In July of 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented new rules that restricted resident work hours to no more than 80 per week and restricted continuous duty to no more than 30 hours (24 hours plus 6 hours for transfer of care, the “24+6” rule). As a result, many major academic medical centers face the problem of handling increasing inpatient volume and ensuring compliance with these new work-hours regulations. The problem has become more pressing as several major academic centers have been cited for work-hours violations by the ACGME, and significant public attention has focused on the impact of excessive work hours on patient safety (1, 2).
Explore this issue:January/February 2005
Given the success of hospitalists in efficiently managing patents in many non-academic environments, one proposed solution has been the creation of hospitalist services to care for patients independent of residents. These services reduce the volume on resident-based services and therefore reduce resident work hours. We have recently implemented our own non-housestaff service at the University of Michigan and in this article describe the challenges and lessons learned.
Planning a Program
The first step for any institution contemplating the creation of a non-resident service is to establish clear goals. Frequently, decisions on the level and scope of uncovered services are made without any rigorous analysis of the data or without a clear idea of what it is that your program should be doing.
Goals for Resident-Service Census and Volume
The first task for any program is to understand what patient volume must be removed to ensure work-hours compliance without impeding the educational experience of the housestaff . Unfortunately, there is little published opinion on optimal resident workload, and the ACGME is surprisingly silent on this vital issue. While the ACGME does proscribe exceeding theoretical maximum workloads for internal medicine, they cite no minimum or ideal patient census (3). In the absence of firm guidelines, it is important to gather data on both the day-to-day variation of inpatient admissions and volume along with peak admission times (usually early evening). The residency program is likely to offer monthly data or a rough guess at what they think is needed. This can be misleading and does not appreciate the variability of patient flow. It is the “peaks’ that are often remembered, whereas the “troughs” are easily forgotten. Vital data elements that should be obtained include the daily admission volume for each resident-service over the course of the past year. We used this data to calculate average per-intern admission volumes and to project what future volume would be under a variety of possible scenarios, including removing a fixed number of patients per day, creating intern-admissions caps or alternating admissions between residents and hospitalists. We then discussed these models and their projected impact on the residents with residency leadership before settling upon our final model.