II. Indications
- Safer Patient Handoffs (sign-outs) on shift changes (e.g. hospital ward, emergency department)
- Patient hand-off from a mid-level practitioner (PA, NP) to a physician
III. Precautions
- Patient care hand-offs are high risk for error
- Initial provider should clearly transfer care to the accepting provider (avoiding interruptions)
- Concise summary of key history (include past medical history and medications)
- To-do list of pending results and Consultations
- Anticipatory guidance (if this result, then...)
- Accepting provider should assume full care of the patient ("own the patient")
- Introduce yourself to the patient and review where evaluation stands and what is pending
- Reconsider differential diagnosis and potential Cognitive Bias
- Especially important with handoff from practitioner with narrower practice scope (e.g. midlevel)
- Document hand-off with times, key findings, pending results and plan
- Discuss results and plan with patient at the time of disposition
IV. Technique: Admission Script (e.g. ED provider to hospitalist) in 1 minute
- Intro
- Summary History and Physical
- Presented from home with 2 days of fever to 102, cough, Wheezing unable to perform ADLs
- Hypoxic with O2 Sat 85% RA, tachypneic to 28/min, tachycardic to 120 bpm, normotensive at 130/75
- Diminished breath sounds and rhonchi left side, mild accessory Muscle use
- CXR with right lower lung lobar Pneumonia, WBC 25,000 with Left Shift, normal Electrolytes, Lactic Acid 4
- ED Course
- Received 30 cc/kg IV fluids, Antibiotics, duonebs, Corticosteroids
- Currently on 2 L NC with O2 Sats at 92% and no current accessory Muscle use, and Lactic Acid now 2.5
- Plan
- Admission for Community Acquired Pneumonia, with COPD exacerbation, Hypoxia and Sepsis
- References
- Orman and Swaminathan in Herbert (2017) EM:Rap 17(3): 1
V. Technique: Mnemonic: SIGNOUT
- Sick
- Unstable
- Resuscitation Status (e.g. DNR/DNI)
- Identifying Data
- Name, age, gender and diagnosis
-
General course
- Initial status and key events
- New events of the day
- Key new findings
- Overall current clinical status
- Clinical status summary (e.g. affebrile and stable Low Flow Oxygen)
- Upcoming possibilities with plan
- Contingency plan for adverse events
- Example: In case of respiratory distress, suspect Fluid Overload and consider Furosemide 20 mg IV
- Tasks to complete after handoff
- Example: Review upcoming Troponin In 2 hours
VI. Resources
- Patient Handoff Tool (IOS and Android)