II. Indications

  1. Safer Patient Handoffs (sign-outs) on shift changes (e.g. hospital ward, emergency department)
  2. Patient hand-off from a mid-level practitioner (PA, NP) to a physician

III. Precautions

  1. Patient care hand-offs are high risk for error
  2. Initial provider should clearly transfer care to the accepting provider (avoiding interruptions)
    1. Concise summary of key history (include past medical history and medications)
    2. To-do list of pending results and Consultations
    3. Anticipatory guidance (if this result, then...)
  3. Accepting provider should assume full care of the patient ("own the patient")
    1. Introduce yourself to the patient and review where evaluation stands and what is pending
    2. Reconsider differential diagnosis and potential cognitive bias
      1. Especially important with handoff from practitioner with narrower practice scope (e.g. midlevel)
    3. Document hand-off with times, key findings, pending results and plan
    4. Discuss results and plan with patient at the time of disposition

IV. Technique: Admission Script (e.g. ED provider to hospitalist) in 1 minute

  1. Intro
    1. I would like to admit to your service, a 75 year old female with COPD, now with CAP, Hypoxia, Sepsis
  2. Summary History and Physical
    1. Presented from home with 2 days of fever to 102, cough, Wheezing unable to perform ADLs
    2. Hypoxic with O2 Sat 85% RA, tachypneic to 28/min, tachycardic to 120 bpm, normotensive at 130/75
    3. Diminished breath sounds and rhonchi left side, mild accessory muscle use
    4. CXR with right lower lung lobar Pneumonia, WBC 25,000 with Left Shift, normal electrolytes, Lactic Acid 4
  3. ED Course
    1. Received 30 cc/kg IV fluids, antibiotics, duonebs, Corticosteroids
    2. Currently on 2 L NC with O2 Sats at 92% and no current accessory muscle use, and Lactic Acid now 2.5
  4. Plan
    1. Admission for Community acquired Pneumonia, with COPD exacerbation, Hypoxia and Sepsis
  5. References
    1. Orman and Swaminathan in Herbert (2017) EM:Rap 17(3): 1

V. Technique: Mnemonic: SIGNOUT

  1. Sick
    1. Unstable
    2. Resuscitation status (e.g. DNR/DNI)
  2. Identifying Data
    1. Name, age, gender and diagnosis
  3. General course
    1. Initial status and key events
  4. New events of the day
    1. Key new findings
  5. Overall current clinical status
    1. Clinical status summary (e.g. affebrile and stable Low Flow Oxygen)
  6. Upcoming possibilities with plan
    1. Contingency plan for adverse events
    2. Example: In case of respiratory distress, suspect Fluid Overload and consider Furosemide 20 mg IV
  7. Tasks to complete after handoff
    1. Example: Review upcoming Troponin In 2 hours

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