If you were a patient, would you want your case to be subject to a game of telephone between doctors? Probably not. But what if I asked the question this way: Would you like two doctors to think about your case or four?
In real life these pluses and minuses go together. Transitioning care from one team of doctors to another is an important part of our jobs as emergency medicine physicians. We all know this experience: Your shift is winding down. You are hurrying to dispo your long list of patients before time runs out. You don’t want to leave a mess behind for the fresh team of doctors coming to relieve you. The “network rules” fill your mind. ABC and CBS. “Always Be Closing” and “Close Before Signout.” As you rush to discharge a couple of patients, admit a few others, you come to the inescapable conclusion that you are going to have to sign out several of your patients to the next shift.
Oh, the shame! In baseball terms, this is akin to batting into the third out of the ninth inning and leaving runners on base. You had wanted to be the hero, ending the game with a base-clearing home run, just like that Hall of Fame legend Babe Ruth, the Sultan of Swat.
A good signout can also be a good consult – fresh eyes and ears from new doctors, often with different areas of expertise. A poor signout can be dangerous, more hole than cheese.
Now you’ve got a new goal: to get everything together and organize a smooth transition of care from one doctor to the next. You’re going to be the Sultan of Signout.
Most residents work on the active skill of signing out a patient to the oncoming team. But we don’t think about receiving sign out as a skill of its own. Instead we devote energy learning to better focus the presentations we give to others, providing the most important information and trying to leave out less important details.
Many use mnemonic devices such as SBAR (Situation, Background, Assessment, Recommendations) to guide this. A good signout leaves the new team knowing who the patient is, why he or she came in, what has occurred so far, the current thinking, and the plan going forward.
Most of the time, the new doctor is scribbling down as much information as possible. Not me. When possible, I type a signout note as a progress note as the presenter is talking. I use an incomplete macro (which I wrote about previously in ACEP News) to organize my notes in real time. But other than good progress notes, are there other ways we can improve on the skill of taking signout when starting a new shift? Yes.