Standardized Sign-Outs: An Opportunity to Improve Patient Safety
The authors present several effective sign-out protocol tools and strategies to improve patient handoffs and outcomes.
I-PASS Handoff System
The I-PASS Handoff System is a landmark multicenter pediatric intervention largely funded by the US Department of Health and Human Services. The mnemonic I-PASS stands for the following:
- Illness severity;
- Patient summary;
- Action items;
- Situation awareness and contingency planning; and
- Synthesis by the receiver.
This system is part of a complete curriculum for pediatrics residents published in 2014.15 Single-center prospective validation found a 45.9% relative risk reduction in preventable medical errors without an increase in verbal sign-out length (32.3 minutes before the intervention vs 33.3 minutes after the intervention).6 This was confirmed in a multicenter prospective validation that found a 23% relative reduction in preventable medical errors—also without a change in sign-out length with versus without the tool (2.4 minutes vs 2.5 minutes, respectively).16 The bundle and curriculum are available for free and may be accessed online.15
,SBAR Tool
The Situation, Background, Assessment, and Recommendation (SBAR) is the time-honored tool most well known in nursing—one that is of benefit to physicians as well.17 In one study, SBAR demonstrated a reduction in unexpected deaths hospital-wide at a single institution when nurses used it to communicate with physicians.18 Additional support, however, is largely based on nurse and physician perception of improved communication and more thorough handoffs.19,20
Format and Outcomes
The format of a sign-out does not appear to influence outcomes, though acronyms and mnemonics appear effective—eg, I-PASS,16 SBAR,17 and IMOUTA21 (an otolaryngology resident tool that stands for identifying data, medical course, outcomes possible tonight, and responsibilities to do tonight). Riesenberg et al5 provide an overview of 24 different mnemonics described in the handoff literature.
In addition to mnemonic tools, paper pocket cards22 and electronic medical record prompts13 also appear effective. Regardless of which tool is employed, the common theme is practice standardization with dedicated time for open commun¬ication.
Practical Challenges
Aside from standardization, there are numerous other factors that can lead to a poor sign-out experience in the ED. These include a loud and disruptive background; the uncertainty of who the charge physician is post-sign-out when both are still physically present; lack of “red flags” that help identify dangerous hand-offs; the goal to be concise; and the economic structure of the physician group.1,5 These systems issues each need to be addressed; however, a standardized hand-off can decrease the margin of error and is relatively easy to implement.
Conclusion
Sign-outs are central to patient care, especially in the ED. Achieving the most effective sign-outs possible is of paramount importance and is deeply supported by respected physician groups.11,12,17,23 Several ED-specific standardized sign-outs exist with varying emphases and empirical support. The method with the most empirical support is the pediatrics initiative, I-PASS, and is one that should be considered by EPs and departments when selecting a standardized method. Even if a department is not adopting a particular method, individual clinicians can implement a standardized sign-out in their own daily practice—beginning with the next shift. A safe and effective sign-out in a reasonable timeframe in a busy ED is not only possible, but imperative.
Dr Phillips is a senior resident in the Stanford/Kaiser Emergency Medicine Residency, Stanford University School of Medicine, California. Mr Malamet is a fourth-year medical student at Philadelphia College of Osteopathic Medicine, Pennsylvania. Dr Williams is the associate program director for the Stanford/Kaiser Emergency Medicine Residency and a clinical associate professor, Surgery - Emergency Medicine at Stanford University School of Medicine, California.
Disclosure Statement: The authors express no conflicts of interest. The views expressed in this article are those of the author and do not represent the official position of the US Air Force, Department of Defense, or US Government.
