title: Achieving balance on the inpatient internal medicine wards: a performance improvement project to restructure resident work hours at a tertiary care center.
abstract: OBJECTIVE
  In an era of increasing duty hours restrictions, a growing body of literature describes how fatigue and handoffs affect patient care and educational experience. Although many studies examine these elements independently, there remains little understanding of how they interact. Previously reported interventions have yielded unexpected results that are likely dependent on local factors.
  
  
  METHODS
  The authors collected data on admissions, emergency department disposition, and team continuity during an 8-day period before and a 12-day period after changing from a night float system to a resident long-call system with a graded transition to a night team. House staff and attendings were surveyed afterwards.
  
  
  RESULTS
  The intervention increased the portion of patients admitted to their primary resident from 47% (43/91) to 82% (75/91) (P < .01) and improved the percentage of emergency room admissions performed in less than 90 minutes from 39% (7/18) to 70% (39/44) (P = .02). The percentage of self-reported duty hours violations decreased from 55% (16/29) to 6.8% (3/44) (P < .01). Survey respondents reported an improved sense of patient involvement, quality of care, and handoffs.
  
  
  CONCLUSIONS
  Designing a call system around a brief assessment of admission intensity resulted in better alignment of resident resources with workload and improvements in multiple outcomes. Optimization of inpatient work structure appears to be significantly affected by local factors. Future trials assessing work hour balance will need to take work intensity into account and assess a wide variety of potential consequences.
authors.affiliation: Dr. Cohee is pulmonary and critical care medicine fellow, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland. At the time of the study, he was chief of residents. Dr. Hartzell is associate program director, Internal Medicine Residency, and infectious diseases faculty, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland. Dr. Shimeall is program director, Internal Medicine Residency, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Cohee
authors.forename: Joshua D
authors.initials: JD
authors.lastname: Hartzell
authors.forename: William T
authors.initials: WT
authors.lastname: Shimeall
mesh_terms: D000328:Adult; D002055:Burnout, Professional / Q000517:prevention & control*; D004503:Education, Medical, Graduate / Q000458:organization & administration; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D004650:Employee Performance Appraisal; D005221:Fatigue; D005260:Female; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency / Q000458:organization & administration*; D008297:Male; D005791:Patient Care / Q000379:methods; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration*; D018570:Risk Assessment; D062606:Tertiary Care Centers / Q000458:organization & administration; D014481:United States; D014940:Work Schedule Tolerance / Q000502:physiology*; D016526:Workload / Q000706:statistics & numerical data*