Where: University of Virginia Medical Center, an academic hospital in Charlottesville, Va.
The issue: Improving the signout of patients from one resident to another.
Both attendings and residents at the University of Virginia (UVA) had noticed wide variation in the ways that residents handed off their patients. “Someone might spend three minutes saying, ‘Here's my signout. Nothing's going on,’ and then someone else would sit down and spend an hour going through each patient,” said Margaret Plews-Ogan, MD, FACP, associate professor of medicine and chief of the division of general medicine, geriatrics and palliative medicine at UVA.
Signout practices were picked up haphazardly, rather than specifically taught to residents. “There wasn't even any real attempt at standardization, so everybody developed their own style,” Dr. Plews-Ogan said.
Duty-hour restrictions had also increased the frequency of signouts. “We, like many institutions, ended up having interesting handoff patterns, like the primary team would leave at 5, sign out to their cross-cover who would then leave at 8, signing out to night float. We wondered how the signout changed as you signed out for the first, second or third time,” she said.
To find out, a team at UVA that included attendings, residents and systems engineers studied their residents' signouts.
How it worked
The researchers used an appreciative inquiry approach in their quality improvement project, meaning they found people who were doing signouts well and interviewed them.
Surveys about signout practices (covering topics such as the appropriate purpose, length and structure of signout) were collected from 89 internal medicine residents. The residents were also asked to identify which of their peers they thought did the best signouts. “There were these few people who immediately rose to the top,” Dr. Plews-Ogan said.
Those top residents were interviewed individually and then brought together for a discussion about their signout practices. They agreed on some key aspects of a good signout, including being concise, covering the most acutely ill patients first, and using a problem-based approach. Including routine laboratory values and medication lists in signout introduced too much potential for error, they decided.
Working together with other residents and faculty, the signout experts then developed a new standard template for signouts. As described in results published in the Journal of General Internal Medicine in March, the template called for:
- patient's name and demographic information;
- a star rating marking the level of acuity from 1 to 3;
- chronic diagnoses;
- important medications;
- inpatient procedures with dates performed;
- active, important problems;
- anticipated events;
- cross-cover tasks and
- an empty box for notes on overnight events.
“These intuitively made sense to our housestaff and they did jive with much of the expert literature around the important components of signout,” Dr. Plews-Ogan said. As well as implementing the new template, the UVA team developed an educational curriculum to teach signout best practices to trainees.
While the researchers suspect that their template would improve patient care if it were applied widely, they weren't able to prove that within the scope of this first study. Dr. Plews-Ogan hopes to investigate effects on outcomes in future research.
Hospitals adopting an appreciative inquiry approach may bump into clinicians unfamiliar with the technique as a method of quality improvement. “It's a new kind of approach. People may resist it initially because it's different,” said Dr. Plews-Ogan.
But once they try out appreciative inquiry, they're likely to approve of it. “It's a lot more fun than a top-down approach, and you often will get engagement and investment in the quality improvement process from the very beginning,” she added.
The UVA team also did some observation of residents' pre-intervention signout practices. They found that night signouts were less than half the length of the day signouts that preceded them (134 seconds vs. 59 seconds). “Your signout is whittled down to very little information,” said Dr. Plews-Ogan.
This loss of information with each handoff should be a consideration when hospitals redesign schedules, she said.