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:
- It arose out of a need
perceived by clinicians to improve the transfer of care process and
improve patient safety.
- The processes and tools
were developed by frontline stakeholders so the level of buy-in was high.
- There was significant
education of all involved stakeholders prior to rollout of the new
processes.
- The tools were structured
to emphasize the important information.
- It emphasized both
transfer of information and transfer of responsibility.
- It emphasized two-way
communication and verbal confirmation of understanding.
- It added minimal time to
the transfer process and did not disrupt workflow.
- A measurement process was
put in place to evaluate effectiveness of the program.
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
Sample handoff template from the OHSU article.
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