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Changes in the maximum shift length for residents, increases in mandatory time off, and inclusion of all moonlighting in total work hours are among the recommendations made in a report issued by the Institute of Medicine last month.
The institute did not recommend changing the average weekly maximum of 80 hours, and it favored retention of the policy allowing a maximum of 88 hours for programs demonstrating a sound educational rationale, while continuing to restrict emergency department residents to a 60-hour work week that includes maximum 12-hour shifts followed by at least 12 hours off.
In the 323-page report, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety,” the IOM committee estimated that it would cost about $1.7 billion to hire support staff, other clinicians, or additional residents to cover the cost of current residents' excess time. Nearly one-quarter of the total amount would go toward bringing residency programs into compliance with the 2003 limits.
Since July 2003, when the Accreditation Council for Graduate Medical Education (ACGME) first implemented the work hour restrictions, residents have been allowed to work 30-hour shifts consisting of up to 24 hours for admitting patients and 6 hours for transitional and educational activities. In contrast, the Institute of Medicine (IOM) recommends that the 30 hours include 16 hours for admitting patients, followed by a 5-hour protected period for sleep between 10:00 p.m. and 8:00 a.m. The remaining time may be used for transitional and educational activities. A simpler, second option is a 16-hour shift with no protected sleep time.
One problem was the 24 plus 6—a lot of sleep literature shows that after 16 hours your performance falls off. So 16 hours is the line in the sand for these researchers,” Dr. Tim C. Flynn, vice chair of the ACGME. Dr. Flynn, professor and associate dean of vascular surgery at the University of Florida in Gainesville, emphasized that his comments were his own and did not reflect the position of the ACGME.
The IOM also cited the compliance issue. “A lack of adherence to current limits on duty hours is common and underreported,” the committee authors wrote in an IOM Report Brief.
“Therefore, the committee recommends changes to ACGME monitoring practices, including unannounced visits and strengthened whistleblower processes to encourage resident reporting of violations of limits and undue pressure to work too long.” The council plans to meet in March 2009 to review the evidence, Dr. Flynn added.
Other recommendations include confining in-house call to every third night without averaging (the ACGME limits permit averaging); limiting the frequency of in-hospital night shifts to four nights, with 48 hours off after three or four consecutive nights of duty; and specifying mandatory time off as 5 days per month, 1 day per week, and at least one 48-hour period per month.
“ACGME had a great battle over moonlighting in the original 2003 rules,” Dr. Flynn said. “This calls for all time off—all moonlighting now counts.'