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What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff
  1. L I Horwitz1,2,
  2. T Moin3,
  3. H M Krumholz1,4,
  4. L Wang5,
  5. E H Bradley4,6
  1. 1
    Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
  2. 2
    Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
  3. 3
    Internal Medicine Residency Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
  4. 4
    Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
  5. 5
    Department of Ophthalmology, New York Presbyterian Hospital, New York, USA
  6. 6
    Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA
  1. Dr L Horwitz, Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 789 Howard Avenue, New Haven, CT 06519, USA; leora.horwitz{at}yale.edu

Abstract

Objectives: To characterise and assess sign-out practices among internal medicine house staff, and to identify contributing factors to sign-out quality.

Design: Prospective audiotape study.

Setting: Medical wards of an acute teaching hospital.

Participants: Eight internal medicine house staff teams.

Measurements: Quantitative and qualitative assessments of sign-out content, clarity of language, environment, and factors affecting quality and comprehensiveness of oral sign-out.

Results: Sign-out sessions (n = 88) contained 503 patient sign-outs. Complete written sign-outs accompanying 50/88 sign-out sessions (57%) were collected. The median duration of sign-out was 35 s (IQR 19–62) per patient. The combined oral and written sign-outs described clinical condition, hospital course and whether or not there was a task to be completed for 184/298 (62%) of patients. The least commonly conveyed was the patient’s current clinical condition, described in 249/503 (50%) of oral sign-outs and 117/306 (38%) of written sign-outs. Most patient sign-outs (298/503, 59%) included no questions from the sign-out recipient (median 0, IQR 0–1). Five factors were associated with a higher rate of oral content inclusion: familiarity with the patient, sense of responsibility for the patient, only one sign-out per day, presence of a senior resident and a comprehensive written sign-out. Omissions and mischaracterisations of data were present in 22% of sign-outs repeated in a single day.

Conclusions: Sign-outs are not uniformly comprehensive and include few questions. The findings suggest that several changes may be required to improve sign-out quality, including standardising key content, minimising sign-outs that do not involve the primary team, templating written sign-outs, emphasising the role of sign-out in maintaining patient safety and fostering a sense of direct responsibility for patients among covering staff.

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Footnotes

  • An additional appendix is published online at http://qshc.bmj.com/content/vol18/issue4

  • Funding: LIH was affiliated with the Robert Wood Johnson Clinical Scholars Program and was supported by the Department of Veterans Affairs during part of the time this work was conducted. EHB is supported by the Catherine and Patrick Donaghue Medical Research Foundation Investigator award.

  • Competing interests: None.

  • Ethics approval: Ethics approval was provided by Yale University Human Investigation Committee.

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