Sign-out Workshop for New Interns

Improving Signout Skills Case-based workshop Intern Orientation Department of Medicine University of Chicago & Mercy Hospital

Goals Review common pitfalls during signout Environmental, cultural and communication barriers Learn To create and update a written signout How to execute a verbal handoff using effective communication strategies

State of Current Signouts (n=34) % noting sometimes, often or always 65% Discovered overnight events that should have been verbally communicated at sign-in 59% Overnight events documented 59% How often do you get morning signout 55% Reporting errors during signout 69% Missed content on signout sheet 72% Uncertain about medical decisions 84% Discovered events should have been notified

What went well in this scenario? Observations Facilitators Other Environmental (e.g., distractions and obstacles interfering with completing proper hand-off procedure) Communication (e.g., vague terms, incomplete information, lack of verification, etc.) Cultural (e.g., not prioritizing hand-offs, following proper procedures, unprofessional behavior, etc.) Observations/Thoughts Barriers

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Debriefing What types of barriers to an effective hand-off did you observe? Environment Cultural Communication Any others?

Pre-handoff Arrival Dialogue Post-handoff Sender organizes & updates handoff information Stop patient care tasks to conduct handoff Specific verbal exchange between sender and receiver (could be in person or over phone) Receiver integrates new information and assumes care of patient(s) Lack of time, poor time management, fatigue, or work prevent updating Lack of clinical judgment to construct proper handoff Vague language No set location or time Not able to contact sender or receiver Competing obligations (work or personal) Handoff not a priority over tasks Sender could Provide disorganized info Use vague or unclear language Fail to provide clinical impression (what is wrong), anticipatory guidance (if/then), plan (to do), & rationale (why) Receiver could Not listen (distractions) Misunderstand Not clarify (ask questions) Forget key tasks or information Not document actions taken Act on plan without taking new arriving information into account Not invest in the care of patient (lack of professional responsibility)

Swiss Cheese Model Modified from Reason, 1991 © 1991, James Reason Triggers DEFENSES Accident Institution Organization Profession Team Individual Technical Regulatory Narrowness Incomplete Procedures Mixed Messages Production Pressures Responsibility Shifting Inadequate Training Attention Distractions Deferred Maintenance Clumsy Technology LATENT FAILURES Goal Conflicts and Double Binds The World

Two Way Street Best understood as a dialogue an interaction that fosters common ground, empathy, and equity to transfer necessary information Gibson CS, et al. Ann Emerg Med 2009 Sender must paint a picture receiver must see it, understand it, act on it, and, ultimately, communicate it to someone else

Mock Chart 10 Minutes to Review H&P Look at the blank signout template and abstract any critical data that you think will be important

Interval Events Video Now we will watch a short video (<3 minute video) that will highlight the events of the day During the video, take note of any changes or updates that you would like to include on your signout

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Execute a Signout When you are ready, turn to your partner to execute the signout

Hand-off CEX Receiver complete this evaluation on the sender Domains assessed: Organization/Efficiency Communication skills Clinical judgment Professionalism 9-point scale

Volunteers Come up and demonstrate a handoff

Core Components of Handoffs Verbal Communication In person or over phone Written communication Signout Transfer of Professional Responsibility

Written Sign-out Review Constructing a written sign-out To abstract from H&P Information that may become important in a critical situation Code status/iv access/PCP/family contact info etc. Admission diagnosis, Admission date, team members caring for patient All patients Even those that are discharged that day Avoid vague language “ tomorrow/ today/ yesterday”

9 D’s iDentity / Doctor / DNR or other directive? Diagnosis & Diseases Diet Drugs Daily Progress Directions If/then To Do

iDentitiy Room Number First thing is location (7 th vs 11 th fl) Patient Name Last Name First Name Age, Gender Medical Record # 726 Yazici,Cemal 30M 135791

Diagnosis and Disease Can place under the same column Diagnosis first It is the reason for admission. The main problem that is being managed/worked up Than the Disease (Co-Morbidities) CHF Exacerbation CAD, HTN, DM, ASTHMA

Drugs Sometimes difficult to list all of them Still possible Can use small font Can use abbreviations Can highlight important ones (antibiotics, narcotics, anticoagulants, If you use cut/paste from EMR, have to spend time to remove unnecessary info

Diet Many calls about NPO status Especially in patients going to surgery or procedures the next day Does not take any space at all Can easily be listed as REG CLD SMD ADA LOW K…

Daily Progress/Plan Things that explain patient’s CURRENT condition, progress, interventions,problems, plans. On Lasix 40mg IV q12 hrs , Neg Bal of 1500cc/24hrs. Improving 2D Echo with EF of 30% Continue diuresis. Cardiology to evaluate

Directions Items To Do  Only important things that needs to be addressed or requires follow up With special instructions with further plans & rationale If/then – anticipatory guidance for what may happen Short and clear to Do Re-evaluate later tonight. Make sure receives Duoneb DIRECTIONS If gets SOB,can give IV Lasix 20mg.

Updating Written Sign-out Update daily – need to build in time to do this! Drugs ideally integrated with EHR but few hospitals have this capability Directions “ to Do” with specific rationale / instruction Avoid “Check BMP” without giving instruction “ If/then” – what may happen and what to do about it Arora, et al, JGIM. 2008

Importance of Updating When comparing meds on sign-out to patient charts, nearly 1/3 discrepant 80% contained at least 1 med omission; 40% one commission Omissions more common; BUT commissions more serious Anticoagulants, iv antibiotics, pain medications like narcotics, hypoglycemics (insulin etc.) Arora, et al, JGIM. 2008 Over half had the potential to cause significant harm to patients Majority persisted after first day - mechanism failure to update

A Word of Caution on Technology Computerized sign-out Brigham and Women’s Hospital ( Petersen, et al. Jt Comm J Qual Improv, 1998) U Washington (Van Eaton, et al. J Am Coll Surg, 2005) IT solutions alone cannot substitute for a “successful communication act” Human vigilance still required Ash et al. JAMIA, 2004 and Kilpatrick et al. BMJ, 2001. In an emergency room, the replacement of a phone call for critical lab values with an electronic results-reporting system with no verbal communication resulted in 45% (1443/3228) of urgent lab results to go unchecked.

Another Caution: CoPaGA Syndrome CoPaGA = Copy Paste Gone Amok Repeated highlighting, copying and pasting text from past EHR notes into current notes, the physician-victim attains several goals; avoiding time-consuming work of talking to patient building a documentation trail that portrays faux work crowd-out of useful information by gluts of useless data zombie-like propagation of inaccuracies that persist 74% of Mercy residents saw cut/paste problems in signout

TMI? Information Overload Overreliance on signouts for your own work Signouts become unnecessarily long shadow chart Often becomes a personal tracker of information “ cognitive artifact” like a grocery list But remember your COVERING INTERN needs it simple Information overload

Improving Handoffs: How to Communicate Better Verbally “ who says what to whom in what channel with what effect” Harold Dwight Lasswell

Psychology of Miscommunication Speakers systematically overestimate how well their messages are understood by listeners Egocentric heuristic – Senders assume that receiver has all the same knowledge that they do Worsens better you know someone Study of pediatric handoffs Optimal environment Dedicated room & time Supervised by senior resident & attending physicians Keysar, et al. Psychol Sci. 2002; J Pers Soc Psychol. 2004; Intercultural Pragmatics. 2007

Same Biases in Signout The most important piece of information was NOT communicated 60% of the time despite the sender believing it had been Did not agree on the rationales provided for 60% of items At times contradictory (pt going home vs. pt needed to stay) Some things more likely to be remembered… To do items (65%) & If/then items (69%) more likely to be remembered than knowledge items (35%), p=0.003 Chang V, et al. Pediatrics 2010

So What Can Senders Do? Think about the “R”eceiver (4Rs) Relevant items that will be Remembered Focus on sickest patients first Daily progress (today’s baseline, updated events) Direction  To Do Items and If/then items Directions with Rationale avoid ambiguity  “check CBC” without giving a reason why and what to do with results Check for receiver understanding Encourage questions and read-back Overcome egocentric heuristic (think about receiver)

What Can Receivers Do? Actively listen stay focused, limit interruptions, taking notes can enhance memory Ask questions to ensure you understand directions the handoff is your learning opportunity Use a system to keep track of to do items that require your action Readback directions to ensure you are on the same page

Use of Read-Backs in Healthcare “ Read-back” Reduces errors in lab reporting “ Read-backs” at your neighborhood Drive-Thru Barenfanger, et al. Am J Clin Pathol, 2004. 29 errors detected during requested read-back of 822 lab results at Northwestern Memorial Hospital. All errors detected and corrected.

Horwitz et al, JGIM. 2007 “ SIGNOUT?” Sample verbal sign-out S Sick or DNR? OK, this is our sickest patient, and he’s full code. I Identifying data (one liner) Mr. Jones is a 77-year-old gentleman with a right middle lobe pneumonia. G General hospital course He came in a week ago hypoxic and hypotensive but improved rapidly with IV levofloxacin. N New events of day Today he spiked to 39.5°C and white count bumped from 8 to 14. Portable chest x-ray was improved from admission, we sent blood and urine cultures. U/A was negative but his IV site looked red so we started vanco. O Overall health status Right now he is satting 98% on 2 L NC and is afebrile. U Upcoming possibilities with plan and rationale If he becomes persistently febrile or starts to drops his pressures start normal saline at 125 cc/h and have a low threshold for calling the ICU to take a look at him because possible sepsis. T Tasks to complete overnight with plan, rationale I’d like you to look in on him around midnight and make sure his vitals and exam are unchanged. I don’t expect any blood culture results back tonight so there is no need to follow those up. ? Any questions? Any questions?

Some Case Examples… Based on real signouts…

A nurse calls because the patient wants to know if they can eat. Signout says “Patient is NPO for surgery tomorrow” Always give dates Avoid use of today/tomorrow/yesterday What procedure? How important?

Your signout says “Check BMP at 8pm” The patient has a sodium of 124. What are you supposed to do with abnormalities? What is the baseline? What are you looking for?

A patient you are covering is being evaluated for small bowel obstruction. The attending surgeon comes by after being in the OR and asks you what the patient’s coags are. You say, I’m sorry but that is not my patient. Handoffs are more than just a transfer of content, but also a transfer of professional responsibility Every patient is your patient

Case of SBAR Originated in Navy to communicate critical situations Adapted for nurse to physician communication Became most commonly described handoff mneumonic

Misuse of SBAR Using “SBAR” as a verb “ I’m SBARing” Failing to customize and specify the precise elements in each category Likely that situation for a L&D unit differs from a geriatrics unit Assumption that using SBAR checklist will result in comprehensive information transfer

SBAR Arora, Johnson, Jt Comm J Qual Patient Saf. Schilling, eds. 2009

Sign-out Workshop for New Interns

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