73. The Value (and pitfalls) of Signout Culture with Mike Weinstock MD

There is no doubt that handing over care of a patient to another clinician is potentially fraught with peril. After all, it’s in the transitional moments when error is most likely to occur. But there’s a balance to strike here because there are also myriad upsides to signouts for both the patient and clinician. In this episode, Mike Weinstock, MD breaks down the arguments in favor of signouts, how to do them well, the big fat hairy signout pitfall,  and why signouts might just be a key ingredient to career longevity and patient safety.

 

Guest Bio: Mike Weinstock MD  is Professor of Emergency Medicine, adjunct in the Department of Emergency Medicine of The Ohio State University’s College of Medicine, and director of research and CME at the Adena Hospital. .

He has lectured nationally and internationally on medical topics and patient safety issues and is the executive editor for UC RAP, contributed to ERcast and Risk Management Monthly, and has published original research in JAMA IM and Annals of Emergency Medicine. He is the author of the Bouncebacks! series of books,and How’d it Go?..  Mike has practiced medicine nationally and internationally including volunteer work in Papua New Guinea, Nepal, and the West Indies.

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We discuss:

How the key to protecting yourself medico-legally is having your primary concern be about patient safety and then documenting such that the chart reflects good medical care [01:50];

• If you are doing things just to protect yourself (i.e.. defensive medicine), that could lead to a worse outcome.
• As clinicians, we often balance our short-term medico-legal risk with what we believe to be the long-term health of the patient. But sometimes we don’t adequately consider the risk of a hospital inpatient stay.

We need to make sure that our thought process is reflected in the medical record so that someone later, if there is an adverse outcome, doesn’t have to guess about it.

 

Principles of medically defensible charting [05:00];

• When documenting what is going on with a patient encounter, we don’t need to be correct every time. If we miss something and the patient has a bad outcome, that doesn’t equal medical malpractice. 
• Medical malpractice has a root cause of two things:  poor data gathering and poor medical decision-making. For marginal cases, explaining what you considered and why you did/did not feel a workup was necessary is vitally important.

Rob’s chest pain template medical decision-making (MDM) [08:30];

• Click here to see Rob’s full MDM for a chest pain patient with a fully negative workup
• Rob includes a paragraph explaining why he doesn’t think each of the potential life threats are at play for the patient. When reviewing the record before discharge, he runs through the list to verify and double check that his thought process accurately reflects the patient’s scenario. 

The importance of remembering that one-directional rules (like PERC for PE) do not obligate you to do a workup if a patient fails the rule [12:00];

• A mistake that people make is that they think if a patient fails PERC, they must  do the PE workup. But really, failing PERC just means you can’t rule the patient out with PERC. You can be PERC negative, but you can’t be PERC positive. 
• People often forget that PERC doesn’t apply to anyone >50 years old or with a heart rate >100 bpm.

Why handing off a patient to the incoming doctor when your shift is over may contribute to a successful career as an emergency physician [13:00];

• Many worry about the medico-legal risk associated with patient handoffs, not understanding that the risk is largely because the receiving physician does not take adequate ownership of the patient.
• A successful career in EM is one that is completed (and not cut short due to burnout).  “One way that for sure is NOT a recipe for finishing a 30 year career is by staying 2-4 hours at the end of every shift completing paperwork or finishing patient workups.”

After an ED shift, your mental, emotional, spiritual, and physical energy are depleted. A 4 hour stay-over just depletes you more.  That accumulation of depletion adds up over years and years, leading to more pre-shift dread and more post-shift lassitude.

 

Whether your level of busy-ness during an ED shift is seen as an extenuating circumstance by a defense or plaintiff’s attorney [18:45];

• While everything that was happening during a shift is discoverable, these details can hurt you – especially if you were seeing lower acuity patients who ‘should’ have waited while you took care of the one who had a poor outcome.

An argument for always reviewing nursing/paramedic notes (and documenting that you did it) and trying to greet EMS when they arrive with a new patient [24:45];

• It is an excellent practice to review any prehospital notes (or chart that they were not available, if that’s the case). This leads to better care and to discoveries about the patient’s pertinent history. You are responsible for anything that ends up in the patient’s chart.

Getting the EMS report verbally from paramedics is a level one priority; it is gold. While it may interrupt your flow, in the end it will save you time.

 

Mike’s opinion of the ideal sign-out culture [32:00];

• In this age of burnout, there are many things we can’t control which lead to frustration. But one thing that we can control, which may prevent burnout, is to strive to help each other wherever possible.
• When Mike arrives on shift, he immediately asks the person he’s relieving which patients he can take over. Unless there are ambulances with multiple new patients or the off-going doctor can quickly wrap up discharges, Mike tries to assume the care of 2-3 patients. 
• Mike closes the loop by sending the off-going doctor a follow-up text or email informing him/her about any results and disposition. 

Some of the most appreciated words when you are at the end of your shift are the other doc coming up to you and saying, ‘Hey, what can I do to get you out of here?’ It’s like manna from heaven. 

 

Some doctors are not comfortable signing out patients, but they take a risk in their career longevity by not doing so [35:30];

• The culture of medicine is that we need to be mentally and physically strong. However, nobody can do that for 20+ years when they’re staying several hours at the end of every shift. It breaks you down. Also, it’s not fair to yourself, your family, or maybe even your patients (if you’re trying to expedite your workup so you can get home).
• We have this ethos in medicine that the patient always comes first. The patient is a high priority, but we’re important too. If we are not practicing self care, we’re not going to be able to adequately and compassionately care for others.

If we’re burned out or distracted, we may be able to complete our work, but can we do it well? Can we move from standard of care to excellence in care? Can we compassionately care for patients in that scenario? Practicing self care is vitally important, not just for ourselves but for our patients also. 

 

Why sign-outs need to have constraints [39:25];

• There has to be consistency across the ED provider group and everyone needs to be on board. Structure and constraint in this area actually give you freedom of practice.
• Ideally, a sign-out should be a binary decision. “We are waiting for X, Y, and Z, and the results lead to disposition X or Y.”  Also, consider sign out rounds, introducing the new doctor to the patients. 
• While sign-out culture is good for wellness and self-care, it’s also one of the riskiest times in the patient’s ED course . You need to be structured, deliberate, and consistent in how you do it. 

 

Further reading on patients handoffs

• Chladek, Melissa Sydow, et al. “The Standardization of handoffs in a large academic pediatric emergency department using I-PASS.” BMJ Open Quality 10.3 (2021): e001254. https://bmjopenquality.bmj.com/content/10/3/e001254.abstract
• Rutherford, Annie. “Only an Effective Pass Scores the Touchdown: End of Shift Hand Off in the Emergency Department.” Lynchburg Journal of Medical Science 4.1 (2022): 75. https://escholarship.org/content/qt4s77z3t5/qt4s77z3t5.pdf
• Lorenzo, C., et al. “Impact of Ambient Background Noise on Sign-Out in the Emergency Department.” Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health 20.4.1 (2019). https://escholarship.org/content/qt7tq801wf/qt7tq801wf.pdf
• Dhingra, Kapil R., Andrew Elms, and Cherri Hobgood. “Reducing error in the emergency department: a call for standardization of the sign-out process.” Annals of emergency medicine 56.6 (2010): 637-642. https://www.annemergmed.com/article/S0196-0644(10)00117-4/fulltext