Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast Paced World
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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
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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
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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
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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
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There are Multiple Resident Hand-Offs Every Day
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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
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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
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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
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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
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Residents Often Miss Key Points During Sign-Out
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Next Steps
Process Tool(s) Education
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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
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Tool We designed an electronic sign-out tool
using an iterative, human centered systems design process
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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
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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”
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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
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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
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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)
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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
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“Music is not just about the notes. Rather it is created by the spaces between the notes”
Claude Debussy
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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
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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