What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff

Abstract

Objectives: To characterise and assess sign-out practices among internal medicine house staff, and to identify contributing factors to sign-out quality.

Design: Prospective audiotape study.

Setting: Medical wards of an acute teaching hospital.

Participants: Eight internal medicine house staff teams.

Measurements: Quantitative and qualitative assessments of sign-out content, clarity of language, environment, and factors affecting quality and comprehensiveness of oral sign-out.

Results: Sign-out sessions (n = 88) contained 503 patient sign-outs. Complete written sign-outs accompanying 50/88 sign-out sessions (57%) were collected. The median duration of sign-out was 35 s (IQR 19-62) per patient. The combined oral and written sign-outs described clinical condition, hospital course and whether or not there was a task to be completed for 184/298 (62%) of patients. The least commonly conveyed was the patient's current clinical condition, described in 249/503 (50%) of oral sign-outs and 117/306 (38%) of written sign-outs. Most patient sign-outs (298/503, 59%) included no questions from the sign-out recipient (median 0, IQR 0-1). Five factors were associated with a higher rate of oral content inclusion: familiarity with the patient, sense of responsibility for the patient, only one sign-out per day, presence of a senior resident and a comprehensive written sign-out. Omissions and mischaracterisations of data were present in 22% of sign-outs repeated in a single day.

Conclusions: Sign-outs are not uniformly comprehensive and include few questions. The findings suggest that several changes may be required to improve sign-out quality, including standardising key content, minimising sign-outs that do not involve the primary team, templating written sign-outs, emphasising the role of sign-out in maintaining patient safety and fostering a sense of direct responsibility for patients among covering staff.

Figure 1

Schema of weekday sign-out pattern for teams with night float. At the start of the day each intern cares for a group of patients, represented by a colored line. Each sign-out is numbered and is represented by a dotted line towards the intern receiving care of that group of patients. Approximate time of day at which each sign-out occurs is indicated along the bottom of the figure. At noon the post-call intern signs out to his or her co-intern. At 5pm the on-call intern receives sign-out from his or her co-intern, as well as from the two interns of his or her “sister team” (here, Team B). The on-call intern in turns signs-out some patients to the night float intern at 7pm. The tape recorder in this study was carried by the on-call intern. Thus sign-out #1, which did not involve the on-call intern, was not eligible for inclusion in the study.

Figure 2

Schema of weekday sign-out pattern for teams without night float. At the start of the day each intern cares for a group of patients, represented by a colored line. Each sign-out is numbered and is represented by a dotted line towards the intern receiving care of that group of patients. Approximate time of day at which each sign-out occurs is indicated along the bottom of the figure. On days when a member of the team is on call (Schedule A), one intern signs out patients to the on-call intern at about 5pm. On days when no members of the team are on call (Schedule B), an ambulatory intern arrives at 5pm to assume care of both interns’ patients, receiving two sign-out lists at that time. Earlier in the day, the post-call intern had signed out to the co-intern. The tape recorder in this study was carried by the on-call intern. Thus sign-out #1 in Schedule B, which did not include the on-call intern, was not eligible for inclusion in the study.

Figure 3

Flow diagram of study participants

Figure 4

Bar graph of information about tasks and anticipatory guidance presented in oral and written form. “Culture if spikes [a high temperature]” is a particular type of anticipatory guidance routinely hand-written on this institution’s written sign-out sheets.