Rant: Shift Change Etiquette

[EMhawkeye]

Professionalism is a lost art

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[BoardingDoc]

Counterpoint: when you're single coverage, it blows staying over for an hour+ dealing with an ICU train wreck admission that rolled in at 7:06 because your relief is late, again, and you had to spend time with lines/tubes/labs/calling...

I don't get this mentality. If this person rolls in at 706 and the 7a doc shows up at 710, you tell them to take over and you leave. I have no idea why you would stay to manage that patient. Hell, if a total Trainwreck rolls in at 655am, I'm generally giving that patient to the 7a doc as well. That's just sort of understood to be a viable option. Is this actually not an option at other people's shops? Am I just taking for granted that I work with a bunch of other actual adults?

 

[Fox800]

I don't get this mentality. If this person rolls in at 706 and the 7a doc shows up at 710, you tell them to take over and you leave. I have no idea why you would stay to manage that patient. Hell, if a total Trainwreck rolls in at 655am, I'm generally giving that patient to the 7a doc as well. That's just sort of understood to be a viable option. Is this actually not an option at other people's shops? Am I just taking for granted that I work with a bunch of other actual adults?

Yeah, you are.

If you're single coverage and a cardiac arrest rolls in at 0703 and your relief is 20 minutes late because of "traffic", you're gonna be doing some stuff and writing a chart. There's no warm handoff of that.

 

[bky3c]

I never actually entered the hospital until about 5 minutes before my shift. I'd get there about 15 minutes early, listen to a bit more of my podcast in the car, reply to a text, etc. and then walk in only when necessary, but still early enough to get settled in time to take signout right on time. That way I felt like it was still my own time, not dead time that I was just wasting. But if I did hit traffic or whatever, the buffer was there.

 

[bky3c]

Yeah, you are.

If you're single coverage and a cardiac arrest rolls in at 0703 and your relief is 20 minutes late because of "traffic", you're gonna be doing some stuff and writing a chart. There's no warm handoff of that.

Exactly. Even if someone is 5 minutes late, that's enough time to be up to your elbows in an intubation or a line or whatever, and even if you didn't do anything but run the resus until you could hand it over, you still have to document that. So now you're leaving at least 15 minutes late because your colleague was 5 minutes late (5 min running code, 5 min handover, 5 min charting). And inevitably something will come up with your own patients (or new ones) during that time, and since you're physically present, you'll get 3 nurses coming to you with questions/orders/concerns "just real quick before you leave."

 

[xaelia]

And inevitably something will come up with your own patients (or new ones) during that time, and since you're physically present, you'll get 3 nurses coming to you with questions/orders/concerns "just real quick before you leave."

As I frequently say – the longer you stay, the longer you stay.

 

[DeadCactus]

Counterpoint: when you're single coverage, it blows staying over for an hour+ dealing with an ICU train wreck admission that rolled in at 7:06 because your relief is late, again, and you had to spend time with lines/tubes/labs/calling consultants/charting and then dealing with worsening traffic on the way home isn't fair so your colleagues can avoid "drinking coffee to avoid ever being late show up at their scheduled times like an adult with a professional job" (there, I took those rose-colored glasses off for you).

One of our noctors is routinely 20-30 minutes late because of "muh traffic" while the department is melting down. Somehow this is just accepted, and the powers that be don't ask her to stay late to make up the difference in scheduled hours.

In the grand scheme of cosmic karma, show up to your damn job on time. Why is this so hard? You had to do it in med school, you had to do it in residency. It's not cute, it's not cool. You can get a pass once in a while. Don't make being late a habit.

Your acting like extreme edge cases in a specific sign-out circumstance are the routine outcome and using inflammatory language to back up a practice that is all about local culture and has nothing to do with professionalism. No one is talking about routinely showing up 30 minutes late but aiming to be on time and rarely being 5 minutes late is reasonable as long as the same courtesy is extended to everyone. You've unilaterally decided to do 2 hours of unpaid time in the hospital a month and think everyone else is shackled by your decision which is not reasonable. The problem is people being on different pages or being treated differently and not with any specific approach. It's the same bull**** that pops up with people calling in sick or having personal emergencies.

 

[BoardingDoc]

Yeah, you are.

If you're single coverage and a cardiac arrest rolls in at 0703 and your relief is 15 minutes late because of "traffic", you're gonna be doing some stuff and writing a chart. There's no warm handoff of that.

Note to self: thank my colleagues for being exceptional.

In your scenario it would be perfectly acceptable to stay and manage that patient from start to finish. It would also be perfectly acceptable to say "I just tubed this guy from our lady of clinical incompetence nursing home, he's a hot mess. Here's what I know. I'll write the intubation procedure note, the rest is all you."

Again to reiterate though, I don't work with anyone who is habitually late by more than a minute or two.

 

[Fox800]

Your acting like extreme edge cases in a specific sign-out circumstance are the routine outcome and using inflammatory language to back up a practice that is all about local culture and has nothing to do with professionalism. No one is talking about routinely showing up 30 minutes late but aiming to be on time and rarely being 5 minutes late is reasonable as long as the same courtesy is extended to everyone. You've unilaterally decided to do 2 hours of unpaid time in the hospital a month and think everyone else is shackled by your decision which is not reasonable. The problem is people being on different pages or being treated differently and not with any specific approach. It's the same bull**** that pops up with people calling in sick or having personal emergencies.

To each their own. I wouldn't routinely hand off an active resus, but maybe the culture of your shop is different. Unless the circumstances were really unusual (patient reasonably stabilized on the vent, has access, waiting for the helicopter, whatever).

This isn't an extreme case, I've worked at CAHs and had enough chronically late coworkers and had it happen a few times.

It gets old managing an unstable resus that rolled in at shift change while your relief walks in with their coffee, there are five new patients that are waiting to be seen, while you still have other patients to sign out.

 

[Fox800]

Note to self: thank my colleagues for being exceptional.

In your scenario it would be perfectly acceptable to stay and manage that patient from start to finish. It would also be perfectly acceptable to say "I just tubed this guy from our lady of clinical incompetence nursing home, he's a hot mess. Here's what I know. I'll write the intubation procedure note, the rest is all you."

Again to reiterate though, I don't work with anyone who is habitually late by more than a minute or two.

I guess it was just the way I was trained, but I wouldn't sign off a patient I just tubed with a procedure note and then yeet it to the oncoming doc. The idea makes me feel weird. It's just not how things are done, it seems sloppy. At least stabilize them to the point they can go to imaging or have the ICU come down and do stuff.

I don't know maybe it's a culture thing or a training/residency thing.

Are ya'll tubing and coding people and then doing just the procedure note or dropping your .signout smart phrase? Jesus

 

[Fox800]

I never actually entered the hospital until about 5 minutes before my shift. I'd get there about 15 minutes early, listen to a bit more of my podcast in the car, reply to a text, etc. and then walk in only when necessary, but still early enough to get settled in time to take signout right on time. That way I felt like it was still my own time, not dead time that I was just wasting. But if I did hit traffic or whatever, the buffer was there.

Same. I leave early with a little buffer, then sit in my car until it's time to walk like 3-4 minutes before shift change.

I don't do unpaid work. I don't start work early, and I go home on time.

We do get paid for staying late for active patient care/delayed signouts if your relief is elsewhere.

 

[CoolDoc1729]

I guess it was just the way I was trained, but I wouldn't sign off a patient I just tubed with a procedure note and then yeet it to the oncoming doc. The idea makes me feel weird. It's just not how things are done, it seems sloppy. At least stabilize them to the point they can go to imaging or have the ICU come down and do stuff.

I don't know maybe it's a culture thing or a training/residency thing.

Are ya'll tubing and coding people and then doing just the procedure note or dropping your .signout smart phrase? Jesus

If I only caught the case because my relief was late, I would have no compunction giving it to them when it’s time for me to leave.

In the single- coverage, no overlap 7:06 code example I would have no compunction about taking the immediate actions and then handing it off as soon as my relief is settled in. And I would expect to take it if I were late.

I can’t imagine working somewhere you’d be expected to stay hours over shift to finish up a single case because a colleague was late… Really seems extreme.

 

[BoardingDoc]

I guess it was just the way I was trained, but I wouldn't sign off a patient I just tubed with a procedure note and then yeet it to the oncoming doc. The idea makes me feel weird. It's just not how things are done, it seems sloppy. At least stabilize them to the point they can go to imaging or have the ICU come down and do stuff.

I don't know maybe it's a culture thing or a training/residency thing.

Are ya'll tubing and coding people and then doing just the procedure note or dropping your .signout smart phrase? Jesus

Side question: "Have the icu come down and do stuff?" I don't think I've ever worked in a hospital, residency at a massive tertiary care centre included, where an intensivist was ever in the ED managing a patient of mine unless I'd already signed it out to them and it wasn't actually my patient anymore. How does that work on your end?

As to the sign out thing, this is again a rather extreme edge case that you've pointed out. I can think of one time in the past 6 years where it's been relevant, but yeah, in that scenario a code came in. I started running it. Guy had already been tubed by EMS. Relief came in maybe 3 min into it. We talked about what was going on for 5 more minutes or so as we co-ran the code and he gradually took over and I went home.

I would expect to do the same for any of my post-overnight colleagues in that scenario if I came in as the morning doc.

 

[Mount Asclepius]

This is completely dependent upon how you are paid. If you are productivity based, then of course you are staying late for critical care. Your dollar per hour is amazing in that scenario. If you are hourly, then you are hyper aware of 5 minutes.

 

[bougiecric]

What I don't get is the cognitive dissonance. I'm assuming it's universal to be annoyed when your relief comes in late. How do the people who are chronically late get irritated at others but rationalize their own behavior?

 

[trackrunner321]

If a sick patient came in while I was waiting for a late colleague, I would do what needed to be done and instantly sign it out upon their arrival.

 

[CoolDoc1729]

What I don't get is the cognitive dissonance. I'm assuming it's universal to be annoyed when your relief comes in late. How do the people who are chronically late get irritated at others but rationalize their own behavior?

I don’t care at all if my relief is 10-15 minutes late. We have 2h overlap , I see pretty much everything up to their start time, document, finish what I can finish and go home when it’s time. We also get paid for overtime if needed. But i wouldn’t be staying over to finish a x:06 code .. that’s more the “saw 3.5/h and still have stuff to do and it will take longer to sign it out than to just do it” situation.

 

[Fox800]

Side question: "Have the icu come down and do stuff?" I don't think I've ever worked in a hospital, residency at a massive tertiary care centre included, where an intensivist was ever in the ED managing a patient of mine unless I'd already signed it out to them and it wasn't actually my patient anymore. How does that work on your end?

As to the sign out thing, this is again a rather extreme edge case that you've pointed out. I can think of one time in the past 6 years where it's been relevant, but yeah, in that scenario a code came in. I started running it. Guy had already been tubed by EMS. Relief came in maybe 3 min into it. We talked about what was going on for 5 more minutes or so as we co-ran the code and he gradually took over and I went home.

I would expect to do the same for any of my post-overnight colleagues in that scenario if I came in as the morning doc.

I don't expect the ICU docs to run the resus, but ours are quite good about doing arterial and central lines. Our nurses can't monitor art lines in the ED.

As long as we have a couple of good peripheral IVs and the patient is intubated and hemodynamically stabilized to a reasonable degree, the ICU doc will come down (typically on their own) and start putting in orders and may start doing central lines, arterial lines, ordering the meds they want, etc. That's what I meant by "doing stuff"...ICU stuff.

 

[Janders]

One of the benefits of being eat-what-you-kill:

If you are staying late, it’s likely bc you’ve seen a ton of sick people and are billing mad RVUs and critical care time and you’re getting paid to be late. Eventually when it is appropriate you sign out a couple of OBSV, psych, and straight forward pending-CT cases.

On these edge cases where a code comes in at 0657 or 0702 and your relief is still walking in from the parking lot…

Keep it yourself, bill the intubation, CPR CPT, 32 minutes of critical care and write a note. Your prerogative to make money.
Or
Handle the first 2x pulse checks, intubate, bill that (a 40 second note), and give a warm handoff to your partner when they walk in. Your prerogative to make a lil money, and get out of dodge when safe.

This said I work with a group of people who would (1) appologize for being late (2) are excellent ED docs and I’d have no compunction signing a code-in-progress to them (3) try to get the post-night doc, specifically, out ASAP.

This is an atypical edge case, but I’ve had a couple similar things happen over the past dozen years. Unstable upper GI bleed comes in at 2059 and I’m in the toilet [working til 2300] and the off going doc (off at 2100) throws 2x US PIVs in, bills for them, and walks off after ordering the labs when I return from my big boy pee pee break. Totally reasonable. I’ve also stayed late and run codes that started 10 minutes AFTER my shift ended when the solo-cover doc is slammed with 12 things to do. So be it, take care of the patients, and get paid.

 

[DocEspana]

I work at a place where the "we are all adults here" rapidly became "no one has etiquette". Thankfully a few of us are newer hires who jumped ship from a nearby place where if you werent at least 1 minute early you were late. The three of us are not so much complaining as we are playing stupid. Whenever someone is >5 minutes late, we text them at minute 6 concerned and making sure they woke up and didnt get into an accident on the way to work.

The people who would show up 20 or even 30 minutes late on the regular are now all making it in 5 minutes late or less because of the power of shame and not knowing how to answer that text every time it comes in.

 

[ercat]

We had a couple of these losers at my previous shop. Literally arriving 20 min late to relieve night shift single coverage guy, putting stuff down, saying "I'm gonna grab breakfast and then take your sign out."

There's a term for this: narcissistic personality disorder.

Yep. There’s a doc in my group who comes in, SEES ME sitting there with my bags at the end of my shift waiting to sign out, and GOES TO THE LOUNGE FOR 25 minutes. Who goes to the lounge for 20 plus minutes at the beginning of their shift anyway?

 

[valianteffort]

Yep. There’s a doc in my group who comes in, SEES ME sitting there with my bags at the end of my shift waiting to sign out, and GOES TO THE LOUNGE FOR 25 minutes. Who goes to the lounge for 20 plus minutes at the beginning of their shift anyway?