Sign-out

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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. Computerized sign-out applications are designed to improve continuity of care during cross-coverage and thereby reduce risk for preventable adverse events.

Clinician sign-out is a special purpose work collaboration system examples of which exist in a number of domains besides medicine. 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. Nurses can also use the system to find the correct 'on-call' house officer.

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 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.

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).

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 EHR).

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 and pharmacy transactions as well as Admission/Discharge/Tranfer (ADT) transactions at the various interfaces and then directing a copy to a temporary data base that uses PHP to format data for a web front end. The front end application allows user input into editable fields. 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). 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.

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 convienent to use a templated print of a patient's sign-out record to serve as a daily progress note.

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."


References

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.