Rip Out action items

Program Directors must:

  1. Acknowledge the growing volume and complexity of patient handoffs in the era of resident duty hour changes

  2. Recognize that poor sign-outs can lead to medical errors

  3. Implement an interactive, workshop-based curriculum for teaching and evaluating written sign-outs by residents and medical students

The Challenge

The Accreditation Council for Graduate Medical Education Common Program Requirements mandate that all residency programs need to monitor and ensure resident competency in patient handoffs.1 Changes in resident duty hours have increased the volume and complexity of handoffs and have increased the use of “bridge” or “float” residents who may not have prior knowledge of the patients. Ensuring proper creation and maintenance of the written sign-out is critical in this environment. Existing curricula to teach sign-out communication to residents have focused almost exclusively on verbal handoffs.2 Tools to facilitate teaching, monitoring, and evaluation of written sign-outs are especially lacking. This becomes even more important given the focus on educational milestones related to written communication, such as providing “legible, accurate, complete, and timely written communication that is congruent with medical standards.”3 

What Is Known

Studies suggest that written sign-outs are often plagued by medication errors, including omissions and erroneous information. Often, these errors result from failure to keep the sign-out updated.4 Although the growing adoption of electronic health records can streamline documentation through linking data to sign-out applications, cut and paste problems and information overload may still occur.5 Ensuring proper creation and maintenance of the written sign-out is critical in today's environment.

Structured templates for documenting handoff information are recommended by professional organizations.6 A recent, appreciative-inquiry study7 in a large internal medicine training program found that handoffs varied widely in the absence of an educational curriculum and that a consistent methodology for sign-out organization is key.

One promising technique for teaching written sign-outs is the use of practice audits, which can promote reflection on past performance and facilitate transfer of knowledge into actual clinical practice.8 

The UPDATED Approach

The UPDATED educational approach to teaching written sign-outs emphasizes the importance of the following attributes of sign-outs:

Updated administrative data

Prioritized problem list

Diagnoses in the one-liner

Anticipated problems clear

prevent Too much information

Error-prone medications highlighted, and

Directions that are clear

The UPDATED mnemonic has been transformed into an audit tool, with specific examples of appropriate and inappropriate language, and incorporates a points system to create an overall sign-out score (figure). The audit tool is intended to facilitate peer- or self-assessment of written sign-outs during a facilitated workshop session. This follows a brief slide presentation that introduces the UPDATED concept with examples of poor and excellent written sign-outs.

figure Is Sign-Out UPDATED?

figure Is Sign-Out UPDATED?

How You Can Start TODAY

  1. Dedicate an intern or resident teaching conference to written sign-out education, in addition to orientations to the wards.

  2. Contact the authors of this Rip Out for the sample slide sets that can be adapted for use at your institution and with your electronic health record system.

What You Can Do LONG TERM

  1. For Program Director and Faculty: Sustain a consistent emphasis on high-quality and standardized written sign-out skills. Prioritize multiple conferences, check-ins, and on-service reminders by teaching attendings on the topic of sign-outs throughout the academic year.

  2. For Residents: Assist residents in appreciating that more than half of a patient's time in the hospital occurs when the primary service is not in-house, and the precision of the written sign-out is critical to safe care. Emphasize that peer- and self-assessment and maintenance of high-quality sign-outs is a professional obligation.

Resources

Resources
1
Nasca
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ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force
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2
Horwitz
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Moin
T
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Green
ML
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Development and implementation of an oral sign-out skills curriculum
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J Gen Intern Med
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2007
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22
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10
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1474
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3
American Board of Internal Medicine. Developmental Milestones for Internal Medicine Residency Training. http://www.abim.org/pdf/milestones/milestones-framework-draft.pdf. Accessed April 19, 2013
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4
Arora
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Medication discrepancies in resident sign-outs and their potential to harm
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J Gen Intern Med.
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2007
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1751
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5
Hirschtick
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A piece of my mind: copy-and-paste
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2006
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2335
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6
Arora
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Basaviah
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Hospitalist handoffs: a systematic review and task force recommendations
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J Hosp Med
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2009
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433
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7
Helms
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Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes
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J Gen Intern Med
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8
Holmboe
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Author notes

Allison S. DeKosky, MD, is Instructor of Clinical Medicine at the University of Pennsylvania Health System; Ananya Gangopadhyaya, MD, is Assistant Professor of General Internal Medicine at the University of Illinois Chicago Medical Center; Bobby Chan, MD, practices Family Medicine at MacNeal Hospital; and Vineet M. Arora, MD, MAPP, is Associate Professor of General Internal Medicine at the University of Illinois Chicago Medical Center.

Drs DeKosky and Gangopadhyaya contributed equally to this research as joint first authors.

Presented in the plenary session at the 2011 Midwest Society for General Internal Medicine Regional Meeting, Chicago, IL, September 15; at the 2012 Association for Hospital Medical Education Conference, Fort Lauderdale, FL, May 18; and as an oral presentation at the 2012 California-Hawaii Society of General Internal Medicine Meeting, San Francisco, CA, January 21.