What's in a Sign-out System Anyway?

I still remember the first night of general medicine wards as an intern. I tried to think over the key points of signing out. I tried to recall the intern orientation several weeks prior, but thoughts were fleeting. We had been taught to include the main diagnosis, problem list, treatment course, pending and important results, contact numbers, advanced directives, and goals of care. These would all be important components as outlined in the Transitions of Care Consensus recommendations.1 What else was there? Perhaps my senior saw my concern, because he instructed me to just observe him. I’d have plenty of opportunities to hone this craft in the future.

We huddled into the residents’ conference room as several other teams waited for one of the four computers that had access to the internal servers with the prized MS Word documents. After about a 10-minute wait, one of the computers became available. My senior quickly updated the list and proceeded to sign out.

Mrs. Johnston (these are all true stories; patient names have been changed) was admitted for cellulitis, on antibiotics, awaiting a venous ultrasound, and should go home tomorrow. Mrs. Smith was admitted for decompensated heart failure with a history of coronary artery disease and atrial fibrillation; she is currently receiving diuretics, and her heart rate is stable. Try to keep her negative one liter overnight. Mr. Jones presented with altered mental status, still awaiting a urine analysis; avoid narcotics since he became quite delirious on a previous admission. He also choked on a muffin during breakfast this morning, so watch for aspiration.

I listened in as the rest of our patients were described, then bid the night team farewell until tomorrow morning.

Over the ensuing year, I would become quite familiar with the art of signing out. I attempted to master the fine line between too little information and too much detail, so that the night teams could attend to admitting and cross-covering effectively. When I was on-call, I started to learn important questions to ask with certain patients to avoid complications overnight. This also helped when I was signing out because I could emphasize these points as well. I also learned to highlight which patients were the sickest and to include code status in sign-out.

As a senior, I soon began to experience frustrations with the sign-out process. Sometimes the servers would update at odd hours, incapacitating the document program and interrupting sign-out; this would often leave residents with incomplete or hand-written sign-out lists. Then, there was always the enjoyable task of completely retyping a list if the file became corrupted. Additionally, only a few computers in the hospital had access to documents on internal servers, which led to delays or lack of updates. With its many shortcomings, this system was still preferable to the index card system that was still being used in the intensive care units. Conversations with several of my colleagues from other institutions revealed that they also used an MS Word or Excel document for sign-out. These findings were similar to a national survey of 202 residency programs published in 2006, which showed that 45% of sign-outs were typed into a text program and 29% were handwritten.2

In 2004, a presentation from Brigham and Woman’s concluded that despite utilizing a computerized sign-out system, only about half of residents provided written and verbal sign-out for every patient, and only 55% of night-float residents felt that relevant information about patients could be found in the sign-out.3

I remember a discussion in spring 2007 with one of the wise hospitalist attendings who was taken aback that we were using “technology from the 90s” for sign-out. Despite his dismay, he expressed hope that the residents would soon have access to software called Sharepoint that the hospitalist department had recently started using. Hospitals around the country were slowly adopting technology solutions. The University of California, San Francisco started to implement a database called Filemaker Pro in 2003 that improved sign-outs from the residents’ perspective. The University of Washington described an improvement in sign-out efficiency and continuity of care after implementing a computerized sign-out system. However, less than 10% of hospitals had the technological infrastructure to implement an integrated sign-out system.4 I was eager to see what benefits the medicine services might gain with this new system and if we could reach the hallowed grounds of an integrated sign-out program.

Sharepoint immediately fixed several of the most cumbersome problems with using MS Word on internal server computers. Specifically, sign-out could take place in any conference room or nursing station in the hospital. This greatly improved efficiency and completeness. Additionally, the system was more stable and secure.

Unfortunately, not all hospital departments had access to Sharepoint. While the medicine services greatly improved the effectiveness of sign-out, other programs in the hospital remained limited to MS Word documents or verbal sign-outs and wished for a better solution.

The origin of the integrated sign-out system dates back to the summer of 2008 when the neurological institute investigated adding a plan of care tool to improve coordination and efficiency among all of the teams and services with a goal to improve patient care and length of stay. Medical Operations approached Dr. Ajay Kumar for advice, and his initial response was to integrate the plan of care tool into the EHR. Discussions with the manufacturer of the software revealed that it could take 3-4 years to implement this plan. Finding this delay unacceptable, Dr. Kumar had to start at square one, and the scheming began.

In late 2008, the hospital charged Drs. Kumar and Morris to analyze, create, and implement a sign-out tool at Cleveland Clinic. A multidisciplinary team was created that included residents, fellows, nurses, and staff physicians, along with Mr. Brett Young, a senior manager in Medical Operations who worked closely with programmers to design the system. Dr. Kumar, Dr. William Morris, and Brett Young scoured the country for a program to utilize or adapt; unfortunately, very few institutions appeared to offer a system that would be flexible, safe, customizable, and available to meet their needs.

At the start of 2009, the team investigated the regulatory requirements and identified with clinicians the critical components of an ideal sign-out system. They wanted a resource that was versatile, secure, HIPPA compliant, flexible to meet service needs, and compliant with regulatory requirements. The system also needed to be able to identify service providers and attendings and update these fields easily.

The first prototype of the software was introduced in March 2009 and was reviewed by individuals from varied departments. The software went to the medical executive committee, legal department, risk management division, and accreditation for approval. It was finally rolled out through various departments starting in June 2009 after an initial pilot in the children’s hospital.

The tool does the usual job of collecting information and to-do’s but has a great advantage of creating a system for continuity of care. The Cleveland Clinic is a tertiary care center and receives a large number of patients from other hospitals and emergency rooms from all over the country. The system allows for the addition of a patient to the sign-out tool, with all relevant information, even before the patient arrives in the hospital. The information is useful for the residents or staff receiving the patient, sometimes hours or a day later. Once the patient arrives in the hospital, the tool reconciles the patient’s location, name, and medical record number, then alerting the provider to the patient’s arrival.

The tool also features a unique multidisciplinary sign-out view, so each team can see what other teams are signing-out about the patient. Nurses can also see the physician sign-out, giving a unique communication to the bedside that is often missing. A study from the Jacobi Medical Center (Bronx, NY) in 2006 showed an improvement in nursing satisfaction, plan of care, and self-confidence with access to the sign-out system.5 There are many other features, which include a smart to-do list, attending physician update feature, and customized reporting option to meet team needs.

The system is now used on 80% of patients at a tertiary care center of about 1,100 beds. User accountability is being monitored to ensure that information is being updated at least every 24 hours. These advances are not without costs. The number of hours invested in this project probably number in the thousands, and the price tag isn’t small. However, this system promises to pay back dividends on the investment in terms of improved efficacy, continuity of care, and patient satisfaction.

References

1. Snow V, Beck D, Budnitz T, Miller DC, et al. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. July 2009;4(6):364-70.

2. Horwitz L, Krumholz H, Green M, Huot J. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. June 12, 2006;166(11):1173-7.

3. Carty M, Smith C, Schnipper J. Intern curriculum: The impact of a focused training program on the process and content of signout out patients. Harvard Medical School Education Day, Boston, MA; 2004.

4. Vidyarthi A, Arora V, Schnipper J, et al. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. July 2006;1(4):257-66.

5. Sidlow R, Katz-Sidlow RJ. Using a computerized sign-out system to improve physician-nurse communication. Jt Comm J Qual Patient Saf. January 2006;32(1):32-6.