Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast Paced World

1. 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

2. Matthew Bolton • Leigh Baumgart • McKinsey Bond • Rick Sledd • Ted Perez • Kim Brantley • Tammy Schlag • Peggy Plews-Ogan • George Hoke • Adam Helms • Luther Bartelt • MangwiAtia

3. 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

4. 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

5. There are Multiple Resident Hand-Offs Every Day

6. 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

7. 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

8. 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

9. How often did something happen you weren’t prepared for? no unexpected event 109 (69%) missing info 40 (82%) unexpected event 49 (31%) no missing info 9 (18%) In 33 of the 40 (79%) cases where information was missing, the problem/issue should have been anticipated during sign-out

10. Residents Often Miss Key Points During Sign-Out

11. Next Steps • Process • Tool(s) • Education

12. 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

13. Tool • We designed an electronic sign-out tool using an iterative, human centered systems design process

15. 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

16. 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”

17. 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

18. Education and Training Over time, we have realizedthe 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

19. 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)

20. 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

21. “Music is not just about the notes. Rather it is created by the spaces between the notes” Claude Debussy

22. 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

23. 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