Department of Surgery Who’s Covering Our Loved Ones: Surprising Barriers in the Sign-Out Process Mara Antonoff MD Elizabeth Berdan MD, Varvara Kirchner

Department of Surgery

Who’s Covering Our Loved Ones: Surprising Barriers in the Sign-Out

Process

Mara Antonoff MDElizabeth Berdan MD, Varvara Kirchner MD, Tara Krosch MD,

Christopher Holley MD, Michael Maddaus MD,

Jonathan D’Cunha MD PhD


Duty Hour Limitations

• Intended consequences:

–Minimize ill effects of trainee sleep deprivation

–Optimize patient safety

–Resident well-being



• Unintended consequences:

–Challenges in providing comprehensive training experience

– Increased handoffs, more frequent transitions of care

Horwitz, Arch Int Med 2006



• Unintended consequences:

–Challenges in providing comprehensive training experience

– Increased handoffs, more frequent transitions of care

Horwitz, Arch Int Med 2006


More Frequent Handoffs

• Decreased familiarity

• Break in continuity of care

• Risk of communication errors

• Increased errors/omissions may lead to serious adverse outcomes

Arora, J Gen Intern Med. 2007


Aims

• Characterize obstacles affecting current sign-out practices

• Evaluate potential impact of standardized sign-out guidelines


Methods: Guidelines

• Developed by committee of residents with faculty supervision

• Based on literature review and ACGME requirements

• 5-page document with detailed policies/guidelines for transitions of care


Methods: Guidelines

• Goals:–Develop set of expected behaviors

–Establish list of required data points for written sign-out lists

–Establish list of required elements of verbal exchange


Methods: Guidelines


Methods: Guidelines

• Implemented June 2011• Program-wide use• 1-hour kickoff presentation for current

trainees• New trainees provided with workshop

at orientation


Methods: Survey

• Designed to assess:–Practices–Attitudes–Barriers to effective communication

• 29 multiple-choice items• Dichotomous and 5-point Likert-type

responses


Methods: Survey

• 2 time points– Immediately prior to guideline

implementation–3-month follow-up

• Comparison pre/post implementation• T-tests & chi-squared analyses, α=0.05


Methods: Survey

• Mini-survey for nurses

• Subset of questions from resident survey

• Goal: to assess perceptions of physician familiarity with patients, patient safety

• Same time points


Results: Resident Survey

• Baseline:–Moderate satisfaction with sign-out

process

–Concerns regarding communication and patient safety



Pre Guidelines

Post Guidelines

PGY-1 satisfaction with signout process 3.33 3.67

N = 37



Pre Guidelines

Post Guidelines


Perceptions of patient safety via continuity of care 3.61 3.68

N = 37



Pre Guidelines

Post Guidelines



Adequacy of patient information provided to on-call resident 3.42 3.89

N = 37



Pre Guidelines

Post Guidelines



Adequacy of patient information provided to on-call resident 3.42 3.89

Adequacy of patient knowledge by on-call resident 3.53 3.57

N = 37



• All trends

• None of these gains reached statistical significance



• During study period, duty-hours also changed

• Reports of double-signouts increased

• New concerns:– Failure to report major events due to

double-signouts– Less complete signouts due to 16-hour

restrictions


Perceived Barriers


Perceived Barriers


Perceived Barriers


Perceived Barriers


Results: Nursing Survey

Pre Guidelines

Post Guidelines

ICU nurses 3.59 3.90

Ward nurses 3.38 3.50

All nurses 3.46 3.66

To what extent does the current signout process provide patient safety

via continuity of care?

N = 46



Pre Guidelines

Post Guidelines




To what extent are residents given adequate information about the

patients whom they cover?

N = 46



Pre Guidelines

Post Guidelines




To what extent does the resident on call at night know your patients?

N = 46


Summary

• Mild improvement in perceptions of patient safety and adequacy

• Improvements reported by–Nurses–Residents


Summary

• Persistent barriers remain

• Additional obstacles have surfaced in setting of further restrictions on duty hours


Conclusions

• Standardized signout guidelines: –May improve continuity of care –Should be universally employed–Do not solve all issues


Conclusions

• Standardized signout guidelines: –May improve continuity of care –Should be universally employed–Do not solve all issues

• Further efforts to optimize patient safety via improved handoff processes are clearly needed

Documents

Department of Surgery Who’s Covering Our Loved Ones: Surprising Barriers in the Sign-Out Process Mara Antonoff MD Elizabeth Berdan MD, Varvara Kirchner