Cover a Service 24-7 Under new Rules?

[Pilot Doc]

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So I've been trying to figure out how you could cover a service 24-7 with an all-resident team under the new rule. The best I've been able to come up with is a 3 resident system that averages about 60 hours a week. It's a cycle of three 6-day blocks

NIGHT
NIGHT
NIGHT
NIGHT
OFF
OFF

DAY
OFF
OFF
DAY
NIGHT
NIGHT

OFF
DAY
DAY
OFF
DAY
DAY

(cycle repeats)

Can anybody do better?

 

[surg]

Not sure if this will come through and yes, I think this is beyond nerdy.

The attached schedule utilizes the minimum of cross cover to get the sleeping periods covered by another service from 10P-3A, and having someone come in early at 2A when your service is on sleep time from 3A-8A (with that intern "waking up" at 8AM to go home since they have signed out at 2AM). 48 hr time periods off are exactly 48hrs off (in purple highlight), single days off marked in green are usually about 40 hrs, and on call days are marked with stars. there are occasional periods about (16 hrs every 2 weeks) where no intern is in house and another service will need to cross cover with a senior resident doing back up or assign a mid level to take that time. generally happens from 2P-6A on a weekend day.

 

[Pilot Doc]

At least a couple of problems after a quick glance

- Can't start a call shift at 2am. At 16 hours you have to get a 5 hours sleep break and that sleep break has to be after 10pm. Means the earliest you can come in for call is 4am.

- Post sleep break call hours can't be used for admitting patients. You only get to do that your first 16 hours. Your schedule sometimes has the call-intern alone in house post sleep. He can't take new patients.

Nuts .... I know

 

[surg]

Guess that's what I guess for looking at them quickly, and hammering that out in 30 min in the middle of the night.

I'm looking at the rules, and again this has to do with the letter, but perhaps not the spirit. It says one can work for 30 hrs, and must have their sleep period between 10P-8A, but doesn't say that the sleep period has to be right @ hr 16. Thus, you could do this. You can't admit after hour 16, but this is simplified by having non-floor interns admit (which most programs I have been associated do, either have the ER consult person who is working more shift work admit). Thus he/she can have new patients show up on their service, but not be "admitting" them. Otherwise, you can have the consult person manage them until the morning (which is what my current program does) then dump them into the team come morning rounds.

Given this, it looks over compliant since I just found out that the 5 hour sleep break DOESN'T count as part of your 80 hours! (see the actual IOM report Appendix B for sample schedules) You can read it one page at a time for free and print it out 1 page at a time at http://www.nap.edu/catalog.php?record_id=12508 <-----------------This is wrong---------- see Pilot Doc's post below.

Anyway the schedule I provided above tries to do some things.
Goals: 1)letter of the law compliance, 2) Ensure that there is someone rounding on the team each morning that has been there or received signout about what happened each time 2A) minimize amount and length of cross cover, 2B) ensure overlap for at least 1-2 hour for turnover/rounding as much as possible 3) keep days off on Fri/Sat/Sun (although you can move the Friday into other weekdays often if the service has an easier weekday than Friday)

Things I gave up to make this work: 1) sane work schedules. 2AM is just NOT normal. It had to happen so that someone could go to bed by 3AM though to get their sleep time in. 2) sometimes there is no one from that team in house (although only 1 day/2weeks and if you wanted you could make a midlevel come in and cover that time I suppose)

I'll have to think about what I'd do with 2 interns/service; still seems doable, but much harder.

New file

 

[Pilot Doc]

You're right about the 16 hours, although that is a loophole that might get closed. By that read, you could work 25 hours straight and then get your 5 hour break.

I'm pretty sure the sleep period does count toward hours.

http://books.nap.edu/openbook.php?record_id=12508&page=30

"The 5 hour period for sleep must count toward total weekly duty hour limits"

 

[surg]

Oops. you are totally right. Somehow, I was reading the Appendix B to say that they were @ 90 hours in that 1st week including 10 hrs for sleep. Revert back to 1st excel file.