Resident Sign-Out: A Precarious Exchange of Critical Information

in a Fast Paced World

Stephen M. Borowitz, M.D.Linda A. Waggoner-Fountain, M.D., M.Ed.

Ellen J. Bass, Ph.D.Justin DeVoge, M.S.

University of Virginia

Rick Sledd Ted Perez Kim Brantley

Matthew Bolton Leigh Baumgart McKinsey Bond

Adam Helms Luther Bartelt

Mangwi Atia

Tammy Schlag Peggy Plews-Ogan George Hoke

Sign-Out a mechanism of transferring information,

responsibility and/or authority from one set of care-givers to another

primary objective is the accurate transfer of information about patient’s state and plan of care

Sign-Out is a Lifelong Skill

In Academic Health Centers, resident physicians sign-out to one another from the very beginning of residency

Few residency training programs formally teach residents how to sign-out

Few residency training programs assess how well residents’ sign-out to one another

Sign-out is a life-long skill

There are Multiple Resident Hand-Offs Every Day

Frequent patient care hand-offs have been associated with:» longer hospital stays»more laboratory tests being ordered»more self-reported preventable adverse

events

Patient Care Handoffs Can Lead to Omissions and Misunderstandings

A Changing Environment Hospitalized patients are sicker and sicker Hospital stays are shorter and shorter The “medical record” has been marginalized as

a source of communication between clinicians There has been an explosion in scientific and

medical knowledge There is an increasing reliance on electronic

health records/electronic data sources In 2003, the ACGME instituted duty hour

restrictions for all residency programs

Sign-Out There is scant research on how sign-out

is actually conducted, and even less is known about how sign-out should be conducted, or how interventions improve the quality of sign-out» most of the available information comes

from other domains, particularly aviation and the military

missing info40 (82%)

no missing info9 (18%)

no unexpected event109 (69%)

unexpected event49 (31%)

How often did something happen you weren’t prepared for?

In 33 of the 40 (79%) cases where information was missing, the problem/issue should have been

anticipated during sign-out

Residents Often Miss Key Points During Sign-Out

Next Steps

Process Tool(s) Education

Process We conducted facilitated sessions with

residents, and pediatric and systems engineering faculty during which we:» defined the goals of sign-out» identified barriers to and opportunities for

improving sign-out» characterized a desired process and the

information that should be exchanged during sign-out

Tool We designed an electronic sign-out tool

using an iterative, human centered systems design process

Education and Training

Initially, we focused on » the type(s) of patient information that should

be exchanged » a training process that emphasized the

“giver” of information more than the “receiver” of information

Who Gives Good Sign-Out and Why?

We surveyed our residents and three residents of varying levels of experience and medical knowledge were identified as sign-out exemplars» “after signing out with them, I feel well

prepared for the next call shift”» “they help me anticipate what might go

wrong during my call shift”» “they give me a chance to ask questions”

Who Gives Good Sign-Out and Why?

We met with our three “sign-out exemplars” and conducted qualitative research about their sign-out techniques and the following themes emerged:» they always achieve “co-orientation”

regardless of whether they are giving or receiving sign-out

» they all have high emotional intelligence

Education and Training

Over time, we have realized the cognitive tasks of sign-out need to be reframed»much less emphasis on the exchange of

information»much more emphasis on the

development of a shared understanding and meaning of the situation at hand –situational awareness and co-

orientation

The Cognitive Tasks of Sign-Out

For a successful sign-out, physicians handing off care and physicians assuming care must assemble a shared mental model of patients they are caring for

This co-orientation is necessary to recognize and analyze problems, to make sense of the situation, and to plan

Co-orientation also provides an opportunity for rescue and recovery (collaborative cross-checking)

Clinicians need more than data to understand a patient’s story and to try and predict future trajectories

During handovers, most high-reliability organizations » exchange few data elements » adhere to the “most important first” heuristic» standardize the handover process » do NOT standardize handover content

The Cognitive Tasks of Sign-Out

“Music is not just about the notes. Rather it is created by the spaces between the notes”

Claude Debussy

Sign–out vs Sign Over Culture change

» from “I’m just the cross-cover” to “This is my patient right now”

Care of patients must no longer be viewed as a marathon run by a single runner, but as a relay race run by many runners» each person must run a leg of the race» you must “hand off the baton” when your leg

is done» if we drop the baton, the race is lost

Resident Sign-Out: A Precarious Exchange of Critical Information

in a Fast Paced World

Stephen M. Borowitz, M.D.Linda A. Waggoner-Fountain, M.D., M.Ed.

Ellen J. Bass, Ph.D.Justin DeVoge, M.S.

University of Virginia