Improving signout skills

JHU/Sinai HospitalMorning report

6/28/13

Goals

Review common pitfalls during signout

Learn to create and update a written signout

Learn how to execute a verbal handoff

Sender oranizes &updates handoffinformation

Specific verbalexchange betweensender and receiver

Pre-handoff Arrival Dialogue Post-handoff•Lack of time, poor time management, fatigue or work prevent updating

•Lack of clinical judgement

•Vague language

•No set location or time

•Not able to contact sender or receiver

•Competing obligations

•Handoff not a priority over other tasks

Sender could:

•Provide disorganized info

•Use vague language

•Fail to provide clinical impression, anticipatory guidance, plan or rationale

Receiver could:

•Not listen

•Misunderstand

•Not clarify (ask)

•Forget key tasks or information

•Not document actions taken

•Act on plan without taking new information into account

•Not invest in the care of patient

Two-way street

Handoffs are dialoguesSender must paint a pictureReceiver must see it, understand it,

act on it, and, ultimately, communicate it to someone else.

Core components of handoffs

Verbal communicationin person or over the phone

Written communicationsign-out

Transfer of professional responsibility

Constructing a written sign-out

Abstracted from H&PInformation that may become important in a critical situation

code status, i.v. access, PCP, family info

admission diagnosis, date, teamAll patients, even those being d/c’d that dayAvoid vague language

tomorrow/today/yesterday…

9 Ds

iDentitiy / Doctor / DNR?Diagnosis and DiseaseDietDrugsDaily progressDirections:

if/then, to-do

iDentitiy

Room numberremember to update it

Patient nameAge, genderMedical record number

Diagnosis and Disease

Same columnDiagnosis first

Reason for admission and/orThe main problem that is being worked up

Then the disease (co-morbidities)

CHF exacerbationCAD, HTN, DM, asthma

Drugs

Sometimes difficult to list all, butyou can use abbreviationshighlight the important ones(antibiotics, narcotics, anticoagulants…)with a * … *

If you copy/paste from Rounds Report, have to spend some time removing cruft

Diet

Many calls about NPO statusEspecially in patients going to

surgery/procedures the next day

Daily progress/Plan

Things that explain patient’s *current* condition, progress, interventions, problems, plans

e.g. On Lasix 40 mg IV q12h, net –ve 1.5L/24hr, improving; echo: EF 30%; continuing diuresis, cardiology to evaluate

Directions

Items To Do: only important things that need to be addressed or require follow up, with special instructions for further plans and rationale—avoid “check BMP”

If/then: anticipatory guidance for what may happen, short and clear

Updating written sign-out

Update daily:DrugsDirections

Nearly 1/3 of signouts discrepant with chart:80% with at least 1 omission40% with one comission

CoPaGA syndrome

Copy/Paste Gone Amok

Repeated copying and pasting text from H&Ps and progress notes into singout

Crowds out useful information by gluts of useless data

Zombie-like propagation of inaccuracies

Information overload

Overreliance on signouts for your own workSignouts become unnecessarily long shadow chartOften becomes a personal tracker of information

But remember, your covering intern needs it simple

Verbal handoffs

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 the better you know someone

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

Some things more likely to be remembered:ToDo (65%), If/then (69%), more likely than knowledge items (35%)

What can senders do?

Relevant items that will be Rememberedfocus on the sickest patient firstdaily progressdirection: to-do and if/then items

Directions with Rationaleavoid ambiguity: “check CBC” without giving a reason why and what to do with results

Check for Receiver understanding

What can receivers do?

Actively listenstay focused, limit interruptionstaking notes can enhance memory

Ask questionsto ensure you understand dirctions

Use a systemto keep track of to-do items

Readback

Example 1

A nurse calls because the patient wants to know if they can eat.

Signout says “Patient is NPO for surgery tomorrow”

Always give datesAvoid use of today/tomorrow/yesterday

What procedure? How important?

Example 2

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?

Example 3

The patient you are covering is being evaluated for SBO. The surgeon comes by after being in the OR and asks you what the patient’s coags are. You say: “I’m sorry, but that’s not my patient”.

Handoffs are more than just a transfer of content, but also a transfer of personal

responsibility.Every patient is your patient.