Improving Inter-team Communication by Standardizing Written Sign Out

From the 2022 HVPA National Conference

Taikchan Lildar MD (Flushing Hospital Medical Center), John Elmeneawy MD, Sana Falak MD, Win Si Thu MD, Kelly Cervellione MA, Tamar Toronjadze MD

Background

Miscommunication amongst providers contributes to around 250,000 deaths annually in US hospitals. Sign-outs are a common place for miscommunication during transition of care. Poor quality sign-outs can result in confusion, delayed treatment, serious adverse events, or even patient mortality. Higher quality sign-outs may prevent loss of information and can clarify team tasks, which should lead to higher quality care.

Objective

The Improving Sign Out (ISO) project is a standardization of written sign-out process designed to improve communication between residents and improve transition of patient care.

Methods 

The ISO project was implemented in a Community Hospital Internal Medicine Program of 53-residents. Through analysis of root causes, investigators identified common problems faced during transition of care. A six-question survey was created to quantify these challenges. Majority of questions used Likert-type responses on a scale of 1-5 (1=never/very poor; 5=always/very well). The survey also allowed for qualitative feedback. Pre-data was collected and after several rounds of Plan-Do-Study-Act, the data was used to create a standardized Hospital Course that prioritized patient’s diagnosis and “To-Do List” which highlighted clinical status, contingency plan, and team-specific tasks. This was implemented after educational intervention with one and three-month follow-up surveys.

Results

Pre-intervention questionnaires revealed a need for improvement across all areas surveyed. After intervention, one-month survey showed statistically significant improvements were noted in how well the resident knew the patient history (“well” to “extremely well” ratings increased from 40% to 86%, p<0.01); how well they knew their To-Do List (“well” to “very well” ratings increased from 28% to 59%, p=0.03). Improvements were also noted in how well the patients’ current condition was known from (“very well” to “extremely well” ratings increased from 8% to 23%, p=0.16). Residents reported a decrease in difficult sign-outs pre- and post-intervention for post-call (48% to 23%;p=0.07), night-float(36% to 18%;p=0.17), MICU(20% to 9%;p=0.06), ER(24% to 9%;p=0.07), and medical floors (28% to 9%;p=0.10), with the exception of telemetry(48% to 50%;p=0.89) that subsequently reduced (30%;p=0.21) on three-month follow-up.

Conclusions

The ISO project resulted in significant improvement in communication during transition of patient care. Remarkable improvements were seen in patient’s history, communications regarding critical illness, and the completeness of the “to-do list” on one and three-month surveys. The one-month survey showed deficiencies in sign-outs related to telemetry transfers, presumably secondary to high volume and rapid patient turn-over. Following educational interventions, the three-month follow-up survey showed notable improvements in resident satisfaction of telemetry sign-outs and consistent improvements in all other areas. The next steps of this project include continued improvement, monitoring, and re-education of the sign-out process and to determine if changes in communication directly affect quality of care.

Clinical Implications

Standardization of the sign-out process led to improved quality transition of care, improved patient safety and improved quality of care.

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