Patient Safety Tip of the Week
January 6, 2015
Yet Another Handoff:
The Intraoperative Handoff
In our many columns on handoffs in healthcare and other
industries (see the full list at the end of today’s column) we thought we had
covered almost every type of handoff. But though we’ve often discussed
perioperative handoffs, there was one we have never discussed: the intraoperative handoff.
Perhaps it is apropos
following last week’s Patient Safety Tip of the Week “Data
Accumulates on Impact of Long Surgical Duration” that we discuss
intraoperative handoffs. However, intraoperative changes in personnel occur not
only during long surgical procedures. Hospitals that have extensive OR
schedules commonly have nurses and anesthesia providers that work in shifts and
those shift changes may take place during even normal duration surgical cases. In
addition, work hour restrictions on physicians in training further increase the
likelihood of transitions in anesthesia care. In fact, a large study at the
Cleveland Clinic found that only 61% of cases had no anesthesia handoffs (Saager
2014). 21% of cases had one anesthesia handoff, 11% had two, 5% had
three, and 3% had four or more handoffs.
We know that
communication failures lead to errors and increased numbers of handoffs may be
associated with adverse patient outcomes in multiple settings. The OR is no
different. In the study by Saager and colleagues (Saager
2014) there was an 8% increase in the composite of mortality and
morbidity for each increase of one handoff. For example, those with 2
transitions had a 17% increase in the composite. Moreover, the increased
occurrence of complications with handoffs affected all the individual
categories of the composite (cardiac, gastrointestinal, bleeding, infection).
Their findings held up after adjustment for multiple potential confounding
factors and in sensitivity analyses. The adverse effect of the handoffs was
similar for attending anesthesiologists, directed residents, and CRNA’s. While
the association does not prove causation, the association is nevertheless
striking and implies the intraoperative handoffs were contributory factors to
adverse outcomes. The Cleveland Clinic at the time of the study did not have a
formal structured handoff process for intraoperative handoffs. The authors
suggest adoption of formal protocols, including checklists, as a potential way
to reduce the adverse impact of intraoperative handoffs on patient outcomes.
A recent study from the Massachusetts General Hospital assessed
the impact of an electronic checklist
on intraoperative handoffs between anesthesia providers (Agarwala
2015). The authors developed a checklist of information to be
transferred at end-of-shift handoffs. Many of the items in the checklist were
pre-populated from their anesthesia information management system (AIMS) and
could be accessed easily by pressing a popup button on the AIMS screen. Use of
the checklist was voluntary. The authors went to the OR and observed the
intraoperative handoffs and assessed transfer of information using a structured
assessment tool. They compared those handoffs that used the checklist against
those that did not. They found significant increases in discussions about
several medications (prophylactic antibiotics, vasopressors, and antiemetics) and increased information about intravascular
lines and fluid balance. (Several other items also showed upward trends, though
they did not reach statistical significance, perhaps because of small sample
size.) Moreover, they also assessed whether the receiving anesthesia staff was
able to recall accurately critical patient information passed on during the
handoff. There was a significant improvement in the anesthesiologist knowing
the antibiotic given and timing of the next dose. Similarly, those using the
checklist were more able to recall the neuromuscular blocking agent used and
the amount of fluids administered. In addition, introduction of the incoming
anesthesiologist to the rest of the OR team increased from just 3% to over 50%.
And discussion about potential areas of concern and post-op plan increased from
less than 50% to over 90%. Providers of multiple types (anesthesiologists,
CRNA’s, residents and fellows, faculty) were generally satisfied with use of
the electronic checklist and use of the checklist, which was voluntary,
increased to 74% by 8 months after its introduction.
Notably, using the electronic checklist did not increase the
time needed for the intraoperative handoff. In fact, multiple providers
responding to a post-implementation survey noted that the handoff felt less
rushed when using the checklist.
Though the study did not measure impact of the improvements
on patient outcomes, one would anticipate that the improvements could likely
reduce untoward patient outcomes. Some of the potential errors that might arise
from inadequate intraoperative handoffs include failure to give second doses of
prophylactic antibiotics when needed, failure to reposition patients leading to
compressive neuropathies, medication errors, failure to fully reverse
neuromuscular blocking agents leading to post-op respiratory complications, and
others. And intraoperative change in OR staff, particularly nursing, has been a
risk factor in retained surgical items.
The Agarwala and Saager studies only addressed permanent (end-of-shift)
handoffs. They did not address temporary handoffs like those that occur when
anesthesiology staff go on breaks (typically 15-30 minutes). It’s important we
don’t ignore the latter. Saager et al cite several
studies from the 1970’s and 1980’s that concluded that breaks for anesthesia
providers do not influence patient outcomes. But, anecdotally, we’ve seen
multiple cases where such intraoperative handoffs were likely factors in
adverse patient events. When an OR team member is gone for a short period of
time and then returns, there is a natural tendency to think not much likely
changed while he/she was gone and such assumptions may be disastrous.
Tan and Helsten previously
described development of an AIMS-based electronic checklist for anesthesia
handoffs at Barnes-Jewish Hospital and Washington University in St. Louis (Tan
2013). Their tool included several useful features and visual prompts to facilitate the handoff.
First, the tabs containing the various checklist items took up only a portion
of the computer screen, allowing critical patient information to still be
visible. Like the electronic checklist developed by Agarwala
and colleagues, they pre-populated
checklist items where possible. But some items are difficult to abstract from
the electronic record and need to be discussed. For example, “stage of surgery”
is displayed in red with the word
“DISCUSS” to prompt the two anesthesia providers to discuss the stage of
surgery. There are also tabs for items like trends in vital signs, oxygenation,
acute events (anesthetic or surgical), and the analgesia plan that should
prompt specific discussion. And lastly, another tab for details of fluid
management and lines.
Some unique issues arise at academic centers where attendings are supervising residents and fellows or sites
where attendings may be supervising CRNA’s. At
Cincinnati Children’s Medical Center a quality improvement project improved the
intraoperative anesthesia handoff (Boat 2013).
The quality improvement team consisted of pediatric anesthesiologists and
CRNA’s with input from the IT department. They discussed key elements of a good
handoff and the various components and analyzed aspects of their current
handoff process. One barrier they identified was that the attending
anesthesiologists often were not present in the OR when they did their handoff.
Such handoffs were often done in the hallway, anesthesia lounge, main desk, or
even on the phone. That left the in-room anesthesia provider (CRNA or
resident/fellow) temporarily unsupervised. More important, it often left the
in-room anesthesia provider out of the loop (i.e. they did not know what was
discussed at the handoff). They developed a standardized checklist and a
campaign to use the checklist and ensure the handoff was done in the OR, both
done over multiple PDSA cycles. In addition, anesthesiologists who failed to
comply with the new process received an email notifying them of the failure and
a follow up phone call to ascertain the reason for the failure and reinforce
the importance of the process. Compared to only 20% compliance with all
elements of the handoff and performance of the handoff within the OR before the
project, compliance increased to 100%. Their IT team later incorporated the
handoff checklist into the intraoperative electronic medical record. That both
allowed for documentation of the handoff and further encouraged compliance with
the handoff protocol. In addition to standardization of the process with a
checklist, key drivers were use of the “team huddle” approach with in-room
anesthesia providers and the supervising attendings
and ensuring situational awareness of the intraoperative environment at the
time of the handoff. Having as “early adopters” those attendings
who had previously experienced the impact of poor handoffs helped overcome the
barrier of other attendings not recognizing the need
for change.
Simulation has
also been used to improve intraoperative handoffs. In a pilot study (Pukenas
2014) 10 anesthesiology residents participated in a one-day
simulation-based handoff course. Each resident repeated simulated handoffs to
deliberately practice with an intraoperative handoff checklist. One year later,
7 of the 10 residents participated in simulated intraoperative handoffs.
Initially, the overall communication failure rate, defined as the percentage of
handoff omissions plus errors, was 29.7%. After deliberate practice with the
intraoperative handoff checklist, the communication failure rate decreased to
16.8%, and decreased further to 13.2% one year after the course.
Screenshots of the electronic checklists are provided in the
full text of the Tan, Agarwala, and Boat papers.
Another important point in the Agarwala study that
we’ve made in our numerous columns on checklists: keep your checklists short! When they developed their electronic
checklist they purposely kept the number of items to a minimum.
Today’s column has focused on the intraoperative handoff as
it pertains to anesthesia staff. Intraoperative handoffs pertaining to nursing
in the OR are beyond the scope of today’s column. But we refer you to the great
resources AORN has on perioperative handoffs (AORN
2012).
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”
References:
Saager L, Hesler
BD, You J, et al. Intraoperative transitions of anesthesia care and
postoperative adverse outcomes. Anesthesiology. 2014; 121(4): 695-706.
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1921547&resultClick=3
Agarwala AV, Firth PG, Albrecht
MA, et al. An Electronic Checklist Improves Transfer and Retention of Critical
Information at Intraoperative Handoff of Care. Anesth
Analg 2015; 120(1): 96-104
Tan JA, Helsten D. Intraoperative
Handoffs. International Anesthesiology Clinics 2013; 51(1): 31-42 Winter 2013
http://journals.lww.com/anesthesiaclinics/Citation/2013/05110/Intraoperative_Handoffs.4.aspx
Boat AC, Spaeth JP. Handoff
checklists improve the reliability of patient handoffs in the operating room
and postanesthesia care unit. Pediatric Anesthesia
2013; 23(7): 647-654
http://onlinelibrary.wiley.com/doi/10.1111/pan.12199/abstract
Pukenas EW, Dodson G, Deal ER, et
al. Simulation-based education with deliberate practice may improve
intraoperative handoff skills: a pilot study. J Clin Anesth 2014; 26(7): 530-538
http://www.jcafulltextonline.com/article/S0952-8180%2814%2900214-1/abstract
AORN (Association of periOperative
Registered Nurses). Patient Hand Off Tool Kit. 2012
http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/
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