How to conduct an
excellent sign-out
Leora Horwitz, MD
Medicine Boot Camp
leora.horwitz@yale.edu
Why is sign-out important?
• Frequent
• Skill set
• Potentially dangerous
Safety attitude questionnaire
• Shift changes are problematic for patients
in this hospital
• Important patient care information is often
lost during shift changes
• Problems often occur in the exchange of
information across hospital units
• Things “fall between the cracks” when
transferring patients from one unit to
another
How are we doing?
2013 Safety Culture Survey, YNHH Medicine, MD/PA/house staff only, N=341
What information is needed?
• Name, age, gender, room, family contact info,
language, attending, consultants
• Code status
• Past medical history, allergies, meds, labs
• Admission diagnosis
• Hospital course
• Scheduled events
• Clinical condition
• To dos, anticipatory guidance
Adding value to data
Why written and oral sign-out?
Why written and oral sign-out?
Oral sign-out
Written sign-out
What’s new
What’s new and old
Most important info
Highlights
Complete info
Details
Interaction, read-back
Critical thinking
Memory aid
Consistent info transfer
How should we say it?
• Consistently
Standardization
Sign-out structure
S ick? DNR?
I D line (name, age, gender, dx)
G eneral info re: hospital course
N ew events of day, scheduled events
O verall health status (clinical condition)
U pcoming possibilities + plan & rationale
T asks to complete + plan & rationale
? Any questions?
How should we say it?
• Consistently
• Concretely
Vague language
• “If the nurse calls you with increased
sugars, can you start insulin?”
• “Over the weekend he was unstable, but
not any more.”
• “He’s DNR/DNI, but kind of do things if
they’re reversible.”
Concrete language
“And then his blood pressure, if it’s greater
than 165/105, you can push 40 of iv
labetalol or 10-20 of hydralazine iv. And
then he has scheduled labetalol, and that
should be given to him unless he’s really
hypotensive, like less than 100/60 is what
they’ve had.”
How should we say it?
• Consistently
• Concretely
• Closed loop
Open loop language
- “If her Doppler’s positive maybe you
could look at the cat scan. I mean it’s not
going to be helpful because there’s no
contrast. But, she’s going to get that done.
Otherwise, it’s not something that you
absolutely need to follow up with.”
- “OK.”
Closing the loop
Intern providing sign-out: “Neck CT is ordered, and
I guess it got done today. I didn’t see anything in
the computer, but the neck CT is to - in the
setting of cervical lymphadenopathy and a breast
mass, concern for malignancy…”
Intern receiving sign-out: “OK. Is the neck CT
something that needs follow-up?”
Intern providing sign-out: “No, I think it won’t
change management tonight.”
How should we say it?
•
•
•
•
Consistently
Concretely
Closed loop
Concisely
Concise, but…
• This is a 56 year old male who presents
with chest pain.
• What is this patient’s probability of cardiac
disease?
Just the facts, ma’am?
• This is a 56 year old male smoker with
diabetes, hypertension, hyperlipidemia,
who presents with several days of chest
pain/pressure after walking up 2 flights of
stairs, relieved by rest.
Concise AND Clinical synthesis
• This is a 56 year old male with multiple
cardiac risk factors who presents with…
Concise AND Clinical synthesis
• This is a 56 year old male with multiple
cardiac risk factors who presents with
several days of classic exertional
angina.
How should we say it?
•
•
•
•
•
Consistently
Concretely
Closed loop
Concisely, with clinical synthesis
Question
Is this a good handoff?
Lack of interaction
Intern providing sign-out: “This woman is a
new person with COPD exacerbation.
Severe COPD. Not really much going on.
The resident ordered ambulatory O2 sat,
just to pass on to the tomorrow morning
people, just so they know.”
Intern receiving sign-out: “OK.”
Practice time
• Recall our patient:
– 64 year old man
– Admitted with new non-valvular atrial
fibrillation
– HTN, DM2, GI bleed
– EF 50%, mildly dilated left atrium
– Unsuccessful cardioversion today
• What will you say in oral sign-out?
• What will you write?
Sign-out structure
S ick? DNR?
I D line (name, age, gender, dx)
G eneral info re: hospital course
N ew events of day, scheduled events
O verall health status (clinical condition)
U pcoming possibilities + plan & rationale
T asks to complete + plan & rationale
? Any questions?
How are we doing?
2013 Safety Culture Survey, YNHH, MD/PA/house staff only, N=1,439
Signs of a bad
hand-off
Uncertainty
• “She’s being heparinized. I think she’s
had a heart attack.”
• “And then the other thing is, what’s the
other thing for him tonight? You know,
he’s on antibiotics for a UTI. He’s on
Zosyn. Or, zosyn or ceftaz? Or, one of
those, for a UTI.”
Omissions
First sign-out, 4pm
• Primary intern to on-call intern; 48 seconds
• “[Ms. X]…went and had an EUS today and they
found a pancreatic mass. And so they did
brushings… They were not able to stent it with
ERCP… Something happened during the
procedure; they said submucosal contrast or
something… They said if she has an increase in
pain or spikes a fever, they said low threshold
for CT of her belly and calling them. I started her
on cipro iv.”
Second sign-out, 7pm
• On-call intern to night float intern
• 12 seconds long
– “Ms. X. She’s got obstructive jaundice. She
was found to have a mass. They said it
wasn’t able to be stented but I think they sent
a biopsy. So there’s nothing to do tonight.”
Delay
“It was a step-down patient. And there was a
question about the patient’s low blood pressure,
but the patient was not on the sign-out… So it
took a phone call to figure out who the patient’s
attending was, who the last note was from, and
then figure out indeed it’s [my cross-cover]
patient, and then go and see the patient.”
- Post-call interview
Adverse event
“I had a patient who I had to send to
the unit. She had some unanticipated
bronchospasm, and apparently she had
been a little bit bronchospastic during
the day, and this wasn’t an issue that
had really been discussed.”
- Post-call interview
What it takes for an error to
reach a patient
Reason, 1990