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
4.
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
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.
