Page Contents
- 1 WHAT IS POST PROCEDURE SIGNOUT?
- 2 WHY IS GIVING A POST PROCEDURE SIGNOUT SUCH A BIG DEAL?
- 3 SO WHAT EXACLTY DOES THE POST PROCEDURE SIGNOUT LOOK LIKE?
- 4 HOW TO STREAMLINE THE POST PROCEDURE SIGNOUT PROCESS AS THE RECIPIENT (USE SMARTPHRASES):
- 5 HOW TO STREAMLINE THE POST PROCEDURE SIGNOUT PROCESS AS THE DONOR (UPDATE THE LIST):
WHAT IS POST PROCEDURE SIGNOUT?
Generally after most larger scale procedures are conducted (such as a surgery case or some interventional radiology procedures) it is a good practice for someone who was involved in the case to communicate with someone who will be involved in managing the patient’s post procedure care. A very typical situation is when a more senior resident involved in helping with a surgical case will reach out to the floor intern after it is finished to tell the intern about the patient and give relevant information that will influence their post procedure care. This is considered a warm handoff because in theory all of the important information will be transferred to the intern and they will able to provide adequate care to the patient now that they are in charge of managing the patient medically.
This page includes tutorial videos in some of its sections (that demonstrates how to perform these features on the UCSF EPIC EMR system). All of these videos can be found in this folder here.
*While the preview feature for these videos may not work on certain mobile browsers, the videos can still be viewed if they are given time to load/the page is refreshed.
WHY IS GIVING A POST PROCEDURE SIGNOUT SUCH A BIG DEAL?
While there are some smaller procedures that perhaps don’t require such a formal handoff of patient information (technically having podiatry clip a patient’s toenails could be considered a procedure and this page is not referring to situations such as that), in most instances this handoff is essential because the provider managing the patient in the post procedure setting was not present during the procedure and is not aware of key information that can be vital to providing appropriate medical care. In some instances the first time the provider who will deliver the post procedure care may be learning about the patient for the first time during the post procedure signout!
Take the following scenario: a senior resident performs a laparoscopic appendectomy with their attending. The case is relatively simple and uncomplicated so the resident decides not to sign out to the floor intern about the patient given the busy OR schedule and instead goes straight into the next case. The patient arrives in the PACU with orders designating that the floor intern is the first call for any issue and within the hour the patient becomes tachycardia and hypotensive. The intern is paged about this issue and without the signout the intern is caught off guard because they don’t know what the patient is, what their past medical history is, and have no clue what procedure they just underwent or how the procedure went. Putting the intern (or any provider) in this position is considered poor etiquette but worse yet, it can delay the delivery of appropriate patient care which is generally considered unacceptable.
SO WHAT EXACLTY DOES THE POST PROCEDURE SIGNOUT LOOK LIKE?
While the format can be up for debate, a generally acceptable way to provide this handoff is to go by system so that nothing critical is missed. Here is a general outline (it is not completely comprehensive but a good starting point):
Case Details: generally will induced one-liner about patient and specifically want procedure was done. Were there any complications? While all the ins/outs may not always be discussed generally giving estimated blood loss is helpful.
Post Op Check (POC) Time: generally done 4-8 hours after the case ends
Patient By System:
- Neuro: pain control is critical to discuss. What is the patient ordered for regarding pain meds? Doe the attending have a preference on whether or not the patient can get NSAIDs? Does the patient have a PCA or an epidural? Is the pain team involved?
- Cardiovascular: are there specific blood pressure goals? Does the patient have any PMH such as HTN requiring meds (and if so what can be resumed and when?). Ok to give fluids if hypotensive (any CHF history/specific attending preference)?
- Pulmonary: was the patient extubated at the end of the case? Any issues/requiring any respiratory support?
- Renal: was a foley placed? Was it removed at the end of the case (when is patient due to void if yes?), does the patient have IV fluids that are needed? Any labs to follow up on?
- GI: what is the patient’s post procedure diet? When can it be advanced (should it be changed during the post op check)?
- Heme: can patient start/resume DVT prophylaxis? Any home blood thinners that need to be restarted (and when they can be restarted). Any labs to follow up on?
- Endo: does the patient have diabetes/insulin requirements? Do they have other endo PMH?
- MSK: any activity restrictions?
Other:
- Drains: were any placed during the case? Any plan for how long they will stay/when they will be removed (parameters).
- Closure: what types of incisions/access? How were the incisions closed? If with staples when should staples be removed?
- Follow up plan: if patient recovers on trajectory is there any sense in what time frame the attending would like them to return to clinic once they are discharged (and is there any specifics needed for follow up?)
- Other: any other anticipated issues or specifics not covered above.
EXAMPLE OF A POST PROCEDURE SIGNOUT:
Here is an example of a post procedure signout that would be reasonable to give after finish a laparoscopic appendectomy. Realistically this signout is a bit more on the extensive side and may be streamlined given the audience, however in theory the recipient of the singout would have all of the following knowledge.
Case Details: Mr. X is a 25 year old male w/ no remarkable past history now s/p lap happy. The case was uncomplicated, however the appendix was ruptured with no frank purulence seen. EBL minimal (5 ml).
Post Op Check Time: case finished at 10 am. POC @ 4 pm.
Patient By System:
- Neuro: pain medications written for (APAP, OXY). OK to get NSAIDS if needed.
- Cardiovascular: BP goals normotensive. No home BP meds.
- Pulmonary: extubated at the end of case, no respiratory issues.
- Renal: foley placed and removed at the end of case. Void check at POC. On 75 cc LR /hour, continue until tolerating PO diet. Labs in the am.
- GI: keep patient NPO w/ sips until POC. Can be advanced to clears if patient is hungry/doing well at POC. Will advanced further tomorrow.
- Heme: DVT prophylaxis will start this evening (ordered heparin), no home blood thinners. CBC with labs in the am.
- ID: patient to continue IV Zosyn post procedure for total of 4 days given ruptured appendix
- Endo: N/A
- MSK: no activity restrictions.
Other:
- Drains: one RLQ JP drain placed and sutured in place. Can be removed if output < 75 cc for 2 days per attending before discharge or at outpatient visit if higher output.
- Closure: 4 lap sites closed with absorbable suture and and glue.
- Follow up plan: patient can follow up in 2 weeks if recovers on trajectory.
- Other: N/A
HOW TO STREAMLINE THE POST PROCEDURE SIGNOUT PROCESS AS THE RECIPIENT (USE SMARTPHRASES):
As is the case with most things, creating a smart phrase will serve you well as you try to streamline how to receive a post procedure. Using one line the one below (for EPIC) can help remind you in the moment what questions to ask if the person giving you signout overlooks a detail that you would like to know more about. Please refer to the section about making and using smartphrases if needed.
This information can be added directly to the patient list so it can be easily accessible (please refer to the section about patient lists as needed).
Example Smart Phrase To Use (For Epic But Can Be Adapted):
Case: @ORAMBPROCP1@
Post Op Check @ ***
– N: NSAIDS *** Epidural ****
– CV: Blood pressure goals: normotensive
– P: Extubated at end of case
– Renal: foley ***
– GI: diet ***
– HEME: Heparin to start ***
– ID: Abx ***
– ENDO: N/A
– MSK: No activity restrictions
OTHER:
– Drain: N/A
– Closure: absorbable suture/glue ***
– F/u: follow up in clinic ***
– Other: N/A
Video Tutorial
HOW TO STREAMLINE THE POST PROCEDURE SIGNOUT PROCESS AS THE DONOR (UPDATE THE LIST):
The above smart phrase can also be used by the individual who is giving signout. In certain situations it is very efficient and advantageous for the person perfmiring the procedure to update the patient list with all the pertinent signout information, and then direct others to read this section of the updated patient list so that they can be up to date about how to best provide care to the post procedure patient.
Video Tutorial
Page Updated: 06.27.2019