Patient Safety Tip of the Week

August 22, 2017    OR to ICU Handoff Success

 

 

Handoffs are critical points in transitions of care at multiple levels. The complexities of the handoff are no better illustrated than in the perioperative handoff. We know that, in a variety of settings, formalizing handoffs with checklists or other structured tools and processes leads to better transitions and fewer unwanted events.

 

Clinicians and researchers at the Oregon Health & Science University (OHSU) recently reported on outcomes following implementation of a structured process for handoffs between their intraoperative cardiac surgery team and the ICU team (Hall 2017). After implementation of a comprehensive, multidisciplinary, structured handoff process they found a significant reduction in preventable patient complications.

 

A team of intraoperative nurses, critical care nurses, anesthesiologists, intensivists, and cardiac surgeons convened to analyze transfer of care from the intraoperative team to the ICU team. Each subgroup identified specific barriers to continuous excellent care and identified steps that might circumvent those barriers.

 

A scripted handover template was a key to the success of the program. Though the templates did use information from clinical information systems, the focus was on the scripted verbal handoff process. As we noted in our January 29, 2013 Patient Safety Tip of the Week “A Flurry of Activity on Handoffs”, the handoff involves 2 key components: (1) transfer of information and (2) transfer of responsibility. The OHSU structured tool emphasized both. They also adopted a key philosophy we employ in developing checklists or other structured tools – don’t clutter your tool with unimportant information. Similarly, all good handoffs are two-way communication vehicles in which the receiving parties have the opportunity to ask questions and get clarification. Importantly, use of “hear-back” is important and verbal acknowledgement using closed-loop communication of the formal transfer of care was crucial. They provide as an example “My patient is now your patient.”.

 

They used the well-known SBAR (Situation, Background, Assessment, Recommendations) format for each handoff tool that was tailored for specific team members. They provide an example template for the handoff from the anesthesia provider to the critical care team.

 

They measured both total complications and preventable complications before and after the implementation of the structured handoff. Total complications were not different after the implementation but preventable complications were statistically significantly different after the implementation (adjusted odds ratio 0.35). Interestingly, younger patients seemed to benefit more that older patients. The authors attributed this to fewer comorbidities and shorter periods of vulnerability in the younger patients.

 

Anesthesiologist transfer of care time was measured and was less than 2 minutes longer after the new process was implemented and did not likely disrupt OR flow. The study did not include measures of adherence to the handoff process or overall satisfaction with the process, though they noted they anecdotally observed overall satisfaction of surgical, nursing, anesthesiology, and ICU team members.

 

There were probably several keys to success of the OHSU project:

 

Having a solid structured process and tools for handoffs is important in ensuring safety and efficacy of transitions in any industry, particularly in healthcare. The OHSU program is another example of how adding such structure leads to improvement in outcomes. The OHSU team is to be commended for its excellent work in this regard.

 

So make sure you add structure to your handoffs, whether in perioperative or other venues. But don’t lose sight of the critical success factors noted above. Sometimes the making of the tools and processes is as important as the final result.

 

 

 

Some of our other columns on the perioperative handoff:

December 2011            AORN Perioperative Handoff Toolkit

March 2012                 More on Perioperative Handoffs

August 2012                Review of Postoperative Handoffs

February 11, 2014       Another Perioperative Handoff Tool: SWITCH

March 2014                  The “Reverse” Perioperative Handoff: ICU to OR

January 6, 2015            Yet Another Handoff: The Intraoperative Handoff

 

 

Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:

 

May 15, 2007              Communication, Hearback and Other Lessons from Aviation

May 22, 2007              More on TeamSTEPPS

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     Hot Topic: Handoffs

November 18, 2008     Ticket to Ride: Checklist, Form, or Decision Scorecard?

December 2008            Another Good Paper on Handoffs”.

June 30, 2009               iSoBAR: Australian Clinical Handoffs/Handovers

April 25, 2009             Interruptions, Distractions, Inattention…Oops!

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

January 29, 2013         A Flurry of Activity on Handoffs

December 10, 2013     Better Handoffs, Better Results

February 11, 2014       Another Perioperative Handoff Tool: SWITCH

March 2014                  The “Reverse” Perioperative Handoff: ICU to OR

September 9, 2014      The Handback

December 2014            I-PASS Passes the Test

January 6, 2015            Yet Another Handoff: The Intraoperative Handoff

March 2017                 Adding Structure to Multidisciplinary Rounds

 

 

 

References:

 

 

Hall M, Robertson J, Merkel MM, et al. A Structured Transfer of Care Process Reduces Perioperative Complications in Cardiac Surgery Patients. Anesthesia & Analgesia 2017; 125(2): 477-482

http://journals.lww.com/anesthesia-analgesia/Abstract/2017/08000/A_Structured_Transfer_of_Care_Process_Reduces.20.aspx

 

Sample handoff template from the OHSU article.

http://links.lww.com/AA/B703

 

 

 

 

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