Dear Director,
I work in a high-volume ED and get productivity pay. While the pay is good, I’m tired of staying so long after my shift to dispo patients. I miss the days of residency where I could just sign out at the end of my shift and go home. What do you think sign out should look like?
Sign out is a critical part of emergency medicine. We learn early on that we need to take care of sick people and we don’t sign out pelvics, rectals, or LPs. Sign out is a high-risk environment that contributes to malpractice risk because of the increased risk of something getting dropped in the handoff.
It also impacts flow as most busy EDs need the oncoming doc to start seeing patients and following up on loose ends of patients received in sign out may be delayed. With that said, docs can’t stay indefinitely after shifts as that contributes to burn out and fatigue, which is already at an all-time high.
Sign out is also cultural to the institution, typically based on several variables. Length of shift, acuity of patients, patient flow, compensation model, and number of docs actively working all help to create the culture. Lower volume EDs where docs do 12 hour (or longer) single coverage shifts need to be able to sign out quickly as the outgoing doc is likely the doc returning in 12 hours as the relief.
As you mention, payment models can also impact sign out. RVUs can only be attributed to one provider so if I start a patient and sign them out to you (we’ll discuss the amount of work you do shortly), who should get the RVU credit, and thus the dollars associated with the RVUs?
The great thing about sign out is that it can vary from ED to ED. It’s cultural. It can be designed to maximize the benefits for the specific ED, including patients and providers. Through surveys and discussion, a sign out process can be developed that outlines key goals and how to accomplish them.
Let’s consider some of the variables that may fit a high-volume ED with productivity-based compensation.
Who gets credit for the patient?
As we think about culture, we must consider who gets credit for the chart (the RVU’s that are produced by the patient visit). We are only allowed to bill under one NPI number and I’m not aware of any companies that have found a way to split RVU’s between physicians. Therefore, the question comes up whether to attribute the RVU’s to the first doc or the doc who does the disposition.
I’ve seen it done both ways. From a flow perspective, I think there is value in assigning the RVUs to the doc who initiates care, as we need to incentivize docs to pick up new patients. If you have a typical 2-3 hour provider to dispo time, assigning RVUs to the dispo doc means people will not be incentivized to pick up charts their last 2-3 hours because they won’t be able to finish them out. And people would never pick up a patient who is intoxicated or has a psychiatric complaint.
All of that together would grind flow to a standstill. Additionally, the doc who comes on to start the shift typically is focused on getting new patients started. They will not be as in tune to radiology results that come back in 15 minutes and allow for a dispo if there are still 3 patients waiting to be seen. And therefore, the disposition on the patient with imaging results is now potentially delayed 45 minutes.
But what about the patient that gets started 15 minutes before the end of a shift and just has a bunch of tests to check on? I believe there has to be some common sense used as we design our sign out culture. I define these kinds of things under citizenship and as professionals, we need to prioritize what’s good for the ER over the RVUs. If you have 15 minutes left in your shift, you’re better off tidying up your sign out then seeing a non-critical patient that can wait for the next doc.
On the other hand, there are times when the “next to see” list is getting pretty large and you do have a few minutes. Therefore, it makes sense to get patient care started on the next patient or two. This helps with department metrics (door to provider and reducing potential left without being seen patients), gets patients orders cooking, and ultimately reduces their length of stay which decreases crowding. There are a variety of ways to see and document the encounter.
I recommend introducing yourself to the patient as the ‘triage doctor” who is going to get their care started. Documentation could vary from not writing a note, to writing a provider triage note (we developed a way to do this in Epic), to writing a brief or full H and P, and then allowing the next doc to take the credit.
How long should I stay after my shift to finish up?
Admitting my own bias, I like to try to stay to finish up my patients and have always believed that staying up to an hour after a shift to complete everything is just part of the profession, as well as feeling ownership for my patients. However, I realize not everyone shares my view, so we’ve surveyed this a couple of times through the years. We’re a high volume RVU compensated place with mostly 8-9 hour shifts.
The general consensus has usually been that it’s reasonable to stay 30-60 minutes after your shift finishing up everything you can. Of course, there are times as your shift ends where you just have a couple of patients to sign out who are waiting on things that will take hours (think MRI, psych or alcohol dispo) and then you sign out. And I completely do that with my own patients as well. Through the years, I’ve also worked with a couple of people who don’t like to sign out anything and routinely stay 90-120 minutes after a shift finishing everything.
What is okay to sign out?
This is another great culture question. Because compensation is involved, sign out has to involve more than rolling the dice (ordering labs and imaging) and then having the next provider see what comes up. A colleague of mine coined the term “good sign out hygiene,” which loosely means taking care of any action that can be done. This breaks down to the following:
- Patient updated on pending doc transition and plan
- Have a clear plan and likely diagnosis
- Try to track down radiology results
- Have discharge instructions done (including prescriptions when possible)
- Make nursing aware of the plan
- Phone calls made to consultants, hospitalist, etc. Get the patient admitted if/when appropriate
- Have a bedside sign out with the oncoming doc so the patient and oncoming doc clearly can hear the same plan
Can the second doc ever take credit?
If the sign outs are pretty clean, then the expectation would be that the second doc rarely takes credit. However, we all know that things can change suddenly and a patient who we thought was going to go home after a test can end up having a cardiac arrest. Rare, but it does happen. Because I want to incentivize docs to pick up charts with the caveat being they need to get the majority of the medical decision making done and have a plan, I tell the second doc that they should feel like they did 51% of the work to take the credit. They should also be comfortable letting the doc they took sign out from that they took the credit.
If you can’t do these things, then you probably didn’t do enough work to earn the credit. I’m happy to take sign out on patient with a CT pending. If the plan is call surgery for an appy or reassess and discharge, that’s only a few minutes of time either way. It’s even easier if the discharge instructions are written and meds are prescribed. Years ago, I had software where I could easily audit how often people were taking credit for patients signed out to them. It turned out that it was generally the same couple of docs who took the credit, but no one did it on a regular enough basis to significantly impact RVU totals.
What goes around comes around
More than 20 years ago, my group at the time went to an RVU model. We were a very tight group with a high acuity patient population. We had decided the first doc would (generally) get the credit but if the second doc had to take over, they could circle their name on the paper chart and that was supposed to trigger the billing company to credit the second doc.
Early on, the culture evolved that we would almost never take credit for a patient. A patient would code, get intubated, CPR, central line, and admitted by the doc who took sign out, and then as part of the update to the first doc, tell them that they documented everything, but left the credit to the first doc.
At $19/rvu, on a 15-20 RVU case, that was a generous gift and docs loved telling the outgoing docs about how many RVUs they contributed to a patient. It was also contagious. It allowed for people to get out when their patients were in a reasonable sign out status, while also knowing that if you took sign out on a patient that crashed, you were going to do the same thing. It was okay because we were all helping each other out.
It can also be contagious if you have a doctor who routinely takes credit for patients when they really should not. This is a citizenship issue that if it’s not rapidly addressed by the medical director, will change how sign out is handled with that individual and create s tears in the cultural fabric.
If you follow the design, most people will be happy with the outcome because they all created the design. However, outliers need to be addressed or the culture will change.
One last caveat
One final thing to consider is how accurate do you think your coding/billing is. I think mine is really good, but not perfect, at coding the level of care and then getting it to the billing team. I’m yet to find a doc who raves about the coding company’s ability to get chart attribution 100% correct when it comes to sign out (or even APP supervision).
For this reason, how you create your template that provides chart attribution (usually a sentence such as I, Michael Silverman, MD, as the first initial provider am the provider of record, etc…) and then work to educate your coding team will take some time. Consistently throughout my career I’ve found that chart attribution is done accurately when there’s only one doc involved, but is very inconsistent when there is a second, or a 3rd, 4th, or 5th like can happen with some psychiatric patients.
Any tricks to help wrap things up at the end of a shift?
Learning how to clean up your board and give a clean sign out is a skill that comes with time and experience. Building relationships and trust with the hospitalists can translate into them taking admissions before you would normally call them (data pending). As long as you have multiple docs leaving at different times, I also think there is value in letting the doc who is about to finish cherry pick their last 60-90 minutes.
If there’s a couple of easy patients they can get seen, that’s great. Also, the outgoing doc shouldn’t’ be picking up complex new patients in the last hour of their shift if a colleague is able to see the patient. Most of that last hour needs to be spent cleaning up your board and finishing up your patients. It’s also a nice touch for the doc coming on in relief to let the outgoing doc know that you still have an entire shift to go and can happily take on what they need you to so they can leave.
Conclusion
Sign out is a part of emergency medicine. However, our incentives don’t always align to get docs out the door. In the interest of reducing burnout, getting out as soon as possible after your shift ends may be beneficial. It is possible to develop a sign out culture based on group input.
This could start by performing a survey to see if common opinions exist for the majority within the group when it comes to the pieces of the puzzle that create our sign out culture. Knowing that we are all accountable to each other for patient flow and care and that how we treat each other will come back to help or haunt us, can help keep people accountable as well.
