The second necessary intervention is the instruction and ongoing evaluation of resident handoffs. A few studies have demonstrated that formalized handoff instruction and supervision have an effect on clinical outcomes. In a survey of 169 internal medicine programs, 70 percent instructed and 53 percent evaluated their house staff in handoffs (Am J Med. 2012;125:104-110). When they looked at acute disease outcomes, the programs that incorporated handoff training and evaluation had a significantly decreased pneumonia mortality rate compared with programs that did not emphasize standardized sign-outs.
Explore This IssueSeptember 2013
Finally, judicious use of EMRs can greatly improve the accuracy and efficiency of the sign-out process. Research suggests that the use of a computerized sign-out tool can save residents up to 45 minutes per day while also improving continuity of care. Seventy percent of the participating residents reported that the new tool helped them adhere to the 80-hour workweek. Medication history, vital signs, allergy information and code status are continually and automatically updated, thus eliminating the need for an error-fraught, resident-maintained phantom record.
Where We Are Headed
Due to ACGME-mandated work hour restrictions, transfers of patient care among resident physicians have greatly increased. While these work hour changes were implemented to improve patient care by reducing physician fatigue, it is now clear that the inadequacy and inconsistency of patient sign-out has offset some of the intended benefit. In response, the ACGME released a “new standards for transitions of care” in 2011, suggesting that programs should implement standardized sign-out procedures using computerized tools as well as educate residents on handoff communication.
There is now widespread use of EMRs due to Affordable Care Act mandates. Looking at other high-stakes industries shows that standardization of communication and breakdown of hierarchical barriers through the use of formalized checklists can drastically improve situations vulnerable to human error. The three phase sign-out study showed that a structured, verbal communication during the handoff demonstrated the greatest improvement in patient safety when compared to written forms of sign-out. What remains to be investigated is whether the use of a computerized sign-out tool, which provides not only automated data but also a structured verbal communication through a checklist, improves clinical outcomes. The creation of such a tool will be increasingly feasible as more hospitals adopt EMRs and more residency programs adhere to the ACGME 2011 guidelines. As sign-outs increase in frequency, the impact of standardization in patient handoffs among resident physicians has enormous potential to improve future patient safety outcomes.