Standardized Sign-Outs: An Opportunity to Improve Patient Safety

Emergency physicians routinely perform sign-outs (also referred to as handoffs and handovers) at shift changes and during consultations. Despite their frequency, however, sign-outs continue to be cited as a significant source of medical error in the ED.¹

Sign-outs should take place in a quiet area of the hospital, with no distractions, and should allot sufficient time to discuss pertinent aspects of patient care. Unfortunately, this ideal handover process is particularly difficult to achieve in the ED.^2-4 Moreover, to date, only a few sign-out studies have evaluated empirical evidence for improved patient care.5

Formal Instruction

Despite multiple studies supporting the implementation of a standardized sign-out process,^1,6,7 a 2013 study by Kessler et al⁴ showed that only 10.9% of US emergency medicine (EM) residents reported receiving hand-off education.⁴ This number is consistent with the 93.9% of EM program directors who stated that assessments of hand-off proficiencies were not conducted in their US programs.⁴

In a survey conducted by Sinha et al, ⁸ only 25.6% of EM residency and pediatric EM fellowship directors reported any formal instruction on sign-outs—even though handoff education is a required component of resident patient safety education in the Clinical Learning Environment Review Program sponsored by the Accreditation Council for Graduate Medical Education in 2011.⁹

A stronger foundation in quality sign-outs during residency will likely enhance patient care. For example, Horwitz et al¹⁰ showed that 29% of house staff had a patient who experienced an adverse event after an ED-to-inpatient transfer. Contributing factors, including inaccurate or incomplete information, can potentially be corrected with a better sign-out process. ¹⁰

Sign-Out Tools

To improve the sign-out process and patient outcomes and experiences, one of the recommendations from the 2012 American College of Emergency Physicians (ACEP) Transitions of Care Task Force Report calls for collaboration with the Society of Hospitalist Medicine to hardwire a process between the EP and hospitalist.¹¹ Since this report, several sign-out materials have become available and are accessible from various organizations. The Table highlights a list of sign-out methods applicable to the ED as well as other hospital departments.

Safer Sign-Out Tool Kit

The most publicized ED tool is Safer Sign Out from the Emergency Medicine Patient Safety Foundation (EMPSF), a third-party nonprofit organization founded in 2003.12 Safer Sign Out focuses on using a physical checklist, dedicated time to sign-out, bidirectional communication, and confirmation of the sign-out with staff. The EMPSF provides all of the necessities to implement their sign-out tool department-wide, including training videos and pre- and postsurveys, in addition to the tool itself. The kit costs $1,695 to implement at a single site.¹² Although widely publicized, this toolkit has not yet been externally validated in the peer-reviewed literature.

Sign-Out Checklist

On a smaller scale, Dubosh et al¹³ recently found success using a sign-out checklist with residents in the ED at a single institution (See Box). The components of their checklist included history of present illness (HPI), ED course, pending studies, likely disposition, possible issues, and algorithms for disposition. In this study, trained research assistants monitored the sign-outs before and after implementation of the checklist. There were statistically significant improvements in the areas of HPI, ED course, possible diagnosis, and team awareness of the treatment plan. Of note, there was no difference in the amount of time required for sign-out with and without the checklist (1.42 vs 1.39 minutes, respectively).¹³ (See the Box for a convenient pocket-sized reproduction of the sign-out tool.)

ABC of Handover Tool

Developed in the United Kingdom, the ABC of Handover tool was specifically designed for use in the ED. This tool focuses on departmental awareness prior to specific patient sign-outs. The full-sheet paper checklist includes bed allocations in the ED and the hospital; available colleagues and consultants; a list of any deaths or dangerously ill patients; and equipment review. .¹⁴ The ABC of Handover tool is essentially a preamble to patient specifics compiled by surveying ED staff and attending physicians at a single urban center. It has not yet been validated in the peer-reviewed literature.¹⁴

ACEP Recommendations

Although ACEP does not endorse a particular sign-out tool,¹¹ its Section of Quality Improvement and Patient Safety created a framework of ED sign-outs and recommendations in which EPs should adhere to the following protocol:

• Limit unnecessary patient handoffs;
• Limit interruptions and distractions during sign-out;
• Provide a succinct overview; </lli>
• Highlight remaining tasks, plans, and possible changes for each patient;
• Have laboratory and imaging studies available during sign-out;
• Encourage bidirectional discourse about the assessments and treatment plans;
• Account for all patients; and
• Clearly signal the moment of full-care transfer.