-888-594-5874 is private and secure.  The Associate Dean and DIO will respond to the recorded messages as appropriate.

6.02 DUTY HOUR EXTENSION

On occasion, individual programs could determine a need to extend the 80-hour work rule to a maximum of 10% above the current limit or a total of 88 hours per week. No other extension of the ACGME guidelines is permitted unless specifically stated by the ACGME. Not all RRC's accept applications to extend the 80-hour guideline.

If the request to extend work hours has been approved by the GMEC, then Program Directors must petition the RRC for permission to extend hours. The letter from the GMEC must be used when communicating to the RRC.

Program Directors must use the following guidelines to petition the GMEC.

  1. Program Directors requesting an extension of duty hours must do so in writing to the Associate Dean for GME.
  2. Blanket exceptions for the entire educational program should be considered the exception, not the rule.
  3. The letter must include the following information.
    1. A description of the resident's work week to delineate specific problem areas,
    2. A clear explanation of why the program cannot maintain the 80-hour limit,
    3. A clarification of the RRC requirements the program will not meet if residents work 80 or fewer hours,
    4. Planned monitoring procedures to assure that residents will not work greater than 88 hours per week,
    5. Information describing how the program will monitor, evaluate and ensure patient safety with extended resident work hours,
    6. A sound educational rationale that should relate to the program's stated goals and objectives for the particular assignments, rotations and levels of training for which the increase is requested,
    7. The program's moonlighting policies and how the program will assure that it is accounting for these hours,
    8. Call schedules for the rotation in question and
    9. Evidence of faculty development activities regarding the effects of residents fatigue and sleep deprivation.
  4. The GMEC Sub-committee on Duty Hours will serve as the ad hoc committee to review requests for extensions of duty hours. The Associate Dean will review the membership of the GMEC Sub-committee to assure that conflicts of interest do not enter the decision process.
  5. The written findings and recommendations of the Sub-committee will be presented at the next regularly scheduled meeting of the GMEC.
  6. Members of the GMEC, based on the letter from the Program Director and the findings and recommendations of the Sub-committee, will develop its report and send this report to the Program Director.
  7. The decision of the GMEC is final.
  8. Program Directors will not implement the extension of duty hours until approved by the ACGME.
  9. Program Directors must monitor resident work hours on a more intense basis if the ACGME has granted an extension.

6.03 MOONLIGHTING POLICY

"Moonlighting" refers to a service performed by a resident in the capacity of an independent physician, completely outside the scope of his/her residency-training program.  "External moonlighting" refers to moonlighting at a facility that is not part of the resident's training program.  "Internal moonlighting" refers to moonlighting at a location within the Emory system but outside the scope of the training program where the resident would normally be expected to provide care.   External and Internal moonlighting hours must be counted toward the 80-hour duty hour limit. 

Residents are not required to engage in moonlighting. 

Residents are prohibited from external or internal moonlighting UNLESS they have the written approval of the Chair of the Department or his/her designee.  The requirements necessary for such approval are set forth below under "External Moonlighting" and "Internal Moonlighting."

Residents do not have insurance coverage through Emory's Residency Training Program for any moonlighting services, whether external or internal.

In addition to the requirements below, the Chair or his/her designee's decision to approve or deny a resident's request to moonlight will depend on a number of factors including, but not limited to, interference with the resident's responsibilities in the training program and the individual circumstances of the resident.

6.04 External Moonlighting Requirements:

1. The Resident must submit a written request for approval to externally moonlight by completing the "Request to do External Moonlighting" form obtained either from the Program Director, Program Coordinator or from Appendix D in this House Staff Manual.

2. In order to be considered for external moonlighting, the resident must meet the following requirements:

a. Residents must agree to obtain a signed contract with the external facility and provide a copy of the signed contract to the Program Director.  The contract must state that the facility will provide professional liability insurance coverage for the resident's moonlighting services and that the resident has received privileges.  If the facility does not provide insurance coverage, residents must obtain their own professional liability insurance and provide proof of such insurance to the Program Director before moonlighting begins.

 b. Residents must be fully licensed to practice medicine in the state where the moonlighting will occur.  A residency-training permit is not a license to practice medicine outside the scope of residency training.

c. Residents on J-1 Visas are prohibited from moonlighting.

d. Residents must not wear identifiers as trainees in Emory University School of Medicine residency-training programs.

e. External moonlighting counts toward the 80-hour limit set by the ACGME.  The Chair of the Department and the Program Director are expected and required to assess the resident's progress in the program and ask the resident to stop moonlighting if performance does not reach an expected level.  The resident must be aware of these expected levels of academic and clinical performance before beginning the moonlighting experience.

6.05 Internal Moonlighting Requirements:

1. The Resident must submit a written request for approval to internally moonlight by completing the "Request to do Internal Moonlighting" form obtained either from the Program Director, Program Coordinator or from Appendix D in this House Staff Manual.

2. In order to be considered for internal moonlighting, the resident must meet the following requirements:

 a. Residents must agree to obtain a signed contract with the facility and provide a copy of the signed contract to the Program Director. The contract must state that the facility will provide professional liability insurance coverage for the moonlighting services and that the resident has received privileges.  If the facility does not provide insurance coverage, residents must obtain their own professional liability insurance and provide proof of such insurance to the Program Director before moonlighting begins. 

b. Internal moonlighting services may occur only in an OUTPATIENT SETTING or in the EMERGENCY DEPARTMENT.  Federal Medicare regulations are very clear on this point. (42 CFR 415.208)

 c. Residents must be fully licensed to practice medicine in the State of Georgia.  A residency-training permit is not a license to practice medicine outside the scope of residency training.

 d. Residents on J-1 Visas are prohibited from moonlighting.

 e. Resident must not wear identifiers as trainees in Emory University School of Medicine residency-training programs

 f. Residents must assure the Program Director in writing that the total hours in residency training and the moonlighting commitment DO NOT EXCEED the limits set by the ACGME.  Fabrication of the duty hour information could result in termination from the training program.