Difference between revisions of "Sign-out"

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# Luo J, Hales RE, Hilty D, Brennan C. Electronic Sign-out Using a Personal Digital Assistant. Psychiatric Services. Feb 2001;52(2):173-174.
# Luo J, Hales RE, Hilty D, Brennan C. Electronic Sign-out Using a Personal Digital Assistant. Psychiatric Services. Feb 2001;52(2):173-174.

Latest revision as of 01:53, 31 January 2015

Clinician sign-out systems (also sign-outs, handoff communications, transfer-of-care communications) provide a provider with enough relevant clinical information about a given patient that they can make decisions about that patient’s care. Sign-outs are becoming more important as inpatient medicine is becoming more reliant on hospitalists, who typically work in shifts and care transitions. [1] [2]

Risk of sign-out communications

Previous work has identified coverage by house staff not primarily responsible for the patient (cross-coverage) as a significant correlate of risk for preventable adverse events. [4, 5] Computerized sign-out applications are designed to improve continuity of care during cross-coverage and thereby reduce risk for preventable adverse events. In 2006 JCAHO added the following National Patient Safety Goal: “2E: Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions”, largely in reaction to this literature. [6]


The challenge in all of these systems is to create applications that capture, store, and display all, or nearly all, the relevant data and shared activities of the team. Various systems have taken different approaches to this challenge, and the functionality of systems range accordingly. The superset of patient data that systems could use spans a vast range of information, including information traditionally found in an EMR (e.g., lab results, medication lists, problem lists, allergies, current orders, demographics) and information that was typically only relayed as part of the sign-out process (e.g., “to do” items, subjective assessments of the patient, fever work-up recommendations, code status, succinct problem descriptions). Systems that focus on the first data set are usually called “rounding lists” and are typically generated out of various EMR systems as reports. Systems that focus on the second data set are usually called “sign-out” systems, and due to their honest (and often considered inappropriate) portrayals of other care teams, patients, or patient families, have traditionally been kept within the individual care teams and not made broadly available. The optimal configuration for users is a mixture of both, but that has been difficult to accomplish largely for technical reasons. However, users make do by copying “missing” information in by hand.


Nurses can also use the system to find the correct 'on-call' house officer, which can save significant time. [7] Nurses also experience improved work satisfaction when given a read-only view of sign-outs. [8] Anecdotally, giving access to case managers and social workers also greatly improves their satisfaction. This appears to be, in part, due to the inclusion of discussions about patient discharge, which are typically excluded from the medical record due to concerns over billing.


One important activity of medical teams is documentation in the medical record. One approach is to automatically capture into the record all communications relevant to a particular case - this is the approach used in EMR applications such as Epic's MyChart and InBox which manage patient-physician and physician-physician and system-physician communications, though each are only point-to-point interactions (i.e., they do not allow any team member's response to remove the task from the box). This can be extended to cover all other activities (including sign-out and other many-to-many interactions) through improvements of the EHR, but does require diplomacy.

Rules of thumb

Another important activity of the team (during the sign-out process) is guidance of team members on rules of thumb in specific situations with specific patients (a form of situation awareness). When thought of this way the exclusion of these data from the medical record seems a liability risk to the extent that they are the driving reason decisions are made (and we know that medical liability often stems from insufficient documentation of decision processes, particularly during hand-off situations). Unfortunately, many clinicians still feel uncomfortable including this information in the actual medical record.

Sign-out is a clinical care activity, therefore, one should strive to find, or build, a system that is as focused as much as possible on the physicians' work-flow and conceptual model of the data, and let that become the human interface to the EHR/medical data collaboration system (which would over time become more efficient and look less like today's EMR).

Having two separate systems by design begs the question of which is the authoritative source of information and of whether we should impose two systems on physicians for one activity (conducting/documenting care).

On the other hand, many organizations have created "stand-alone" sign-out applications using various tools and methods including:

Using a Microsoft Word or Excel document that is updated prior to each handoff. Such a system creates a document that is electronic, allows updating rather than re-writing with each iteration - clearly, conducting this with a more sophisticated database (with ADT feeds, etc...) and portal moves again toward building a collaboration system, which among professionals should be as tightly integrated with the EHR (the primary collaboration system of medical professionals) as possible.

Alternatively, a sign-out application can be created from laboratory, pharmacy and Admission/Discharge/Transfer (ADT) transactions, storing a copy to a temporary data base, and then using standard web programming tools (e.g., PHP, Ajax) to format data for a web front end. The front-end application allows user input into editable fields, which are stored in the same database. The resulting presentation can then be made available (password protected, of course) across the enterprise to all residents. The system allows patients to be assigned to one or more roles, positions, or teams creating a census (e.g. team I, intern 1 or nightfloat). These are also known as “team lists”, “patient lists”, “provider lists”, or simply “the sign-out”. Here is an example screen print.

Other organizations encourage residents to create their own custom patient list within their EMR application. They can proxy this to other members of their team and use it for sign-out purposes as well as quick access when on-call. Regenstrief has developed a version of this that they call "Pocket Rounds", which has been very popular with their housestaff. [9, 10] CPOE systems have also been used for this purpose. [11]

Some organizations keep all previous sign-out data on line to help pre-populate new records for patients who are frequently admitted.

An interesting by-product of the sign-out application is that the residents have found it convenient to use a templated printout of a patient's sign-out record to serve as a daily progress note. They have also been used to create discharge summaries. [12]

In virtually all cases, the sign-out can be printed out for easy reference in paper form. This allows for easy transition from more traditional sign-outs (which are usually paper-based), but also provides very fast random access to information. It has the added benefit of providing for resilience to IT failures that are still prevalent. [13] This reliance on paper will likely change slowly as portable computing options evolve,[10, 14] but currently they are the exception rather than the rule. [3]

There is much debate about whether the information required in a clinician sign-out system should be included within the EMR. Here is one argument for why it should not be: While the discrete clinical data elements originate from the EMR, some of the other items that housestaff tend to want to communicate really should not be a part of the record; communications may range from "Patient complains of shortness of breath every night but always has normal SaO2, normal CXR, and normal EKG" (which may arguably belong in the record) to the more inflammatory "avoid going in the room when visitors are there; patient's family is a bunch of lunatics" (which clearly has no place in the record but is important to communicate - although there are more diplomatic ways to indicate the information, post-call surgical residents have little time for diplomacy!).

On the other hand, an attorney commenting on the "discoverability" of the data from this separate application might say, "Something is discoverable if it exists. If it once existed and no longer exists, that is discoverable as well. Individuals and/or institutions do not decide what is discoverable, although they often try."



  1. Horwitz LI1, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. http://www.ncbi.nlm.nih.gov/pubmed/16772243
  2. R. Ram and B. Signing out patients for off-hours coverage: comparison of manual and computer-aided methods. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2248075/
  1. 1
  2. 2005-2006 SHM Survey: State of the Hospital Medicine Movement
  3. 3
  4. Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994 Dec 1;121(11):866-72.
  5. Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998 Feb;24(2):77-87.
  6. The Joint Commission: 2006 Critical Access Hospital and Hospital National Patient Safety Goals
  7. Kannry J, Moore C. MediSign: Using a Web-Based SignOut System to Improve Provider Identification. Proc AMIA Symp. 1999:550-554
  8. Sidlow R, Katz-Sidlow RJ. Using a computerized sign-out system to improve physician-nurse communication. Jt Comm J Qual Patient Saf. 2006 Jan;32(1):32-6.
  9. McDonald CJ, Overhage JM, Tierney WM, Dexter PR, Martin DK, Suico JG, et al. The Regenstrief Medical Record System: a quarter century experience. Int J Med Inf. 1999 Jun;54(3):225–53.
  10. Thomas SM, Overhage JM, Warvel J, McDonald CJ. A comparison of a printed patient summary document with its electronic equivalent: early results. Proc AMIA Symp. 2001:701–5.
  11. Frank G, Lawless ST, Steinberg TH. Improving physician communication through an automated, integrated sign-out system. J Healthc Inf Manag. 2005 Fall;19(4):68-74.
  12. Kannry J, Moore C, Karson T. Discharge Communiqué: Use of A Workflow Byproduct To Generate an Interim Discharge Summary. AMIA Annu Symp Proc. 2003; 2003: 341–345.
  13. Nemeth C, Nunnally M, O’Connor M, and Cook R. Creating Resilient IT: How the Sign-Out Sheet Shows Clinicians Make Healthcare Work. AMIA Annu Symp Proc 2006. 2006:584–588.
  14. Luo J, Hales RE, Hilty D, Brennan C. Electronic Sign-out Using a Personal Digital Assistant. Psychiatric Services. Feb 2001;52(2):173-174.