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Limiting residents' work hours may have unintended consequences on continuity of care

Physician fatigue and associated errors were the primary reasons for development of new rules that limit residents' weekly work hours. As residency programs work towards compliance with the new regulations, their impact on continuity of inpatient care should concern both physicians and patients, caution Sanjay Saint, M.D., M.P.H., of the University of Michigan Health System, and his colleagues in a recent paper. Their work was supported in part by the Agency for Healthcare Research and Quality (HS11540).

The new rules, which went into effect in 2003, state that residents cannot work more than 80 hours per week and must take 1 day off-duty per week. They should have at least 10 hours between duty periods, and their tour of duty must be limited to 24 consecutive hours, with 6 additional hours allowed for teaching and transfer of care (to ensure continuity of care).

Transfer of care often increases the likelihood of misinformation and error. Frequent transfer of care also can disrupt patients' relationships with their doctors and care satisfaction. Furthermore, many doctors prefer to care for patients throughout their illness and say they learn from such experience. Float systems and shift work are two solutions being tried to balance resident fatigue with continuity of care. Night-float systems generally involve a resident or team of residents initiating their duties at night to relieve the on-call team of some responsibilities. Day float systems have also been used.

The United Kingdom has implemented shift-work systems. On full shifts, trainees rotate through shifts that begin and end at different times; on partial shifts, they work normal daytime hours with an occasional extra shift. During partial-shift duty, residents often receive breaks and protected time for sleeping. Other potential solutions have been studied less or not at all, such as patient-admission caps, physician extenders, and reorganizing ward teams so that coverage is staggered.

See "Balancing continuity of care with residents' limited work hours: Defining the implications," by Kathlyn E. Fletcher, M.D., M.A., Dr. Saint, and Rajesh S. Mangrulkar, M.D., in the January 2005 Academic Medicine 80(1), pp. 39-43.

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