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Improving signout skills
JHU/Sinai Hospital
Morning report
6/28/13
Goals
Review common pitfalls during signout
Learn to create and update a written signout
Learn how to execute a verbal handoff
Sender oranizes &
updates handoff
information
Specific verbal
exchange between
sender and receiver
Pre-handoff Arrival Dialogue Post-handoff
•Lack of time,
poor time
management,
fatigue or work
prevent
updating
•Lack of clinical
judgement
•Vague
language
•No set
location or
time
•Not able to
contact
sender or
receiver
•Competing
obligations
•Handoff not
a priority
over other
tasks
Sender could:
•Provide
disorganized info
•Use vague language
•Fail to provide
clinical impression,
anticipatory
guidance, plan or
rationale
Receiver could:
•Not listen
•Misunderstand
•Not clarify (ask)
•Forget key tasks
or information
•Not document
actions taken
•Act on plan
without taking
new information
into account
•Not invest in the
care of patient
Morning report 6/28/13: Handoffs
Two-way street
Handoffs are dialogues
Sender must paint a picture
Receiver must see it, understand it, act on
it, and, ultimately, communicate it to
someone else.
Core components of handoffs
Verbal communication
in person or over the phone
Written communication
sign-out
Transfer of professional responsibility
Constructing a written sign-out
Abstracted from H&P
Information that may become important
in a critical situation
code status, i.v. access, PCP, family info
admission diagnosis, date, team
All patients, even those being d/c’d that day
Avoid vague language
tomorrow/today/yesterday…
9 Ds
iDentitiy / Doctor / DNR?
Diagnosis and Disease
Diet
Drugs
Daily progress
Directions:
if/then, to-do
iDentitiy
Room number
remember to update it
Patient name
Age, gender
Medical record number
Diagnosis and Disease
Same column
Diagnosis first
Reason for admission and/or
The main problem that is being worked up
Then the disease (co-morbidities)
CHF exacerbation
CAD, HTN, DM, asthma
Drugs
Sometimes difficult to list all, but
you can use abbreviations
highlight the important ones
(antibiotics, narcotics, anticoagulants…)
with a * … *
If you copy/paste from Rounds Report, have
to spend some time removing cruft
Diet
Many calls about NPO status
Especially in patients going to
surgery/procedures the next day
Daily progress/Plan
Things that explain patient’s *current*
condition, progress, interventions,
problems, plans
e.g. On Lasix 40 mg IV q12h, net –ve
1.5L/24hr, improving; echo: EF 30%;
continuing diuresis, cardiology to evaluate
Directions
Items To Do: only important things that
need to be addressed or require follow up,
with special instructions for further plans
and rationale—avoid “check BMP”
If/then: anticipatory guidance for what may
happen, short and clear
Updating written sign-out
Update daily:
Drugs
Directions
Nearly 1/3 of signouts discrepant with chart:
80% with at least 1 omission
40% with one comission
CoPaGA syndrome
Copy/Paste Gone Amok
Repeated copying and pasting text from
H&Ps and progress notes into singout
Crowds out useful information by gluts of
useless data
Zombie-like propagation of inaccuracies
Information overload
Overreliance on signouts for your own work
Signouts become unnecessarily long
shadow chart
Often becomes a personal tracker of
information
But remember, your covering intern needs it
simple
Verbal handoffs
Speakers systematically overestimate how
well their messages are understood by
listeners
Egocentric heuristic—senders assume that
receiver has all the same knowledge that
they do
Worsens the better you know someone
Biases in signout
The most important piece of information
was not communicated 60% of the time,
despite the sender believing it had been
Did not agree on the rationales provided for
60% of items
Some things more likely to be remembered:
ToDo (65%), If/then (69%), more likely
than knowledge items (35%)
What can senders do?
Relevant items that will be Remembered
focus on the sickest patient first
daily progress
direction: to-do and if/then items
Directions with Rationale
avoid ambiguity: “check CBC” without
giving a reason why and what to do with
results
Check for Receiver understanding
What can receivers do?
Actively listen
stay focused, limit interruptions
taking notes can enhance memory
Ask questions
to ensure you understand dirctions
Use a system
to keep track of to-do items
Readback
Example 1
A nurse calls because the patient wants to
know if they can eat.
Signout says “Patient is NPO for surgery
tomorrow”
Always give dates
Avoid use of today/tomorrow/yesterday
What procedure? How important?
Example 2
Your signout says
“Check BMP at 8pm”
The patient has a sodium of 124.
What are you supposed to do with
abnormalities?
What is the baseline?
What are you looking for?
Example 3
The patient you are covering is being
evaluated for SBO. The surgeon comes by
after being in the OR and asks you what
the patient’s coags are. You say: “I’m sorry,
but that’s not my patient”.
Handoffs are more than just a transfer of content,
but also a transfer of personal responsibility.
Every patient is your patient.

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Morning report 6/28/13: Handoffs

  • 1. Improving signout skills JHU/Sinai Hospital Morning report 6/28/13
  • 2. Goals Review common pitfalls during signout Learn to create and update a written signout Learn how to execute a verbal handoff
  • 3. Sender oranizes & updates handoff information Specific verbal exchange between sender and receiver Pre-handoff Arrival Dialogue Post-handoff •Lack of time, poor time management, fatigue or work prevent updating •Lack of clinical judgement •Vague language •No set location or time •Not able to contact sender or receiver •Competing obligations •Handoff not a priority over other tasks Sender could: •Provide disorganized info •Use vague language •Fail to provide clinical impression, anticipatory guidance, plan or rationale Receiver could: •Not listen •Misunderstand •Not clarify (ask) •Forget key tasks or information •Not document actions taken •Act on plan without taking new information into account •Not invest in the care of patient
  • 5. Two-way street Handoffs are dialogues Sender must paint a picture Receiver must see it, understand it, act on it, and, ultimately, communicate it to someone else.
  • 6. Core components of handoffs Verbal communication in person or over the phone Written communication sign-out Transfer of professional responsibility
  • 7. Constructing a written sign-out Abstracted from H&P Information that may become important in a critical situation code status, i.v. access, PCP, family info admission diagnosis, date, team All patients, even those being d/c’d that day Avoid vague language tomorrow/today/yesterday…
  • 8. 9 Ds iDentitiy / Doctor / DNR? Diagnosis and Disease Diet Drugs Daily progress Directions: if/then, to-do
  • 9. iDentitiy Room number remember to update it Patient name Age, gender Medical record number
  • 10. Diagnosis and Disease Same column Diagnosis first Reason for admission and/or The main problem that is being worked up Then the disease (co-morbidities) CHF exacerbation CAD, HTN, DM, asthma
  • 11. Drugs Sometimes difficult to list all, but you can use abbreviations highlight the important ones (antibiotics, narcotics, anticoagulants…) with a * … * If you copy/paste from Rounds Report, have to spend some time removing cruft
  • 12. Diet Many calls about NPO status Especially in patients going to surgery/procedures the next day
  • 13. Daily progress/Plan Things that explain patient’s *current* condition, progress, interventions, problems, plans e.g. On Lasix 40 mg IV q12h, net –ve 1.5L/24hr, improving; echo: EF 30%; continuing diuresis, cardiology to evaluate
  • 14. Directions Items To Do: only important things that need to be addressed or require follow up, with special instructions for further plans and rationale—avoid “check BMP” If/then: anticipatory guidance for what may happen, short and clear
  • 15. Updating written sign-out Update daily: Drugs Directions Nearly 1/3 of signouts discrepant with chart: 80% with at least 1 omission 40% with one comission
  • 16. CoPaGA syndrome Copy/Paste Gone Amok Repeated copying and pasting text from H&Ps and progress notes into singout Crowds out useful information by gluts of useless data Zombie-like propagation of inaccuracies
  • 17. Information overload Overreliance on signouts for your own work Signouts become unnecessarily long shadow chart Often becomes a personal tracker of information But remember, your covering intern needs it simple
  • 18. Verbal handoffs Speakers systematically overestimate how well their messages are understood by listeners Egocentric heuristic—senders assume that receiver has all the same knowledge that they do Worsens the better you know someone
  • 19. Biases in signout The most important piece of information was not communicated 60% of the time, despite the sender believing it had been Did not agree on the rationales provided for 60% of items Some things more likely to be remembered: ToDo (65%), If/then (69%), more likely than knowledge items (35%)
  • 20. What can senders do? Relevant items that will be Remembered focus on the sickest patient first daily progress direction: to-do and if/then items Directions with Rationale avoid ambiguity: “check CBC” without giving a reason why and what to do with results Check for Receiver understanding
  • 21. What can receivers do? Actively listen stay focused, limit interruptions taking notes can enhance memory Ask questions to ensure you understand dirctions Use a system to keep track of to-do items Readback
  • 22. Example 1 A nurse calls because the patient wants to know if they can eat. Signout says “Patient is NPO for surgery tomorrow” Always give dates Avoid use of today/tomorrow/yesterday What procedure? How important?
  • 23. Example 2 Your signout says “Check BMP at 8pm” The patient has a sodium of 124. What are you supposed to do with abnormalities? What is the baseline? What are you looking for?
  • 24. Example 3 The patient you are covering is being evaluated for SBO. The surgeon comes by after being in the OR and asks you what the patient’s coags are. You say: “I’m sorry, but that’s not my patient”. Handoffs are more than just a transfer of content, but also a transfer of personal responsibility. Every patient is your patient.