Standardized Sign-Outs in the ED: An Opportunity to Improve Patient Safety

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Authors: Peter Malamet, OMS-IV, Philadelphia College of Osteopathic Medicine
Andrew W. Phillips, MD MEd, Stanford/Kaiser Emergency Medicine Residency Program
Sarah Williams, MD, Stanford University, Division of Emergency Medicine

Originally Published: Common Sense, January/February 2015

The Importance of Sign-outs
Emergency physicians routinely perform sign-outs, both at shift change and during consultations and admissions. Sign-out, also known as a hand-off or turnover, is a time to summarize information about current patients and transition their care from one provider to the next. This sign-out can be between emergency physicians (EPs) or between EPs and other health care providers. However, despite being so common in everyday practice, sign-outs continue to be cited as a large source of medical error in the emergency department (ED).[1] It is critical for patient safety that this process is optimized.

The ideal sign-out happens in a quiet area with no distractions, with sufficient time to discuss pertinent aspects of patient care.[2] This may be possible on a medicine floor, although even here there are challenges. However, this is particularly difficult to achieve in the ED.[3,4] Nonetheless, recent research shows that a standardized sign-out process can reduce medical errors.[3]

Standardized Sign-Outs
Multiple studies support the use of a standardized sign-out process.[1,5,6] However, in practice this has been challenging to implement. Kessler et al., reported that only 10.9% of emergency medicine (EM) residents reported that they received hand-off education.[3] In addition, 93.9% of EM program directors stated that assessments of hand-off proficiency were not conducted in their program.[3] This is a troubling statistic in light of multiple studies showing that poor transfer of care practices can lead to significant patient morbidity.[7] Horwitz and colleagues showed that 29% of house staff had a patient who experienced an adverse event after ED to inpatient transfer.[7] Many contributing factors, such as communication failures and inaccurate or incomplete information and orders, have the potential to be corrected with a better sign-out process.[7]

One form of standardization that has been studied across other specialties is using acronyms or other mnemonics during sign-out. Connor and colleagues found success using an “IMOUTA” acronym with otolaryngology residents.[8] This stands for identifying data (I), medical course (M), outcomes possible tonight (OU), responsibilities to do tonight (T), and opportunity to ask questions or give feedback (A). In this study, residents who used the acronym felt much better prepared for on-call duties.[8] A component of this acronym that deserves to be highlighted is the opportunity to ask questions. Multiple articles have discussed the need for active listening.[1,8] The physician who is receiving the sign-out needs to be encouraged to ask questions and clarify information.

Another form of standardization can be a template that practitioners carry with them. Bavare and colleagues used a pocket card template in the pediatric intensive care unit.[10] The front of the card contained: situation and background, patient identification, primary diagnosis, problems, condition, disposition, code status and lines. The back of the card contained the assessment and goals. In their study, according to a pre- and post-survey comparison, there was perceived improvement with sign-out completeness and comprehensibility.[10]

Dubosh et al., recently found success using a sign-out checklist with residents in the ED. The components of their checklist included: HPI, ED course, pending studies, likely disposition, possible issues and algorithms for disposition.[11] In this study, trained research assistants monitored the sign-outs before and after implementation of the checklist.[11] There were statistically significant improvements in the areas of HPI, ED course, possible diagnosis and team awareness of the plan.[11] In addition, there was no difference in the amount of time the sign-out took (1.39 vs 1.42 minutes).[11]

Physicians can also find blank templates online. Organizations such as Safer Sign-out provide templates and offer training and other tools that can help standardize sign-outs, as do I-PASS ( and TeamSTEPPS ([12]

Electronic standardized sign-outs deserve special mention as well. Some EDs use full electronic medical records (EMR), while others utilize a hybrid system of paper charting and EMR. There are currently electronic record programs that can assist with sign-out. Van Eaton and colleagues used the University of Washington Computerized Rounding and Sign-out System (UWCores), a web-based system, for sign-out.[13] Physicians can organize their patient lists and add patient data, labs, etc. With this system, 69.6% of residents reported better sign-out quality and 66.1% agreed there was a better continuation of care.[13] A related study using UWCores showed fewer skipped patients during rounds and less time spent pre-rounding.[14] It may be possible to implement and customize this type of EMR system for ED use. Physicians can track their patients on the computer throughout the shift, then have a uniform template with all the pertinent information available at the end of the shift. The training required for a new EMR functionality may be initially resource intensive. However, as it is adopted into the work-flow this could be a very convenient tool.

Practical Challenges
Aside from the lack of standardization, there are numerous other factors that can lead to a poor sign-out experience. These include a loud and disruptive background, uncertainty about which physician is in charge post sign-out when both are still physically present, lack of “red flags” that help identify dangerous hand-offs, the desire to be concise, and the economic build of the physician group.[1] These systems issues each need to be addressed. However, a standardized hand-off algorithm can decrease the probability of error and makes such issues easier to address. This is the goal of a standardized sign-out. Even when there is a full department with numerous distractions, a safe and effective sign-out can be accomplished in a reasonable time frame.

The importance of improved hand-offs is supported by multiple leading health organizations. The American College of Emergency Physicians recommends the use of hand-off training and assessment and support tools to enhance the transition of care process.[16] Additionally, for the Next Accreditation System, the ACGME established the Clinical Learning Environment Review (CLER).[16] This focuses on the quality and safety of the patient care environment.[16] A main component emphasizes formal education and enhanced processes for the transition of patient care.[16]

Several sign-out tools are already available, as discussed above. Which tool is chosen will depend on several departmental considerations and further studies are indicated to determine the optimum design for ED use. However, it is already clear that utilizing a standardized sign-out in the ED has the potential to drastically improve patient safety and should be considered an important part of departmental policy.

The views expressed in this article are those of the author and do not represent the official position of the U.S. Air Force, Department of Defense, or U.S. Government.


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