patient sign-out: patient sign-outFigureFigureOne of the most dangerous procedures we perform is the patient handoff. Every sign-out from emergency physician to emergency physician carries a risk to the patient and liability to the outgoing and incoming care teams. Patient handoff in the emergency department is analogous to passing the baton in a relay race. Transitioning care is passing the baton of responsibility from one physician or team to the next while minimizing distractions and impediments to ED flow. The emergency physician is prone to cognitive errors because of numerous environmental factors, including frequent distractions, interruptions, loud noises, and phone calls, as well as the complexity and diversity of diseases and conditions in our patients. Physician attributes are also associated with errors during sign-out. Physician decision fatigue is more likely to occur at the end of shift, while an incoming physician is more likely to fall into cognitive error traps such as diagnosis momentum. Recent literature highlights the great variability in handoff practices and our assessment of implementing these procedures. It is surprising that not all ED groups and emergency medicine training programs have systems to avoid errors during sign-out given the dangers and risks of sign-out. Most concerning is that a large group of residents is learning this skill informally and with great variability among programs. Would we accept similar training and outcomes for educating our trainees in airway management? A cross-sectional study investigating handoff practices from emergency physician to emergency physician in academic programs found that more than half of the respondents had a standardized system in place for sign-out, which was an improvement from a comparison study in 2011 when only 43 percent did. The authors still concluded that communication still has room for improvement in education and practice. (Acad Emerg Med 2016;23[2]:197.) Most research on handoffs is centered around emergency to inpatient communication. (West J Emerg Med 2017;18[1]:86.) The most common algorithms used are SBAR and IPASS. ACEP has made available a Safer Sign-Out form, which is to be used for EP-to-EP handoffs and provides recommendations for sign-out procedures. (http://bit.ly/2BcKs2r.) These are made up of the five Rs: record, review, round, relay to the nurse/team, and receive feedback. Using the sign-out form, the incoming EPs have the oportunity to record information about results and outcomes that can be followed up by the outgoing team. Less discussed in the literature is physician resistance to implenting effective handoff procedures and the frequent malignant narratives around the sign-out process. Despite the availability of sign-out forms and algorithms, each ED has its own sign-out culture, and each practioner has his own approach. We came up with several recommendations to troubleshoot dangerous transitions that we think can augment the utility and success of an already established handoff process. DO: Recognize the vulnerability to error that occurs during sign-out. Ensure the outgoing doctor introduces the incoming team to the patient and reviews the current workup and plan together, involving the patient. Make sure the incoming and outgoing teams are on the same page. Involve nursing in rounds and the sign-out process. Ensure the incoming doctor arrives early for shifts and becomes familiar with the board prior to receiving sign-out. Be kind to the outgoing doctor; she has worked a long shift and needs to know she is leaving the ED in good hands. DON'T: Don't rush the person giving sign-out. Expect that sign-out will take time. Don't demand the outgoing doctor stay past his shift for trivialities. Don't delay seeing a patient who was endorsed to you. Don't fall into common diagnostic error traps, such as diagnostic momentum that can occur during the sign-out process. In an ideal sign-out, there would be a checklist and overlapping shifts, allowing enough time for the outgoing and incoming physicians to go to the bedside and make sure they are on the same page. During a sign-out, the incoming team should be introduced to the patient and the patient updated on her care plan. This is a good time to involve the patient in his care. Preferably, the entire team would be involved in the sign-out process: physicians, nurses, technicians, residents, pharmacy, and respiratory therapy. Unfortunately, this may not be feasible given the constant influx of new patients and high turnaround. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].