1. 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

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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. Department of Surgery Methods: Guidelines

10. 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

11. 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

12. 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

13. 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

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

15. Department of Surgery Results: Resident Survey Pre Guidelines Post Guidelines PGY-1 satisfaction with signout process 3.333.67 N = 37

16. Department of Surgery Results: Resident Survey Pre Guidelines Post Guidelines PGY-1 satisfaction with signout process 3.333.67 Perceptions of patient safety via continuity of care 3.613.68 N = 37

17. Department of Surgery Results: Resident Survey Pre Guidelines Post Guidelines PGY-1 satisfaction with signout process 3.333.67 Perceptions of patient safety via continuity of care 3.613.68 Adequacy of patient information provided to on-call resident 3.423.89 N = 37

18. Department of Surgery Results: Resident Survey Pre Guidelines Post Guidelines PGY-1 satisfaction with signout process 3.333.67 Perceptions of patient safety via continuity of care 3.613.68 Adequacy of patient information provided to on-call resident 3.423.89 Adequacy of patient knowledge by on-call resident 3.533.57 N = 37

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

20. 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

21. Department of Surgery Perceived Barriers

22. Department of Surgery Perceived Barriers

23. Department of Surgery Perceived Barriers

24. Department of Surgery Perceived Barriers

25. Department of Surgery Results: Nursing Survey Pre Guidelines Post Guidelines ICU nurses 3.593.90 Ward nurses 3.383.50 All nurses 3.463.66 To what extent does the current signout process provide patient safety via continuity of care? N = 46

26. Department of Surgery Results: Nursing Survey Pre Guidelines Post Guidelines ICU nurses 3.533.81 Ward nurses 3.343.43 All nurses 3.413.59 To what extent are residents given adequate information about the patients whom they cover? N = 46

27. Department of Surgery Results: Nursing Survey Pre Guidelines Post Guidelines ICU nurses 3.714.00 Ward nurses 3.483.36 All nurses 3.573.63 To what extent does the resident on call at night know your patients? N = 46

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

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

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

31. 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