New Duty Hour Restrictions

[Allerian1004]

How did your program handle the new work hour restrictions? I've heard some pretty awful schedules. An IM program near me does 7am to 9pm. Yuck. We do 6:30-6pm (signout). With two months of nights throughout the year. I don't think any of the rotations our 2nd or third years do are the traditional q4hr call.

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[MJB]

All I will say is that the "new and improved" rules made the schedule much, much worse in my opinion.

To me, working 8-10 (even 12) hour days with the occasional 24-30 hour call thrown in is MUCH better and less exhausting than doing a bunch of 14-16 hour shifts in a row, mingled in with some 16 hour overnights.

Thanks a lot to whoever did this.

 

[Doctor4Life1769]

All I will say is that the "new and improved" rules made the schedule much, much worse in my opinion.

To me, working 8-10 (even 12) hour days with the occasional 24-30 hour call thrown in is MUCH better and less exhausting than doing a bunch of 14-16 hour shifts in a row, mingled in with some 16 hour overnights.

Thanks a lot to whoever did this.

Thank you, ACGME.

 

[turkeyjerky]

All I will say is that the "new and improved" rules made the schedule much, much worse in my opinion.

To me, working 8-10 (even 12) hour days with the occasional 24-30 hour call thrown in is MUCH better and less exhausting than doing a bunch of 14-16 hour shifts in a row, mingled in with some 16 hour overnights.

Thanks a lot to whoever did this.

I don't really understand exactly why the rule changes have "forced" some programs into having residents work "six 16 hr days per week" (which obviously shouldn't actually happen as it's an hours violation). It seems like it's just a way for angry PDs to stick it to the interns.

I've had a couple of rotations where the residents would work 7-5 or so, with an admitting team staying until 9 or 10 (taking any new admits until 7) and getting out a bit early the next day, with nightfloat from 7-7.

 

[MJB]

Most PD's seemed to be VERY high on having the overnight person round in the morning...so, 8pm til noon the next day (or earlier if rounding and work is done).

We will basically be doing 6a-5/5:30p...or 6a-8p, or 7:30P to "after rounds".


Old system was 6a-5p and 4:30p to "after rounds". Would have been SWEET.


This "new and improved" system will increase the number of hand-offs...more specifically, increasing the number of hand-offs from one 'tern to another as well. Recipe for bad mojo imo.

 

[dragonfly99]

The reason that attendings, PD's and probably most fellows like to have at least one member of the admitting team there on rounds is that otherwise there is NOBODY there on rounds who knows the patient. So you have some paper and/or verbal signout on some patient that none of the people on rounds has ever seen...not a recipe for good patient care.

I think the initial 80 hr rule/30 hour thing was a very good thing, but I'm not sure why the radical shortening of intern hours all of a sudden...we'll have to see how it works...whether a total disaster vs. not.

 

[MJB]

The reason that attendings, PD's and probably most fellows like to have at least one member of the admitting team there on rounds is that otherwise there is NOBODY there on rounds who knows the patient. So you have some paper and/or verbal signout on some patient that none of the people on rounds has ever seen...not a recipe for good patient care.

I think the initial 80 hr rule/30 hour thing was a very good thing, but I'm not sure why the radical shortening of intern hours all of a sudden...we'll have to see how it works...whether a total disaster vs. not.

I agree that it's important for the night float to be there for rounds. That's why I purposely looked for non-night float programs. Before these new rules, it's my opinion my program was the best of both worlds.

You have to wonder whose input is accepted when these rules changes are dreamed up.

 

[QofQuimica]

To me, the whole nightfloat versus 30-hr call argument is bunk. By the end of an inpatient rotation, I feel equally exhausted whether I was taking Q4 call or doing night float, and given my druthers, I'd just as soon not do either of them.

OP, our schedule is pretty similar to yours except nights are an hour or two longer for rounds/signout.

 

[MJB]

given my druthers, I'd just as soon not do either of them.

Amen...which is why I'll do my time, then outpatient medicine, here I come! No silly shifts, no silly call.

 

[ShyRem]

hospitalist. I'm thinking hospitalist.

 

[Mattchiavelli]

Theoretically, shouldn't every admitted patient have an admission H&P that will tell you everything the admitting physician knows about a patient? If you can't direct patient care based on the written record, isn't that more of a documentation issue rather tan a coverage issue? In addition, everything that happened on night float should be documented and available for review the next AM [it's the second thing I check on patients in the AM after vitals].

 

[SouthernSurgeon]

Theoretically, shouldn't every admitted patient have an admission H&P that will tell you everything the admitting physician knows about a patient? If you can't direct patient care based on the written record, isn't that more of a documentation issue rather tan a coverage issue? In addition, everything that happened on night float should be documented and available for review the next AM [it's the second thing I check on patients in the AM after vitals].

Written communication is not always a substitute for effective verbal communication. Additionally the chart is not always the place for supposition or clinical intuition, and is an attempt at balancing effective/comprehensive documentation with appropriate brevity. Good handoffs require direct communication and the opportunity to ask/answer questions.

 

[Smurfette]

Theoretically, shouldn't every admitted patient have an admission H&P that will tell you everything the admitting physician knows about a patient? If you can't direct patient care based on the written record, isn't that more of a documentation issue rather tan a coverage issue? In addition, everything that happened on night float should be documented and available for review the next AM [it's the second thing I check on patients in the AM after vitals].

Sure there's an H&P. But depending on how long the patient has been in the hospital, it may not be feasible to easily find the info you're looking for in the chart AND you may not be able to physically look at the chart when you're answering the page. It's not always easy to find what you're looking for, and you can't assume that everything is documented as well as you would like it to be. A lot can happen to a patient in a very short period of time.

And not everything requires a note by night float. Major events, yes. If every time you give an order or get a page from nursing, you try and write a note about it, you will go crazy trying to keep up. Usually a verbal signout to communicate is more helpful than trying to read a ton of charts in the morning before rounds and allows you to ask questions. We generally cross covered well upwards of 50 patients on call, and our own average service census was anywhere from 12-30ish patients (not like IM which has patient caps).

 

[Law2Doc]

Theoretically, shouldn't every admitted patient have an admission H&P that will tell you everything the admitting physician knows about a patient? If you can't direct patient care based on the written record, isn't that more of a documentation issue rather tan a coverage issue? In addition, everything that happened on night float should be documented and available for review the next AM [it's the second thing I check on patients in the AM after vitals].

The H&p becomes relatively obsolete once folks start to do things to an admitted patient. Things can change on a daily basis, and some patients re in the hospital for weeks. As for documentation, sure everything is hopefully somewhere in the chart, but the issue tends to be time. You really don't have the time to sit down with the chart when things start going downhill and figure out what's going on. So you really need a handout that is the equivalent of the cliffs notes for the patients with major issues being handed off to you. Also bear in mind that in the day of cross coverage, some residents end up covering 20-40 patients, not a handful that they can sit down and read all the charts.

See also southern's response above. It has to be a verbal, concise handoff or things will not get highlighted appropriately.

 

[Mattchiavelli]

I guess I wan't the clearest- I was referring to someone on night float admitting with a handoff in the AM and the accepting team seeing them on rounds the next day alone vs the admitting resident rounding the next day. Some participants had made it sound like if the admitting night float resident wasn't rounding on the patient the next AM that all was lost.

I get the concept of handoffs/cross coverage.

And where I'm working, nursing writes the notes about events that happen overnight as to what they called about and what action was taken. It's usually a 2 or 3 sentence blurb about reason called and action taken.

 

[Doctor4Life1769]

hospitalist. I'm thinking hospitalist.

ew.

 

[ZagDoc]

Surgical intern here... our schedule "works" within the new limitations but sucks pretty badly.

Night float system. Day shift 6am - 7pm. Night shift 6pm - 7am. There's supposed to be a half hour overlap in the AM/PM for signout, half hour for rounds. Both 'terns rounds in the morning - night shift 'tern puts in orders, day shift 'tern writes notes and organizes floor work for the day. Monthly schedule is generally 3 weeks on days, 1 week on nights, 1 weekend on days, 1 weekend on nights, one golden weekend.

The issue that has come up is that no surgical service ever rounds at 6:30. We're told the expectation is that if the chief wants to round earlier than 6:30 am, the day intern is supposed to get there early enough to sign out and pre-round. Well on conference days and early OR days or busy service days (typically 3 or 4 days a week), we often round at 5:30. Which means getting in at 4:45-5am as the day intern. If you do 6 13's in a week you're already at 78 hours, so add in a couple days of coming in early and most of us have been over 80 pretty easily already. Not to mention is PM rounds run late you're not always out at 7pm on the dot. They've tried to mitigate this by having the night intern do the pre-rounding, but then as the day intern you don't know you patients as well. We're supposed to get 5 days off a month, but two of those are DOMAs when you're switching between night and days or vice versa.

Like I said, it "works", it just sucks. Would love to have a post-call day or two. We're told we're supposed to be "working" on nights, but none of the ancillary staff is, so besides the occasional admit and putting out a few fires, you're bored a lot. Once I get comfortable working up chest pain, fiddling with hypotension, etc those days are going to be of no educational benefit to me.

 

[Law2Doc]

...
And where I'm working, nursing writes the notes about events that happen overnight as to what they called about and what action was taken. It's usually a 2 or 3 sentence blurb about reason called and action taken.

In theory you are correct. However you will learn to be very jaded and suspect of these blurbs. Plenty of nurses float from hospital to hospital and arent equally dedicated. There will be times when nothing is written yet something significant happened, and times when it looks like someone just copied the same thing over and over again. Plus you get no sense of whether there is a patient care plan here, and whether the doctor is actually treating something significant, or simply treating the nurse -- ie giving the patient something benign to get the nurse to stop calling him. You need sign out from the actual doctor involved or you are gonna get burned at some point.