Espresso: Sign Out

Read on with ACOG Committee Opinion: Sign Out

Sign Out: A Critical Moment

• Sign out or hand off – transferring of patient knowledge and plan between two physicians or care teams. 

• Patient care transitions represent a potential challenge to all of us:

• Communication is challenging - different styles and preferences

• External dynamics (interruptions, emergencies, home-life demands)

• Internal dynamics (power differential, hierarchy, fatigue)

• Interpersonal characteristics (defensiveness, minimizing, conflict-averse or conflict-prone)

• Communication errors are frequently identified as pain points or root causes of safety events.

• Three primary focuses to improve sign out:

• Setting the stage

• Being a good (and thorough) “giver” of sign out.

• Being a good (and vigilant) “receiver” of sign out.

Setting The Stage for Effective Handoff

• Preparation

• The “giver” of signout should organize and update information to be prepared for handoff.

• Updating any signout template or process used at your institution.

• Reviewing daily updates to ensure most salient points are reviewed during verbal discussion.

• Identify any tasks or specific guidance for the receiving team to complete.

• Consider organizing sign out order by acuity/urgency or timely completion of these tasks.

• Physical Environment

• The environment should be set appropriately. Ideal physical environments are:

• Quiet, and ideally away from distractions; i.e., a quiet conference room vs at nursing station.

• Areas where patient confidentiality is preserved.

• “Warm hand off” in a patient room as appropriate for particularly significant cases. 

• Paper forms for hand-off should be legible and organized.

• Fortunately many EMRs are incorporating sign-out templates, but don’t be afraid to ask your institution to modify things if needed to apply to your environment.

• Sufficient time should be set aside to protect effective handoff.

• Consider assigning someone specifically to address acute patient concerns during sign out - this keeps a significant amount of the team intact to focus on information exchange. 

• This requires redundancy in those who are aware of patients on the service - sign out is a team responsibility, not an individual one!

• Communication Environment

• Use of medical terminology

• Try to stick to understood medical language: i.e., “Category II for repetitive variable decelerations” instead of “this baby’s been a little naughty.” 

• Standardized terminology allows for conveyance of the appropriate message and plan of care; colloquialisms may leave significant room for error due to being inexact.

• Also consider language importance with respect to professional communication - attention to terms that may be culturally or personally insensitive, or the use of judgment statements rather than objective facts.

• Culture and Hierarchy

• Many times in OB/GYN residency, sign out is predicated on a structural hierarchy. 

• Certainly, all patients should have a primary individual or team responsible for them, but a back-up system should be in place in case the primary contact is unavailable.

• These hierarchies may lead to communication challenges in patient care:

• I.e.,A student, first year resident, or RN should all be as comfortable to communicate in sign out as the senior resident or attending regarding a concern. 

• Senior residents and attendings should role model effective communication and elicit team member concerns.

• Senior residents sign out should strive to serve as a role model for junior team members to demonstrate communication style, active listening, and prioritization.

• At the same time, sign out should be recognized as a patient safety event and treated the same:

• Unique learning points for safety may be raised

• However, sign-out is not a time to do an in-depth review on basic topics - lengthy interruptions should be avoided.

Sign Out Time: The Verbal Discussion

• “Giver” of signout should ideally follow a standardized presentation strategy for each patient.

• Common frameworks:

• IPASS - Illness severity, Patient summary, Action list, Situational awareness, Synthesis by receiver.

• SBAR - Situation, Background, Assessment, Recommendation

• Use of a structure for sign out has been shown in some studies to reduce preventable adverse event rates by as much as 30%.

• Verbal hand-off should focus on the most important items, and ensure your communication is structured to make those points stick for the receiver.

• Even in optimal conditions, studies have shown that in those not using structured communication strategies, the receiver fails to identify the main concern 60% of the time! 

• You as a giver of hand-off should prioritize issues to help the receiver, who is new to the patient - don’t make them prioritize and learn the patient simultaneously!

• Critical to relay tasks to be done, and anticipatory guidance for events that may occur:

• I.e., “The tracing was previously category II for some variable decelerations. If it occurs again, I would recommend an IUPC and amnioinfusion.” or 

• “She is known to have CHF and received 2L IVF intraoperatively. If she is short of breath, she should be evaluated for pulmonary edema and if suspected, start with 60mg IV lasix per cardiology.” 

• Giver should likewise use strategies to check receiver understanding, like read-back and interactive questioning. More on those momentarily!

• “Receiver” of sign out has an equally important role in comprehending sign out and actively listening:

• Read-back communication allows the sender to check that information is received by a recipient. It is rarely employed in hand-offs, but it is one of the most effective strategies to effective communication.

• I.e., last example – “Got it. She’s at high risk for pulmonary edema. If I suspect it, I will give 60mg IV lasix.” 

• Active listening should also be employed - that’s more than just head-nodding or uh-huh-ing!

• Take notes

• Ask questions

• Clarify the plan when needed

• If for a patient you do not hear any “critical events” or “tasks” - take that as a signal to ask!

• Giver and receiver should both be aware that there are high risk scenarios for sign-out failure:

• When a patient is physically moving locations

• When a patient is clinically unstable

• If the hand off is permanent, i.e., a service change, transfer to another facility, or a patient who is newly being admitted at sign out.

• In these scenarios, there is evidence for higher risk of a patient safety event due to hand-off concerns.

• Both should be acutely aware of importance of thorough sign-out in these scenarios.