Work Hours, Resident Supervision, Anesthesia Monitors Mandated
Work rules for the duration of call and supervision of house officers in New York, proposed last year, are about to become reality. Likewise, specific electronic monitoring during anesthesia will soon be required by state regulation.
The New York State Hospital Review and Planning Council endorsed new regulations for the revised Hospital Code on June 9. These now only await the approval of the Commissioner of the New York State Department of Health. The revised NYS Hospital Code states that as of July 1, 1989, resident hours other than in the emergency department will be limited to 24 continuous hours within the hospital. Nor can the weekly total exceed 80 hours per week when averaged over four weeks.
Clinical tours of duty must be separated by at least eight non-working hours. Also, senior attending physicians will be required to be on duty in the hospital 24-hours a day to provide contemporaneous and immediate on-site supervision of house staff.
Additionally, hospitals must review each resident’s credentials and specify in detail his or her clinical privileges. The mechanism for review leads to assignment of residents to one of three categories regarding invasive procedures. Depending on the resident’s knowledge and experience, he or she will be able to (1) perform a specific procedure alone, (2) under the general or indirect supervision of an attending physician or (3) only with immediate direct supervision and observation by the attending physician.
These elements in the new Hospital Code arose as a consequence of the “Libby Zion affair” in which the daughter of Sydney Zion, an influential lawyer and writer died in a New York City hospital after allegedly receiving improper care. An impaneled Grand jury in Manhattan investigating the death implicated unsupervised and fatigued residents as contributory in the death. In response to this, Dr. David Axelrod, Commissioner of Health appointed an Ad Hoc Advisory Committee on Emergency Services (the “Bell Committee”) to make recommendations on the supervision and working hours of residents in teaching hospitals. It was these Bell Committee recommendations that became the substance of the new hospital code
At a recent meeting of the New York Society for Thoracic Surgery in February of this year, Dr. Axelrod discussed the Bell Committee report and answered questions from medical educators in the audience. Dr. Axelrod spoke of his “wider view of public health” and the need for equal distribution of preventable risk. He sees systemic problems in teaching institutions and, much like a modem day Flexner, he feels there is a need for immediate government intervention. He points to a failure of the voluntary sector to adjust to the rapidly changing hospital environment which is ever-increasingly dominated by sicker patients. Coupled with this, he sees an, inordinate faculty emphasis on practice income which has eroded teaching and supervision.
Poor Outcome From Inadequate Supervision
Dr. Alfred Gellhorn, co-chairman of the Advisory Committee on Physician Recredentialing, and the NYS Department of Health’s Director of Medical Affairs also spoke at this meeting. Dr. Gellhorn is well known to medical educators throughout the State for his efforts as the chairman of the Council on Graduate Medical Education which seeks to reduce and reallocate the number and type of residency training positions in New York. Dr. Gellhorn stated that as a result of the Malpractice Act of 1985 which set up an adverse incident monitoring system, the New York State Department of Health had determined that poor patient outcomes could be directly linked to inadequate resident supervision; thus, according to Dr. Gellhorn, an existing problem was only highlighted by the Libby Zion case. More incidents appear to occur on nights and weekends when there is less supervision. He also pointed out that the average intensity of each case is increasing and the decreased patient contact time due to DRG mandated short stays only aggravates the problem.
New York City’s Health and Hospital Corporation (HHC), which is the largest provider of municipal health care in the country, estimates that for its hospitals alone, it will cost a minimum of $58 million more per year to both provide for the ancillary staff and attending physician staff necessary to comply with these new regulations. These municipal hospitals are likely to be the hardest hit as their budget are already strained with the ever-increasing cost of AIDS cam It is estimated that by 199 1, the cost of AIDS care in New York City will total more than one billion dollars. The Greater New York Hospital Association representing the private and voluntary hospitals placed the cost of replacing the lost resident hours at an additional $80 million annually. The cost for the whole state has been put at over $200 million by the Commissioner’s office. It is still unclear where the funding will be found to implement these radical changes. The Department of Health proposes that hospitals receive more funding through increased reimbursements under DRGS. Whether it be from the public coffers or from third party payers, the public will ultimately assume the cost of the-se changes either through taxes or increased
costs. The Bell Committee, in its report of October 7, 1987, made 17 distinct recommendations; the last was that “AU the recommendations are based on the understanding that the Department of Health will make available to hospitals the necessary funds to implement the recommendations.” Hospital administrators and medical educators remain skeptical that funds will be forthcoming.
Despite the seeming inevitability of these regulations during evolution of the proposal over the last I 8 months and the discussion and debate they have triggered, few hospitals have made definitive contingency plans to deal with the changes. To meet the expected shortfall, particularly in junior resident hours, some institutions are considering expanding senior resident hours or adding nurse practitioners, while others plan to add physician assistants or full-time house physicians
Traditional physicians and educators may see this as a major encroachment on graduate medical education and a compromise of patient cam Those with more moderate pedagogical views recognize the need for some reform but fear that by cutting daytime hours to allow continued night call, resident training experiences will be reduced; residents will attend fewer lectures and conferences and thereby have less interaction with senior staff. The more liberal educators and public health officials see this as a major advance that will soon spread throughout the country. They claim that it will both improve patient care and attract better residents to New York. Commissioner Axelrod sees this as a major advance in physician training and quality assurance. He anticipates that hospitals will relieve valuable house staff of the burden of scut work by hiring less skilled and cheaper ancillary personnel to perform these tasks.
The new Hospital Code also specifically addresses appropriate anesthesia monitoring. Section 405.13 on Anesthesia Services in its provisions states the following requirements:
“All anesthesia care shall be provided in accordance with accepted standards of practice and shall ensure the safety of the patient during the administration, conduct of and emergence from anesthesia. The following continuous monitoring is required during the administration of general and regional anesthetics… During the administration and conduct of all anesthesia on and after January 1, 1989 the patient’s oxygenation shall be continuously monitored to ensure adequate oxygen concentration in the inspired gas and the blood through the use of a pulse oximeter or superior equipment. During every administration of general anesthesia using an anesthesia machine, the concentration of oxygen in the patients breathing system shall be monitored by an oxygen analyzer with a low oxygen concentration alarm… For every patient receiving general anesthesia with an endotracheal tube, the quantitative carbon dioxide content of expired gases shall be monitored through the use of end tidal carbon dioxide analysis or superior technology. In all cases where ventilation is controlled by a mechanical ventilator, there shall be in continuous use an alarm that is capable of detecting disconnection of any components of the breathing system.”
It is axiomatic that the regulatory environment is event-driven. This is certainly true in aviation and increasingly so in medical care. These described changes to the Hospital Code in New York reflect a growing disenchantment by State public health officials with the traditional voluntary consensus organizations and professional guilds that have overseen medical education, clinical care and practice standards to date
Dr. Lees is Professor and Chairman of Anesthesiology at New York Medical College and a member of the Editorial Board of the APSF Newsletter.
Does the advent of strict governmental practice regulations portend a return to simpler times and techniques in anesthesia and surgery?