Pardon the Interruption(s)—Enabling a Safer Emergency Department Sign-Out

Ryan Thompson, MD

Patient ‘handoffs’ in medicine are widely recognized as a highly vulnerable time for medical errors to occur. The ED is uniquely susceptible with its fast pace and propensity for frequent distractions. Significant attention has recently been given to checklist-based initiatives such as the EMPSF’s “SAFER Signout” that aim to standardize ‘handoffs’ in the ED. Despite emphasizing the content of patient sign-outs, we recognized a high rate of interruptions in our ED that compromised the effectiveness of sign-out. Our primary objective was to evaluate whether simple interventions prior to sign-out could minimize interruptions.

Our interventions included a distinct alert audible through the ED, diversion of phone calls from care team members, and a pedestal sign placed outside the physician work area to signify sign-out rounds occurring. Utilizing a before and after study design, a research assistant directly observed team sign-outs at various shift changes throughout the day.

Primary outcome measure was the quantity of interruptions that occurred during sign-out (nursing, ECGs, phone calls, etc.) Total sign-out interruptions were significantly decreased by the interventions from an average of 6.1 interruptions to 1.1 interruptions. Additionally, the total time spent during sign-out was reduced by almost 3 minutes. There was also a trend toward timeliness of attending and resident physician arrival, enabling sign-outs to increasingly start at the scheduled time.

Minimization of interruptions is imperative during this period to optimize transfer of patient care and reduce missed information. Simple interventions prior to sign-out significantly decreased interruptions, led to shorter sign-out periods, and trended towards increased timeliness of providers-all contributing to a safer sign-out. Checklists and similar safety tools will be ineffective without first establishing a culture and environment that facilitate meaningful communication of standardized sign-out content. Both quality environment and quality content must be present for an optimally successful and safe sign-out.

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