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Experience with Faculty Supervision of an Electronic Resident Sign-out System

      Reductions in residency work hours during the past 20 years have resulted in a corresponding increase in both the number of transitions of care and the chances of medical errors related to such transitions.
      • Conigliaro J.
      • Frishman W.H.
      • Lazar E.J.
      • Croen L.
      Internal medicine housestaff and attending physician perceptions of the impact of the New York State Section 405 regulations on working conditions and supervision of residents in two training programs.
      Despite considerable efforts to improve the house staff handoff process,
      • Arora V.
      • Johnson J.
      A model for building a standardized hand-off protocol.
      • Berthold J.
      Improving handoffs through better communication.
      • Chacko V.
      • Varvarelis N.
      • Kemp D.G.
      eHand-offs: an IBM Lotus Domino application for ensuring patient safety and enhancing resident supervision in hand-off communications.
      • Chu E.S.
      • Reid M.
      • Schulz T.
      • et al.
      A structured handoff program for interns.
      • Horwitz L.I.
      • Moin T.
      • Green M.L.
      Development and implementation of an oral sign-out skills curriculum.
      • Johnson J.K.
      • Arora V.M.
      Improving clinical handovers: creating local solutions for a global problem.
      • Kemp C.D.
      • Bath J.M.
      • Berger J.
      • et al.
      The top 10 list for a safe and effective sign-out.
      • Lee L.H.
      • Levine J.A.
      • Schultz H.J.
      Utility of a standardized sign-out card for new medical interns.

      Smorenburg S, Johnson J. Spotlight on the night: a 5-star programme to improve safety at night and weekends. International Forum on Quality and Safety in Health Care, March 20, 2009, Berlin.

      • Van Eaton E.G.
      • Horvath K.D.
      • Lober W.B.
      • Pellegrini C.A.
      Organizing the transfer of patient care information: the development of a computerized resident sign-out system.
      • Wayne J.D.
      • Tyagi R.
      • Reinhardt G.
      • et al.
      Simple standardized patient handoff system that increases accuracy and completeness.
      • Van Eaton E.G.
      • Horvath K.D.
      • Lober W.B.
      • et al.
      A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.
      problems remain.
      • Johnson J.K.
      • Arora V.M.
      Improving clinical handovers: creating local solutions for a global problem.
      • Horwitz L.I.
      • Moin T.
      • Krumholz H.M.
      • et al.
      What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff.
      Recent studies demonstrate that an alarming proportion of handoffs continue to omit important information, contain erroneous information, and lack a standardized structure.
      • Horwitz L.I.
      • Moin T.
      • Krumholz H.M.
      • et al.
      What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff.
      • Borowitz S.M.
      • Waggoner-Fountain L.A.
      • Bass E.J.
      • Sledd R.M.
      Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey.
      Of note, although lack of supervision was one of the main problems that led to the implementation of 405 regulations in New York and similar regulations elsewhere, the idea of faculty supervision of the sign-out process has received little attention.
      • Chu E.S.
      • Reid M.
      • Schulz T.
      • et al.
      A structured handoff program for interns.
      • Horwitz L.I.
      • Moin T.
      • Krumholz H.M.
      • et al.
      What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff.
      In the past, it would have been difficult for faculty members, each of whom had only a few patients in the hospital at a given time, to oversee the sign-out process. However, most academic medical centers now operate under fully developed hospitalist care models where the faculty typically remain in-house throughout the day, manage teams with fairly uniform schedules, and are available at the time of afternoon sign-outs.
      • Conigliaro J.
      • Frishman W.H.
      • Lazar E.J.
      • Croen L.
      Internal medicine housestaff and attending physician perceptions of the impact of the New York State Section 405 regulations on working conditions and supervision of residents in two training programs.
      Given the technologic advances and the changes in the care structure, we believe that the time has come for faculty to assume full supervision of the sign-out process.
      • Reductions in residency work hours have increased the number of transitions of care and the chances of medical errors related to such transitions.
      • Transitions of care (sign-outs) have not traditionally involved attending supervision.
      • The hospitalist care model, combined with technologic advances, makes possible faculty oversight of the house staff sign-out process.
      • Surveyed hospitalists and house staff at an academic medical center (which incorporates faculty supervision of sign-out within the computerized sign-out software) found the system to be useful and practical, and to enhance patient safety.
      • A handheld system eliminates privacy concerns related to misplaced paper versions of sign-out.
      • A handheld version of the sign-out software permits faculty to oversee sign-out and multiple other features of house staff patient care in real time.
      More than a year ago, we began using the computerized Patient Documentation Transfer System (PDTS) on the medicine service to improve on our preexisting handoff system that already included face-to-face sign-outs at standard locations and times and where interruptions were minimized. Like similar systems in use elsewhere, the PDTS database stores key patient information and allows printing of standardized sign-out sheets that are relayed from primary teams to “on call” and “night float” teams (5 PM and 9 PM, respectively). However, during the past year we enhanced PDTS to include a faculty “oversight module” by which faculty review and approve all handoff information before it can be signed out to coverage teams and through which data regarding sign-out were collected.
      • Conigliaro J.
      • Frishman W.H.
      • Lazar E.J.
      • Croen L.
      Internal medicine housestaff and attending physician perceptions of the impact of the New York State Section 405 regulations on working conditions and supervision of residents in two training programs.
      We supplemented the data collected from the oversight module with data derived from surveys of both the faculty and house staff using the system. The current report describes our experience with the new computerized sign-out system.

      Materials and Methods

      Attending physician hospitalists began supervision of all sign-outs on the general medicine service in June 2008 using drop-down and free text boxes as shown in Figure 1.
      Figure thumbnail gr1
      Figure 1Snapshot of attending oversight module.
      Interns completed entry of sign-out data by 4 PM, after review by the supervising resident. Between 4 and 4:30 PM, the hospitalists made corrective notations via any hospital (or Internet capable) computer. The supervising residents (in cooperation with the chief resident) then reviewed all oversight attending evaluations and contacted relevant team members to ensure that faculty corrections to the sign-out were entered. In the event that information was considered to be of immediate import to patient care, the attending physician personally notified the primary intern or resident regarding the desired change of plans in addition to correcting the sign-out on PDTS. Only after ensuring that all changes to their patient information had been approved by the attending physician did the interns complete the sign-out process between 4:30 and 5 PM in the presence of the chief resident. The attending oversight data were maintained in the PDTS administrative database and reviewed daily by chief residents and the program director.

      House Staff Survey

      In March 2009, we surveyed the 24 members of our 30-person intern class who were not off-service using a series of 29 questions that had been prescreened for clarity by 3 chief residents and the Program Director. Of the 29 questions, there were 15 multiple choice, 3 Likert-scale, 5 Likert-style, 1 ordinal, and 5 open-comment type questions. These assessed the perceptions of interns regarding the functionality and usefulness of the PDTS system, as well as their perceptions regarding the effects that attending oversight and adverse events reporting had on the quality of patient care and safety, and the sign-out process itself. The data regarding “adverse events” reporting and the “peer-to-peer” sign-out evaluation process will be presented elsewhere. No citation is available at present as the manuscript is in final stages of preparation.

      Faculty Survey

      In July 2009, each of the 8 hospitalists who supervised the general medicine service house staff during this study responded to a survey, which consisted of 19 fill-in-the-blank and multiple choice questions regarding the general functionality of PDTS, the faculty's supervision of handoffs before and after the implementation of PDTS, and the faculty's perceptions regarding the usefulness of the oversight system.

      Results

      Attending Oversight

      During February 2009, 1225 sign-outs on the general internal medicine service were reviewed by faculty for accuracy and completeness of demographics, code status, allergies, history of present illness, recent clinical events (daily update, “very sick” status), medication list, diagnosis, and plan of action (“to-do's”) for the on-call and night-float teams. Of the 1225 sign-outs, 7% were considered to be incorrect. Of those, Figure 2 shows the percentage of handoffs that were incorrect with respect to each defined category. Faculty rated 6.5% of handoffs to be incorrect for Department of Medicine house staff compared with 12.4% for intern “rotators” on the medicine service.
      Figure thumbnail gr2
      Figure 2Percentage of handoffs noted to be defective by faculty with respect to each defined PDTS sign-out data category. HPI=history of present illness; Dx = diagnosis.

      House Staff Survey

      Functionality

      Sixty-three percent of interns thought that the PDTS system was either good or excellent in terms of its overall quality in managing patient sign-out information. Eighty-four percent stated that they would use this system over any other method of sign-out. Eighty-nine percent believed the system took either the same time or saved time compared with other sign-out methods. With respect to time spent updating sign-out information each day, 5%, 48%, 19%, 24%, and 5% of interns reported using the system 0 to 10 minutes, 11 to 20 minutes, 21 to 30 minutes, 31 to 40 minutes, and 41 to 50 minutes, respectively. No interns reported using more than 50 minutes to update patient information. Comments affirmed the intern classes' overall approval of the system's functionality but requested improved speed and sought a handheld version of the system.

      Patient Safety, Attending Oversight, Adverse Events

      Of surveyed interns, 67% believed that PDTS improved patient safety. When asked, “with what frequency do you believe having readily available information through PDTS prevents an adverse event from occurring?” 24% responded greater than 10 instances per month, 29% answered 5 to 10 instances per month, 18% stated 1 to 5 instances per month, and 29% responded 1 or less instances per month. The intern class was asked, “how much is the quality of [your] sign-out information improved by attending oversight?” to which 84% thought that it was improved to some degree. In response to the statement, “An attending's oversight evaluation results in a change in my patient's management with respect to what percentage of sign-outs,” 23% of the interns responded “almost never,” whereas the remaining interns believed that at least 10% of his/her patients' management was altered by faculty supervision of sign-outs. When asked, “with what frequency would you estimate that attending feedback on a sign-out prevents an adverse event from occurring …?” 36% believed that oversight prevented an adverse event 50% of the time or more, and 65% thought that oversight prevented adverse events 25% of the time or less.

      Faculty Survey

      Of the faculty responding to our survey, the average number of years in practice was 12. All physicians (8/8) surveyed believed that PDTS “improved the information available to [him/her] regarding [his/her] patients' transfers of care.” Only 1 faculty member (1/8) reported having previously reviewed (before PDTS implementation) his/her patients' sign-out information, and none had previously received a written copy of sign-out information. However, since the date on which the PDTS system was implemented, each faculty member stated that s/he now routinely reviews all sign-out information. The average time spent per patient by attendings in overseeing sign-outs was 2 minutes. Each faculty member believed that the implementation of PDTS allowed him/her to feel more confident (than was the case prior to PDTS inception) that he/she is “aware of what information is being signed out on [his/her] patients?” The mean percent of handoffs that faculty estimated they “correct” was 12. Of the corrected sign-outs, the faculty estimated that 7% (mean) of those sign-outs “represent a serious matter related to patient safety or quality of care.” Over the course of an average month on the general medicine floors, faculty estimated that on approximately 1 to 2 occasions (range 0-5), their oversight of PDTS sign-out information prevented the occurrence of a serious medical error or adverse event. Each physician agreed that the implementation of PDTS oversight regarding “very sick” patients made it easier to ensure that “nothing [was] overlooked.” The faculty thought that with the addition of PDTS oversight they had improved “control” of sign-out information and better access to information about what happened with their patients overnight.

      Discussion

      The characteristics of an ideal patient handoff system are not certain. However, several features have been identified as being desirable.
      • Berthold J.
      Improving handoffs through better communication.
      • Chacko V.
      • Varvarelis N.
      • Kemp D.G.
      eHand-offs: an IBM Lotus Domino application for ensuring patient safety and enhancing resident supervision in hand-off communications.
      • Chu E.S.
      • Reid M.
      • Schulz T.
      • et al.
      A structured handoff program for interns.
      • Horwitz L.I.
      • Moin T.
      • Green M.L.
      Development and implementation of an oral sign-out skills curriculum.
      • Johnson J.K.
      • Arora V.M.
      Improving clinical handovers: creating local solutions for a global problem.
      • Kemp C.D.
      • Bath J.M.
      • Berger J.
      • et al.
      The top 10 list for a safe and effective sign-out.
      • Lee L.H.
      • Levine J.A.
      • Schultz H.J.
      Utility of a standardized sign-out card for new medical interns.
      • Wayne J.D.
      • Tyagi R.
      • Reinhardt G.
      • et al.
      Simple standardized patient handoff system that increases accuracy and completeness.
      • Petersen L.A.
      • Orav E.J.
      • Teich J.M.
      • et al.
      Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events.
      In 2006, the Joint Commission made a “standardized approach to ‘hand off’' communications” a National Patient Safety Goal. The 2009 Safety Goals state that effective hand-off communication includes interactive communication that allows for questioning between the giver and the receiver of patient information. The handoff should be based on up-to-date information and include a method to verify the accuracy of received information and should allow an “opportunity for the receiver of the hand-off information to review relevant patient historical data . . . . ” Interruptions during hand-offs should be limited to minimize the possibility that information fails to be conveyed or is forgotten.
      The Joint Commission on Accreditation of Healthcare Organizations
      National Patient Safety Goals, Elements of Performance; 2009.
      Standardization of the sign-out format and order and use of written templates for sign-out improve sign-out consistency and accuracy.
      • Arora V.
      • Johnson J.
      A model for building a standardized hand-off protocol.
      • Chacko V.
      • Varvarelis N.
      • Kemp D.G.
      eHand-offs: an IBM Lotus Domino application for ensuring patient safety and enhancing resident supervision in hand-off communications.
      • Chu E.S.
      • Reid M.
      • Schulz T.
      • et al.
      A structured handoff program for interns.
      • Lee L.H.
      • Levine J.A.
      • Schultz H.J.
      Utility of a standardized sign-out card for new medical interns.
      • Van Eaton E.G.
      • Horvath K.D.
      • Lober W.B.
      • Pellegrini C.A.
      Organizing the transfer of patient care information: the development of a computerized resident sign-out system.
      • Van Eaton E.G.
      • Horvath K.D.
      • Lober W.B.
      • et al.
      A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.
      • Petersen L.A.
      • Orav E.J.
      • Teich J.M.
      • et al.
      Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events.
      Specialized training of house staff in the art of sign-out also has been recommended.
      • Chu E.S.
      • Reid M.
      • Schulz T.
      • et al.
      A structured handoff program for interns.
      Although supervision of house staff has been identified as importantly related to patient safety,
      • Hobgood C.
      • Hevia A.
      • Tamayo-Sarver J.H.
      • et al.
      The influence of the causes and contexts of medical errors on emergency medicine residents' responses to their errors: an exploration.
      • Shojania K.G.
      • Fletcher K.E.
      • Saint S.
      Graduate medical education and patient safety: a busy—and occasionally hazardous—intersection.
      actual attending supervision of information signed out by house staff seems to be unusual.
      • Chu E.S.
      • Reid M.
      • Schulz T.
      • et al.
      A structured handoff program for interns.
      • Horwitz L.I.
      • Moin T.
      • Krumholz H.M.
      • et al.
      What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff.
      • Horwitz L.I.
      • Krumholz H.M.
      • Green M.L.
      • Huot S.J.
      Transfers of patient care between house staff on internal medicine wards: a national survey.
      Whether such supervision might prove to be of benefit to the handoff process is not yet known. However, the results of this study suggest that this must be the case.

      Attending Oversight

      We now provide formal attending oversight of all sign-outs on the general medicine service. Of 1225 sign-outs reviewed by faculty during a 1-month time period, 7% were found to be deficient and were modified on the basis of the attending's feedback. Our results agree with earlier studies showing that sign-out data are often deficient.
      • Horwitz L.I.
      • Moin T.
      • Krumholz H.M.
      • et al.
      What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff.
      • Arora V.
      • Johnson J.
      • Lovinger D.
      • et al.
      Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.
      • Gandhi T.K.
      Fumbled handoffs: one dropped ball after another.
      • Sutcliffe K.M.
      • Lewton E.
      • Rosenthal M.M.
      Communication failures: an insidious contributor to medical mishaps.
      As expressed by Borowitz and colleagues,
      • Borowitz S.M.
      • Waggoner-Fountain L.A.
      • Bass E.J.
      • Sledd R.M.
      Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey.
      the “sign-out between resident physicians is often inadequate and incomplete … possibly due to exchange of the wrong information during the sign-out process.” In our study, although 65% of interns surveyed stated that attending oversight improved the quality of sign-out information either “not at all,” “somewhat,” or “a little,” 77% of the interns nevertheless stated that attending oversight resulted in a change in patient management 10% of the time or more. Our faculty estimated that they “correct” 12% of sign-outs. Of those corrected sign-outs, faculty estimated that 7% of the sign-outs “represent a serious matter related to patient safety or quality of care.” Faculty estimated that on 1 to 2 occasions per month their oversight of PDTS sign-out information prevented the occurrence of a serious medical error or adverse event. These data suggest that faculty supervision has already made a significant contribution to patient safety in our hospital.
      On the basis of survey results, attending review of sign-out requires only approximately 2 minutes per patient and requires interns to await feedback from attendings for approximately 15 to 30 minutes before completing sign-out. Thus, the attending oversight process does engender some inconvenience to faculty and house staff. However, the benefits are potentially significant. First and foremost, the attending physician is responsible for ensuring that information relayed to covering physicians is accurate and useful. It is therefore reasonable to expect that the attending physician would personally approve of such information before it is passed along to call teams. If only a small additional percentage of handoff problems are “caught” by such formal oversight, the effect could be substantial on a larger scale. Attending feedback at the end of the work day also may promote a sense of team unity and provide valuable guidance to interns in terms of learning how to formulate optimal sign-outs. Notably, the intern receiving faculty-approved handoff information is empowered to “trust” the information s/he receives, allowing him/her to perform more effectively.
      • Johnson J.K.
      • Arora V.M.
      Improving clinical handovers: creating local solutions for a global problem.
      As discussed by Johnson and Arora,
      • Johnson J.K.
      • Arora V.M.
      Improving clinical handovers: creating local solutions for a global problem.
      “… a resident who does not trust information received during handover will ultimately check each detail of each patient to obtain information needed to provide the best patient care,” wasting valuable time that could have been spent on more important tasks.
      • Johnson J.K.
      • Arora V.M.
      Improving clinical handovers: creating local solutions for a global problem.
      Given the potential benefits of faculty sign-out oversight and the modest commitment of time required for the process, it seems that faculty supervision of handoffs is both practical and desirable. Additional studies are necessary to demonstrate whether attending oversight actually prevents adverse events (as suggested by our survey results) or improves the sign-out technique by house staff.

      Future Direction: Handheld-based Sign-outs

      The experience gained during the modifications of our PDTS sign-out system led to generalizations that have been useful in guiding further developments with this technology. First, the sign-out computer system must be easy to use and must contain complete, reliable, accurate, and up-to-date information. To this end, we have transferred most of the functions of the system to handheld devices, whereas personal computer workstations will back up the features located on handhelds. The new system allows sorting of patient information to guide the on-call physician through work duties. For example, at that beginning of a call shift the software now automatically generates a complete list of patients within each on-call intern's coverage area and prompts sign-out of high-risk patients first. As each patient is signed out, the covering intern checks that patient off on his/her coverage list (ensuring the actual sign-out of all patients). Thereafter, the default screen appearing on the handheld displays the intern's “to-do” list compiled from all sign-outs received. The “to-do's” are ordered by priority and due times so that the most urgent matters are always at the top of the intern's “to-do” list. During the call shift, the intern is guided by the “to-do” list and checks off each “to-do” as it is completed, compiling a record of all work done for later sign-out. When the intern is notified of a new clinical event, s/he finds the patient's name on a list and taps on a “called on” button and completes drop-down and free text boxes to make a notation of the event. New “to-do's” placed by a covering intern and new patients admitted are automatically added to the intern's on-call report. Should the intern require additional information about a patient, the coverage list or the entire patient list is accessed and the particular patient's name is tapped, linking the intern to that patient's full set of information. At the end of the call shift, PDTS compiles a “sign-out” report by which the intern signs out his/her coverage activities.
      By organizing an intern's on-call work around the tasks requiring active intervention (to-do's) and keeping close at hand (but in the background) the key clinical information the intern might need for contingencies, the PDTS system is tailored to compensate for limitations of the human mind and to enhance physician effectiveness in handling coverage duties. This information is available to the attending on call and for review by the attending physician of record. This helps the attending prioritize which patient to see first on arrival for rounds the next morning.
      Other important innovations found in our handheld-based system include instant messaging, which allows a user to send an automatically routed message to the person caring for a particular patient. For example, a radiologist can instant message the intern caring for a patient with a pulmonary embolus on a computed tomography scan without needing to refer to a coverage schedule or to make a phone call.
      • Chacko V.
      • Varvarelis N.
      • Kemp D.G.
      eHand-offs: an IBM Lotus Domino application for ensuring patient safety and enhancing resident supervision in hand-off communications.
      Critical laboratory values also are messaged directly to the covering physician's handheld device. We anticipate using the messaging function for rapid recognition events and for calling codes in the near future.
      PDTS now also has an “autopopulation” function that generates a new patient identification whenever an arriving patient is placed by the admitting office into the hospital's order entry system. This sends a “to-do” to the admitting resident's handheld device, prompting the resident to admit the patient or to transfer and sign-out the patient to the correct house staff member for admission. By having all admissions routed through this system, we ensure that no patient can slip through “the cracks” and be admitted to a hospital bed without proper notice to a physician. Once the patient is entered into the system, all “to-do's,” messages, and other tasks are tracked and verified, with sequential messaging to supervising house staff and attending physicians in the event a task is not completed timely or a message is not timely answered.

      Conclusions

      The sign-out systems of the future will rely increasingly on innovative technologies that permit rapid access to the most relevant patient information, guide clinicians in their work duties, and incorporate quality improvement features that do not increase physician work load. We also believe the time has come for faculty to assume responsibility for the accuracy and safety of the sign-out process and believe strongly that PDTS technology provides a suitable means for accomplishing this goal. Successful implementation of this technology on a large scale could go a long way in reducing errors in patient care related to sign-outs in teaching hospitals.

      Acknowledgments

      The authors thank Drs Harry Steinberg, Cindy Baskin, and Howard Kerpen of North Shore-Long Island Jewish Health System for introducing us to the PDTS software program. The authors also thank Reggie Carrion for the significant software enhancements that allow for attending supervision and correction of the sign-out process. The PDTS software package is now commercially available. New York Medical College at Westchester Medical Center Internal Medicine Residency Training Program is an Education Innovations Project designee. The program is a by-product of the innovations process fostered by the Education Innovations Project.

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