Researchers at the University of Virginia Health System (Charlottesville, USA) conducted a mixed methods study of resident sign-out that involved 89 internal medicine residents. The study included a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement. The surveys were then analyzed, and observations of sign-out sessions were characterized for duration and content. Common effective strategies were then identified from the five exemplar residents using an appreciative inquiry approach.

The study identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were accurate. The duration of observed sign-outs averaged 134 per patient for the day shift sign-out, compared with only 59 for the subsequent night shift sign-out for the same patients. Active problems, treatment plans, and laboratory test results were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out identified strategies for sign-out: discussing acutely ill patients first, minimizing discussion on straightforward patients, limiting plans to active issues, using a systematic approach, and limiting error-prone chart duplication. The study was published early online on October 20, 2011, in the Journal of General Internal Medicine.

“The apparent degradation of information that occurs with multiple sequential sign-outs during a 24-hour period is striking and has not been previously reported,” concluded lead author Adam Helms, MD, and colleagues. “Initiating an educational curriculum for sign-out at teaching hospitals is critical, not only for establishing a standardized process for sign-out, but also for creating a culture of patient ownership among cross-covering physicians.”

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