An ACGME Duty Hour Compliant 3-Person Night Float System for Neurological Surgery Residency Programs

Abstract

Background In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted the 24+6-hour work schedule and 80-hour workweek, and in 2011, it enhanced work hour and supervision standards. Innovation In response, Oregon Health & Science University's (OHSU) neurological surgery residency instituted a 3-person night float system. Methods We analyzed work hour records and operative experience for 1 year before and after night float implementation in a model that shortened a combined introductory research and basic clinical neurosciences rotation from 12 to 6 months. We analyzed residents' perception of the system using a confidential survey. The ACGME 2011 work hour standards were applied to both time periods. Results After night float implementation, the number of duty hour violations was reduced: 28-hour shift (11 versus 235), 8 hours off between shifts (2 versus 20), 80 hours per week (0 versus 17), and total violations (23 versus 275). Violations increased only for the less than 4 days off per 4-week interval rule (10 versus 3). No meaningful difference was seen in the number of operative cases performed per year at any postgraduate year (PGY) training level: PGY-2 (336 versus 351), PGY-3 (394 versus 354), PGY-4 (803 versus 802), PGY-5 (1075 versus 1040), PGY-7 (947 versus 913), and total (3555 versus 3460). Residents rated the new system favorably. Conclusions To meet 2011 ACGME duty hour standards, the OHSU neurological surgery residency instituted a 3-person night float system. A nearly complete elimination of work hour violations did not affect overall resident operative experience.

Effects of 24-hour versus night-float call schedules on the clinical and operative experiences of postgraduate year 2 and 3 neurosurgical residents

“…In surgical specialties, most adaptations have sought to optimize resident operative experience in the face of progressively restrictive duty-hour limits. [2][3][4][5][6][7] Our program recently transitioned from a night-float to a 24-hour call schedule by assigning a greater share of overnight call duties to PGY-3 residents. We sought to quantify the effects of this change on formative junior resident clinical experiences both inside and, in the first report to our knowledge, outside of the operating room.…”

“…We did not study the timing at which bedside procedures were performed in this or the previous study of the night-float system at our institution. 2 In the only study to examine this to datea single junior resident's call log from a different institution-a significantly higher proportion of bedside procedures was performed during the daytime. 1 At OHSU, PGY-2 residents took similar proportions of the daytime call under the 24-hour and night-float call systems, possibly accounting for the unchanged procedural volumes between the two systems.…”

“…Transitions to either system have garnered strong support among residents at various individual programs. 2,4,6,8,9 Data comparing the effects of these schedules on resident call-related workload are notably lacking,…”

Defining Service and Education in Pediatrics

“…Duty hour restrictions have led many programs to implement night float systems so as to avoid long stretches of continuous hours working overnight on call and minimize duty hour violations. 11 Such innovative schedules have led to improved resident satisfaction and quality of life, 12 and some data indicate residents perceive quality of care to be higher with a night float system. 13 On the other hand, eliminating overnight call has also compromised clinical exposure in some training settings 14 and may actually be detrimental for trainee sleep.…”

On resident duty hour restrictions and neurosurgical training: review of the literature

“…In general surgery, there has been no overall decrease in the operative experience for junior and senior residents who started training prior to the 2011 changes; however, maintaining operative experience for interns was only feasible with the implementation of a novel call system. 35 The same has not been true for neurosurgical residents, excepting for programs adopting unusual night float systems, 33 which as a tradeoff may increase patient handoffs and so potentially compromise patient care. It seems that the predicted decrease in technical training due to the 2011 intern guidelines may not be been borne out, but maintaining intern case volume has necessitated new systems of duty hours (night float, naps) and increased use of midlevel providers, 18 which reduces the exposure of residents to practice.…”