- Appreciate the prevalence of handoffs and sign out related errors.
- Understand the key elements of a safe and effective written and verbal sign out.
- List Kotter’s 8 steps to leading change.
Case & Commentary: Part 1
An 83-year-old man with a history of chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and paroxysmal atrial fibrillation with sick sinus syndrome was admitted to the cardiology service of a teaching hospital for initiation of dofetilide (an antiarrhythmic medication) and placement of a permanent pacemaker.
The patient underwent the pacemaker placement via the left subclavian vein at 2:30 PM. A routine postoperative single view radiograph was taken and showed no pneumothorax. The patient was sent to the recovery unit for overnight monitoring. At 5:00 PM, the patient stated he was short of breath and requested his COPD inhaler. He also complained of new left-sided back pain. The nurse found that his pulse oxygenation had dropped from 95% percent to 88%. Supplemental oxygen was started and the nurse asked the covering physician to see the patient. The patient was on the nurse practitioner (NP) non-housestaff service; however, the on-call intern provides coverage for patients after the NPs leave for the day. The intern, who had never met the patient before, examined him and found him already feeling better and with improved oxygenation with the supplemental oxygen. The nurse suggested a stat x-ray be done in light of the recent surgery. The intern concurred, and the portable x-ray was done within 30 minutes. About an hour later, the nurse wondered about the x-ray and asked the covering intern if he had seen it. The covering intern stated that he was signing out the x-ray to the night float resident, who was coming on duty at 8:00 PM.
Meanwhile, the patient continued to feel well except for mild back pain. The nurse gave the patient acetaminophen as prescribed and continued to monitor his heart rate and respirations. At 10:00 PM, the nurse still hadn't heard anything about the x-ray so he met with the night float resident. The night float had been busy with an emergency but promised to look at the x-ray and advise the nurse if there was any problem. Finally at midnight, the nurse signed out to night shift, mentioning the patient's symptoms and noting that the night float had not called with any bad news.
This elderly man's experience of discontinuous care is typical in teaching hospitals today. The Accreditation Council of Graduate Medical Education (ACGME) duty hour mandates increased the number of handoffs–the transfer of patient care responsibility from one practitioner to another–throughout the country.(1) The mechanism by which that responsibility and necessary patient information is transferred is referred to as a signout.(2) For example, after duty hours were reduced, UCSF's Internal Medicine residency program experienced a 40% increase in signouts.(1) We estimate that our residents engage in signouts 300 times a month, more often than they attend conferences, meet new patients, or even eat. But discontinuities involve other professions as well, because all care providers working finite hours need to handoff and sign out their patients. For example, this case also illustrates nursing handoffs. In our institution, when one adds up all the provider-to-provider handoffs, 4,000 signouts occur daily, a total of 1.6 million per year. When one considers that 16.9 million patients are admitted to teaching hospitals each year, the number of handoffs and signouts are staggering.(3)
In a previous AHRQ WebM&M commentary (4), a structured handoff was highlighted as a mechanism to improve team communication. This concept is now the basis for the 2006 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Patient Safety Goal 2E, which requires all health care providers to "implement a standardized approach to handoff communications including an opportunity to ask and respond to questions." JCAHO's expectations for this goal include interactive communications, up-to-date and accurate information, limited interruptions, a process for verification, and an opportunity to review any relevant historical data.(5)
Case & Commentary: Part 2
The next morning, the radiologist read the x-ray performed at 4:00 PM and notified the NP that it showed a large left pneumothorax. Cardiothoracic surgery service was consulted and a chest tube was placed at 2:30 PM, nearly 23 hours after the x-ray was performed. Figure 1 shows the timeline of coverage and clinical events. Luckily, the patient suffered no long-lasting harm from the delay.
In this case, important information was lost due to handoffs, causing diagnosis and treatment delay and a near miss error. This is not uncommon. Most signout errors are "content omissions" in which critical information is not communicated.(6) Of errors in general, omission errors are common and occur at a rate of 1/100.(7)
Many of these errors are caught before harm reaches the patient, as practitioners have a variety of methods to ensure that gaps in care are managed effectively.(8) Some errors, though, do reach the patient and most of these can be attributed to communication failures, including signout miscommunications.(5) Signouts have also been linked to in-hospital complications and preventable adverse events.(9,10)
One solution to mitigate patient harm due to handoffs is to standardize or structure the signout.(1,2,11,12) Many strategies, proven successful in non-health care industries (13), have been suggested for hospitals and clinics.(2) A recently published review recommends strategies for safe and effective resident signout (including both written and verbal signouts) that can be generalized to all health care providers.(1)
The elements of a safe and effective written signout are included in the mnemonic "ANTICipate": Administrative, New information (clinical update), Tasks, Illness, and Contingency plans. Accurate administrative information, such as patient name and location, is one of the most important components of a written signout according to surveys of internal medicine night-floats at UCSF (Unpublished data from October 2004 evaluation interviews of cross-coverage internal medicine residents at UCSF). New information includes a brief history and diagnosis, updated medications and problem list, current baseline status (eg, cardiac status), and recent procedures and significant events. Tasks are the "to-do" list, or the things that need to be completed during cross-coverage. Listing the tasks in "if, then" statements reduces the need for conjecture on the part of the cross-coverage practitioner. For example, in this case, the written signout would include: "Check CXR which was taken at 4:00 PM. If clear, call nurse to communicate results; if PTX, call thoracic surgery." "Illness" is the primary provider's subjective assessment of the severity of illness, and contingency planning includes statements that assist the cross-coverage in managing anticipated problems. It is also important to report what therapeutic interventions have been successful in the past–thus giving the cross-coverage provider important historical background to assist in decision making. Given our case, an appropriate contingency plan could be: "If patient is short of breath, try an albuterol inhaler (given history of COPD), but consider pneumothorax since he recently had a subclavian line placed."
Written signouts can take many forms. Computerized templates that specify categories of information necessary for the signout have been recommended. At our institution, many types of templates have been used, including those built on MS Word, Filemaker Pro, and MS Excel. These systems depend on the user for accurate data entry. An evaluation of such a written signout system found wide variability of content accuracy.(14) A technological solution to decrease user-entered false information is to link the signout to the hospital electronic medical record (EMR). An example of this is Synopsis, a platform built within the UCSF Medical Center EMR (Figure 2). Systems like these have the capacity to populate the written signout by importing data from the EMR, such as administrative information, laboratory results, medications, allergies, and code status. Such systems have been shown to improve resident efficiency and the quality of signouts (15), as well as to reduce the risk of signout-related medical injuries.(16)
Although electronic mechanisms for written signout can facilitate the standardization of written content, face-to-face verbal communication adds additional value.(17) Verbal signout should be tailored to the needs and skills of the recipient. For example, a less experienced practitioner who is new to the patient may require more information in the signout than an experienced practitioner who is familiar with the patient. Verbal signouts should take place in a designated place and time, free from distractions and interruptions (such as pagers and telephone calls), with access to up-to-date information. The information transmitted should be structured in a format that is consistent for each signout. An example of such a structure is SBAR (Situation-Background-Assessment-Recommendation), a communication tool originating in the Navy that has been effective in health care communication.(18) At UCSF, our internal medicine residents are expected to verbally signout administrative information, a brief history, tasks, and anticipated problems on all patients who are perceived to be ill or who have plans in flux. It takes approximately 7 minutes to complete this process for 10 patients. The receiver of signout should "repeat-back" or "read-back" the information in the tasks, thus allowing for interactive questioning to clarify information.(19) For example, in our case, the receiver would repeat-back: "So, I should check the CXR which was taken at 4:00 PM and act upon the results–was there another one taken before or after 4:00?"
Case & Commentary: Part 3
The team subsequently learned that the night float resident had mistakenly examined the radiograph done immediately postoperatively rather than the chest x-ray done at 4:00 PM, and therefore did not see the film with the large pneumothorax.
Although few data have documented an improvement in signout processes or outcomes due to implementation of a structured signout system, JCAHO mandates and expert opinion strongly advocate for such systems.(1,2,11,20,21) Implementing these changes may seem relatively easy, but they are not, even with the most advanced EMR and the availability of experts.(22) Fortunately, many teaching hospitals and residencies, having recognized the consequences of poor signouts on quality and safety, now seem ripe for transformation.
At UCSF, the transformation to a system-wide structure of written and verbal signout was facilitated by a conceptual framework to manage the change, using Kotter's 8-step approach.(23)
- 1. Establish urgency. We first established a sense of urgency. Residents recognized the urgency of improved signouts quickly, but the introduction of the JCAHO patient safety goal added to the medical center's sense of urgency.
- 2. Form a powerful guiding coalition. We then formed a powerful coalition which included the main stakeholders: Information Technology (IT), Medical Center, and Graduate Medical Education (GME) leadership.
- 3. & 4. Create and communicate a vision. We created a vision, a signout system that could grow with our new EMR, making resident work more efficient and the signout process safer for patients. We then actively communicated that vision to leadership at numerous committee meetings.
- 5. Empower others to act on the vision. We empowered others to act by engaging the medical center IT and GME leadership to help the core group of "champions" move forward in development of Synopsis.
- 6. Plan for and create short-term wins. We designed a "rounds report" linked to Synopsis (Figure 2), allowing for information consolidation and tracking increasing resident work flow efficiency. We also piloted the project on our non-teaching service, which had previously lacked a robust signout system, thus gaining enthusiasm prior to the resident roll-out.
- 7. Consolidate improvements, creating more change. Synopsis spread organically once residents saw its capacity on one of the pilot units.
- 8. Institutionalizing new approaches. We institutionalized this new system by passing policies at the GME and Medical Center level.
By using these 8 steps, coupled with a comprehensive training program, we were able to train the majority of our residents on safe and effective signout strategies. At this point, more than 50% of the patients at our 600-bed acute care hospital are cared for with the assistance of Synopsis, and this percentage continues to grow.
Signouts are a reality of life in academic and community hospital settings. Although each signout introduces risk, the strategies outlined above can improve the processes for signouts, thereby reducing the potential for error.
- Signouts and discontinuity are an inevitable part of today's hospital systems.
- Patients are at risk for errors due to discontinuity and signouts.
- Structured signout systems, including verbal and written standards, can assist in improving the effectiveness of the signout process. Ideally, these structures will be integrated into an electronic medical record.
- A change framework can be an effective strategy to implementing safe and effective signout systems.
Arpana R. Vidyarthi, MD Director of Quality, Inpatient General Medicine Assistant Professor of Medicine University of California, San Francisco
Faculty Disclosure: Dr. Vidyarthi has declared that neither she, nor any immediate member of her family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, their commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.
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Figure 1. Handoff Timeline
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Figure 2. Synopsis: University of California San Francisco Medical Center Signout System*
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*Note that laboratory findings and vital signs are imported from (and automatically updated by) the electronic medical record. The rest is hand entered by each provider, although the medication section will ultimately be populated by the computerized order entry system.