Table.

Themes, subthemes and discussion of ED adaptation of I-PASS, a mnemonic (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) for patient handoff.

Themes and subthemes	Representative quotes	Discussion for ED adaptation
Time
Time + order	“I think we need to do it at the end of all the patients and have it be very brief, otherwise our sign out will be too long” “A disadvantage to I-PASS would be a longer signout, due to the mnemonic as a whole or because of a specific aspect”	Summary by Receiver should wait until all the patients’ handoffs have occurred and should be very brief. Important to engage and educate residents and staff to reinforce goal of I-PASS and consider timing previous signout and comparing to I-PASS signout.
Time as environment	“I think we need a blocked out time for sign out – it is already a long process because we are constantly being interrupted by nursing staff, which throws everything off and then things get missed… maybe the signing out team goes to a separate area for signout so we aren’t interrupted”	Important to engage and include nursing staff in the handoff process in order to minimize interruptions.
Time + safety	“Need uninterrupted time in quiet space to allow for safer transition handoffs”	Important to optimize staffing and space to provide protected time for handoff.
Order
Storytelling – how	“For patient summary, we can keep it shorter – for example, we don’t need the full hospital course, just a brief synopsis of ED care”	Shorten Patient Summary for ED setting and lead with disposition to help frame presentation.
Storytelling - content	Benefit of I-PASS is “pointed action plan rather than nebulous recommendations” “Allows the listener to frame what their role in the patient’s care will be: to ‘watch’, to ‘follow up labs and dispo’ or ‘start from scratch’”	Agreement that the I-PASS system helps to provide specific items to follow up and plan. Agreement that I-PASS system provides a useful structure to frame the oncoming team’s role in the patient’s care. Assists the team to create a shared mental model.
Culture
Ways of thinking	“I-PASS is more aligned with ED thinking”; “[previous process] never made sense to me. I-PASS seems very similar to what I am doing now without any particular training” I-PASS as “more like real life what we need to know; less artificial”
Ways of learning	The last two S’s in your [mnemonic] are meaningless without seeing the patient. You cannot truly know what is ‘going on’ if you have not laid eyes on it.” “Training people. Sticking to the script”; “Everyone learning it and getting acclimated”; “Forcing providers to consistently use it”; “Everyone adopting or trying to give sign out in this way to someone who doesn’t like it” “Learning a new system is usually inefficient until all users are up to speed.”
Reticence to change	“[I-PASS is] not helpful at all… Don’t need another mnemonic”; “Don’t really like it that much”; “Don’t really like mnemonics. Would not use it”. “Dislike either [mnemonic device]. Like to just tell about the patient. Say what is important” “culture of individuality, old habits, hard to practice and implement change when you’re already tired”
Acceptance of change	“ I like it. It seems easy and useful”; “I-PASS would need to demonstrate better utility than SBAR*” “Seems reasonable to try, as long as it doesn’t increase duration of the sign-out”
Environment	“My concern isn’t the mnemonic, honestly. It’s everything else. (Frequent interruptions, people insisting on giving prolonged ‘one liners’ on patients who are discharged, etc.)”
How tools are used	“I feel like [I-PASS] should have a written component though… by the passer or the receiver. With multiple patients often being handed off, its easy to cross wires with plans” “I-PASS would need to demonstrate better utility than SBAR*, but even so, may not be used properly”; or, inability to fully integrate existing tools into current culture: “I like it [I-PASS] and think you could make it work if it was incorporated into our system rather than making an extra ‘note’ or boxes that you have to fill out”	Necessary to have both a verbal and written structure and process for the I-PASS system in the ED. Success depends on education, training and reinforcement of any handoff process, especially when new residents start the year. Engage faculty with the handoff process. Incorporation of I-PASS into the existing unique culture and environment can be important for acceptance of new process.
Team Dynamics and interactions	“The last two letters however force the idea of recapping key points.” I-PASS as an advantage because it “in-corporates… closed loop communication”; “I-PASS provides clear communication”

SBAR, Situation Background Assessment Recommendation.