Terrible Sign Outs

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Dakota said:
How do you guys handle these? Have you ever refused to take sign out? Do you argue with your colleague over management? Do you nod politely then when your coworker is gone do whatever you want? After saving the day do you talk things over with your coworker? Bring it up with your peer review? Pat yourself on the back and soldier on?
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I just smile and nod, then re-do everything once they've left.
I figure that as much bad decision making as they are turning over to me, they're making the same amount of bad decision making all throughout their shift and it'll come back around on them regardless. The hospitalists are probably complaining a lot as well.

Dakota said:
A further frustration is that we are RVU based and production goes to the person who started the patient rather than the one who finishes the patient. I would be a lot less upset about taking on a high risk, thus far mismanaged patient if I was at least getting paid to do so. I am trying to get this changed. Want to collect the RVUs? Stick around until they are admitted or discharged.
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Yea; at my last RVU-based shop, the credit went to the last person's name on the chart. It kept people from signing up for a bunch of people in the last 15 min of their shift then signing out a half-assed workup.
 
I usually nod politely and then start completely over with the patient. I'm responsible for that patients care and outcome and I want them to be treated as well as the rest of my patients. Most of the time, people have done more than I would have rather than less. But, either way - sign out is rare enough at my shop that it's worth it to me to just start completely over.

At my shop RVU goes to person discharging so that helps soften the extra work and also limits our signouts. I bet I get 1 signout every 2-3 shifts.
 
Dakota said:
We have all had them. Terrible sign outs. I am fortunate in that most of our shifts have overlap which reduces the number of patients signed out but I have still had a rash of stupendous bad sign outs recently.

How do you guys handle these? Have you ever refused to take sign out? Do you argue with your colleague over management? Do you nod politely then when your coworker is gone do whatever you want?

After saving the day do you talk things over with your coworker? Bring it up with your peer review? Pat yourself on the back and soldier on?

I used to try arguing during sign out, now I find myself doing far more nodding politely then starting over with a patient.

Most of the other attendings I work with are sharp/trustworthy doctors and sign out is no issue. There is one in particular, however, who is often problematic. I have tried arguing about management during sign out (this is met with a blank stare). I have tried discussing cases with him after the fact (that URI you wanted me to discharge after one last neb yesterday, yeah, she was septic from multilobar pnuemonia). This gets met with an "Oh really?" or meek "Thanks." Thus far i have not sent a case to peer review, but I have been sorely tempted. What is your threshold for referring a case to peer review? I hate this somewhat nuclear option for fear of making an enemy/getting even worse sign outs/causing unnecessary discord/making my own life worse.

A further frustration is that we are RVU based and production goes to the person who started the patient rather than the one who finishes the patient. I would be a lot less upset about taking on a high risk, thus far mismanaged patient if I was at least getting paid to do so. I am trying to get this changed. Want to collect the RVUs? Stick around until they are admitted or discharged.

I know the answer to most of these questions is, "depends on the circumstances." Just needed to vent about my least favorite part of the job.
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I have never heard of a shop that gave RVUs to the person who signs up instead the one who dispos. Sign out is a known high risk practice so most groups try to limit sign out as much as possible. Your group effectively has a policy that financially encourages people to pick up patients, do a half-### work up, and sign it out to the next person. I cannot think of a single reason to do it this way as it incentivizes bad behavior. Your group needs to sit down and discuss changing that. I would probably take a look at all of your groups business practices and see if there are other similar areas with room for improvement. Get rid of your policy and you will either get rid of the problem or at least feel better about those sign outs since you get credit for them.
 
I say as little as possible, ask as few questions as possible, and just start over doing what seems right to me. Repeat the H & P as needed. Fortunately there is almost no one in my group that I don't trust.

I'd speak to your department chief or medical director informally and see if there is a pattern with this person.
 
I take sign outs, because I want my colleagues to take them from me should I need to.

In general before agreeing I review all labs/testing with the other provider and make sure that the patient really needs to be signed out. Often I can convince them to just admit the patient based on the workup that's already done.

The worst sign out ever was a new grad who tried to sign out a young girl with dehydration. Her vitals had normalized after fluids, but because the urine showed "ketones", she wanted to sign out based on getting a repeat UA in an hour to demonstrate the ketones were gone. She did not have DKA or any other concerning lab abnormality and felt better. I discharged the patient as soon as the other provider left WITHOUT the repeat UA.
 
Dakota said:
A further frustration is that we are RVU based and production goes to the person who started the patient rather than the one who finishes the patient.
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This policy encourages, not discourages sign outs. RVUs to the last name on the chart is the standard in this industry, that is quite an odd policy.
 
Agree with odd policy, dispo is usually significantly harder than initial eval unless packaged in neat bow. It does incentivize not leaving patients sitting for the next doc, FWIW.

In terms of taking sign out, one of my shops has very minimal sign out, the other has 1-3 per shift (12 hr). I'm not usually a fan of the "just admit the patient" school of taking sign out because I've usually factored in how long (not necessarily how difficult) it's going to take to get a patient to get admitted when deciding to sign out. Sure I can admit once the UA comes back, but patient hasn't peed yet and they have a private doc that takes 80 min to call back. That's not a big deal if I'm wrapping up 3 or 4 other patients but kinda sucks if I'm in the middle of 4 overnights and they're my only active patient.
 
I take and give one or two signouts most shifts. I prefer it that way. I would much rather get sign-outs, even crappy ones, than not be able to leave them. Our pph are relatively low, so almost always the incoming doc can handle the extra workload.

I think the key is to have a collegial discussion (not argument) at sign-out about appropriate management you both agree on. I look at all results that are back prior to them leaving (as we're talking usually) and we come up with a plan of what to do depending on what remaining results and consultations show. I don't take or give pelvics, rectals, or procedures (although I've done a rare LP, but never recall leaving one.)

In your situation, you've got one of two choices. # 1- Start over with each of those patients. Not a bad idea anyway, but especially if you don't trust the doc. # 2 Attempt the collegial discussion approach discussed above.

I think sending him to peer review is a bad idea. I think arguing with him is a bad idea. If after the collegial discussion, the two of you can't agree on management and when there is doubt, we generally defer to the guy coming on as his mind is fresher and he'll have more risk, then he doesn't get to sign the patient out. He sits there until the patient leaves the department.

As far as stuff that turns out to be bad later, I would very much appreciate hearing about that crappy sign-out I gave, again in a collegial manner, as a learning experience. The last one of those ended up sucking up tons of time doing a complicated psych dispo. I bought the doc chocolate for the extra effort she put in. But seriously, if I hadn't signed it out I would have been there for 5 hours after my shift. Sorry. That's gotta be signed out, no matter how crappy it turns out in the end.
 
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We do a fair amount of signing out, only because with our size and volume and staffing patterns if you didn't sign out patients you would stay even LONGER after your shift is "over".

That said we're a small group, so the golden rule applies. If the oncoming guy is getting slaughtered, you stay later and minimize signout. Signouts are preferably tied up with a bow. Signouts preferably are missing a single thing with a clear, either/or decision left for the doc-- i.e. "Waiting for the formal CT read, low suspicion of Appy, d/c home if negative".

Common things requiring signout--> results of CT or US, as these can take a long time. Less commonly, results of blood work (repeat troponin being common, or say a first trimester bleed waiting for a blood type to return).

I'd say on an average shift I'll sign out 4 or 5 patients-- typically 1 or 2 are psych-holds /observations, 1 or 2 are already admitted waiting to go upstairs, and 1-2 have a hopefully easy disposition !written down! for the oncoming doc to complete.

Our charting/overview system has very user friendly way of writing a little post-it note type of message on the patients, which isn't part of the medical record. We use it to keep our sign outs clean.

It is good manners to write discharge instructions up for those signouts you know are very likely to go home, thus minimizing work for the next doc.

One exception to this rule is the overnight doc signing out to the AM doc. The overnight doc can immediately sign out everything and go to sleep if they want. They are drained, and standard practice is to do anything you can to let them leave 🙂

Interestingly, we are eat-what-you-kill and the person writing the primary chart (first to touch the patient) gets credit. The final dispo'ing doc just writes a few line addendum. This works well as long as no one abuses it, and in a small friendly group... no one abuses it! We all give each other sign out, so it all evens out in the end. In the rare occurrence of a simple patient crashing and turning into an hour of critical care, the second doc CAN write a brand new chart and claim credit-- something we do rarely but when needed.

If a doc had a serious pattern of poor signout, we would have to sit and talk-- it impacts patient care, and peer job satisfaction, which are basically the two most important things we have.
 
When you mean signout do you guys mean active patients or just patients in general? Our ED always has dozens of patients boarding that require signout.

Plus there always seem to be imaging pending. How fast are you getting CT reads back from the time you order them? Sometimes it literally can take nearly half my shift if the department is busy.
 
link2swim06 said:
When you mean signout do you guys mean active patients or just patients in general? Our ED always has dozens of patients boarding that require signout.

Plus there always seem to be imaging pending. How fast are you getting CT reads back from the time you order them? Sometimes it literally can take nearly half my shift if the department is busy.
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Be sure not to choose a final job that can't figure out how to solve the boarding problem. For now, that just impacts your education. Later, it also impacts your income and liability.
 
The nice thing about shops with overlapping shifts is that it's generally accepted that during your last hour you don't pick up any "complex" patients. Usually that hour is enough for me to dispo all of my remaining patients. Often my only sign outs are waiting for the admitting physician to call back to give order, as they sometimes take 3 hours to call back (Texas culture for sure!). I do like to leave on time, and I don't think it's reasonable for anyone to stay longer than 15-20 minutes after their shift. I often volunteer to take sign outs if I see my exhausted colleagues waiting for something that's taking a long time.

I don't pick up an abdominal pain/chest pain/SOB/neuro patient in my last hour unless the department is swamped, and there is a prolonged wait time. I sign these occasional patients out as soon as the next doc comes on.
 
One of my attendings from residency told me about a signout he got.
Pt waiting for psych eval.
When he went to check on the pt, they were dead.
Called back the other doc and told him he had to come back in and deal with it.
I think this was in the days of paper charting, so I don't think there was a record of the second doc being involved.
 
Our system also gives the credit to who whoever saw the original patient. However, most of us stay after our shift to clean things up. I was taught in residency that it's inappropriate to sign out a patient unless there's a crystal clear plan: home if CT negative, transfer to rehab at 4 PM, admit after CT is read, etc. "Go evaluate the patient again and see if they need imaging or admission or not" is not an appropriate signout.
 
Xerxes1729 said:
Our system also gives the credit to who whoever saw the original patient. However, most of us stay after our shift to clean things up. I was taught in residency that it's inappropriate to sign out a patient unless there's a crystal clear plan: home if CT negative, transfer to rehab at 4 PM, admit after CT is read, etc. "Go evaluate the patient again and see if they need imaging or admission or not" is not an appropriate signout.
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I'm wondering if those of you who trained under these rules trained back in the day? 3 separate rotations in med school and now a 4th place for residency and I have yet to see a program with a policy like this. It wouldn't have been feasible at any of these places either, for reasons obvious to anyone working in a busy inner-city shop. Good sign-outs are one thing, but staying until the dispo is 'crystal clear' on all patients is basically a non-starter on most shifts.
 
As an EM doc, your sign out should be exactly what is the patient dispo; that is what differentiates the EM trained from not. "If the troponin is positive, to the CCU, if negative, step down." It is that clear. This does NOT mean "until the diagnosis is clear".
 
They say all politics are local. In places with policies like these if there is enough institutional memory you can usually trace it back to a person or two. "Ol' Bob refused to take any patients in the last 3 hours of his shift because there was a chance he might not get credit for them." So to keep things moving they agreed decades ago that the person who first saw a patient got all the credit.

In most places things adapt to better practices. But there are a few that can be reactionary over the smallest issues. They say in academia "the battles are particularly fierce precisely because the stakes are so small." That idea is not completely unknown in EM.
 
Door to doc is a federally monitored core measure. The downside of never signing a patient out without a clear dispo is that anyone that's even vaguely perceived as a difficult dispo is going to be left for the incoming doc if they're anywhere near the average cycle time away from end of shift. In places with efficient labs and radiology this may be a 30 min gap and won't sink flow. If you average 2-3 hrs to turn over a patient you're looking at a pretty ugly situation.
 
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hoot504 said:
I'm wondering if those of you who trained under these rules trained back in the day? 3 separate rotations in med school and now a 4th place for residency and I have yet to see a program with a policy like this. It wouldn't have been feasible at any of these places either, for reasons obvious to anyone working in a busy inner-city shop. Good sign-outs are one thing, but staying until the dispo is 'crystal clear' on all patients is basically a non-starter on most shifts.
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Residency and community medicine are worlds apart. It's usually not feasible to minimize sign outs in residency as most places don't have overlapping shifts. My sign out is very different now that I started moonlighting. My first moonlighting shift, I tried to give a garbage sign out (I forget exactly what it was) like I would at my residency program. The person to whom I was signing out flat out said "nope." I was kind of taken aback, but since then I've drastically changed how I sign out in residency and in moonlighting.

I used to think it was the right thing to do to see every single patient that showed up, even if the oncoming resident was walking in the door. I used to think that it made me seem more hard working and like a stronger resident. This would lead to many patients being signed out with nebulous dispos and a lot to do; plus it would keep me late. Now, I will let 1-3 patients wait if they aren't critically ill for the new resident. When I turn over my pod to them, they will have to deal with a few new patients, but they will have either nothing to do on any of my patients, or they will have clear direction - CT negative they go home; CT positive, call surgery; Second trop negative, they go home, discharge paperwork is on the chart; I've already called this consult but they are just waiting on final recs, etc

You will notice a change in how you view patients as you advance through residency and start to moonlight. You start understanding which tests are actually required for dispo. When I was an intern and, to a lesser extent, PGY-2 I would want everything back before I would call a consult or admission. I'd have a hypoxic septic shock patient with a lactate of 6, pneumonia on CXR and AKI but I'd wait for the urine to call the MICU. That's crazy and only works in academics. If you know the patient is going to the MICU, make the call - it will free up a bed and help clear the waiting room. If you have a blood sugar of 600 and pH of 6.9, make the call.

This is kind of hard to understand as a junior resident. I get some funny looks from interns, but when they try to sign out "EKG changes, positive troponin, waiting on CBC and BMP to call cards" I will tell them to make the call. I think this may be off-putting to some of them, but I think it's important.
 
Arcan57 said:
Door to doc is a federally monitored core measure. The downside of never signing a patient out without a clear dispo is that anyone that's even vaguely perceived as a difficult dispo is going to be left for the incoming doc if they're anywhere near the average cycle time away from end of shift. In places with efficient labs and radiology this may be a 30 min gap and won't sink flow. If you average 2-3 hrs to turn over a patient you're looking at a pretty ugly situation.
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This is a true and crappy reality.
So luckily the last couple of place I've been everyone is on board and if you are too busy to take them and won't realistically get to a binary point, then say "hi" to the pt make sure stable to wait and put some orders in, as many or little as you think, and just let the incoming doc know you RME'd room x for ya🙂
 
TrumpetDoc said:
This is a true and crappy reality.
So luckily the last couple of place I've been everyone is on board and if you are too busy to take them and won't realistically get to a binary point, then say "hi" to the pt make sure stable to wait and put some orders in, as many or little as you think, and just let the incoming doc know you RME'd room x for ya🙂
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Exactly. At HCA I sign up for the patient order labs/studies if the workup is obvious, then tell the next doc. I don't even start a chart on them.

Not sure how the "10 minute door to doc" became a standard at HCA, but it basically means if you eat, go to the bathroom, or take a minute to yourself, then you will fail this measure. Often the nurses haven't even triaged them until 20 minutes in, so you fail before they even show up on the tracker. The clock starts the second they walk in the door. We also get dinged if we click on more than one patient in a 5 minute interval. That means if 2-3 patients come in at exactly the same time, you fail! At HCA, all roads lead to fail.
 
GeneralVeers said:
Exactly. At HCA I sign up for the patient order labs/studies if the workup is obvious, then tell the next doc. I don't even start a chart on them.

Not sure how the "10 minute door to doc" became a standard at HCA, but it basically means if you eat, go to the bathroom, or take a minute to yourself, then you will fail this measure. Often the nurses haven't even triaged them until 20 minutes in, so you fail before they even show up on the tracker. The clock starts the second they walk in the door. We also get dinged if we click on more than one patient in a 5 minute interval. That means if 2-3 patients come in at exactly the same time, you fail! At HCA, all roads lead to fail.
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Yep. This all day long at my 'old' HCA job. It was the primary reason why I quit.
 
GeneralVeers said:
Exactly. At HCA I sign up for the patient order labs/studies if the workup is obvious, then tell the next doc. I don't even start a chart on them.

Not sure how the "10 minute door to doc" became a standard at HCA, but it basically means if you eat, go to the bathroom, or take a minute to yourself, then you will fail this measure. Often the nurses haven't even triaged them until 20 minutes in, so you fail before they even show up on the tracker. The clock starts the second they walk in the door. We also get dinged if we click on more than one patient in a 5 minute interval. That means if 2-3 patients come in at exactly the same time, you fail! At HCA, all roads lead to fail.
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Why is this even a measure?
 
Psai said:
Why is this even a measure?
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Simple. Corporate greed.

When I started my HCA job 3 years ago, the door-to-doc metric was 20 minutes.
Then it dropped to 15 after about a year or so.
Then it dropped to 10.

... and Veers is also correct in saying that if you sign-in on more than one patient in (2 minutes, at my shop), you get dinged.

... and a sizable amount of your paycheck (up to 25%) is dependent on these metrics.
 
GeneralVeers said:
At my site it's $10/hour incentive for 10 minute door-to-doc average, and $10/min an hour for no "duplicate MSEs"
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It used to be: 10/hour for 20 minute door-to-doc, and 10/hour for "no duplicate MSEs"

Now, they're changing it to:

10/hour for a 10-min door to doc.
10/hour for no duplicate MSEs
10/hour for door-to-discharge less than 2 hours (want to observe a allergic rxn that you gave epi to for the recommended 3-4h? - FAIL!)
and 30/hour for press-ganey over (whatever).

That's sixty bucks. And yes, they lowered the base rate just enough from what it was.
 
RustedFox said:
10/hour for door-to-discharge less than 2 hours (want to observe a allergic rxn that you gave epi to for the recommended 3-4h? - FAIL!)
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Nobody actually recommends that anymore. You can discharge as soon as they're better. Rebound happens sometime between 10 min and 168 hours.
 
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Dr.McNinja said:
Nobody actually recommends that anymore. You can discharge as soon as they're better. Rebound happens sometime between 10 min and 168 hours.
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Oh did NOT know that. That's great to know. Thanks!
 
There will always, always, always be terrible sign outs. Just when you think you've fixed the "vexing terrible sign out problem" you know what happens?

You get a God ---king awful signs so unfrockingbelievably bad, you just can't even believe that a stubbed toe turned into a meds dysmorphic, autistic sedation with an eyelid lid lac, with a spreading petechial rash below the nipple line.

Sorry. It's EM, not radiology. Live the dream. 🙂
 
southerndoc said:
What is the deal with duplicate MSE's?
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Bump 🙂

The rest make sense in that they're all core measures now that are publically reportable. I Google'd and got nothing on duplicate MSEs.
 
I don't work at an HCA hospital, maybe the others will chime in. I did work a place that used this as a test for whether "signing up for a patient" meant you really went to go see them. The logic was that you couldn't be in 2 rooms at once. It did get a little annoying because if there was 5 people waiting to be seen, I couldn't just sign up for the next 3 and see them. I had to go see them and chart one at a time and then sign up for the next one. It felt like they were saying: "go really fast and cheat the system but don't go too fast or make it clear you're cheating the system."

Most of the time, I'm happy to see patients one at a time if they're complicated or need orders written/revised. But it's nice to be able to swing by an ankle sprain, cellulitis, chest pain with the labs back already, etc on your way back from something more serious and then write both notes at once.
 
two guys said:
I don't work at an HCA hospital, maybe the others will chime in. I did work a place that used this as a test for whether "signing up for a patient" meant you really went to go see them. The logic was that you couldn't be in 2 rooms at once. It did get a little annoying because if there was 5 people waiting to be seen, I couldn't just sign up for the next 3 and see them. I had to go see them and chart one at a time and then sign up for the next one. It felt like they were saying: "go really fast and cheat the system but don't go too fast or make it clear you're cheating the system."

Most of the time, I'm happy to see patients one at a time if they're complicated or need orders written/revised. But it's nice to be able to swing by an ankle sprain, cellulitis, chest pain with the labs back already, etc on your way back from something more serious and then write both notes at once.
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This. HCA wants it both ways. They give a wink wink, nudge nudge to cheat the system, but we can't cheat it TOO much. Hence if you sign up for two patients within 5 minutes it's considered a duplicate MSE and you get dinged for it.
 
This thread has made me realize the terribleness of many sign outs I receive (and give). I try to make them all very clear if x then y, if not x then z, discharge papers are written in case not x and going home. I've also realized our mid-levels give much worse sign outs than fellow residents and often haven't bothered to tell the patient the plan.
 
GeneralVeers said:
This. HCA wants it both ways. They give a wink wink, nudge nudge to cheat the system, but we can't cheat it TOO much. Hence if you sign up for two patients within 5 minutes it's considered a duplicate MSE and you get dinged for it.
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Does one work for hca directly or are these hca metrics via cmgs?
 
How do you guys deal with the terrible multi-doc signout?

The patient undergoing some long ED workup that was signed out to another doc and is now being signed out to you.
Had a case recently where the plan just didn't make any sense to me.
The doc who initially saw the patient was long gone and now another doc was signing this mess out to me.
I didn't want to give the doc signing the patient out to me a hard time, but I would have likely made the original doc dispo the guy.

I basically just started over from scratch.
The problem was this patient had now been in the ED for 14 hours by the time I saw them, and didn't want to go along with my recs.
 
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gman33 said:
How do you guys deal with the terrible multi-doc signout?

The patient undergoing some long ED workup that was signed out to another doc and is now being signed out to you.
Had a case recently where the plan just didn't make any sense to me.
The doc who initially saw the patient was long gone and now another doc was signing this mess out to me.
I didn't want to give the doc signing the patient out to me a hard time, but I would have likely made the original doc dispo the guy.

I basically just started over from scratch.
The problem was this patient had now been in the ED for 14 hours by the time I saw them, and didn't want to go along with my recs.
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That's the way to deal with any sign out that bothers you. It does make your life painful when the set expectations don't match your recs.
 
GeneralVeers said:
The worst sign out ever was a new grad who tried to sign out a young girl with dehydration. Her vitals had normalized after fluids, but because the urine showed "ketones", she wanted to sign out based on getting a repeat UA in an hour to demonstrate the ketones were gone. She did not have DKA or any other concerning lab abnormality and felt better. I discharged the patient as soon as the other provider left WITHOUT the repeat UA.
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Provider? was this an NP or something. Are there any places in EM without "providers" and only physicians?
 
In the words of a trauma surgeon I know, when I was an intern:

"Something funny happened over the last five or ten years or so. I became a 'provider.' I'm pretty sure I didn't go to medical school and through residency to be a 'provider.' This (gesturing to his MD credentials on his badge) doesn't say 'provider.' Patients don't call me 'provider so-and-so.' I'm a surgeon. And a physician. I'm not a f*ckin' provider."

Can't say I disagree with the sentiment.
 
Replaceable Provider FTE

(FTE = Full time equivalent)
 
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