Who ’ s Covering Our Loved Ones: Surprising Barriers in the Sign-Out Process

1. Who’s Covering Our Loved Ones: Surprising Barriers in the Sign-Out Process Mara Antonoff MD Elizabeth Berdan MD, Varvara Kirchner MD, Tara Krosch MD, Christopher Holley MD, Michael Maddaus MD, Jonathan D’Cunha MD PhD

2. Duty Hour Limitations • Intended consequences: • Minimize ill effects of trainee sleep deprivation • Optimize patient safety • Resident well-being

3. Duty Hour Limitations • Unintended consequences: • Challenges in providing comprehensive training experience • Increased handoffs, more frequent transitions of care Horwitz, Arch Int Med 2006

4. Duty Hour Limitations • Unintended consequences: • Challenges in providing comprehensive training experience • Increased handoffs, more frequent transitions of care Horwitz, Arch Int Med 2006

5. More Frequent Handoffs • Decreased familiarity • Break in continuity of care • Risk of communication errors • Increased errors/omissions may lead to serious adverse outcomes Arora, J Gen Intern Med. 2007

6. Aims • Characterize obstacles affecting current sign-out practices • Evaluate potential impact of standardized sign-out guidelines

7. Methods: Guidelines • Developed by committee of residents with faculty supervision • Based on literature review and ACGME requirements • 5-page document with detailed policies/guidelines for transitions of care

8. Methods: Guidelines • Goals: • Develop set of expected behaviors • Establish list of required data points for written sign-out lists • Establish list of required elements of verbal exchange

9. Methods: Guidelines

10. Methods: Guidelines • Implemented June 2011 • Program-wide use • 1-hour kickoff presentation for current trainees • New trainees provided with workshop at orientation

11. Methods: Survey • Designed to assess: • Practices • Attitudes • Barriers to effective communication • 29 multiple-choice items • Dichotomous and 5-point Likert-type responses

12. Methods: Survey • 2 time points • Immediately prior to guideline implementation • 3-month follow-up • Comparison pre/post implementation • T-tests & chi-squared analyses, α=0.05

13. Methods: Survey • Mini-survey for nurses • Subset of questions from resident survey • Goal: to assess perceptions of physician familiarity with patients, patient safety • Same time points

14. Results: Resident Survey • Baseline: • Moderate satisfaction with sign-out process • Concerns regarding communication and patient safety

15. Results: Resident Survey N = 37

16. Results: Resident Survey N = 37

17. Results: Resident Survey N = 37

18. Results: Resident Survey N = 37

19. Results: Resident Survey • All trends • None of these gains reached statistical significance

20. Results: Resident Survey • During study period, duty-hours also changed • Reports of double-signouts increased • New concerns: • Failure to report major events due to double-signouts • Less complete signouts due to 16-hour restrictions

21. Perceived Barriers

22. Perceived Barriers

23. Perceived Barriers

24. Perceived Barriers

25. Results: Nursing Survey To what extent does the current signout process provide patient safety via continuity of care? N = 46

26. Results: Nursing Survey To what extent are residents given adequate information about the patients whom they cover? N = 46

27. Results: Nursing Survey To what extent does the resident on call at night know your patients? N = 46

28. Summary • Mild improvement in perceptions of patient safety and adequacy • Improvements reported by • Nurses • Residents

29. Summary • Persistent barriers remain • Additional obstacles have surfaced in setting of further restrictions on duty hours

30. Conclusions • Standardized signout guidelines: • May improve continuity of care • Should be universally employed • Do not solve all issues

31. Conclusions • Standardized signout guidelines: • May improve continuity of care • Should be universally employed • Do not solve all issues • Further efforts to optimize patient safety via improved handoff processes are clearly needed