Sign outs

[Primate]

Curious about how different programs handle sign-out between shifts. I've noticed that in medicine at my august institution (tongue in cheeck), sign-outs can really suck and leave the next team with alot of scut - of course, what comes around goes around and it sometimes happens that one can't even sign out on time even with your patients tucked in.

I'm curious whether or not most programs enforce "giving good sign-out," or if people get stuck working longer or picking up slack. My EM rotation starts in a couple days, so I'll see it first hand here, but I'm curious about the rest of the world, too.

Happy New Year all,
P

---

Members don't see this ad.

 

[Scrubbs]

Different programs do different things... I interviewed at a few places that endorsed staying until you've completely wrapped up your patients (as long as that takes). Our program is very into getting people out on time. Sometimes you get sign-out and have a lot to finish up, but when your shift is over, your tired, and all you want to do is go home, signing stuff out sounds like the best thing in the world! Its a give and take situation, and I really appreciate my fellow interns telling me to hand stuff over and GO HOME!

 

[The White Coat Investor]

Amen. What he said. I had 6 sign-outs when I came on yesterday and I signed out 7 when I left. I don't expect that will be so easy when I'm an attending, but for now when I work 5-6 days a week, it'll work.

 

[DrQuinn]

Originally posted by Desperado
Amen. What he said.

Or is it a "she?"

At our program, we don't sign out.

We do'nt have enough interns/residents! I suspect it will be like the average EM residency when we get a full complement. Sign out within 10-15 minutes of shift change, then go home.

Q, DO

 

[Coleman]

Scrubbs is right, she always is (hint hint).
I was never aware of the difference in sign-out time until I did an away rotation. I was amazed at the variation. Like she said, some places are very dedicated to getting you out after your shift. However, I have seen places with 1-2 hour sign-outs post-shift, often times because the resident was responsible for "wrapping" up issues with their patients. That can be tough when you have a few complicated patients whose issues are not readily resolved.

This is definitely a quality of life question that is worth looking into at each program. Email the residents at places you are looking at, a 12 hour shift that quickly becomes 14 hours is a whole new animal!

 

[sweetfynesse]

My program is very good about getting residents out on tme. We have ~5-10 minute sign out at shift's end for residents and attendings. No one is upset about signouts, unless you're signing out a rectal exam (ie something that can easily be done). The thing is there should be a plan with the signout, ie if CT neg, then send home or if patient continues with vomiting after po challenge admit for xyz. etc...

At my program they stress the idea that EPs are here to work their shift and immeditately go home afterwards. Thats part of the joy of ER. If you're staying 30min-1 hour after your shift its because you just want to (or a trauma/medical code arrived 10mins before you were to get off, and even then you're not going to be there for tolong)...most people are telling you to go home.

 

[The White Coat Investor]

I can take a hint. Sorry scrubs. It would be a lot easier if everyone had an accurate picture like Quinn's....or not.

To the applicants...make sure you know the sign-out culture of the program's you're ranking highly. I usually leave between 30 minutes before the end of my shift to 45 minutes after the end...again trying to "wrap things up" (not always easy) as best I can.

 

[DocWagner]

our unofficial policy is that acutely ill patients are NOT to be signed out. People with dispositions based upon a pending radiologic diagnostic test are NOT to be checked out. Pending transfers are NOT to be checked out.

 

[Sessamoid]

Originally posted by DocWagner
our unofficial policy is that acutely ill patients are NOT to be signed out. People with dispositions based upon a pending radiologic diagnostic test are NOT to be checked out. Pending transfers are NOT to be checked out.

This policy isn't practical in many institutions, with the often long waits for CT to open up. Are you going to wait around the 1-2 hours it takes for the CT to become available (or fixed) and the study to be read? I don't think that's reasonable, and I've never had any problem taking those sign-outs.

Same with transfers. Those can take a stupidly long time.

At my residency, it was customary for the attendings to take sign-outs that had no further educational value, or those with complex psychological or social issues that it would be unfair to dump on the resident coming on. We got out on time almost without exception.

 

[Scrubbs]

Ohhhh... are you boys all fighting over my identity? No hidden parts here...

 

[sweetfynesse]

Originally posted by DocWagner
our unofficial policy is that acutely ill patients are NOT to be signed out. People with dispositions based upon a pending radiologic diagnostic test are NOT to be checked out. Pending transfers are NOT to be checked out.

No offense, but that one of the most ridiculous things I've ever heard. You have to wait, and do absolutely nothing, on a read from radiology..and acutely ill patients can be in the ED forever, at exactly which point do you leave...when they've gone to the OR or the ICU? That doesnt make sense. Is this for strictly educational purposes or are the residents/attendings coming on too lazy to take care of the pts in the ED?

 

[ERMudPhud]

At my residency program we tended not to sign out patients until they were nearly tucked in. There were exceptions to this if they were getting a CT a few hours from now than we would go ahead and sign it out. We didn't sign out procedures like lacs, LP's, SA exams etc... If a patient only has a little left to do before they leave it hardly seems fair to turn that over to someone else. Likewise, a complex patient whose final disposition is going to depend on one final test is not going to be a lot of fun to call to the admitting team if you barely know the patient. We did make sure to stagger our shifts so that people could concentrate on wrapping up their patients in the last 0.5-1 hour of their shift. Its nice not having to pick up and dispo a whole load of patients you don't know at the beginning of your shift.

For my current job I went to a place that does it the same way. It works for me.

The biggest problem I had with signouts was the difficult dispositions where you knew the person signing out the patient either couldn't or wouldn't make up their mind what to do so they were basically turfing the decision to you.

Both systems work, choose what your comfortable with

 

[The White Coat Investor]

Originally posted by DocWagner
our unofficial policy is that acutely ill patients are NOT to be signed out. People with dispositions based upon a pending radiologic diagnostic test are NOT to be checked out. Pending transfers are NOT to be checked out.

Thus we see why I didn't rank Ethan's program. There's nothing more boring than sitting around for two hours at the end of your shift waiting for a patient to drink po contrast, percolate, get a CT, and then get it read before dispositioning the patient. As an attending I plan to do ERMudPhud's philosophy....but "tucked" means different things to different people. The only sign-outs we consider inappropriate are rectals, pelvics, calls to the admitting service (unless you're waiting for a CT or something,) calls to an outside attending, and procedures such as LPs. Our labs can take as long as getting a CT sometimes, so we don't feel obligated to wait for those. My colleagues know how to interpret labs, and don't mind going in to feel a patient's belly before sending them home.

 

[DocWagner]

whooooooaaaaa hold on there trigger!!!

First, if you didn't rank my program, sucks for you.

Second, my original discussion was if we are awaiting RESULTS of diagnostics (awaiting that abd CT to be read)...if the patient is sick enough, they ain't getting PO contrast anyway...so the question is moot. (I love that word).

In my residency we work at ALL of the city hospitals, so we see the problems with transfers when the orginal "work up" Doc has headed home, leaving someone else to do the transfer...crap they don't know a thing...leaving the receiving doc (many times us if we are in the ICU) out to dry. BAD MEDICINE, BAD JUJU's!!

You gotta transfer the patient, then you make the call and tuck the patient in. You gotta CT pending, wait for the official read, then leave. You gotta unstable patient...then for the patients sake...hang out till they go upstairs or the team arrives!!

That was what I meant, for those of you who were confused with my previous statement.

 

[jawurheemd]

It seems to me like Desperado understood. I have no problem signing out pending CTs/labs etc. Sure I would like to have all my patients tucked, but if I pick up a patient fifteen minutes before I sign out, I'm not going to hang out until all of the diagnostics are back. I also have no problem getting CTs/labs signed out to me. Usually when I get signed out a patient with stuff that's pending, I make sure that I talk/lay hands on the patient -- that way I know what's really going on -- I'm also glad that my colleague picked up the patient 15 minutes before I came in because that's one less chart I have to do completely and I have stuff cooking on the patient.

Just my thoughts.

 

[sweetfynesse]

Originally posted by DocWagner
whooooooaaaaa hold on there trigger!!!

...
...
...
You gotta transfer the patient, then you make the call and tuck the patient in. You gotta CT pending, wait for the official read, then leave. You gotta unstable patient...then for the patients sake...hang out till they go upstairs or the team arrives!!

That was what I meant, for those of you who were confused with my previous statement.

I understood you the first time, and I still think that sucks.

 

[SHOX]

At CCHS we have a 1 hour overlap on most shifts. It's a win, win, win situation. Win 1: resident leaving can stop picking up patients when new resident comes in and dispo their patients (they can sign out after an hour what is left... usually very little). Win 2: resident coming in can start clean/fresh and not have to worry about a bunch of pending tests. Win 3: patients benefit from more continuuity of care and the patient flow is better.

 

[jazz]

most places the policy at docwagner's place wouldn't work.

i'd say at most places unacceptable sign outs are pelvics and rectals and calls to admitting docs if the admission is a given (ie labs won't change anything).

waiting for ct dispo's is impractical at most places as a radiology read can take up to an hour or more. one night radiology reads were so backed up that i was signed out an lp since the head ct results were still pending. well, it was four more hours before the results were back -- wouldn't want to wait for that. and i was glad to do the lp since i know that if it were the reverse, i would want that lp done for me.

and in a lot of city hospitals, patients board in the er for long periods of time (including sick, icu ventilated patients). to me, i can't even comprehend how you could/would wait for transfers.

 

[Freeeedom!]

I totally agree with DocWagner on this one.

Jazz...so you are telling me, you get an ACUTE CT of the head and they are waiting 4 hours for the read...yeah, enjoy sitting in court explaining that one!!
I think his point was that if YOUR wet read was negative...then head out...regardless, waiting 4 hours for ANY ACUTE PATHOLOGY is unacceptable and is NOT the standard. So, a PE protocol chest reading takes how long at your facility??? Sure hope your D-dimer is negative.

Once again, if you look at what he wrote regarding transfers...you CALL FOR THE TRANSFER YOURSELF, give the status to the recieving doctor, then head out...why in the hell would you give the transferred patient to someone that has not even seen them...yeah, enjoy explaining that one to the lawyer "well, mr. lawyer guy, I had to go home and play putt putt, I gave the dispo of the acute head bleed to the change of shift doctor...derrrrr"
Nope.
If you are transferring an acutely ill patient (MI, trauma, child with fever, head bleed) and you are at a facility that cannot handle those patients for any reason...YOU had better call, and YOU had better arrange the transfer with the recieving doctor...otherwise YOU could be in serious trouble.

 

[DocWagner]

Now think about it...why in the WORLD would I pick up a chart on a patient ACUTELY ILL right before the end of a shift and then order CT diagnostics that may take hours??
The point was, "hey , I have an ACUTELY ILL patient...they are really sick, why would I #1 sign this potential train wreck out to a fellow resident #2 perhaps it is a good karma to hang out and take care of the patient for just a few minutes...do unto others"
If I have a patient that is getting a chest CT PE protocol, I would only spend someone elses money (the patient) if my suspicion is high, and if the patient is acutely ill, I think it is poor medicine to simply toss them to the next R2 on shift.
If the attending is not getting killed, and wouldn't mind the sign out then I will. But staying over (10 hour shift) once a week is not an uncommon thing.
I guess I really don't understand the misconception here. I suppose if we did 12 hour shifts, well then, staying over and hour would be pretty terrible (agreed)...but then again, I don't ever plan on doing 12 hour shifts.

Keep on rockin...

 

[jazz]

few things...

yes,i always talk to the admitting team about critically ill patients and get them admitted before i leave. i wait for the admitting team to come to the er to tell them about the patient and i make sure all studies, lab work, medications, etc are ordered before i leave. i don't wait for them to go upstairs as that could take hours.

for head cts, unfortuantely many are ordered and a small portion are acute. obviously, stroke protocol mandates faster reads. but change in mental status/febrile head cts do take longer to read.... if my clinical suspicion for meningitis is high -- then antibiotics are started prior to the head ct/lp anyhow.

again, if clinical suspicion for pe is high, heparin can be started prior to the read.

as for picking up acutely ill patients at the end of your shift -- if there is another resident there then s/he will take the patients but at some places there is only one resident on the overnight and you know what... can't stop what rolls through the door at 730am.... and yes, i do stay over my shift to tuck the patient and make sure the patient is admitted and handed over to the icu team...

 

[Sessamoid]

Originally posted by DocWagner
Now think about it...why in the WORLD would I pick up a chart on a patient ACUTELY ILL right before the end of a shift and then order CT diagnostics that may take hours??

Maybe not now, but you may not always be working in an academic center with double/triple coverage. An acutely sick patient needs care immediately, and if you're in a single coverage situation, then you pick up the chart immediately, no matter when the patient happened to present. To do otherwise is doing a disservice to the patient. Remember that the world of academics is not all there is to the practice of emergency medicine. Lots of places (including academic centers) have 12 hour shifts, and staying over more than 15 minutes gets really painful.

 

[DrQuinn]

No joke. We have 12 hour shifts at our program, and since there are only six of us, I usually don't have to sign out to anybody... I just tell either the attending I'm with (who usually doesn't leave when I do) or the attending coming on.

But man I've stayed maybe a half hour to an hour after a shift is over just to continue running a code or what not, and I'm tuckered... 13 hour ER shift! Not saying it was torture but I can't do that more than a few times a week.

Q, DO

 

[DocWagner]

There...now there is understanding.
Sorry for the defensive posture, but we have the nice 10 hour shifts (gotta luv em), and staying over to finish dispositions is common practice, I think it is good practice in this particular environment. Furthermore, as we run every ED in the city (save Grandview the DO institution), we see screwed up transfers when the original Doc is no longer there for the transfer and WE are the recieving Docs. It potentially is dangerous, wastes time, and makes all ED docs look bad.
While hanging out for many dispos may not be ideal for 12 hour shifts ...then again, 12 hour shifts really aren't good for anyone(and the AAEM would agree wholeheartedly with this). Double resident coverage during the last hour of shifts is our policy and allows for wrapping up dispos quite nicely.
Later guys.

 

[endo]

Just got off my 4th 12-13hr shift in a row... I don't have any problem taking signouts that are in the air / not mostly wrapped up. When I arrive I'm fresh, eager to get started and I'm going to be working for 12-13 hours, so why not take the sign-outs? You really are wiped out mentally and physically after 12 hours in the ED, especially if its your 4th-5th in a row. Plus, people make such a big deal about pelvics / rectals. Who cares, they're easy to do and don't bother me a bit. I suppose it's not exactly PC to check'em out but man you do so many of each it's just routine.

Bring it on. Yo.

-Sven, Cinci EM-1

 

[jawurheemd]

Yeah -- why would you pick up a patient with only 10 minutes in a shift if the patient has acute respiratory distress and needs to be intubated -- they can wait a few more minutes until you sign out. Why pick up acute onset of shortness of breath who just got off a plane and has one swollen leg 10 minutes before you sign out -- they can wait a few more minutes to get anticoagulated.

 

[Primate]

Why are pelvics and rectals tiptoed around. They're just another part of the exam. OK, maybe not to the patient, but shouldn't they be to medical professionals? To suggest otherwise opens a big ole bag o' worms.

Besides, as said, they're easy.

 

[mikecwru]

We pick up pt's close to shifts end, because we don't have overlapping shifts and sometimes you have to (front room/critical pts). If we're still waiting for a bed assignment and a team to call to, we're stuck having to sign out the report calling to the oncoming EM resident. If I get a bed before I leave, but have pending imaging/tests, what I do is call the admitting doc and give report and say "I have incomplete data, we're still working this up, but I wanted you to hear the story from me. The oncoming resident will call you back with the rest of the info when it's available." I do this as a courtesy to the oncoming resident, because it's easier to just call with a result then admit a pt you haven't touched yet/reinvent the wheel. The admitting residents are usually cool with this, although there are some of them that cannot grasp the concept that the pt is sick enough for the ICU but I don't have the CBC back yet. They'll get it eventually.

mike

 

[The White Coat Investor]

The concept behind the rectal/pelvic policy is not that they're "icky" or "difficult" or even "time-consuming." Its simply a matter of patient-doctor relationships. I find it embarrassing to walk into a room and tell a woman, "I've heard all about what's going on with you, now we just need to do the pelvic exam." I think a little H&Ping before doing a pelvic makes for better PR. Just my 0.02.

 

[roja]

I think that common sense and professional courtesy should really dictate sign out.

At our program, in general, sign out takes about ten minutes. We attempt to make it so that sign outs are painless. around 45 minutes prior to shift change, you start making sure you can wrap up your patient. And at minimum have a dispo plan.

Certain things are not signed out... rectals, for example. A pt that needs an LP that has a clear CT.

In general, we leave within fifteen minutes. However, there have been one or two times where I have had to stay an hour or two. Sign outs to big and lots of patients for hte new team to see. It happens.

And yup, I have said, sorry, tihs is a crappy sign out, but I have also been on the other end of it. it all kind of comes even in the end.

Its ridiculous to assume that someone in respiratory distress is not going to be seen becasue its fifteen till shift change. However, I might not see the 3 year old with a runny nose for 3 days.

 

[jashanley]

Originally posted by jawurheemd
Yeah -- why would you pick up a patient with only 10 minutes in a shift if the patient has acute respiratory distress and needs to be intubated -- they can wait a few more minutes until you sign out. Why pick up acute onset of shortness of breath who just got off a plane and has one swollen leg 10 minutes before you sign out -- they can wait a few more minutes to get anticoagulated.

Do I sense sarcasm? Is that allowed?

Anything for a tube!
I would stay an extra hour or two for a good procedure or an unstable patient. But that is just me.

 

[sweetfynesse]

Originally posted by jashanley
Do I sense sarcasm? Is that allowed?

Anything for a tube!
I would stay an extra hour or two for a good procedure or an unstable patient. But that is just me.

a good procedure would have to be somewhere on the order of a thoracotomy...but a chest tube or an endotracheal tube--no way...

otherwise, if it were my 5th or 6th 12 hour shift in a row, I'd leave in a heartbeat once the new team came on and took signout. esp, if i had to be back the next day...

 

[jawurheemd]

I just wanted to illustrate that sometimes it's impractical to get everyone "tucked" before signing out as we need to deal with emergent problems emergently. I'm not going to stick around after I tube a comatose patient to see what the final punchline is -- especially since I'll probably get him signed out back to me as a patient when I come on for my next shift 12 hours later as lately we have no beds in the hospital. I just signed out a patient out to the original resident who saw her 2 shifts before mine (and even though neurosurgery knew about the patient, the patient still wasn't tucked -- still needed an MRI/MRA after her CT scan, LP, CT angio).