Department of Surgery 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

Department of Surgery Duty Hour Limitations Intended consequences: –Minimize ill effects of trainee sleep deprivation –Optimize patient safety –Resident well-being

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

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

Department of Surgery 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

Department of Surgery Aims Characterize obstacles affecting current sign-out practices Evaluate potential impact of standardized sign-out guidelines

Department of Surgery 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

Department of Surgery 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

Department of Surgery Methods: Guidelines

Department of Surgery Methods: Guidelines Implemented June 2011 Program-wide use 1-hour kickoff presentation for current trainees New trainees provided with workshop at orientation

Department of Surgery Methods: Survey Designed to assess: –Practices –Attitudes –Barriers to effective communication 29 multiple-choice items Dichotomous and 5-point Likert-type responses

Department of Surgery 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

Department of Surgery 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

Department of Surgery Results: Resident Survey Baseline: –Moderate satisfaction with sign-out process –Concerns regarding communication and patient safety

Department of Surgery Results: Resident Survey Pre Guidelines Post Guidelines PGY-1 satisfaction with signout process N = 37

Department of Surgery Results: Resident Survey Pre Guidelines Post Guidelines PGY-1 satisfaction with signout process Perceptions of patient safety via continuity of care N = 37

Department of Surgery Results: Resident Survey Pre Guidelines Post Guidelines PGY-1 satisfaction with signout process Perceptions of patient safety via continuity of care Adequacy of patient information provided to on-call resident N = 37

Department of Surgery Results: Resident Survey Pre Guidelines Post Guidelines PGY-1 satisfaction with signout process Perceptions of patient safety via continuity of care Adequacy of patient information provided to on-call resident Adequacy of patient knowledge by on-call resident N = 37

Department of Surgery Results: Resident Survey All trends None of these gains reached statistical significance

Department of Surgery 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

Department of Surgery Perceived Barriers

Department of Surgery Perceived Barriers

Department of Surgery Perceived Barriers

Department of Surgery Perceived Barriers

Department of Surgery Results: Nursing Survey Pre Guidelines Post Guidelines ICU nurses Ward nurses All nurses To what extent does the current signout process provide patient safety via continuity of care? N = 46

Department of Surgery Results: Nursing Survey Pre Guidelines Post Guidelines ICU nurses Ward nurses All nurses To what extent are residents given adequate information about the patients whom they cover? N = 46

Department of Surgery Results: Nursing Survey Pre Guidelines Post Guidelines ICU nurses Ward nurses All nurses To what extent does the resident on call at night know your patients? N = 46

Department of Surgery Summary Mild improvement in perceptions of patient safety and adequacy Improvements reported by –Nurses –Residents

Department of Surgery Summary Persistent barriers remain Additional obstacles have surfaced in setting of further restrictions on duty hours

Department of Surgery Conclusions Standardized signout guidelines: –May improve continuity of care –Should be universally employed –Do not solve all issues

Department of Surgery 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