What's the problem with signing out your pts to incoming residents??

Discussion in 'Emergency Medicine' started by 1stresident, Jun 3, 2008.

  1. 1stresident

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    Hi all,
    Im about to start my residency this July in EM ( Actually thinking about switching to surgery after this year is over (Yeah I know it sounds crazy but that's another story) and I was wondering why people get so upset when you sign out your patients. When I rotated as a med student in the fall, I would bust my arse to continuing seeing people as long as there were people to see and not just sit around and sometimes I would have like 2 or 3 people waiting on labs when it was time for board rounds and the new shift. I kind of got ragged on about that, but I mean what the ** you STILL have to see the patient no matter what. The patient's chart will still be in the rack regardless if I haven't seen them yet or not. They don't go away. If me resident "Joe" signs out to resident "sue" what's the big deal? If me Joe decides not to see patient "Jim" because Joe doesn't want to dump on Sue then Jim DOESN't leave, Jim is still waiting on Sue. At least Joe got half the work done for Sue when he signs out. I don't know I just don't get it. Is there something Im missing? I really don't want to be looked down on when I start. One of the residents when I was a student politely mentioned "So the goal next time is no sign outs right?" That REALLy annoyed me.
     
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  3. jaeida8

    jaeida8 Senior Member

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    That's a residency-dependent thing. The culture at the ED you rotated at might be that residents tie everything up and don't tend to sign out workups in-progress. At my residency, signing out several patients with labs, consults and/or studies pending is never an issue. Unless you're at at a residency where you stop picking up new charts an hour before shift change, you're almost always going to have some things pending at signout if you're going to get out within 15-20 minutes after your shift is over.
     
  4. theCamel

    theCamel wessssside

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    i may be way off base but maybe the reasoning in not wanting to receive too many sign outs is that there's minimal learning involved since all of the real 'thinking/managing' has already been done, and you're essentially waiting to d/c or dispo the patient instead of doing real critical thinking.

    that seems like the only difference from a resident's view b/w a new chart on the wall, and somebody with abd pain being signed out to you as "yea i'm not sure what's going on she doesn't look too sick so i sent off lft's/cbc/lytes, you might want to call surg i'm not sure but i'm out dude seeya"

    i don't mind getting sign outs from others so they can leave within 15 minutes of their shift change, b/c i like to leave at the end of my shift too. obv i don't sign out stuff i just don't want to do myself, and if somebody does that to me more than once i'll have no problem calling them on it.

    i personally like to pick up patients right up to that 1 hour window for selfish and non-selfish reasons. as a student/incoming pgy-1 i see the pts as a chance to learn something, and i learn more when i'm doing the work up when i'm the first one talking to the pt. but i also feel bad for the pt getting seen an hour later so when put in that situation i like to be the nice guy too. i imagine my idealism could change, but i'm riding it out as long as i can.
     
  5. TysonCook

    TysonCook Senior Member
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    This will change for you as you become a resident, and then each year after...and it will change for those you check out to as well. Also, check out is the "most dangerous time" for patients as most likely the time that you wil mess up (and be liable), lots of data and studies on this.

    I try not to check out anything that is mid stream work up. I NEVER check out if at all possible the following:

    1. Pelvics (sux for the patient and the new resident)
    2. LP's
    3. Lac Repairs

    By midstream I mean patients in a middle of a w/u. For example I check out the following who are at the beginning or the end of a w/u:

    1. Someone that just came w/in 20 minutes of check out, I'll go in and get the basics, and start some basic labs so when the next resident sees them, labs/radiology is going, and I try to ALWAYS let the patient know that another MD is coming to see them.

    2. Someone that has been fully worked up, labs are back +/-, films done, and the consultant has been called and dispo relatively finished. (e.g. PNA being admitted waiting for orders, CVA stable waiting for a bed etc).

    It is really painful to be on the recieving end of a check out that is midstream, or have consultants that you have to call w/out "knowing" the patient etc.

    These are just my opinions, as many other here have their own "rules" etc
     
  6. Greenbbs

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    Sign out isn't really a problem unless there's a resident (and there's a couple at my joint) who want to sign out someone whose w/u is done, but they haven't called the attending yet to dispo the patient.....that's my ultimate pet peeve when it comes to sign out. Some people don't get that when their shift is over at a certain time (say 3, 7, or 11), that they don't really get to leave at that time, and they're expected to complete their work.

    We've got a guy who as soon as it's like 3:01 PM, wants to sign everything out instead of finishing the dispos, and it's getting old.

    I'll never sign out anything being worked up (like i'm just waiting a CT report or CSF or something), because i know that patient like the back of my hand by then, and can dispo to an attending over the phone in a minute when things get back...if it delays me by a half hour, so be it....

    attendings are expected to stay an hour or so after to tie their stuff up, why shouldn't we be expected to not dump on our fellow residents?
     
  7. pillowhead

    pillowhead Senior Member

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    From the admitting side, if you really suspect a patient is going to need admission, it is very helpful if the first ER admitting resident is the same one that calls the admitting physician. (I do realize this isn't always possible but when you're getting a phone call at 3:10pm from the new resident to admit the patient and the ER shift ended at 3pm, it makes you wonder why the old resident couldn't have waited for that 10 minutes to call). As an IM intern this year, the worse thing to hear is a story that starts out "Well, I didn't work up the patient initially but....." It's basically starting out with an excuse that I'm not going to know the whole story but it's not my fault (but it is your problem as the admitting wards team).

    Now really sick patients that need immediate attention at 2:45pm but obviously aren't going to be finished with work up for a couple of hours...by all means, sign them out. We realize that you are shift workers and need to go home.
     
  8. bulgethetwine

    bulgethetwine Banned
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    Tyson is right on here. The trifecta of things never to sign out (pelvics, LP, lacs) is the culture at where I've trained and worked. Awaiting IV access is another no-no to sign out (pretty much any procedure shouldn't be signed out, and trust me, once you're out billing for yourself, you wouldn't do this anyway).

    In addition, any disposition that can be made pending only a call to an admitting service, consult service, or radiology read was always the etiquette as far as I was concerned.

    However, signing out patients in whom some of the workup remained to be done or finalized (e.g. the LP *result* or the CT abdo that hte patient is choking down the contrast for) was never a problem to sign out.

    In these latter cases, I was always sure to fill out as much of hte paperwork, though, such as follow up plan, prescriptions, tentative diagnosis, etc.
     
  9. Greenbbs

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    the problem with waiting for that "result" is that sometimes, albeit not too often, can drastically change the outcome for that said patient. Nothing sucks worse than getting an unexpected result on a signed out patient and then being "what the eff do I do with this now?", especially when you don't know the patient that well to begin with.
     
  10. GiJoe

    GiJoe Senior Member

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    this is not a rare event and is an inevitable reality of our specialty. you just have to go back to the patient, talk to them and go over their chart and know them better. sure its more work and it sometimes sucks but its worth it. being able to go back to your normal life after a shift from hell is well worth the price of having to deal with an unexpected result.
     
  11. bulgethetwine

    bulgethetwine Banned
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    Agreed. But it's part of the job. When I leave my patients mid-workup, I let them know that a new doctor will take over, at least prepare them for a new face, and let them know that if things turn out to be surprising, the new colleague is capable of on-going management.

    Sorry if it turns out that the CT scan I ordered for the seemingly benign abdo pain turns out to show a hot appy, but do you really have a problem explaining this to the patient in a way that at least gives the appearance of continuity of care?
     
  12. met19

    met19 Member

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    i disagree. Part of EM is signing out labs, f/u, reassess pt. Now certain things are a no-no to sign out (see tyson's post). However, i think it is very reasonable to sign up f/u labs, rads, etc. An appropriate sign out would include pt drinking for scan, f/u, if nl ok with d/c. If abnormal reassess pt. Rounds a my place take about 45 min, after that i quickly scan labs/rads to see if I can dispo my sign outs- if not i ain't staying for another hour.
     
  13. bartleby

    bartleby Senior Member

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    Handoffs in medicine, whether in the ED or as an inpatient, are a dangerous time. Principally, this is because important information can get lost in the signout and furthermore you have someone who does not know the patient well making decisions which impact.

    If you can pick up a patient and get them to a decision point before you signout, then fine. Nobody wants signout that goes: "This is a 50 y/o lady I just picked up with a vague story of 2 days of bilateral lower quadrant abdominal pain, tenderness in the same spots. Labs, urine and CT are pending. Dispo per those tests... " The best signout is a patient with either a clear dispo already arranged or a binary decision (If test x shows a then d/c on abx. If it shows b then admit for c.) But if there are a bunch of downstream decisions and phone calls to make, you probably shouldn't have picked the patient up in the first place. Don't pick up complicated patients 30 minutes before the end of your shift when you have no change of getting this patient to a decision point.
     
  14. EM2BE

    EM2BE Elf

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    I had an attending tell me that's what they all tried to do at the hospital. They would have about 2-3 patients to hand off because their cases ended up more complicated than first expected and/or testing took longer than expected. They took in the minor stuff for the last hour of the shift.
     
  15. 1stresident

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    I think Bart hit the nail on the head(whatever that means)...Im just going to plan on picking up all the runny noses/ankle pains or whatever in the last hour and stay away from the CC's of vaginal bleeds or side notes of diabetic with glucose>400. The thing though is that I would love to do that, but Im just so afraid of getting yelled at by my attending if Im just sitting on the counter in the last hour just scrolling through my cell or talking to nurses and just chillin.
     
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  17. DrQuinn

    DrQuinn My name is Neo
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    This is how I practice.

    Actually when I became an attending a wee two years ago, I found signouts where I curently work to be horrible. People would sign out LPs, pelvics not done, OB u/s not done, etc. I actually put it upon myself to shape things up (and things will be published hopefully soon research wise!).

    I try to keep signouts as clean as possible. A chest pain rolls in 30 minutes before I leave... EKG looks ok? Pt looks ok? I'll leave it for the next person. However, someone is sick or even remotely sick, I'll go see them and get dispo started. However, you can tell if the person is going ot be admitted for a chest pain "rule out." So I will get teh chart nice and tidy so all that needs to be done is for the next EP to just call the hospitalists to admit to the obs unit, and they click a button and the rest is done.

    I am thankfully on the good graces of most of the medical staff where I'm at, so 60 minutes to done time I will start making some phone calls. You can tell if a patient is going to eb admitted or not. So I start cleaning up then.

    I am definately not at the upper echelon of patients/hr where I'm at, I am about smack dab in the middle, but I tend to pride myself on my signouts.

    Compare that to the "3:01" person mentioned above who will dump about 5 CTs on you, and you'll begin to realize how precious a clean signout is.

    One other thing... make sure the patient is "cool with the plan." I hate when I get signouts like "CT is normal just discharge." Then you go and talk to the patient and they're like super upset they thought they were getting admitted, etc. So I make sure to say "the patient is cool with that, right?" It forces the doc to atleast touch base. Yes, there are still attendings who will see the patient ONCE for the initial H&P and never go back. That is just piss poor.

    Q
     
  18. GeneralVeers

    GeneralVeers Globus Hystericus
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    When I take sign out, I always ask what the plan is going to be:

    "If the CT is negative, will this patient go home?"

    "If the patient goes home who will they follow-up with and when?"

    "If they need admission, who is going to do it?"

    When I sign out patients who I have a high degree of certainty that they will be going for, pending a urinalysis or CT (sometimes UA takes longer than CT here!), I try to write up the discharge instructions and/or prescriptions before I leave.
     
  19. met19

    met19 Member

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    totally correct. but if the pt is really sick they might need to get the ball rolling. sometimes on those patients: drew labs, started a line, quick talk to decide if need any acute intervention, pain meds, etc. And on sign out I say, started the workup, but you NEED to see the pt. Labs cooking, urine pending, CXR done, pain meds given, etc.

    In other words: get the Cr faster if they need a CT, urine for UCG, so that way by the end seeing the pt, some labs are back and either further workup, or a dispo can be done!
     
  20. Jarabacoa

    Jarabacoa non carborundum ilegitemi

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    I think that the key here is that you are a medical student. In general, medical students are regarded as a huge nuisance. When a student picks up patients, it often actually creates work for the attending or resident involved. I personally enjoy working with students, but I don't think that any of my attendings do. When attendings work in an academic center, they tend to get really spoiled. When they work with a resident, they don't have to do rectal exams, vaginal exams, laceration repairs. They have the entire chart filled out and sign their name at the bottom, usually adding some statement to the effect of "agree with above." The calls to admitting physicians are made by somebody else. They hear a presentation from a resident for 30 seconds, discuss it for 20 seconds, and then go see the patient for 2 minutes, doing a focused physical exam, and verifying the key elements of history. When the patient is ready to dispo, the attending has another discussion with resident for 30 seconds. Total time spent on one patient... 4 minutes.

    Compare this with a student, who you might need to help with the vaginal exam, and who you feel obligated to repeat entire history and physical from top to bottom. Depending on the institution, or department policy, the attending may have to do all of the documentation by themselves, or at least, a lot more than when they see a patient with a resident. Then, in general, there is a lot more discussion with a medical student. There is a lot more teaching, which can be really irritating when there is a billion patients to be seen and you are discussing basic medicine with somebody.

    I think that is why you got some irritible comments. Generally, for the sake of department flow, and time constraints, attendings and residents want a medical student to see only one patient at a time. Nothing is more irritating than a medical student who sees a bunch of patients, forcing you to do a bunch of documentation, teaching, and extra time spent with patient care that you normally wouldn't have seen. If attendings are good and honest, they will be up front with you and tell you how many patients they want you to see and what level of acuity they feel comfortable with you seeing.

    This is a long-winded way of saying that the ED is much funner as a resident.
     
    #18 Jarabacoa, Jun 6, 2008
    Last edited: Jun 7, 2008
  21. bartleby

    bartleby Senior Member

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    This is completely reasonable. But it is by definition a rare occurrence, as opposed to the person you dread taking signout from because he or she who routinely tries to sign out patients 45 minutes into a 4 hour workup.

    Nobody you work with will bedgrudge you trying to help them out by picking up a couple of simple patients an hour before you leave, particularly if you explain that this is what you've been doing.

     
  22. met19

    met19 Member

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    As Bartleby states


    Im my shop we're quite busy, so as it gets close to sign out rounds: I gen pick up easy quick dispos (asthma ready to go, lacs, etc) or long work up stuff that I can get going for the next team.
     
  23. beriberi

    beriberi Senior Member

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    Out here in community hospital attending-ville, we have a pretty solid no-sign out policy. I think there are two reasons: I work for a big corporation (you probably know and love them) who cares a lot about liability and making lots of money (as do the docs that work for them). Signing out creates a lot of liability -- most lawsuits involve patients that were seen by more than one doc in the ED. Patients may tell the first doc, "this feels just like that time I had x" -- which doesn't get communicated to the next doc.

    In terms of money, as far as I know, only one doc can get paid for seeing a patient. If someone signs out a "Asthma, needs a few treatments, will probably go home" and has done a full document H&P, they will get paid for that. Even if I have to call an admitting service, transfer the patient and exercise judgment and liability in the process. (Unless, I cross their name off the chart and write my own in -- thus taking full liability and compensation for the case. In that case the doc that did the original workup doesn't get paid.)

    Our (few) signouts are typically as follows: "Drunk, needs to sober and reeval. I have sent some labs, but go ahead and take over the case." Or "Drunk, needs mental health eval when sober, they are fully ready for discharge or transfer after they are seen by the psych people."

    This works for a couple of reasons -- we have very limited in house consultation, so rarely are you waiting for a specialist to see the patient. We have very efficient labs, radiology, etc. We also stop taking patients 2 hours before our shift is over (we work 9s). The new doc comes on 1 hour before the shift is over. That leaves 1 hour when charts build up. However, I will try to see those patients-- "Hi, I'm doctor Beriberi, and I see you are having quite a bit of vomiting. Dr. Rickets is going to be here in a few minutes to see you, but I want to get a few things started so that you aren't waiting -- I am going to have the nurse draw some blood, and get you some pain and nausea medication. Are you allergic to anything?"

    That was the long version, in short:
    Outside of academic hospitals, you will find a lot less signout.
     

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