What’s New in the Patient Safety World

March 2014



·        The “Reverse” Perioperative Handoff: ICU to OR

·        New ASGE Endoscopy Safety Guidelines

·        39-Week Campaign Challenged in Repeat C-Sections

·        Another Strike Against Hyperoxia




The “Reverse” Perioperative Handoff: ICU to OR



We’ve highlighted perioperative handoffs in several columns (see our Patient Safety Tip of the Week for February 11, 2014 “Another Perioperative Handoff Tool: SWITCH” and our What’s New in the Patient Safety World columns for December 2011 “AORN Perioperative Handoff Toolkit” and March 2012 “More on Perioperative Handoffs”). But those have mostly dealt with handoffs of patients coming out of the OR or PACU.


Now a new study highlights vulnerabilities in handoffs in the opposite direction: from the ICU to the operating room (Evans 2014). The authors cite several case vignettes of problems with patient care emanating from poor handoffs as patients go to the OR from the ICU. They note the inability of the patient to provide history in many cases (altered mental status, sedation, intubation, etc.) increases the need for a detailed clinician-to-clinician handoff.


They also note that most of the standardized handoff formats we’ve discussed in our many columns on handoffs (see list below) don’t work well for this “reverse” perioperative handoff. So they developed their own checklist for this type of handoff and this could be completed on paper or electronic format. This checklist includes not only those items you’d expect in a handoff (demographics, current illness, past medical history, medications, allergies, lab results, etc.) but also specifics about various lines and catheters, DNR status, hemodynamic trends, airway problems, ventilator settings, antibiotic regimens, infusions, cardiac implantable devices, etc.


The authors appropriately note that a mandatory verbal handoff still needs to take place. We’ve stressed on numerous occasions that the combination of written and verbal handoff almost always outperforms handoffs that only use either the written or verbal format. Again, we stress that performing the verbal handoff in a venue free of distractions and interruptions works best and that handoffs are “two-way” where adequate opportunity must be present for the recipient to ask questions and get clarifications.



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









Evans AS, Yee M-S, Hogue CW. Often Overlooked Problems with Handoffs: From the Intensive Care Unit to the Operating Room. Anesthesia & Analgesia., POST AUTHOR CORRECTIONS, 9 January 2014






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New ASGE Endoscopy Safety Guidelines



The American Society for Gastrointestinal Endoscopy has revised its guidelines for safety in the gastrointestinal endoscopy unit (Calderwood 2014). The guideline focuses on multiple facets of patient and staff safety: facilities, staffing, infection control, and sedation.


The section on facilities focuses on ensuring adequate space and equipment are provided to facilitate the procedures, patient recovery, storage, and infection control measures. More complex procedures should be assigned to larger procedure rooms with space for more specialized equipment and additional staff. One thing we like is their position that there should be a written plan for traffic patterns within the unit.


The section on infection control discusses hand hygiene, use of PPE, safe medication practices, and topics related to safe handling of potentially contaminated equipment, reusable medical equipment, and terminal cleansing issues. It is recommended that a qualified staff member must be responsible for implementation of a specific infection prevention plan. The section on safe medication practices focuses heavily on infection prevention.


They have recommendations for staffing before, during and after endoscopic procedures and for qualifications and training of staff.


Like any procedure, a “timeout” for verification of correct patient and procedure is necessary. Actual marking of the site is not required for endoscopic procedures because endoscopy does not involve lateral right-left distinction levels such as those found in spinal procedures or those done on multiple structures such as fingers or toes. Before starting an endoscopic procedure, the patient, staff, and performing physician should verify the correct patient and procedure to be performed.


The section on sedation discusses equipment, medications, monitoring, and staffing. Regarding personnel during moderate sedation, a nurse should monitor the patient and can perform interruptible tasks. If more technical assistance is required, a second assistant (nurse, licensed practical nurse [LPN], or unlicensed assistive personnel [UAP]) should be available to join the care team.


The ASGE position on use of capnography is that there is inadequate data to support the routine use of capnography when moderate sedation is the target. Our own warning is that the “target” of moderate sedation is often overshot and some patients inadvertently receive deep sedation. While the evidence base for use of capnography in this setting may be limited, it only takes one case of a disaster related to oversedation to destroy whatever other good work you’ve done. Capnography is rapidly becoming a standard of care whenever patients are being given intravenous sedation or opioids.


Lastly, they have a section on management of emergencies and need for a plan for transfer of patients to higher level facilities where necessary.






Calderwood AH, Chapman FJ, Cohen J, et al for the ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force. Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointestinal Endoscopy 2014; article in press published 30 Jan 2014






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39-Week Campaign Challenged in Repeat C-Sections



Just as The Leapfrog Group has released its most recent report showing dramatic reductions in medically unnecessary C-sections and inductions before 39 weeks, another study raises questions about the ideal time for repeat C-sections in patients having multiple C-sections.


For several years now there has been a campaign to reduce non-medically indicated labor inductions prior to 39 weeks of gestation (see our February 8, 2011 Patient Safety Tip of the Week “Inducing Too Early”). That campaign, originally sponsored by the March of Dimes, Leapfrog Group, California Maternal Quality Care Collaborative and the California Department of Public Health; Maternal, Child and Adolescent Health Divisions, and later adopted by the American College of Obstetricians and Gynecologists (ACOG) highlighted the risks to newborns delivered prior to 39 weeks of gestation and provided tools to help avoid “elective” inductions prior to 39 weeks. We’ve been on board for that campaign.


The Leapfrog Group has been publicly reporting hospital rates since 2010, though hospital reporting has been voluntary. This month The Leapfrog Group published the rates for 2013 and they demonstrate a continued striking improvement trend. The national average of 4.6 percent in 2013 stands in sharp contrast to the national average of 17 percent in 2010. Moreover, in 2013, 71 percent of the reporting hospitals met Leapfrog’s early elective deliveries target rate of less than 5 percent, compared to 46 percent of hospitals in the 2012 survey.


While the public reporting likely got more hospitals involved, the real reason for the improvement has been that hospitals have done a good job educating both pregnant women and providers about the benefits of avoiding early induction. Most hospitals we’ve worked with have simply not allowed scheduling of elective inductions in cases lacking a medical indication (though simply requiring the provider to give a medical reason and then doing audit and feedback also successfully reduced rates of inappropriate early inductions).


But a new study, presented as an abstract at the 2014 Society for Maternal-Fetal Medicine Annual Meeting, seems to challenge delaying repeat C-sections in some women who have had prior C-sections (Hart 2014). The researchers studied over 6000 women with prior cesarean section deliveries who lacked medical or obstetrical indications for early delivery during their current pregnancy. They found that for women with 2 prior cesarean section deliveries the risk of adverse maternal outcomes increased three-fold with a concomitant increase in the risk of adverse perinatal outcomes between 38 to 39 weeks. In women with ≥ 3 previous cesarean section deliveries, the risk of maternal complications increased four-fold between 37 to 38 weeks. They conclude that their findings suggest the optimal time for scheduled delivery of women with 2 previous cesarean section deliveries is between 38 wks 0 and 38wk 6 days and between 37 wks 0 and 37 wks 6 days for women with ≥ 3 previous cesarean section deliveries.


It’s not the first time there has been a challenge to the campaign. In our October 2013 What’s New in the Patient Safety World column “Challenging the 39-Week Campaign” we noted a study by researchers at the Oregon Health & Science University (Darney 2013) that found no difference in the risk for severe lacerations, operative vaginal delivery, perinatal death, NICU admission, respiratory distress, or macrosomia between the groups at any week studied. There was an increased risk of hyperbilirubinemia in infants with inductions lacking medical indication at 37 and 38 weeks of gestation and an increased risk of shoulder dystocia at week 39.


Note also that another study (Stock 2012) had found that elective induction of labor between weeks 37 and 40 was associated with decreased odds of perinatal mortality compared to expectant management and did not increase the risk of cesarean sections. Admissions to a neonatal unit were, however, increased in those cases having elective induction prior to 41 weeks.


The studies highlight the importance of ensuring that recommendations are evidence-based. The Hart study would seem to indicate that adherence to the 39-week “rule” might actually have some unintended consequences in some cases.







The Leapfrog Group. Hospital Rates of Early Scheduled Deliveries. March 2014




Hart L, Refuerzo J, Sibai B, Blackwell S. Abstract 40: Should the “39 week rule” apply to women with multiple prior cesarean deliveries? American Journal of Obstetrics & Gynecology 2014; 210(1 Supplement): S27, January 2014




Darney BG, Snowden JM, Cheng YW, et al. Elective Induction of Labor at Term Compared With Expectant Management: Maternal and Neonatal Outcomes. Obstetrics & Gynecology 2013; published ahead of print 6 September 2013




Stock SJ, Ferguson E, Duffy A, et al. Outcomes of elective induction of labour compared with expectant management: population based study. BMJ 2012; 344: e2838 Published 10 May 2012






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Another Strike Against Hyperoxia



In several of our prior columns on use of oxygen (see our Patient Safety Tips of the Week April 8, 2008 “Oxygen as a Medication” and January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”) we have commented that in the past we often routinely gave oxygen to patients with myocardial infarction or stroke. But such use was more reflexive in nature and not evidence-based.


In our What’s New in the Patient Safety World columns for July 2010 “Cochrane Review: Oxygen in MI  and February 2012 “More Evidence of Harm from Oxygen” we discussed the lack of evidence to support the routine use of oxygen in the acute MI patient and the possible deleterious effects in these and some other cardiac patients.


Now another new study (Rincon 2014) shows that hyperoxia was independently associated with in-hospital death as compared with either normoxia or hypoxia in ventilated stroke patients admitted to ICU’s. Their data underscore the need for studies of controlled reoxygenation in ventilated critically ill stroke populations. They recommend that, in the absence of results from clinical trials, unnecessary oxygen delivery should be avoided in ventilated stroke patients.


As we’ve recommended before, hospitals need to look at their existing protocols (and actual practices) for managing a variety of medical conditions where oxygen use may be considered. How many of you have standardized order sets that directly (or indirectly by poor use of checkboxes) encourage inappropriate use of oxygen in MI or stroke patients? Going back to our Patient Safety Tips of the Week April 8, 2008 “Oxygen as a Medication” and January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!” we strongly support facilities doing audits of their oxygen practices. You’ll probably be surprised at the opportunities you uncover to improve practices (and save money at the same time!).


And don’t forget that in many cases high doses of oxygen are administered by the pre-hospital emergency response teams. Making them aware of the potential dangers is also important.








Rincon F, Kang J, Maltenfort M, et al. Association Between Hyperoxia and Mortality After Stroke: A Multicenter Cohort Study. Critical Care Med 2014; 42(2): 387-396






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Print “March 2014 What's New in the Patient Safety World (full column)

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

Print “March 2014 New ASGE Endoscopy Safety Guidelines

Print “March 2014 39-Week Campaign Challenged in Repeat C-Sections

Print “March 2014 Another Strike Against Hyperoxia



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