In Practice: Reflections from NPs and PAs

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

My house is a disaster zone. After working a string of 12-hour shifts, there is a mountain of dishes in the sink and a minefield of dirty clothes on the floor. As I navigate that post-apocalyptic landscape, my mind tends to wander back to the hospital I just left. I sometimes pause on the small victories, sure, but more often I find myself focused on all of the potential improvements.

I’ve noticed that the flavor of reflection often depends on my very last interaction of the day. For shift work in the ICU, that means sign-out: the ritual of passing pertinent patient information from one clinician to the next. There’s a reason it feels like that single act can make or break a shift. Because it can.

Sign-out can be a stressful time for medical providers and a dangerous time for patients. Every transition of patient care presents a chance for effective communication or an information fumble. It can be the difference between a missed diagnosis and a brilliant save. It can mean success or failure.

There might not be a single perfect method of sign-out, but there are key concepts to keep in mind and pitfalls to avoid. I offer some here:

Find a system: A little organization goes a long way toward ensuring a safe sign-out process. Variation between clinicians is O.K. as long as everyone provides information in a logical fashion.

Some teams and hospitals, particularly large-volume academic centers that feature many individual hand-offs in a given day, have developed standardized systems to assist in the sign-out process. At least one randomized crossover study suggests that a computerized system can save time and might improve patient care.

Allow Questions: The absent smile, the slow nod. The glazed-over eyes that stare right through you. If you see these signs, chances are you’ve lost your audience. It happens more than we like to admit and is a sure-fire way to miss important information. It’s also the reason sign-out should be a safe place for both parties to ask questions and seek clarification.

Of course, how and when we ask questions is just as important. Avoid confrontational language or tone and try to limit interruptions. A good sign-out should sound more like a dialogue than an interrogation.

Lose the Retrospectoscope: It’s tempting to become a sports analyst during sign-out, to look at information and retrospectively judge the decisions of our predecessors. Of course, that kind of glaring hindsight bias is unfair to our colleagues, especially if we don’t have a complete understanding of the context of those decisions. A harsh critic on the receiving end of sign-out will only hamper communication and may foster an environment of animosity rather than an open and honest exchange of information.

Avoid Anchoring: In an effort to give a complete sign-out, we often include our opinion, theories, and clinical judgment in the information we pass on to our colleagues. It makes sense to summarize our conclusions and attach a diagnosis or prognosis to the patients for whom we cared. Why make our counterparts reinvent the wheel, right?

Unfortunately, this habit anchors our colleagues’ brains to our ideas and negates much of the benefit of having a fresh set of eyes on a problem. We may unintentionally influence them to ignore signs that would otherwise prompt a workup, or to stick to a particular treatment plan despite an evolving clinical situation. Even if we are conscious of these risks, once an idea is planted in a colleague’s mind, it will continue to exert subconscious bias on future decisions. An idea can be as contagious as a virus.

Sign-out is a great time to take a step back and reexamine possibilities that might have been dismissed. It is an opportunity to open up the differential diagnosis, however briefly, and acknowledge alternative possibilities. This doesn’t mean we should start every workup from scratch. But we should maintain the same skepticism that we would apply to a new patient. Besides, if two clinicians still reach the same conclusion, they are much more likely to be on the right track.

Of course, this concept is not restricted to the world of diagnosis. It’s just as dangerous to transmit other judgments about our patients. If we say a patient is mean or rude, we have set up our coworkers to be less empathetic toward that person. If we dismiss someone as “just a little crazy,” the next caregiver could miss important signs of withdrawal or intracranial hemorrhage. The negative effects of cognitive bias are dangerous enough without passing them on to the next shift.

There are many great ways to improve clinical sign-out. Please leave yours in the comment section below.