Handoff and Signout

Why handoff matters Where information dies

Everything you know about your patient lives in your head. The chart holds a fraction of it, buried in forty notes. At 6 p.m. you walk out and the rest leaves with you.

Picture the person receiving: 20 patients they have never met, three floors, a pager. They will not read your H&P. When the nurse calls at 0240 saying the systolic is 78, your signout is all they have. Most signouts are a med list read aloud, and nobody derives reasoning from a med list at 3 a.m. A good signout is not a summary of the patient, it is instructions for a stranger.

The I-PASS structure

I-PASS is what most programs teach. Use it, because it forces the two things everyone skips: contingencies and read-back.

Illness severity Stable, watcher, unstable

Stable means you would be surprised to get a call. Unstable means sick right now: pressors, escalating oxygen, an active bleed, a rhythm you are watching. The receiver lays eyes on that patient before sitting down.

Watcher is the category that matters and the one people underuse. Stable this minute, and you would not be surprised to hear about them overnight. What earns it:

• They needed something today they did not need yesterday: oxygen, a bolus, a rate control drug.
• They are trending wrong inside the normal range. A creatinine going 0.9 to 1.3 to 1.6 is a watcher.
• The diagnosis is not settled and you are treating two things at once.
• They are on a drug with a narrow margin: heparin, insulin infusion, IV antihypertensives.
• Something about them bothers you and you cannot name it. Say it out loud.

The failure mode is always the same: called stable at 6 p.m., intubated by 4 a.m. Overcalling costs nothing. If you are debating it, they are one.

The patient summary

A one-liner, then only the events that matter. Nobody needs day three. Age, one or two anchoring comorbidities, admitting diagnosis, hospital day, then what changed today and where the thinking stands.

That last sentence cannot be reconstructed from the chart, and it is what tells the receiver what to think about when the phone rings.

The action list Tasks only

Every line has a verb, an owner and a time. Without all three it is not a task, it is a feeling.

That last row is a rule. Twelve action items on a stable patient means the person covering 20 is doing your job instead of watching the sick.

If-then planning The part everyone skips

This is the section that saves people and the first one dropped when signout runs long. An if-then hands a decision you made carefully to someone with no time to make it. Give the number, the drug, the dose, and the point at which they call you.

Every one does the same thing. You made the decision already. The receiver executes it instead of making it at 3 a.m. blind.

Anticipatory guidance

Some overnight events are not emergencies, just predictable. Naming them saves an hour of somebody's night.

• Pain medication. "He had 4 mg IV morphine at 1400 and 1800 and will ask again around midnight. One more dose is fine. If he needs more, something has changed. Examine him."
• Family arriving from out of town. "The daughter lands tonight and comes straight from the airport. She does not know he was intubated. Do not be the one who tells her in a hallway. Give her the facts. The team meets the family at 10 a.m."
• The consultant who calls back late. "GI calls after their last case, around 9. The question is scope tonight or in the morning. If tonight, she is NPO from that moment and anesthesia needs a heads up."

The code status line

Every signout, every patient, every night, in words. Not "see the chart." It is the thing most likely to be needed instantly and least likely to be found in thirty seconds, and the version in the record is sometimes yesterday's.

The third is the useful one. A code status nobody has discussed is a landmine and the receiver deserves to know it is there. Document the conversation itself in the chart, with quotes and named participants: see the charting guide.

Synthesis by the receiver Read-back

The receiver summarizes the key points, the actions and the contingencies back in their own words. You listen and correct. It is the only step that catches an error while it can still be fixed, and everyone experienced has had a read-back come back wrong in a way that was entirely reasonable given what they heard.

If you are receiving, ask the two questions that surface what got left out: "What are you most worried about overnight?" and "What would make you come back in?"

What does not belong in a signout

• The full past medical history. Give what changes management tonight, not the cholecystectomy in 1998.
• The entire medication list. It is in the chart and more current there. Name what matters overnight: anticoagulants, insulin, drips, anything sedating.
• Your feelings about the patient. "Difficult." "Drug seeking." "The family is a nightmare." These poison the receiver's judgment before they enter the room, and the document is discoverable.
• Anything you would be embarrassed to have read back to you. That is the whole test.

Written and verbal, both

The verbal handoff carries the reasoning and the uncertainty. The written one carries the detail nobody can hold in their head, and it is what gets read at 3 a.m., nine hours later. Verbal alone is forgotten. Written alone loses what you are worried about. Do the verbal face to face, document open in front of both of you.

A worked signout

Ninety seconds to say, four minutes to write. Notice what it is: not a description of a patient, but a set of decisions already made, handed to someone who would otherwise make them alone with a pager in hand.