In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” we noted that a structured communication format or tool is important but that the exact tool or format needed will vary by the nature of the handoff so “one size does not fit all”. Particularly in the perioperative setting, the nature of handoffs is often very different from the resident-to-resident or nurse-to-nurse handoffs done on a medical unit.
We highlighted the AORN toolkit in our December 2011 What’s New in the Patient Safety World column “AORN Perioperative Handoff Toolkit”. It focuses on standardized handoff communications and stresses that handoffs should be held where there is adequate time, with minimal distraction, and allow for interactive discussion where the recipient is able to review all relevant material and has ample opportunity to ask questions. They stress the importance of using language that is clearly understood by all parties and use of “read-back”, “repeat-back” and “hear-back” to ensure that communication is understood by all parties. They also stress the importance of not only passing on information during a handoff but also passing on responsibility for care of the patient.
A new systematic review of the literature (Segall 2012) found of dearth of studies on postoperative handoffs that offered interventions and even fewer that measured the impact of recommended interventions. They describe numerous barriers to effective communication at such handoffs, including distractions (eg. performing other clinical duties at the same time), lack of participation by all team members, incomplete transfer of information, lack of structure or consistency, poor standardization and others. They do note strategies recommended, including the “sterile cockpit” concept, completing urgent care tasks prior to the handoff, having all team members present but ensuring only one person talks at a time, using structured tools (checklists, protocols), use of various support documentation, and providing enough time for questions and clarification. They list the types of information that must typically be communicated during such postoperative handoffs and note that automated population of handoff checklist from electronic health records might make handoffs more efficient. They note that poor handoffs and poor patient outcomes go hand in hand but raise the interesting question as to which comes first, i.e. do the poor handoffs lead to the poor outcomes or do unstable patients lead to poor handoffs. The latter possibility certainly raises the issue of structuring such handoffs to ensure complete communication despite unstable patients. Good review of the current status of postoperative handoffs and good bibliography. Interestingly, all 4 of the studies that included an assessment of the impact of a handoff intervention were on the same kind of population – pediatric cardiac patients. That raises the question of how generalizable the results are. Tells us, however, that there is considerable room for improvement and further research.
Recall that our March 2012 What’s New in the Patient Safety World column “More on Perioperative Handoffs” highlighted work from Johns Hopkins that took the perioperative handoff to a new level (Petrovic 2012a). That handoff process is a true multidisciplinary and interdisciplinary handoff, designed for transfers of patients from OR to PACU or PACU to ICU, etc. It consists of a protocol and series of checklists. The protocol has 5 steps and takes place with the entire team in the patient room. The first step involves identifying the patient and introducing all members of the team. Step 2 involves “transfer of technology” (monitors, lines, etc.). Subsequent steps are checklist-guided handoffs by the surgeon, anesthesiologist, and OR nurse. Each of the latter 3 handoffs concludes with a statement of “anticipatory guidance” by the presenter, stating what he/she is most concerned about regarding the patient. Plenty of time is provided for members of the receiving team to ask questions and clarify items. The handoff formally concludes with an announcement “the handoff is now complete”. The article includes copies of the checklists and protocol and delineates the steps you need to go through to implement the protocol. The authors also have prepared a multimedia toolkit for those who want to implement the protocol at their institutions.
In a companion paper, they also have published some outcome measures from that protocol and process (Petrovic 2012b). After the protocol's implementation, the presence of all handoff core team members at the bedside increased from 0% at baseline to 68%, the percentage of missed information in the surgery report decreased from 26% to 16% , and handoff satisfaction scores among intensive care unit (ICU) nurses increased from 61% to 81%. On average, the duration of handoff increased by 1 minute.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “ ”
May 22, 2007 “ ”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “ ”
November 18, 2008 “ ”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “ ”
April 25, 2009 “ ”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
AORN. Perioperative Patient 'Hand-Off' Tool Kit.
Segall N, Bonifacio AS, Schroeder RA, et al. Review Article: Can We Make Postoperative Patient Handovers Safer? A Systematic Review of the Literature
Anesth Analg 2012; 115: 102-115; published ahead of print April 27, 2012
Martinez EA, Aboumatar H. Implementing
a Perioperative Handoff Tool to Improve Postprocedural Patient Transfers. Joint
Commission Journal on Quality and Patient Safety 2012; 38(3): 135-4AP(-130)
Petrovic MA, Aboumatar H , Baumgartner WA. Pilot Implementation of a Perioperative Protocol to Guide Operating Room–to–Intensive Care Unit Patient Handoffs. J Cardiothorac Vasc Anesth 2012; 26(1): 11-16