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).
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.
Structural Reform of the Resident Services
Besides the question of volume, there is also the issue of whether the new service will also be used to create other structural changes in the resident services. Some areas that programs may consider include modification of the existing call rotation such as reducing or eliminating short-call, changing the frequency of long-call, or implementing limitations on night-time admissions to the housestaff.
Each of these possibilities comes with its own structural needs, so it is vital to decide whether any of these changes are to be attempted.
There is significant temptation to use established hospitalist workload standards and apply them to non-resident services in academia. To do so is to invite disaster. The complexity of patients on most academic internal medicine services is quite different from the average community service. One big variable to address here is whether or not the new hospitalist service will have a selected patient population (such as low-complexity or “non-teaching” cases). Without specifically selected low-complexity cases, most hospitalist programs will realize that established community work standards do not apply.