What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff

Objectives: To characterise and assess sign-out practices among internal medicine house staff, and to identify contributing factors to sign-out quality. Design: Prospective audiotape study. Setting: Medical wards of an acute teaching hospital. Participants: Eight internal medicine house staff teams. Measurements: Quantitative and qualitative assessments of sign-out content, clarity of language, environment, and factors affecting quality and comprehensiveness of oral sign-out. Results: Sign-out sessions (n = 88) contained 503 patient sign-outs. Complete written sign-outs accompanying 50/88 sign-out sessions (57%) were collected. The median duration of sign-out was 35 s (IQR 19-62) per patient. The combined oral and written sign-outs described clinical condition, hospital course and whether or not there was a task to be completed for 184/298 (62%) of patients. The least commonly conveyed was the patient's current clinical condition, described in 249/503 (50%) of oral sign-outs and 117/306 (38%) of written sign-outs. Most patient sign-outs (298/503, 59%) included no questions from the sign-out recipient (median 0, IQR 0-1). Five factors were associated with a higher rate of oral content inclusion: familiarity with the patient, sense of responsibility for the patient, only one sign-out per day, presence of a senior resident and a comprehensive written sign-out. Omissions and mischaracterisations of data were present in 22% of sign-outs repeated in a single day. Conclusions: Sign-outs are not uniformly comprehensive and include few questions. The findings suggest that several changes may be required to improve sign- out quality, including standardising key content, minimising sign-outs that do not involve the primary team, templating written sign-outs, emphasising the role of sign- out in maintaining patient safety and fostering a sense of direct responsibility for patients among covering staff.