• Joshua W Joseph, Bryan A Stenson, Nicole M Dubosh, Matthew L Wong, David T Chiu, Jonathan Fisher, Larry A Nathanson, and Leon D Sanchez.
• Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
• J Emerg Med. 2018 Aug 1; 55 (2): 244-251.

BackgroundTransitions 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.ObjectiveWe sought to determine whether the number of patients a physician receives in sign-out affects productivity.MethodsThis 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.ResultsWe 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).ConclusionsOverall, 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.Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

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