Sign-Out Bombs and Resident Productivity

Written by Nicole McCoin

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With ED boarding, the burden of sign-out patients is greater than ever. This study shows just what I expected.  All of these sign-out patients negatively affect how many new cases each resident is able to see on each shift.

Why does this matter?
Many physicians believe that the trade-off of taking care of more sign-out cases for fewer new cases is detrimental to a resident’s educational experience. This article suggested a call-to-action for program leadership to take a close look at how sign-out patients are distributed in order to enhance resident education.

My personal three goals if I am ever a patient in the ED:
 1. Don’t go to the hospital on July 1st
 2. Wear nice undergarments
 3. Don’t be a sign-out patient.

This was a retrospective cohort study that spanned 19,389 shifts over 7 years for 91 Emergency Medicine PGY-1 and PGY-2 residents. PGY-1 residents without sign-out evaluated 10.3 patients and generated 31.6 RVUs. Each signed-out patient was associated with -0.07 new patients but no statistically significant decrease in RVUs. PGY-2 residents without sign-out evaluated 13.6 patients and generated 47.7 RVUs. Each signed-out patient was associated with -0.25 new patients and -0.89 RVUs. Overall, sign-out burden was associated with a small decrease in resident productivity.

Program leaders need to look at their shift schedules closely, assuring that one particular shift doesn’t get the sign-out extravaganza compared to the others.  However, I want to give a little shout-out to the sign-out patient. I think that there is definite educational benefit in learning how to optimally care for sign-out patients. After sitting through years of M&M, the crux of most cases centers around the sign-out itself or some element of failed communication. So, let’s not hate on the sign-out list too much. Let’s just make sure we balance the list out between our various resident shifts so that our residents get some experience with sign-outs as well as plenty of fresh, new cases. Everything in moderation...

The Effect of Signed-Out Emergency Department Patients on Resident Productivity.  J Emerg Med. 2018 Jun 25. pii: S0736-4679(18)30591-2. doi: 10.1016/j.jemermed.2018.05.020. [Epub ahead of print]
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Reviewed by Thomas Davis

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