Re-framing continuity of care for this century.

I t is widely accepted that ‘‘continuity of care’’ is vital to its quality and safety. The traditional approach to achieving this in the inpatient setting has been to minimize transfers among providers to reduce interruptions in the care process. In recent years the effort to limit duty hours for resident physicians (junior doctors) in the US, UK, and EU has highlighted the fact that continuity of care in teaching hospitals cannot depend on trainees working beyond limits that are advisable from a performance and safety perspective. Changing practice in teaching settings and a general movement toward shift and team based approaches to patient care have thrust into prominence the patient ‘‘hand-off’’ (also referred to as ‘‘handover,’’ ‘‘sign-out,’’ or ‘‘sign-over’’) as the process that enables multiple physicians collectively to ensure continuity and currency of information and care. Hand-offs occur at many places in the care process. In teaching hospitals their frequency has increased since the imposition of limits on resident (junior doctor) hours, in large part due to the use of duty shifts and ‘‘short-call’’ and ‘‘cross-coverage’’ models in which responsibility for patients is transferred several times during the traditional 24 hour call period. Duty hour limits also appear to affect the hand-off in other ways, such as reducing the time available for this critical aspect of care.