SUNY Downstate Health Sciences University
Neurology Residency Program at OBH
Work Hours and Fatigue Policy
PURPOSE:
This Policy is intended to comply with ACGME Program Requirements for Graduate Medical Education
in Neurology, the New York State Department of Health “Part 405 Regulations” (10 NYCRR 405.4(b)(6)),
and the SUNY Downstate Health Sciences University’s Institutional Policy on Resident Work Hours and
Fatigue, as the same may be amended from time to time (the “Institutional Work Hours Policy”). This
Policy is intended to support a work environment that is conducive to resident education and the
provision of safe and effective patient care by ensuring that physicians are fit for duty.
This Policy applies to the OBH Neurology Program sponsored by SUNY Downstate Medical Center (the
“Program”), and pertains to its faculty and residents.
DEFINITIONS:
Attending Physician: An appropriately credentialed and privileged member of the medical staff who
accepts full responsibility for a specific patient’s medical/surgical care and who may or may not be
responsible for supervising residents.
Faculty: Any individual who has received a formal assignment to teach and/or supervise residents or
fellows. At some participating sites, appointment to the medical staff of the hospital or medical center
constitutes appointment to the Faculty.
Fatigue mitigation: Methods and strategies for learning to recognize and manage fatigue to support
physician/caregiver well-being and safe patient care (e.g., Strategic napping; judicious use of caffeine;
availability of other caregivers; time management to maximize sleep off-duty; learning to recognize the
signs of fatigue, and self-monitoring performance and/or asking others to monitor performance;
remaining active to promote alertness; maintaining a healthy diet; using relaxation techniques to fall
asleep; maintaining a consistent sleep routine; exercising regularly; increasing sleep time before and
after call; and ensuring sufficient sleep recovery periods).
Fitness for Work: Also referred to as “fit for work” – mentally and physically able to effectively fulfill
responsibilities, perform required duties and promote patient safety.
Moonlighting: Voluntary, compensated, medically-related work performed beyond a resident’s clinical
and educational hours and in addition to the work required for successful completion of the Program.
Moonlighting may be performed within SUNY Downstate and its related participating sites (Internal
Moonlighting) or outside SUNY Downstate or any of its participating sites (External Moonlighting).
Night shift or Night float: Residents assigned to night float are assigned on-site duty exclusively during
evening/night shifts, are responsible for cross-covering patients until morning, and do not have daytime
assignments. This may not exceed 6 nights in a row. Such a rotation must have an educational focus.
On-Call: A period during which a resident is assigned to be in-house or available at home in addition to
the regularly scheduled duty activities.
Resident or Residents: Also referred to as “trainees” – an individual enrolled in the Program.
Scheduled Work Period(s): Assigned work within the institution encompassing hours which may be
within the normal work day, beyond the normal work day, or a combination of both. A typical work
period includes both clinical and educational required activities.
Strategic napping: Short sleep periods, taken as a component of fatigue management, which can
mitigate the adverse effects of sleep loss.
Transitions of Care: Also referred to as “transitions in care” – the relaying of complete and accurate
patient information between individuals or teams in transferring responsibility for patient care in the
health care setting.
Work Hours (Clinical and Educational Work Hours): Time spent in all clinical and academic activities
related to the Program; i.e., patient care (both inpatient and outpatient), administrative duties relevant
to patient care, the provision for transfer of patient care, time spent in-house during call activities,
clinical work done from home, all moonlighting and scheduled program activities such as conferences.
Work hours do not include reading, studying and preparation time spent away from the duty site.
POLICY:
The Program is designed to provide Residents with educational opportunities, as well as reasonable
opportunities for rest and personal well-being. As required by the Part 405 Regulations and consistent
with ACGME Requirements, the Program Director shall take appropriate action to ensure that Residents
are in compliance with Work Hour maximums or limitations. Work Hours shall be tracked and monitored
by SUNY Downstate, the Program Director, and participating sites in accordance with this Policy and the
Institution Work Hours Policy.
Maximum Hours of Work per Week
Work Hours shall not exceed 80 hours per week, averaged over a four-week period, inclusive of all in-
house clinical and educational activities, clinical assignments, clinical work done from home, and all
approved Moonlighting. Activities which count toward the 80-hour work week and for the consecutive
Work Hours work rules include inpatient assignments, outpatient clinic, emergency and acute care
assignments, attendance at educational activities such as Grand Rounds and teaching rounds, and
moonlighting. There will be no exceptions to this requirement.
Scheduling in the Program will be structured so that Residents are able to complete most work on-site,
during Scheduled Work Periods.
Maximum Clinical and Education Work Period Length
Resident Work Periods must not exceed a maximum of 24-hours of continuous scheduled clinical
assignments (including in-house On Call). After 24-hours of continuous in-house Work Hours, Residents
may remain on duty for a maximum of three (3) hours (as per Part 405 Regulations guidance) for effective
Transitions of Care, Rounds, or Grand Rounds/resident education. Residents will not be assigned
additional clinical responsibilities during this time and this time cannot be scheduled as part of assigned
work periods. This period of transition time must be counted towards the 80-hour weekly limit.
In rare circumstances, after completing a scheduled work period and handing off all other
responsibilities, a resident, on their own initiative, may elect to remain or return to a clinical site in the
following circumstances: To assist in the care of a single patient due to severity of the illness or
instability; to attend events of unique academic/educational importance; or to provide humanistic
attention to the needs of a patient or family. These additional hours of care or education count toward
the 80-hour weekly limit and must comply with 405 regulations. Documentation of the reason a
Resident remains or returns beyond a Scheduled Work Period must be submitted to the Program
Director, who will review each submission of additional work time and track and monitor both individual
Residents and Program-wide occurrences. The Program Director is permitted to prohibit a Resident(s)
from staying or returning to a clinical site in order to protect patient safety, a Resident’s health and/or
to ensure regulatory compliance.
In-House Night Float
Night-float must occur within the context of the 80-hour and one-day-off-in-seven requirements. There
may be no more than two consecutive weeks of night float, or half a calendar month (16 days).
Maximum Frequency of In-House On-Call
Residents must be scheduled for in-house call no more frequently than every third night (when averaged
over a four-week period).
At-home On Call
At-home calls must not be so frequent or taxing as to preclude rest or reasonable personal time for each
Resident. Time spent on patient care activities by Residents on at-home On Call must count toward the
80-hour maximum weekly limit. The frequency of at-home calls is not subject to the every-third-night
limitation on calls, but it may not be scheduled on the day that serves as a Resident’s One Day Off per
week. Residents are permitted to return to the hospital while On Call at-home to provide direct care for
new or established patients and these hours of inpatient patient care must be included in the 80-hour
maximum weekly limit.
The Program shall maintain records of clinical care by Residents on On-Call at home and adjust call
schedules if patient care during home call regularly causes Residents to exceed the 80-hour work week.
At-home call activities that must be counted toward Work Hour limitations include, without limitation:
responding to phone calls and other forms of communication, as well as documentation, such as
entering notes in an electronic health record.
Minimum Time Off between Scheduled Work Periods
Residents shall have at least 8 hours off between Scheduled Work Periods. When Residents choose to
stay to care for their patients or return to the hospital with fewer than eight hours free of work, this
must occur within the context of the 80-hour and the one-day-off-in-seven requirements. Residents
must also have at least 14 hours free of clinical and educational obligations after a 24-hour in-house call.
Mandatory Time Free (One Day Off per Week)
Residents shall be scheduled to receive a minimum of one day (24 hours) free of work per week. There
must be no scheduled activities during this time and at-home call cannot be assigned on these free days.
The One Day Off per week requirement may not be averaged over a four-week period.
Fatigue Mitigation
Residents and Faculty shall be unimpaired and fit for work when engaging in patient care. It is the
responsibility of all peers, supervising residents, chief residents, Attending Physicians and Faculty in the
Program to monitor for Resident fatigue or impairment and to help ensure that necessary relief or
mitigation is provided when necessary. In accordance with the Institutional Work Hours Policy and the
ACGME Common Program Requirements, the Program will:
- Educate all Faculty members and Residents on recognizing the signs of fatigue and sleep deprivation and strategies for alertness management and Fatigue Mitigation processes;
- Adopt, and encourage Residents to use, Fatigue Mitigation techniques, such as Strategic naps or back-up On-Call schedules, to manage the potential negative effects of fatigue on patient care and learning;
- Have a process to ensure continuity of patient care in the event that a Resident may be unable to perform his/her patient care duties; and
- Provide adequate sleep facilities and/or safe transportation options for Residents who may be too fatigued to safely return home.
Furthermore, a Resident who is unable to engage in patient care due to fatigue or impairment should
notify the Attending Physician at his/her clinical site and the Attending Physician will discuss the
matter further with the Program Director and/or the Vice Chairman of the Department. As
appropriate, the Resident may then take a break from his/her clinical duties or return home. If public
transportation is not a safe option for the Resident, a taxi service will be provided.
There are no negative consequences and/or a stigma when Residents use Fatigue Mitigation strategies in
the Program. Residents who are impaired rather than fatigued or sleep deprived may require
additional evaluation, referral and/or intervention and assessment by employee health services. See
the SUNY Downstate GME Policy on Impaired Residents for additional information.
Moonlighting:
Residents at the PGY 4 level only are permitted to moonlight upon approval of the Department Chair
and Program Director. The Institutional DIO and GME Office are also informed. Residents approved for
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moonlighting submit the information and documentation required before and during their
moonlighting, as noted in the Institutional GME Residents’ Handbook. All moonlighting must be logged
in New Innovations and be in full compliance with all work hours rules. Moonlighting is a privilege and
may be revoked should it interfere with resident learning.
Compliance Expectations
The Program Director will review Work Hours on a regular basis and will submit any Work Hour violations
to the DIO and GMEC for further review. In the event of a Work Hour Violation, the Program Director
will also re-educate Faculty and Residents on the Work Hour limitations and maximums. Residents who
knowingly violate the Work Hour rules or Fatigue Mitigation policies can be subject to various corrective
actions or disciplinary actions, which may include, but are not limited to: suspension, probation,
demotion, nonrenewal or termination.