The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

OBJECTIVES: The Accreditation Council for Graduate Medical Education recently released new standards for supervision and duty hours for residency programs. These new standards, which will affect over 100,000 residents, take effect in July 2011. In response to these new guidelines, the Society of Critical Care Medicine convened a task force to develop a white paper on the impact of changes in resident duty hours on the critical care workforce and staffing of intensive care units. PARTICIPANTS: A multidisciplinary group of professionals with expertise in critical care education and clinical practice. DATA SOURCES AND SYNTHESIS: Relevant medical literature was accessed through a systematic MEDLINE search and by requesting references from all task force members. Material published by the Accreditation Council for Graduate Medical Education and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force corresponded by electronic mail and held several conference calls to finalize this report. MAIN RESULTS: The new rules mandate that all first-year residents work no more than 16 hrs continuously, preserving the 80-hr limit on the resident workweek and 10-hr period between duty periods. More senior trainees may work a maximum of 24 hrs continuously, with an additional 4 hrs permitted for handoffs. Strategic napping is strongly suggested for trainees working longer shifts. CONCLUSIONS: Compliance with the new Accreditation Council for Graduate Medical Education duty-hour standards will compel workflow restructuring in intensive care units, which depend on residents to provide a substantial portion of care. Potential solutions include expanded utilization of nurse practitioners and physician assistants, telemedicine, offering critical care training positions to emergency medicine residents, and partnerships with hospitalists. Additional research will be necessary to evaluate the impact of the new standards on patient safety, continuity of care, resident learning, and staffing in the intensive care unit.

Provider to patient ratios for nurse practitioners and physician assistants in critical care units.

BACKGROUND: Nurse practitioners and physician assistants are being increasingly integrated into intensive care unit and hospital-based care teams, yet limited information is available on provider to patient ratios. OBJECTIVE: To determine current provider to patient ratios for nurse practitioners and physician assistants working in intensive and acute care units and to assess factors that affect the ratios. METHODS: A descriptive study design was used with a Web-based survey of members of the American Association of Nurse Practitioners, American Academy of Physician Assistants, and the Society of Critical Care Medicine. RESULTS: Responses were received from 222 nurse practitioners and 211 physician assistants from all but 8 of the 50 United States and from Canada. Mean provider to patient ratios in intensive care were 1 to 5 (range, 1 to 3 - 1 to 8). In pediatric intensive care, the mean ratio of nurse practitioners to patients was 1 to 4 (range, 1 to 3 - 1 to 8). Factors that affected nurse practitioner and physician assistant provider to patient ratios included patients' severity of illness, number of patients in the unit, number of providers in the unit, patient diagnosis, number of physicians in the unit, time of day, and number of fellows and medical residents on service. CONCLUSIONS: Additional information on factors influencing provider to patient ratios and specific components of the roles of nurse practitioners and physician assistants will be important to ensure the best utilization of these providers to enable optimal patient care outcomes.