Sign-out Process Research Articles

Standardized sign-out improves completeness and perceived accuracy of inpatient neurology handoffs

As residency programs adjust to new duty hour restrictions, the use of cross-coverage systems requiring handoffs will rise. Handoffs are vulnerable to communication failures when unstructured. Accordingly, we implemented a standardized sign-out process on our inpatient neurology services and assessed its effect on completeness and perceived accuracy of handoffs. Residents spent the first half of their rotations utilizing unstructured sign-out. They transitioned to a structured sign-out system (using the situation-background-assessment-recommendation format) during the second half of their rotations. We analyzed survey responses before and after implementation to evaluate for an effect. Residents utilizing structured sign-out were significantly more likely to share test results with patients/families prior to shift changes (p = 0.037), update our electronic service list (p = 0.045), and feel all important data were being transmitted (p = 0.041). Overall satisfaction (scale 1-10) increased from 6.2 ± 1.6 to 7.4 ± 1.3 (p = 0.002). Our findings demonstrate that standardized sign-out improves the completeness and perceived accuracy of handoffs. Such improvement has the potential to improve patient safety and quality of care.

Implementing Faculty Evaluation of Written Sign-Out

Purpose: Recently the Accreditation Council for Graduate Medical Education mandated decreased shift duration for intern physicians to no more than 16 hours. Such work-hour restrictions are likely to increase patient care hand-offs. It is well accepted that sign-out (i.e., hand-off) processes are error prone and lack standardization. Moreover, many residency programs do not evaluate sign-out. We designed and tested whether a sign-out evaluation process could be implemented to improve written sign-out. Method: Based on observed sign-out deficiencies at our institution we adapted a simple curriculum incorporating the SIGNOUT mnemonic, which we paired with weekly faculty member evaluation and feedback on sign-out using a structured sign-out evaluation tool. Later in the week, written sign-out was independently scored by 2-blinded senior resident reviewers who compared the inclusion of sign-out content, organization, and readability. Results: Compared to baseline data in 128 written sign-outs, the pairing of a 1-page curriculum with weekly faculty member evaluation of written sign-out improved the inclusion of advanced directives from 38% to 69% (p < .001) and anticipatory guidance from a mean score of 1.8 (SD = 1.2) to 2.3 (SD = 1.5) on a 5-point scale ( p = .01) in 177 written sign-outs. Readability and organization were unchanged. Conclusions: A simple curriculum paired with structured faculty evaluation and feedback can improve some parameters of sign-out. Structured evaluative sign-out tools may be useful to improve and teach sign-out skills.

Use of an Appreciative Inquiry Approach to Improve Resident Sign-Out in an Era of Multiple Shift Changes

Resident duty hour restrictions have resulted in more frequent patient care handoffs, increasing the need for improved quality of residents' sign-out process. To characterize resident sign-out process and identify effective strategies for quality improvement. Mixed methods analysis of resident sign-out, including a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement. Internal medicine residents (n = 89). An appreciative inquiry process identified five exemplar residents and their peers' effective sign-out strategies. Surveys were analyzed and observations of sign-out sessions were characterized for duration and content. Common effective strategies were identified from the five exemplar residents using an appreciative inquiry approach. The survey identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were frequently accurate. The duration of observed sign-outs averaged 134 ±73s per patient for the day shift (6p.m.) sign-out compared with 59 ± 41s for the subsequent night shift (8p.m.) sign-out for the same patients (p = 0.0002). Active problems (89% vs 98%, p = 0.013), treatment plans (52% vs 73%, p = 0.004), and laboratory test results (56% vs 80%, p = 0.002) were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out (mean vote 11 ± 1.6 vs 1.7 ± 2.3) identified strategies for sign-out: (1) discussing acutely ill patients first, (2) minimizing discussion on straightforward patients, (3) limiting plans to active issues, (4) using a systematic approach, and (5) limiting error-prone chart duplication. Resident views toward sign-out are diverse, and accuracy of written records may be limited. Consecutive sign-outs are associated with degradation of information. An appreciative-inquiry approach capitalizing on exemplar residents was effective at creating standards for sign-out.

Experience with Faculty Supervision of an Electronic Resident Sign-out System

Reductions in residency work hours during the past 20 years have resulted in a corresponding increase in both the number of transitions of care and the chances of medical errors related to such transitions.1 Despite considerable efforts to improve the house staff handoff process,2-13 problems remain.7,14 Recent studies demonstrate that an alarming proportion of handoffs continue to omit important information, contain erroneous information, and lack a standardized structure.14,15 Of note, although lack of supervision was one of the main problems that led to the implementation of 405 regulations in New York and similar regulations elsewhere, the idea of faculty supervision of the sign-out process has received little attention.

Improved Physician Work Flow After Integrating Sign-out Notes into the Electronic Medical Record

In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed. A printable sign-out report was implemented within the EMR system at a tertiary academic children's hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey. The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process. EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.

Standardized Sign-Out Reduces Intern Perception of Medical Errors on the General Internal Medicine Ward*

Background: Prior research on reducing variation in housestaff handoff procedures have depended on proprietary checkout software. Use of low-technology standardization techniques has not been widely studied. Purpose: We wished to determine if standardizing the process of intern sign-out using low-technology sign-out tools could reduce perception of errors and missing handoff data. Methods: We conducted a pre–post prospective study of a cohort of 34 interns on a general internal medicine ward. Night interns coming off duty and day interns reassuming care were surveyed on their perception of erroneous sign-out data, mistakes made by the night intern overnight, and occurrences unanticipated by sign-out. Trainee satisfaction with the sign-out process was assessed with a 5-point Likert survey. Results: There were 399 intern surveys performed 8 weeks before and 6 weeks after the introduction of a standardized sign-out form. The response rate was 95% for the night interns and 70% for the interns reassuming care in the morning. After the standardized form was introduced, night interns were significantly (p < .003) less likely to detect missing sign-out data including missing important diseases, contingency plans, or medications. Standardized sign-out did not significantly alter the frequency of dropped tasks or missed lab and X-ray data as perceived by the night intern. However, the day teams thought there were significantly less perceived errors on the part of the night intern (p = .001) after introduction of the standardized sign-out sheet. There was no difference in mean Likert scores of resident satisfaction with sign-out before and after the intervention. Conclusion: Standardized written sign-out sheets significantly improve the completeness and effectiveness of handoffs between night and day interns. Further research is needed to determine if these process improvements are related to better patient outcomes.

Effects of the Accreditation Council for Graduate Medical Education Duty-Hour Limits on Sleep, Work Hours, and Safety: In Reply

We greatly appreciate the thoughtful response to our article from Chang and Arora. Although our study was not specifically designed to evaluate the quality of the handoff process, we agree that poorly managed handoffs introduce considerable potential for errors as a result of miscommunications. Communication failures are a contributing cause in approximately 2 of every 3 sentinel events reported to the Joint Commission,1 and handoffs in particular have been associated with an increased risk of preventable adverse events. At the same time, however, a considerable body of research has emerged demonstrating that 24-hour shifts endanger both residents and their patients.2 Therefore, we strongly endorse the recommendation of Chang and Arora that handoffs be addressed in conjunction with efforts to restrict duty hours. As evidence of the hazards of extended shifts has accumulated, perpetuation of extended shifts as a means of avoiding the risk of handoff errors cannot be justified. Rather, efforts to implement evidence-based reductions in work hours should be accompanied by simultaneous efforts to improve the sign-out process.There are 2 major elements to the handoff: the verbal and written sign-outs. Standardizations in the structure of the verbal sign-out process have been found in preliminary work to decrease the risk of adverse events.3 Enhancements to the written sign-out process, particularly the use of computerized sign-out tools, was likewise associated in 1 study with the elimination of the increased baseline risk of errors being made by cross-covering residents.4 To date, both types of interventions have been underused. Very few hospitals nationwide have adopted computerized sign-out tools, and although some efforts are underway to improve verbal handoffs, these efforts, too, are at an early stage of development. Enhancing the written and verbal sign-out processes could greatly mitigate the risk of miscommunications caused by shorter shifts and lead to even greater gains in safety than those seen in initial interventions that eliminated 24-hour shifts.5

The Top 10 List for a Safe and Effective Sign-out

With the advent of the 80-hour workweek, much attention has been focused on the benefits of shorter work hours regarding resident fatigue and reduced medical errors. Along with this change, however, there has been more reliance on multiple teams of residents who assume the care of inpatients at different times. In this new paradigm, a safe and effective sign-out process is needed to ensure a seamless transition of care from one resident to another. Several studies have been published on the sign-out process among interns in internal medicine, but the literature is sparse with regards to the best way to hand over care of a busy inpatient surgical service. To aid in this process, the Halsted surgical interns performed a review of the current literature on this topic. They also reflected on their personal experiences and developed a 10-point method for safe and effective sign-outs. This process is emphasized for incoming interns and used across the various surgical services at The Johns Hopkins Hospital.

Adequacy of information transferred at resident sign-out (inhospital handover of care): a prospective survey

Background:During sign-out (handover of care), information and responsibility about patients is transferred from one set of caregivers to another. Few residency training programmes formally teach resident physicians how to sign...

Need for Standardized Sign‐out in the Emergency Department: A Survey of Emergency Medicine Residency and Pediatric Emergency Medicine Fellowship Program Directors

To determine the existing patterns of sign-out processes prevalent in emergency departments (EDs) nationwide. In addition, to assess whether training programs provide specific guidance to their trainees regarding sign-outs and attitudes of emergency medicine (EM) residency and pediatric EM fellowship program directors toward the need for the development of standardized guidelines relating to sign-outs. A Web-based survey of training program directors of each Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency and pediatric EM fellowship program was conducted in March 2006. Overall, 185 (61.1%) program directors responded to the survey. One hundred thirty-six (73.5%) program directors reported that sign-outs at change of shift occurred in a common area within the ED, and 79 (42.7%) respondents indicated combined sign-outs in the presence of both attending and resident physicians. A majority of the programs, 119 (89.5%), stated that there was no uniform written policy regarding patient sign-out in their ED. Half (50.3%) of all those surveyed reported that physicians sign out patient details "verbally only," and 79 (42.9%) noted that transfer of attending responsibility was "rarely documented." Only 34 (25.6%) programs affirmed that they had formal didactic sessions focused on sign-outs. A majority (71.6%) of program directors surveyed agreed that specific practice parameters regarding transfer of care in the ED would improve patient care; 80 (72.3%) agreed that a standardized sign-out system in the ED would improve communication and reduce medical error. There is wide variation in the sign-out processes followed by different EDs. A majority of those surveyed expressed the need for standardized sign-out systems.

Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign‐out

Restrictions in the hours residents can be on duty have resulted in increased sign-outs, that is, transfer of patient care information and responsibility from one physician to a cross-coverage physician, leading to discontinuity in patient care. This sign-out process, which occurs primarily in the inpatient setting, traditionally has been informal, unstructured, and idiosyncratic. Although studies show that discontinuity may be harmful to patients, this is little data to assist residency programs in redesigning systems to improve sign-out and manage the discontinuity. This article reviews the relevant medical literature, current practices in non-health professions in managing discontinuity, and summarizes the existing practice and experiences at 3 academic internal medicine hospitalist-based programs. We provide recommendations and strategies for best practices to design safe and effective sign-out systems for residents that may also be useful to hospitalists working in academic and community settings.

Practicing Neonatology in a Blackout: The University Hospital NICU in the Midst of Hurricane Katrina: Caring for Children Without Power or Water

August 26: 3 Days Before Landfall: Like most Friday afternoons, our 12-person neonatology group went through the weekend sign-out process of patients divided among the 9 area hospitals for which we provide NICU coverage. I was assigned to University Hospital for the weekend. University Hospital is a state-run public hospital in downtown New Orleans, Louisiana, that serves primarily indigent patients as part of the campus of the old Charity Hospital. It has a level 3 NICU and is a full-service teaching hospital for the medical schools at Louisiana State University and Tulane University. I was aware of Hurricane Katrina, then a category 1 storm in south Florida, and all indications were that the storm was targeting the coast of the Florida panhandle. By evening, as the storm's predicted path had dramatically changed westward, I began to review our available on-call neonatologists and plan for hospital coverage in the event that this new prediction held true. I also began to make plans for the evacuation of my wife and 5 children but hoped, as had been the case in recent years with other hurricanes, that Katrina would steer clear of New Orleans. As the predictions for the storm passing over or near New Orleans remained consistent, plans for covering each of our hospitals with an in-house neonatologist for the duration of the hurricane threat were finalized. Dating back to at least Hurricane Andrew in 1992, our division had gone through this process multiple times. Although several hurricanes during this time threatened to hit New Orleans, our city had managed to avoid any direct hit. Despite many doomsday scenarios, New Orleans had not experienced a direct hit since Hurricane Betsy in September 1965. In recent years, there were increasing efforts to evacuate the city with such threats. Hospital evacuation had been discussed, … Address correspondence to Brian M. Barkemeyer, MD, FAAP, Children’s Hospital NICU, 200 Henry Clay Ave, New Orleans, LA 70118. E-mail: bbarke{at}lsuhsc.edu

Examining Issues in Communicating Patient Care Information Across Shifts in a Critical Care Setting

This study addresses issues associated with sign-out reports occurring during shift changes in the pediatric intensive care unit of a large metropolitan hospital. The issues include the need for organizing our knowledge concerning the types of errors that providers are susceptible to during the sign-out process, the roles of personality, experience, and cultural factors, particularly as they may affect the incoming provider's inquisitiveness, and the potential impact on patient care of various different methods of performing sign-outs. We observed eight outgoing nurses and four residents who gave sign-out reports, and conducted eight semi-structured interviews with nurses, residents, nurse managers, and attending physicians. The results revealed important and intricate relationships among many of the variables that were investigated and suggested a number of interventions that might improve the sign-out process. Overall, our data on shift change sign-outs in an acute care setting confirmed the resiliency of health care providers and their capability for managing patient care under extremely demanding conditions.

Realizing the potential of clinical judgment: a real-time strategy for predicting outcomes and cost for medical inpatients

PURPOSE: We sought to determine whether illness severity and anticipated level of function, as evaluated at the time of admission, were associated with outcomes and costs of care for patients admitted to the medical service. METHODS: All 1,759 patients admitted to the medical service at a large urban academic medical center between July 1, 1997, and September 30, 1997 (excluding those admitted directly to the intensive care units or for protocol chemotherapy), were evaluated and categorized by the admitting intern by illness severity (not ill, mildly ill, moderately ill, severely ill, or moribund) and anticipated level of function at discharge (excellent, good, fair, or poor) as part of their routine sign-out process. Interns’ ratings were always available within 24 to 28 hours of admission. In-hospital mortality, length of stay, cost of hospitalization, and anticipated billing revenue were evaluated. RESULTS: Patients who were more severely ill had significantly greater in-hospital mortality. For example, mortality was 1.1% (11 of 972) among those who were not ill or mildly ill, 3.6% (26 of 724) among those who were moderately ill, and 15% (9 of 60) among those who were severely ill. Illness severity ( P = 0.003) and anticipated functional status ( P < 0.01) were significant predictors of in-hospital mortality. Illness severity and function were also significant predictors of greater length of stay and greater costs of hospitalization (all P < 0.0001). The 389 patients who were moderately ill with fair or poor anticipated function were associated with the largest cumulative losses (about $330,000 during the 3-month period), whereas the 798 mildly ill patients with good or excellent function were associated with the largest cumulative profits ($550,000). CONCLUSION: Physicians’ estimates of patients’ illness severity and anticipated function at the time of discharge, as made by interns using a system designed to help them sign out to their colleagues, predict outcomes and costs of hospitalization. Such a system may be useful in developing new approaches to management strategies based on prognosis.

Qualitative research methodologies in emergency medicine.

Qualitative research methodologies, though often used in other fields and in medical educational investigations. have not been used to study problems in emergency medicine (EM). These methodologies address qualitative data and provide a process of describing, interpreting, and explaining the dynamics of a population or phenomenon. The stages of a qualitative investigation include initial narrative description, interpretation, theory development, assessment of generalization, and evaluation. Important differences between this framework and those of quantitative research methods are described. These methods may be applied to systematic investigation of virtually any observable phenomenon or process in EM in which a better understanding of process would be valuable, such as patient flow, patient satisfaction issues, patient turnover and sign-out processes, bedside teaching, EM teamwork dynamics, and development of the career interests of students and residents. As with quantitative research, EM academicians should seek collaboration and appropriate training with guidance by established qualitative investigators when applying these methods.