Background: Signout of newly admitted patients from a night admitting physician to a primary team is common, making up roughly 40% of admissions to the inpatient medical service at our hospital. Nevertheless, little is known about these “holdover” signouts, and there is no standardized format for ensuring they contain appropriate information transfer and maximize patient safety.
Methods: We conducted a qualitative study using focus groups and interviews of internal medicine (IM) residency leadership, hospitalists, and IM residents at our academic tertiary care hospital. We used a standardized set of nine questions developed by the study investigators after review of signout literature. The questions explored participants’ perceptions of the safety, efficiency and education of current holdover signout and elicited ideas about how to improve these domains. All sessions were audio recorded, transcribed, and analyzed by two investigators using content analysis.
Results: We conducted three focus groups and eight structured interviews comprised of 12 hospitalists and 15 residents. No significant differences were noted between resident and hospitalist opinions. Participants thought that the purpose of holdover signout was safe and efficient transfer of patient care to a primary team. They noted that no formal framework exists for this signout at our institution and that presentation style varies. Participants thought that holdover signout was often inefficient due to repetition of information and poor logistics. Safety concerns were common, and involved unclear code status and severity of illness, delays in seeing patients, and poor medication reconciliation. Formal education was rarely present. Participants agreed that holdover signout should use several best practices previously identified in the signout literature, including quiet location, minimal interruption, and verification of understanding and to-dos. Most thought that holdover presentations should be shorter than the traditional new patient history and physical, and should take fewer than 15 minutes. Most favored creating a standardized format that minimizes presentation of objective data that is available in the chart. Participants identified feedback on presentation skills and clinical reasoning as the most important educational opportunity.
Conclusions: Holdover signout is common, but minimal literature exists for this process. Our study found that holdover signout faces both common and unique challenges compared to other signout and may benefit from some but not all established signout best practices. While our study was limited to a single academic center and residency program, our findings suggest that holdover signout may benefit from a unique standardized format.
