What Is the Effect of ACGME Duty Hours Regulations?

There will be costs associated with implementing the recommendations, such as hiring additional staff at various levels. Along with the changes, the IOM recommends creating programs to monitor and evaluate the effectiveness of the changes, and follow-up to help fine-tune duty hour programs.

Some of the key changes in recommendations include:

• Maximum shifts should be no more than 30 hours, which includes admitting patients for up to 16 hours plus a five-hour protected sleep period between 10 PM and 8 AM. (Remaining hours would be for transitions and educational activities.)
• The maximum in-hospital on-call frequency would be every third night, but with no averaging.
• The minimum time off between scheduled shifts would be 10 hours after day shifts, 12 hours after night shifts, and 14 hours after any extended duty period of 30 hours.
• There is now a maximum frequency of in-hospital night-shifts: a four-night maximum; 48 hours off after three or four nights of consecutive duty.
• Internal and external moonlighting both count against the 80-hour weekly limit. All other duty hour limits apply to moonlighting in combination with scheduled work.

Further details of the recommendations can be found at the IOM Web site at www.iom.edu/CMS/3809/48553/60449.aspx .

Making Duty Hour Regulations More Effective

According to Christopher P. Landrigan, MD, MPH, there are several factors that can help make reduced duty hours more effective.

The current ACGME regulations don’t go far enough in terms of the types of recommendations, and don’t necessarily lead to decreased physician fatigue or improved performance overall, he said. Indeed, one study showed that residents working 24-hour shifts made 36% more serious errors and 460% more serious diagnostic errors compared with those working 16-hour shifts.

Dr. Landrigan was coauthor of an article in a recent edition of JAMA (Sept. 10, 2008) which highlights ways to improve duty hour effectiveness:

1. Move to a 16- to 18-hour shift limit. Eliminate 24-hour shifts.
2. Implement a mandatory overnight sleep program to allow residents enough protected time to sleep (ideally, seven to eight hours) when they are at their circadian nadirs.
3. Rotate shifts in a clockwise manner to allow for easier circadian adjustment.
4. Schedule shorter shifts, but allow for substantial shift overlap to minimize any discontinuity of care.
5. Redesign the flow of patients and assignment to teams. This can allow better workflow over time.
6. Improve sign-out procedures-structured computerized tools can help with this.
7. Make sure there is adequate staffing and supervision.

A useful resource doctors can turn to for developing safe schedules is the Harvard Work Hours Health and Safety Group, which has information for developing safe schedules: http://workhoursandsafety.org .