Effectiveness of written hospitalist sign‐outs in answering overnight inquiries

Abstract

Background Hospitalists are key providers of care to medical inpatients, and sign-out is an integral part of providing safe, high quality inpatient care. There is little known about hospitalist-to-hospitalist sign-out. Objective To evaluate the quality of hospitalist/physician-extender sign-outs by assessing how well the sign-out prepares the night team for overnight events and to determine attributes of effective sign-out. Design Analysis of a written-only sign-out protocol on a non-teaching hospitalist service using prospective data collected by attending physician survey during overnight shifts. Setting Yale-New Haven Hospital (YNHH), a 966-bed, urban, academic medical center in New Haven, CT with approximately 13,700 hospitalist discharges annually. Results We recorded 124 inquiries about 96 patients during 6 days of data collection in 2012. Hospitalists referenced the sign-out for 89 (74%) inquiries, and the sign-out was considered sufficient in isolation to respond to 27 (30%) of these inquiries. Hospitalists physically saw the patient for 14 (12%) of inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety-five (77%) of inquiries were considered to be “somewhat” or “very” clinically important by the hospitalist. Conclusions Overall, we found that attending hospitalists rely heavily on written sign-out to address overnight inquiries, but that those sign-outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign-out is needed to help improve the safety of overnight care.

Evaluating Outcomes of Electronic Tools Supporting Physician Shift-to-Shift Handoffs: A Systematic Review

“…All but 2 of the studies (95%) 24,35 were conducted to evaluate shift-to-shift handoffs in physicians in training. Academic medical centers appear to be conducting the majority of the research on handoffs.…”

“…22,[24][25][26]28,29,35,[44][45][46][47][48][49][50][51][52] One study found that 92% of errors were committed in a core data element and could have been prevented with auto-population. 44 While many studies with process outcomes specifically showed fewer data omissions, 24,25,28,29,34,44-47,49-52 1 found that less than 50% included allergies or code status when using the electronic handoff system.…”

“…53 Another study found that 96% of electronic handoffs were updated within 24 hours, 51 while a third study found an increase in the documentation of 12 of 16 specific data elements studied, a decrease in 3 elements, and no difference in 1 element. 48 Three studies noted that an electronic handoff tool should include free-text options for current anticipatory guidance and comments, 25,35,48 and another reported that users need to be encouraged to be vigilant in revising and updating free-text sections. 29 In a study that used faculty estimates for inaccuracies in handoffs and data from actual reviews, when attending physicians provided oversight of the content of residents' electronic handoffs they reported that 7% contained inaccuracies.…”

“…In 22% of the included studies, respondents reported increased or improved handoff content, 22,[29][30][31][32][33][34][35] and 22% of studies also reported high provider satisfaction with use of an electronic handoff system. [22][23][24][25][26][27]31,32 However, in 1 of these studies, 22.6% of respondents reported there was information they did not receive at handoff that would have helped them care for patients.…”

The authors reply “variation in printed handoff documents: Results and recommendations from a multicenter needs assessment”

“…1 Despite the routine use of written handoff tools as a reference by on-call physicians, 2 it is well known that they can be misleading to on-call providers, resulting in medical errors.…”