Background: Transitions of care and patient hand-offs between physicians have important implications for patient care. However, what effect caring for signed-out patients has on providing care to new patients and education is unclear. Objective: We sought to determine whether the number of patients a physician receives in sign-out affects productivity. Methods: This was a retrospective cohort study, conducted at an emergency medicine residency program. A general estimation equation was constructed to model productivity, defined as new patients evaluated and relative value units (RVUs) generated per shift, relative to the number of sign-outs received, and training year. A secondary analysis evaluated the effect of signed-out patients in observation. Results: We evaluated 19,389 shifts from July 1, 2010 to July 1, 2017. Postgraduate year (PGY)-1 residents without sign-out evaluated 10.3 patients (95% confidence interval [CI] 9.83 to 10.7), generating 31.6 RVUs (95% CI 30.5 to 32.7). Each signed-out patient was associated with −0.07 new patients (95% CI −0.12 to −0.01), but no statistically significant decrease in RVUs (95% CI −0.07 to 0.28). PGY-2 residents without sign-out evaluated 13.6 patients (95% CI 12.6 to 14.6), generating 47.7 RVUs (95% CI 45.1 to 50.3). Each signed-out patient was associated with −0.25 (95% CI −0.40 to −0.10) new patients, and −0.89 (95% CI −1.22 to −0.55) RVUs. For all residents, observation patients were associated with more substantial decreases in new patients (−0.40; 95% CI −0.47 to −0.33) and RVUs (−1.11; 95% CI −1.40 to −0.82). Conclusions: Overall, sign-out burden is associated with a small decrease in resident productivity, except for observation patients. Program faculty should critically examine how signed-out patients are distributed to address residents’ educational needs, throughput, and patient safety.
Joseph, J. W., Stenson, B. A., Dubosh, N. M., Wong, M. L., Chiu, D. T., Fisher, J., … Sanchez, L. D. (2018). The Effect of Signed-Out Emergency Department Patients on Resident Productivity. Journal of Emergency Medicine, 55(2), 244–251. https://doi.org/10.1016/j.jemermed.2018.05.020