Advice on giving a good sign out

[famdoc2015]

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Hope everyone is enjoying intern year so far! I just wanted to see if any seniors can offer some advice on giving a good sign out when you are on call. I know my patients very well, but when it comes to knowing whats going no with my co-residents patients during sign out - I don't have a very good grasp on this. I know it will just come with practice, but just wanted to see if anyone had some advice for giving a good sign out on your teams patients.

Thanks!!

 

[45408]

If some of your patients are sick, you should always go over those patients in more detail. If you think there's a decent chance this patient will go to the ICU, need to be intubated, need a transfusion, etc., then make sure you discuss that possibility. Make sure you explain what you think might need to be done, because you know the patient better than the person on call. If the patient looks "iffy" and your team/attending has decided not to do certain more aggressive interventions or work-up, let them know that as well and why. It's never wrong to actually go see the patient with the person on call as part of your sign out, but obviously that will take up a lot more time.

I'm in surgery, so virtually all of our patients are a full code, so if there's a DNR patient, I include that info in sign-out. If one of them is actually likely to die, I definitely include that as well.

If there is something that needs to be done or managed overnight, you need to include that. If someone is getting a diagnostic study/lab test done, tell the person on call what the study is, what results they might reasonably expect, and what they should do about the study.

For our routine post-op patients without significant co-morbidities or abnormal treatment courses, I prefer pretty brief sign outs.

 

[cpants]

Include all the important info, none of the unimportant info. Easier said than done, but it will come with experience. A general outline should be:
1. Why the patient is here. (85 y.o. with acute cholecystitis, include relevant comorbids)
2. What you are doing to manage that. (On unasyn, got perc chole tube today)
3. What other issues are going on. (Developed rapid afib today, started on cardizem drip, now rate in 80's, cards consult pending)
4. What needs to be done and plans for contingencies (If he gets tachycardic again bolus cardizem and go up on the drip, call cards. If he spikes a fever again don't worry about cultures because we sent them this afternoon, etc.)
5. Should they be worried about the patient? (This guy might get sick, needs a roll by.) When you hear that in sign out you should make sure to star or highlight the patient on your list and confirm their code status.

For floor patients you should be able to get through all of this in 1-2 minutes per patient. If it's something simple, you can even get away with a one liner, but you'll have to earn that privilege. First week intern can't sign out 'Straight forward lap appy, home in the morning.'

 

[deleted103644]

Your verbal signout should focus on

1) things that need to be done by coverage (labs, vitals, neuro checks, etc) and
2) things that might need to be done by coverage (critically ill pts, active issues, etc)

Most other key information should be readily apparent by your physical signout sheet but doesn't necessarily need to be relayed directly during verbal signout.

Also, try to avoid signing out BS.

If you have a seriously sick patient, deal with immediate issues before trying to signout.

Don't signout non-critical labs, scut work that you don't want to do yourself, etc etc.

 

[Tired Pigeon]

Agree with all of the excellent advice above. I also include my cell phone # on the signout sheet and encourage the oncall resident to call me if there are any questions or confusing situations arise. I've found that fellow residents won't abuse this privilege -- in 3+ years, I've only been called by the night float person twice, both times with legit questions relating to urgent circumstances that had come up with my patients overnight.

 

[gutonc]

Anything you want followed up on needs to be an if/then statement. If you want me to follow up on a lab or study then tell me what YOU want me to do about it. It's your patient and your plan. Don't make me try to year your mind. Also tell me if there's an expected abnormal lab or vital sign that you don't want me to deal with. And if you sign out a CBC for me to follow up on, there better be a transfusion consent in the chart already.

 

[Groove]

It should be very brief... Only pertinent information, no fluff.

1) "What have I got?" i.e. Age, problem, (sick or not sick, which can be conveyed or stated) brief history.
2) "What am I doing about it?" i.e. What have I done so far. How's the pt's state right now? Stable vs unstable.
3) "What's my plan" i.e. What information am I waiting to follow up on, what was my original plan and what do I intend to do about it based on the incoming information. What do I expect to find, what am I most worried about. Did you consult X or intend to based on labs coming back? You gonna stick around and do that or do I need to? etc..

If you talk more than 2 minutes, you're going to lose me. Sign outs should be brief.

The reality is that it's not meant as a blueprints for me to follow, at least I've never used them as that. It's more to give me a general indication of what kind of baby elephant I'm inheriting and what their status in the dept is at that time. It also gives me an indication of dispo times and how much resources that patient is going to utilize in the next 1-2 hours.

After that, I go round and meet them all and get my own HPI and brief physical along with developing my own gestalt which may or may not agree with the person who signed out but it doesn't matter, that's medicine.

Don't ever be fooled into being overconfident about a sign out from someone who's "been doing this for 20 years", etc.. People make mistakes and people disagree and that doesn't make them a bad clinician. I got a sign out moonlighting from an IM doc who had been doing IM for 10 years. She signed out a "DKA" pt with a standing order for 20U bolus of insulin and an insane infusion rate with no chemistries back, no labs whatsoever, just a FS that read 400s and a VBG that was normal. The nurses were just about to give it all before I cancelled everything and evaluated myself. Merely a poorly controlled DM2 that got sugar under control in an hour with fluids and tiny dash of insulin. If I had just taken her word for it, I would have probably been called into the room 45 minutes later for a seizing patient and who knows what her potassium would have been.

People get hasty during sign outs and tend to pay less attention. I wish it wasn't so, but I've been just as guilty of it on occasion. I really appreciate the people that stay a little bit later to wrap up an admission or consult or lac repair, etc..

I don't mind dealing with bogus stuff if I'm coming into the ED at 8am and it's essentially empty but don't do that to me at 8pm.

 

[Groove]

Oh crap, sorry... I thought I was in the EM forum. Disregard my sign out approach unless you work in the ED. Oops!

 

[deleted103644]

Oh crap, sorry... I thought I was in the EM forum. Disregard my sign out approach unless you work in the ED. Oops!

To be honest, an ED signout is probably more in depth than a typical IM signout (or at least should be), just because all issues are acute for an ED patient. Same (and even more so) for ICU.

 

[Mattchiavelli]

It's funny, when I did an ICU month my prelim year the EM people's signouts were the briefest, usually a few lines per patient, and they were the shortest. The longest were the med/peds people because they got into a lot of the chronic medical issues. The EM residents went into every situation where they got called to as an ABCs first and then time to think scenario while the medicine people liked to mull it over en route (assuming it wasn't something super urgent like,say, a code)

A few things to add/add to-
-you will get this the more cross cover you do but any deviations from normal night reactions should be mentioned such as
>low BP --> IV fluid --> why a patient would need less or no fluid like "patient has ESRD on dialysis"
-issues others have had overnight and how to deal with them
-things that keep coming up and have a consistent remedy like "patient has TBI and is nonverbal so will have abnormal vitals like hypertension and tachycardia but he just needs repositioned off his broken ribs"
-big social issues like "pt has a daughter that will try to make medical decisions for her demeted mother but she is not the POA"
-baseline neurologic status IF not normal/really old, can just do a brief cognitive and peripheral/motor like "patient is oriented to self and sometimes place, left hand dysfunction from war injury" to save on wasted CTs/stroke freakouts

Not needed in verbal changeover-
-stuff that has been written down on your changeover sheet
-instructions to do what anyone would do in a situation like "this patient is in with unstable angina so if he has sustained heavy chest pain get an EKG"

both are pet peeves of mine and some of my friends

 

[DrBowtie]

It's funny, when I did an ICU month my prelim year the EM people's signouts were the briefest, usually a few lines per patient, and they were the shortest. The longest were the med/peds people because they got into a lot of the chronic medical issues. The EM residents went into every situation where they got called to as an ABCs first and then time to think scenario while the medicine people liked to mull it over en route (assuming it wasn't something super urgent like,say, a code)

A few things to add/add to-
-you will get this the more cross cover you do but any deviations from normal night reactions should be mentioned such as
>low BP --> IV fluid --> why a patient would need less or no fluid like "patient has ESRD on dialysis"
-issues others have had overnight and how to deal with them
-things that keep coming up and have a consistent remedy like "patient has TBI and is nonverbal so will have abnormal vitals like hypertension and tachycardia but he just needs repositioned off his broken ribs"
-big social issues like "pt has a daughter that will try to make medical decisions for her demeted mother but she is not the POA"
-baseline neurologic status IF not normal/really old, can just do a brief cognitive and peripheral/motor like "patient is oriented to self and sometimes place, left hand dysfunction from war injury" to save on wasted CTs/stroke freakouts

Not needed in verbal changeover-
-stuff that has been written down on your changeover sheet
-instructions to do what anyone would do in a situation like "this patient is in with unstable angina so if he has sustained heavy chest pain get an EKG"

both are pet peeves of mine and some of my friends

Agree with above. After my first month on NF as an intern, please tell me about pt specific normal deviations from normal protocol for low or high BP, HR, O2 etc as I don't have time to thoroughly plow through the chart before initiating management.