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Signing out patients

October 2007

We have a lot to learn from nurses. That became very clear to me during my clinical rotations as a medical student and during my first year out of medical school. The wise ones among my group of interns at a Baltimore hospital made sure they paid close attention to whatever nurses had to say, and we continue to do so some five, 10 and more years later.

I was reminded of this yet again this past week when I started as medical director for the Virtua Healthcare System. I was listening to one of the ICU nurses sign out a patient–something that, if you haven’t had a chance to hear recently, you should take a minute to do.

The ICU sign-outs are always verbal, either recorded or face-to-face, and extremely detailed, right down to the description of the Foley and all-dwelling lines. (It is worth noting that Sanjay Saint, MD, authored a study in 2000, which indicated that only 38% of attending physicians know if their patient has an in-dwelling Foley.)

Obviously, trying to replicate this system for hospitalists is not practical. We need to sign out as many as 20 patients in increasingly complicated practice environments, particularly when we work–as I do–in a program that is in-house 24/7 and includes diverse shifts, with nocturnists, rounders, admitters and swing-shift physicians.

Despite the 2006 Joint Commission mandate to structure patient sign-outs to improve safety, I think it is fair to say that we are still struggling to master the art of the sign-out.
This was indeed the case at Virtua, where I found no formal sign-out system in place.

All of my new colleagues agreed that we needed to make that change right away, even though creating more work for everyone is never a popular solution. In previous groups where I’ve worked, we used a self-designed Word document that each doctor updated every day.

But while this type of Word-based sign-out works well with a census of 30, it would be impossible to maintain for a census of 100. So, I asked myself, how do we get the best result from a minimal amount of time, cost and effort?

The immediate solution was developing an Excel sheet (available for download here PUT IN LINK). The new sheet has its advantages: We can alphabetize patients by name, and we can use drop-down lists for personalized information and for preferences of different primary care physicians. Further the list is on a shared drive that can be accessed anywhere in the hospital.

The sheet also has disadvantages. It is not linked, for instance, to a handheld so we can’t update the sheet at the bedside except to alter the paper version we carry. Nevertheless, it is a fine fix for the time being, particularly when we couple it with as much face-to-face sign-out as possible.

My sense is that the majority of hospitalist groups are using similar systems, all of which work but are less than ideal. We may never be as thorough with sign-outs as ICU nurses, who obviously carry far fewer patients. But we should learn from their example and work to make the sign-out process as comprehensive as possible.

I know there are some excellent commercial products available, all of which cost a lot more than a free excel sheet, that ultimately may be worth the price tag. I am very interested to hear what others in this situation have chosen to do. The more we can exchange information and ideas about this process, instead of trying to innovate in a vacuum, the better off both we and our patients will be.

(Here is another form PUT IN LINK that you can download that I also put in place my first week at Virtua. It is for a Excel-based scheduling system that utilizes drop down lists and date functions. Again, I am anxious to see if others have found better systems for scheduling for large groups.)