Published in the June/July 2004 issue of Today’s Hospitalist
The patient arrived at the emergency department of an academic hospital complaining of shortness of breath. Within 48 hours, she had seen nine different residents and was the subject of 10 different sign-outs.
There was the night-float resident who admitted her, the regular day resident, the ICU resident who took over when she decompensated, the cross-coverage resident who took over when the ICU resident had clinic hours, the day-float resident who got the hand-off when the duty-hour regulations forced the regular resident to go home, the next night float, the on-call intern and a few others.
While the patient suffered no harm as a result of seeing so many different physicians, the example illustrates the challenges that hospitalists face in making sure that sign-outs function properly, especially when they are working with physicians in training. A workshop at the annual Society of Hospital Medicine meeting in New Orleans used the scenario as a starting point to discuss potential problems of sign-outs.
“This may be an extreme example, but it’s a real one at our institution, and probably at yours,” explained Arpana Vidyarthi, MD, a hospitalist at the University of California, San Francisco (UCSF), who led the session. She has been researching the effect of the new duty-hour regulations on discontinuity of care.
While there is little to no research defining how to best conduct sign-outs, Dr. Vidyarthi added, plenty of research has shown that when sign-outs are done poorly, they hurt continuity of care.
“We know that discontinuity has an increased risk of preventable adverse events, and we also know that discontinuity decreases patient satisfaction,” she said. “We know as well that discontinuity increases the length of stay and the number of tests that are ordered.”
The bad news is that current trends threaten to only intensify problems with sign-outs.
As Dr. Vidyarthi explained, many hospitalists are drawn to shift work, which raises concerns about continuity of care. And at teaching hospitals, the year-old work-hour reforms that limit medical residents to an 80-hour work week with a guaranteed 24-hour break every seven days are heightening concerns about sign outs and continuity of care.
Written or verbal sign-outs?
In part, it’s difficult to address problems with “and improve “sign-outs because of a lack of standardization.
There is no formal curriculum in medical schools or training programs for teaching how to safely sign-out, Dr. Vidyarthi explained. On an even more basic level, there is little agreement among physicians about what constitutes a safe and effective sign-out, let alone any evidence proving that one method is the best way to pass primary responsibility for a patient from one physician to another.
When Dr. Vidyarthi surveyed all the different medical training programs at UCSF, she found that nearly every program tackled this everyday situation differently. Strategies ranged from computerized forms to hallway conversations that take place “on the fly.”
While face-to-face oral communication often can be the best way to communicate critical information about a patient, she said, studies in Australia found that 11 percent of their 30,000 annual preventable adverse events were due to communication gaps.
The problem, Dr. Vidyarthi explained, is that in hospitals, sign-out discussions are inevitably interrupted. Distractions lead to forgetfulness, misunderstandings and problems in patient care.
While written sign-outs seem like an obvious solution, research has shown they can be just as problematic.
Vineet Arora, MD, a hospital medicine fellow at the University of Chicago who co-moderated the workshop, said that research has found that the written component of sign-outs are often missing important information, including code status, allergies, age or even the patient’s gender. In one study, she said, researchers found that the only consistent information in a written sign-out was the patient’s location or room number.
Mapping “broken” processes
Dr. Arora conducted a series of structured interviews with University of Chicago interns who had signed out to each other over the course of 24 hours. She asked if anything bad happened overnight or almost happened because of an inappropriate or improper sign-out. She uncovered 21 errors in communication.
Sign-outs have become “a critical component of inpatient care,” Dr. Arora said. “But how they happen is very variable, often unstructured and informal, and full of potential risks.”
As part of the workshop, Drs. Arora and Vidyarthi led participants on an exercise to “map” a broken sign-out process. The goal was to see if they could identify the points in the process that were prone to error.
Most of the points fell into three basic categories There were problems with the environment, like printers that were out of paper or a lack of meeting spaces to have uninterrupted face-to-face discussions about hand-offs.
Problems with communication occurred when information was omitted, or when shorthand and colloquialisms were misunderstood on the receiving end. And problems with the culture of the hospital occurred when physicians failed to see the importance of the sign-out.
Those findings were echoed in a lively discussion during the workshop in which dozens of participants shared their experiences “and frustrations “with less-than-adequate sign-outs.
Sometimes, doctors in the audience said, they get too little information in a sign-out. Other times, too much information changes hands, obscuring the real issues.
One participant at the workshop said he often encounters interns and residents who provide lots of detail but miss an essential piece of information, such as a change in code status. As several participants at the workshop said, trainees often miss the forest for the trees.
Others said that poor sign-outs are rooted in a medical culture that assigns this important task to the lowliest member of the medical team: the intern. “What this says is that since interns do the scut work, sign-outs must be scut work,” one physician at the workshop said.
Even the notorious macho attitudes of some residents and doctors interfere with effective sign-outs, several audience members noted. They described some residents who believe they are such good doctors that the person taking over care of their patients overnight will never need to do anything; everything has already been taken care of.
On the flip side, others portrayed doctors who feel they will be able to handle anything that comes their way. As a result, they think they have no need for any information that comes to them in a sign-out.
And as one participant commented, some residents exhibit less-than-professional behavior when it comes to caring for patients that are only theirs for a shift or so. “They think they have no stake in this patient, that the patient really isn’t their responsibility” the physician said. “I’m wondering if residents understand why a sign-out is important.”
“I’m hearing this across the country,” Dr. Vidyarthi echoed, “that shift work breeds unprofessional behavior. How do we train our residents to understand they need to be responsible? There are definite lapses due to unprofessionalism.”
While no one at the workshop claimed to have solved the sign-out problem, several said they were experimenting with ways of formalizing the process with paper forms and computer templates. Some also describe ways to use personal digital assistants to beam sign-out information between physicians.
Others, however, noted that sign-out problems have brought into sharp focus the limitations of the existing medical chart, which is being asked to perform too many functions “from billing to medico-legal documentation “to work properly as a guide for real-time patient care anymore.
As one hospitalist at the workshop said, the need for a written sign-out “in some sense, a parallel chart “”is a sign that the medical record is broken.” Another attendee asked, “Why are we spending so much time inventing another medical record?”
Deborah Gesensway is a freelance writer specializing in health care. She is based in Glenside, Pa.