How to Give a Good Signout

With the advent and evolution of work-hour restrictions, the importance of the signout as a learned skill and a necessary aspect of patient care has grown considerably. The signout or “pass off” is viewed by some senior physicians as a necessary evil (with the emphasis on “evil”), but as work shifts for residents become shorter and the population of hospitalists expands, it becomes ever more important to learn how to do a signout right.

What is a signout or pass off?

By its nature, it is:
[1] A temporary yielding of responsibility for a patient’s care to another physician.
[2] A process by which one prepares the covering physician to perform at maximum capacity as if he or she were the primary physician directing the care of one’s patient.

These two aspects of the signout are essential and intertwined; one cannot exist without the other. Some residents eagerly throw the responsibility for their patients at a fellow resident without adequately preparing them for anticipated or potential overnight complications. On the other hand, some residents overprepare their night shift colleagues, poring over every lab value and detail, while also signing in from their home computers to update electronic signouts and notes. The best strategy is to find the right balance of information transfer and a secure handing over of patient care responsibility.

Granted, it takes two to tango: signout requires both an effective transmitter of information and an actively engaged recipient. The person receiving the signout needs to know what questions to ask and needs to know when to jump in regarding a clarification or to keep things on track when the other resident starts to lose steam and digress.

What are the essential elements of the signout?

While some residency programs and hospitals are trying to standardize signout processes and even study their efficacy, the current process lacks standardization across programs and hospitals. Nonetheless, a few key details form the backbone of a solid signout. Signout can take a long time and is often interrupted by pages and requests, so the most important information that requires verbal transmission must be shared first.

[1] The Red Highlighter – “Which patients are the sickest? Which patients are changing in condition?”

Identifying the sickest patients alerts the on-call resident to the patients who need to be re-evaluated more frequently or who are most likely to have complications or changes in condition overnight. This helps the resident prioritize his or her time and also potentially evaluate these patients early during the shift so that reevaluations later can be compared to a baseline examination.

[2] The Code Status – “Which patients are DNR/DNI? Are any patients CMO?”

Night shifts in particular can be chaotic, and nothing is more chaotic than a Code. Accordingly, the algorithms underlying Codes are meant to provide order and structure for a situation where interventions must be rapidly delivered. However, not all of these interventions are desired by the patient, and so the Code Status must be the hand that stays the trigger finger in these cases.

Identifying patients who are “comfort measures only” and may likely pass during the shift helps the on-call resident prepare, particularly if he or she has questions regarding the cause of death (which will have to be documented and can be an ardurous process).

[3] The One-Liner – “Mr. T is a 43 year old man with a history of hypertension, coronary artery disease, and diabetes presenting with intermittent substernal chest pain for one day, most likely representing acid reflux.”

This skill is learned by medical students, but it still requires honing and perfection throughout residency and beyond. It is important to be able to convey key details of information in a compact amout of time and space. This includes age, pertinent past medical history, the presenting complaint, and the suspected diagnosis.

This is also a common area which can balloon in size and detail: the entire past medical history does not need to be conveyed, only the important aspects. Nonetheless, these details can be important, and it helps to provide some detail in a written version of the signout. For example, it helps to know the left ventricular ejection fraction for a patient with Congestive Heart Failure, that a patient with chronic renal insufficiency has a baseline creatinine of 1.6, that a patient with CAD has coronary stents, and that a patient with a prior left MCA stroke has residual right arm and face weakness.

[4] The Plan – “He is being ruled out for myocardial infarction and evaluated for other causes of chest pain.”

The “second line” following the one-liner should indicate what is being done for the patient. In particular, night shift residents are often called to the bedside to update patients and their families regarding the medical team’s plan of action because that is the time when family members are off work and can visit their loves ones in the hospital. This information also helps the night shift resident think about the direction of the patient’s care and potentially offer contributions in the form of suggested investigatory testing, additional history taking from the patient, or collecting collateral information from visiting family members. This can empower night shift residents to continue the work of the day time.

[5] The To-Do’s – “He has cardiac enzymes pending at 2000 and 0400.”

This part is a no-brainer. If there are specific tests to follow up or re-evaluations that must be done at a particular time, this should be communicated clearly and concisely. A plan of how to react to potential data points is also important here. For example, what should be done if the patient’s lungs have more crackles than before? What should be done if the patient’s blood pressure drops below a desired range?

[6] The Contingencies – “If he has recurrent chest pain, reassess, check his telemetry, and consider a repeat ECG. If his cardiac enzymes turn positive, call the Cardiology fellow and consider Heparin.”

Part of the day resident’s job is to anticipate potential problems or complications that might occur based on his or her current knowledge of the patient and the suspected disease process. This should accordingly be communicated to the night resident, and they should plan together how to react to these situations. In some places, these are called “disaster rounds” where the residents discuss worst-case scenarios and develop plans on how to deal with them.

This how-to guide should provide some structure and tips on how to make signouts systematic and effective. Signouts will continue to be a part of practicing medicine, wherever and whenever one is involved in patient care. Are there other aspects of the signout process not listed here that you believe are important to include? Has your program developed signout strategies that are particularly helpful or effective?

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