Assessment of internal medicine trainee sign-out quality and utilization habits

Abstract

Transfers of care have been associated with adverse events. High quality sign-out may help mitigate this risk. The authors sought to characterize the clinical questions asked of physicians covering patients overnight and to determine the adequacy of current sign-out practice to anticipate inquiries. The authors conducted a prospective, self-report study of interns’ overnight experience at two hospitals. We collected data from novice interns (July 7–August 3, 2010) and experienced interns (March 2–March 29, 2011) in an Internal Medicine residency program. Interns recorded information about overnight inquiries regarding cross-covered patients. For each inquiry about a patient, the intern was asked to record what the situation was about, who initiated the contact, where the intern found the desired information, whether all required data was located, whether the call could have been anticipated by the primary team, if so, whether the call was anticipated, whether the sign-out was sufficient, the time required to address the question, and whether the patient was physically visited. Twenty-one interns (13 novice, 8 experienced) reported 167 overnight inquiries. Most were from nursing staff (87 %) about a wide range of topics, with orders (25 %) and plan of care (20 %) being most common. Trainees used the oral or written sign-out to answer 56 % of inquiries. The proportion of inquiries successfully anticipated (47 % overall) significantly decreased as the academic year progressed (AOR = 0.4, 95 % CI 0.2, 0.8). Trainees rely on sign-out to answer nearly half of overnight inquiries, but the quality of sign-out may decrease over the course of the academic year. The deterioration of sign-out quality from novice to experienced interns and the common use of sign-out as a reference by covering interns suggest continued education, support and oversight by supervising physicians may be beneficial.

Nighttime clinical encounters: How residents perceive and respond to calls at night

“…Although residents report that the written sign-out is useful, it was deemed useful for resolving a clinical issue only 27% of the time. Previous reports have found variable and conflicting rates of written sign-out utilization, as well as variable quality of a written sign-out, [21][22][23] and our data support infrequent usage. Residents were much more likely to access the electronic medical record than they were to use the handoff tool.…”

Communicating Neurocritical Illness: The Anatomy of Misunderstanding

“…Communication between healthcare workers involves communication of an incoming patient or outgoing patient with transfer in the hospital or out the hospital. Handoffs (sign-outs) have been best studied and the importance of the handoff is bolstered by the observation that night interns reference the written or verbal sign-out in order to answer questions that arise during the night [ 6 ].…”

A Quality Improvement Approach to Standardization and Sustainability of the Hand-off Process

“… 4 Another study identified the importance of patient hand-offs, citing that night interns referenced the written or verbal sign-out 56% of the time in order to answer questions that arose during the night. 5 When a standardized method of hand-off is instituted, the risk of missing critical data is minimized. In fact, following standardization of hand-off, night interns have been shown to be significantly less likely to report missing data.…”