Transfers of responsibility (sign-outs or hand-offs) for patient care are common in academic hospitals and have become increasingly important following work-hour restrictions. Despite this importance, the sign-out processes during shift changes are rarely standardized and often haphazardly managed. Most resident physicians receive little training in sign-out skills, are poorly supervised when conducting sign-outs, and rely on low-tech forms of communication.
In a study by Horwitz and colleagues, postcall and night-float interns were asked to identify any sign-out–related problems occurring during the coverage period and to identify the associated sign-out inadequacies.
1. Current Clinical Condition Omitted
When the current clinical condition of the patient was omitted during sign-out, it was difficult for health care providers to prioritize care or identify clinical deterioration. For example, one patient was sent to the intensive care unit in the middle of the night because of significant bronchospasm. Only then did the covering intern discover that the patient had been bronchospastic during the day as well; this condition was omitted from the oral and written sign-out.
2. Recent and Scheduled Events Omitted
Interns also had difficulty caring for patients when they did not know what events had recently occurred or were planned for the night. For instance, one patient with diabetes mellitus had her insulin withheld because of hypoglycemia
3. Anticipatory Guidance Omitted
Failure to provide anticipatory guidance for likely overnight events resulted in some of the most serious problems observed by covering interns. For example, one patient who had seizures repeatedly during her hospitalization was signed out without any guidance about effective treatment:
4. Task Not Assigned
In several cases, the sign-out omitted an assignment to follow up the result of a test performed during the day. This meant that abnormal results could be overlooked. For instance, one patient underwent ultrasonography on the day of the sign-out to monitor a large abscess that had first been diagnosed by an earlier ultrasound. The new ultrasound image showed no improvement despite surgical intervention. However, the patient was signed out to the intern covering that evening with no mention of the second ultrasound, no assignment to check the results, and an ambiguous assignment to follow up a new consult note
5. Plan Not Provided
Several interns reported that they were assigned tasks without being told how best to complete them. For example, an intern was told to discontinue treatment with an insulin drip without being told what subcutaneous insulin regimen to use afterward, another was instructed to send a patient for a vascular study without being told what to do about the patient’s anticoagulation afterward, and others were asked to replete potassium levels in patients with renal failure without being told what dosage was typically effective. These examples highlight the fact that interns frequently had to improvise plans for medications with high potential for harm if prescribed incorrectly, such as insulin, anticoagulants, and potassium.
6. Rationale Not Provided
Even if a task included a plan of action, health care providers were unable to deal efficiently or effectively with unanticipated sequelae if they did not fully understand why the task was assigned in the first place. For example, the neurosurgery service requested that one patient undergo an urgent magnetic resonance imaging (MRI) scan to help determine whether he would require surgical treatment for a brachial plexus injury. The patient’s primary intern scheduled the MRI and asked the covering intern to check the results and call neurosurgery when it was completed. She stressed the high-priority nature of the study but did not fully explain why it had been ordered. That evening, the conscious sedation nurse on call, who was pregnant, declined to assist with the procedure. As the night-float intern reported the next day: “And there was a patient who was supposed to get an MRI, and I was told it was very important, but it wasn’t clear why it was important. . . . So . . . when I couldn’t get it done, I wasn’t clear on how important it was [to push for the study].”
The night-float intern was faced with the choice of calling in another nurse from home or deferring the test but was unsure what to do because he was unaware of the precise indication for the MRI. In the end the patient did not receive an MRI that night, delaying his diagnosis.
The study confirms the link between inadequate communication at sign-outs and adverse events experienced several hours later by patients. The authors call for the standardization of sign-out procedures, focusing on ways to convey an overall picture of the patient and assist in decision-making. The authors also call for research into factors that may affect sign-out quality and the impact of sign-outs on longer-term outcomes.