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

l Rick Sledd l Ted Perez l Kim Brantley l Matthew Bolton l Leigh Baumgart l McKinsey Bond l Adam Helms l Luther Bartelt l Mangwi Atia l Tammy Schlag l Peggy Plews-Ogan l George Hoke

Sign-Out l a mechanism of transferring information, responsibility and/or authority from one set of care-givers to another l primary objective is the accurate transfer of information about patient’s state and plan of care

Sign-Out is a Lifelong Skill l In Academic Health Centers, resident physicians sign-out to one another from the very beginning of residency l Few residency training programs formally teach residents how to sign-out l Few residency training programs assess how well residents’ sign-out to one another l Sign-out is a life-long skill

There are Multiple Resident Hand-Offs Every Day

l 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

A Changing Environment l Hospitalized patients are sicker and sicker l Hospital stays are shorter and shorter l The “medical record” has been marginalized as a source of communication between clinicians l There has been an explosion in scientific and medical knowledge l There is an increasing reliance on electronic health records/electronic data sources l In 2003, the ACGME instituted duty hour restrictions for all residency programs

Sign-Out l 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

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

Residents Often Miss Key Points During Sign-Out

Next Steps l Process l Tool(s) l Education

Process l 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

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

Education and Training l 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

Who Gives Good Sign-Out and Why? l 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”

Who Gives Good Sign-Out and Why? l 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

Education and Training l Over time, we have realized the 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

The Cognitive Tasks of Sign-Out l 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 l This co-orientation is necessary to recognize and analyze problems, to make sense of the situation, and to plan l Co-orientation also provides an opportunity for rescue and recovery (collaborative cross-checking)

l Clinicians need more than data to understand a patient’s story and to try and predict future trajectories l 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

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

Sign–out vs Sign Over l Culture change »from “I’m just the cross-cover” to “This is my patient right now” l 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

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