POLICY FOR DUTY HOURS AND WORK ENVIRONMENT
The Department of Emergency Medicine will comply in complete accordance with the Accreditation
Council for Graduate Medical Education (ACGME) guidelines for resident duty hours. It is the duty of the
Program Director, in conjunction with the Emergency Medicine chief residents, to ensure that resident
schedules in the Emergency Departments (ED) meet ACGME requirements. All residents should have
appropriate duty hours when rotating on other clinical services, in accordance with the ACGME-approved
program requirements of that specialty. Residents are expected to be aware of the duty hour
requirements and inform the residency program administration when these duty hour limits are exceeded.
Residents are required to report Duty Hours compliance/violations in New Innovations. The Department
will conduct audits of all rotations. There is also a ‘concerns/suggestion box’ to allow the opportunity for
anonymous feedback.
Explanation of ACGME program requirements
The ACGME has common program requirements that refer to all residency programs, and special
program requirements that are specialty specific. The common program requirements always apply, but
the special program requirements may amend or elaborate on these requirements.
This is the case with resident work hours. The common program requirements restrict resident’s duty
hours to 80 hours per week. The Emergency Medicine (EM) program requirements restrict residents to
60 hours per week in the ED. A copy of the text of each of these requirements from the ACGME web site
is indicated below; please refer to www.acgme.org for the most up-to-date version. Note that both EM
residents and other residents rotating in the ED must abide by the EM special requirements. When EM
residents are off-service, they are protected by the common program requirement of 80 hours per week UNLESS that specialty has its own special requirements that also further limits the work hours or has an
ACGME approved exception to the work hour requirements (see below). When EM residents are off
service, the Department expects that they are treated fairly according to that specialty’s guidelines. It is
incumbent upon the residents to inform the administration when these duty hour limits are violated.
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Special Requirements for Emergency Medicine Duty Hours
a. Emergency medicine rotations
1. As a minimum, residents shall be allowed 1 full day in 7 days away from the institution
and free of any clinical or academic responsibilities, including planned educational
experiences.
2. While on duty in the emergency department, residents may not work longer than 12
continuous scheduled hours. There must be at least an equivalent period of continuous
time off between scheduled work periods.
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3. A resident should not work more than 60 scheduled hours per week of patient care in the
emergency department and no more than 72 duty hours per week during their scheduled
ED month. Duty hours comprise all clinical duty time and conferences, whether spent
within or outside the educational program, including all on-call hours.
b. Other Rotations: The program director must ensure that all residents have appropriate duty
hours when rotating on other clinical services, in accordance with the ACGME-approved program
requirements of that specialty.
c.
Extracurricular activities: Activities outside the educational program may not be mandated, nor
may they interfere with the resident’s performance in the educational process as defined in the
agreement between the institution and the resident.
ACGME Common Program Requirements:
44B
Duty hours
a. Duty hours are defined as all clinical and academic activities related to the residency program,
i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the
provision for transfer of patient care, time spent in-house during call activities, and scheduled
academic activities such as conferences. Duty hours do not include reading and preparation time
spent away from the duty site.
b. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of
all in-house call activities.
c.
Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities,
averaged over a four week period, inclusive of call. One day is defined as one continuous 24hour period free from all clinical, educational, and administrative activities.
d. A 10 hour time period for rest and personal activities must be provided between all daily duty
periods, and after in-house call.
On-Call Activities
The objective of on-call activities is to provide residents with continuity of patient care experiences
throughout a 24 hour period. In-house call is defined as those duty hours beyond the normal work day
when residents are required to be immediately available in the assigned institution.
a. In-house call must occur no more frequently than every third night, averaged over a four-week
period.
b. PGY I—Continuous on-site duty, including in-house call, must not exceed 16 consecutive hours.
PGY-1 residents should have 10 hours, and must have eight hours, free of duty between
scheduled duty periods
c.
PGY II and above—Continuous on-site duty, including in-house call, must not exceed 24
consecutive hours. It is essential for patient safety and resident education that effective
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transitions in care occur. Residents may be allowed to remain on-site in order to accomplish
these tasks; however, this period of time must be no longer than an additional four hours.
Residents must not be assigned additional clinical responsibilities after 24 hours of continuous inhouse duty. Intermediate-level residents should have 10 hours free of duty, and must have eight
hours between scheduled duty periods. They must have at least 14 hours free of duty after 24
hours of in-house duty.
d. No new patients may be accepted after 24 hours of continuous duty. A new patient is defined as
any patient for whom the resident has not previously provided care.
e. Residents must not be scheduled for more than six consecutive nights of night float.
f.
At-home call (pager call) is defined as call taken from outside the assigned institution.
1. The frequency of at-home call is not subject to the every third night limitation. However,
at-home call must not be so frequent as to preclude rest and reasonable personal time
for each resident. Residents taking at-home call must be provided with 1 day in 7
completely free from all educational and clinical responsibilities, averaged over a 4-week
period.
2. When residents are called into the hospital from home, the hours residents spend inhouse are counted toward the 80-hour limit.
3. The program director and the faculty must monitor the demands of at-home call in their
programs and make scheduling adjustments as necessary to mitigate excessive service
demands and/or fatigue
Moonlighting
a. Because residency education is a full-time endeavor, the program director must ensure that
moonlighting does not interfere with the ability of the resident to achieve the goals and objectives
of the educational program.
b. The program director must comply with the sponsoring institution’s written policies and
procedures regarding moonlighting, in compliance with the Institutional Requirements III. D.1.k.
c.
Moonlighting that occurs within the residency program and/or the sponsoring institution or the
non-hospital sponsor’s primary clinical site(s), i.e., internal moonlighting, must be counted toward
the 80-hour weekly limit on duty hours.
d. See Moonlighting Policy for Emergency Medicine at RC desk or online on New Innovations
Oversight
a. Each program must have written policies and procedures consistent with the Institutional and
Program Requirements for resident duty hours and the working environment. These policies must
be distributed to the residents and the faculty. Monitoring of duty hours is required with frequency
sufficient to ensure an appropriate balance between education and service.
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b. Back-up support systems must be provided when patient care responsibilities are unusually
difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to
jeopardize patient care.
a. See alertness fatigue policy: http://medicine.missouri.edu/gme/uploads/GME-05--Alertness-Management-&-Fatigue-Mitigation.pdf
Violation of Duty Hours
a. Every resident is encouraged to immediately report any duty hours violations to the Program
Director immediately when said violations are realized. There is an alternate, anonymous
reporting system available by filling out a blank concern form and leaving it in the Resident
Lounge.
b. Once a violation has been identified, the Residency Steering Committee will immediately review
the circumstances with the following outcomes possible:
a. Unintentional or resident chosen violation of duty hours
i. Re-educate resident on ACGME policy one-on-one with the Program Director
ii. Re-educate resident on the Alertness Fatigue policy and the importance towards
patient safety
iii. Closely monitor that resident for the next 3 months for any possible duty hours
violations
iv. Report all of the above electronically to the DIO (Associate Dean of GME)
b. Violation of duty hours imposed by the service the resident is rotating on
i. This can be either a perceived imposition of extra hours or a clearly defined
violation.
ii. Program director must immediately contact the person responsible for the
rotation to address the violation and if a corrective action is not taken to the
satisfaction of the Residency Steering Committee, the violation should be taken
to the DIO for resolution and if necessary be addressed with the Dean’s Office.
Duty Hours Exception
See for procedures on duty hours exception:
http:/medicine.missouri.edu/gme/uploads/GME-24---Request-for-Duty-Hour-Exception.pdf
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Reviewed February 2013