The Impact of Environmental Context on Intern Sign-Out Quality.

BACKGROUND: Resident duty-hour restrictions have led to more sign-out transitions, increasing the potential for preventable harm. An unfavorable environment is expected to exacerbate sign-out risks to patient safety. OBJECTIVE: The aim of the study was to evaluate the impact of noise, interruptions, long sign-outs, and sign-outs exceeding allotted time on sign-out quality. METHODS: Eight trained observers evaluated 620 evening patient sign-outs between interns for 40 weeknights between February and April 2015 at a large internal medicine training program. Quality of sign-out was measured three ways: information quality, scores from the Handoff CEX Tool, and peer evaluations. RESULTS: Noise had no impact on information quality. Interruptions negatively affected information quality (-0.10 < r < -0.15, P < 0.001) and Handoff CEX quality scores (-0.11 < r < -0.26, P < 0.001). Long sign-outs taking more than 1 hour negatively affected sign-out quality (-0.09 < r < -0.23, P < 0.05). Sign-outs exceeding allotted time negatively impacted peer evaluations (-0.11 < r < -0.22, P < 0.001). CONCLUSIONS: Interruptions, long sign-outs, and sign-outs exceeding allotted time were related to lower sign-out quality. Improving the environment to reduce interruptions and training interns to manage their time during sign-outs may improve sign-out quality.

A Randomized Cohort Controlled Trial to Compare Intern Sign-Out Training Interventions.

BACKGROUND: Although previous studies have investigated the efficacy of specific sign-out protocols (such as the illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by reviewer [I-PASS] bundle), the implementation of a bundle can be time consuming and costly. We compared 4 sign-out training pedagogies on sign-out quality. OBJECTIVE: To evaluate training interventions that best enhance multidimensional sign-out quality measured by information exchange, task accountability, and personal responsibility. INTERVENTION: Four general internal medicine firms were randomly assigned into 1 of the following 4 training interventions: didactics (control), I-PASS, policy mandate on task accountability, and Plan-Do-Study-Act (PDSA). SETTING: First-year interns at a large, Mid-Atlantic internal medicine residency program. MEASUREMENTS: Eight trained observers examined 10 days each in the pre- and postintervention periods for each firm using a standardized sign-out checklist. RESULTS: Pre- and postintervention differences showed significant improvements in the transfer of patient information, task accountability, and personal responsibility for the I-PASS, policy mandate, and PDSA groups, respectively, in line with their respective training foci. Compared to the control, I-PASS reported the best improvements in sign-out quality, although there was room to improve in task accountability and responsibility. CONCLUSIONS: Different training emphases improved different dimensions of sign-out quality. A combination of training pedagogies is likely to yield optimal results.