Resident Sign-Out and Patient Hand-Offs: Opportunities for Improvement

Abstract

Background: Inpatient care is characterized by multiple transitions of patient care responsibilities. In most residency programs trainees manage transitions via verbal, written, or combined methods of communication termed “sign-out.” Often sign-out occurs without standardization or supervision. Purpose: The purpose was to assess daily sign-out with a goal of identifying aspects of this process most in need of improvement. Methods: This was a prospective, observational cohort study of interns’ sign-out conducted by industrial engineering students. Daily sign-out was analyzed for inclusion of multiple criteria and scored on organization (on a scale of 0–4) based on how effectively written information was conveyed. Results: We observed 124 unique verbal and written sign-outs. We found that 99% of sign-outs included a general hospital course. Sign-outs were well organized with a mean of 3.1, though substantial variation was noted (SD = 0.8). Directions for anticipated patient events were included in only 42% of sign-outs. Do Not Resuscitate (DNR) or advanced directive discussions were reported in only 11% of sign-outs. Only 50% of successive daily sign-outs were updated. Conclusions: We found variability in the content and organization of interns’ sign-out, possibly reflecting a lack of instruction and supervision. Standardization of sign-out content, and education on good sign-out skills are increasingly important as patient hand-offs become more frequent.