Combined Handover Presentation

Process Improvements and Healthcare IT:

OR-to-PACU Transfer-Of-Care

Aalap Shah, MDChair, Surgical Services Committee

UW Housestaff Quality and Safety Committee

Mentor: Thomas Varghese, MD

Handover - Definition“Transfer of information,

responsibility, and authority from one health care provider to another.”

BackgroundTransfers of information represent

high-risk, error-prone patient care episodes1

Relationship between handovers and patient outcomes2,3

Standardization with protocols or checklists are recommended1,4

1Segall, 20122Greenberg, 20073Kulger, 20024Moller, 2013

Background• Gawande 2003

• Review of 100 incident reports from 45 surgeons• 60% of events in OR+PACU• 43% due to communication failure; of

which 2/3 were due to inadequate handoffs.

• Joint Commission 2006 –o Requirement for standardized handoff

approach at accredited institutions• Joint Commission + WHO 2008 –

o Highlighted role for standardized processes to identify and reduce handoff-related errors

• Institute of Medicine 2008 – o Increased focus on handoff processes to

improve patient safety• ARRA 2009 –

• $19.2B (of $>170B) stimulus package allocated to Healthcare IT

Background

Current Obstacles at HMCLack of institutional standardization5,6

◦When should the handoff take place No established order

◦Who should be present Surgeon presence not required until recent

◦How the handover should be recorded Purple Sheet (UWMC), Pieces of Paper (HMC) No concurrent, matching documentation of handover

in EHR◦Where should handover process improvements

be targeted UW OR-ICU, HMC OR-ICU, but not elsewhere

5Chen, 20096Catchpole, 20077Smith, 20088Joy, 20119Nagpal 2011

Current Obstacles at HMCPoor Quality7

◦Organization◦ Interruptions8

◦Absence of essential personnelInformation omission9

◦What information is relevant to the patient & case

Lack of anticipatory guidance8

HMC Postoperative

Un-planned

ICU

1. Bay Assigned2 Arrive in PACU,

Handover- Attach O2- Monitors- Positioning- MD: Verbal

handoff, +/- anticipatory guidance, +/- surgical plan

- RN: SSHR filled

Stable for Dispo?

(Aldrete)***

Monitor in PACU

CODE/still unstable?

Home

Floor Txor

Planned ICUOrders in?

Bed avail?

Yes! To floor

Yes! Go home

Outpt Rx ready?

No No

Limbo

Limbo

RN-RN hand-over

RN-RN hand-over

Post-Handover- Providers leave

immediately

- RN checks post-op orders afterwards,

pages if incomplete

- Pt. wakes up, +/- pain, +/- PONV, +/- cardio-respiratory

issues

- Call for additional post-op orders or

dose changes

Additional MED-SURG Admission Guidelines

****

PASS

Project Goals

Process standardizationCreate anticipatory guidance

Control the settingIncrease Stakeholder Involvement

Improve Information Reporting Interventions:

1. Visual Checklist (MD/CRNA) large/laminated, at each PACU bay

2. PowerNote Checklist (RN) becomes part of the EHR matches the visual checklist

Ultimate Goal:Replace Nursing Written Handover Notes with Electronic

Documentation

Study DesignProspective interventional study with

pre-/post-implementation comparison◦ Interventions:

Standardized transfer of care checklist (March 2015) Electronic checklist in EMR (April 2015)

Setting: HMC PACU West

Study DesignAuditors observe post-operative

handovers in PACU West using Audit Form◦ Information compared against Anesthesia

Record◦ Information collected and stored in REDCap

Post-Handover, the PACU RN voluntarily completes the Handoff CEX

Inclusion/ExclusionInclusion Criteria

◦Patients receiving elective surgery AND planned post-operative inpatient admission to HMC

Exclusion Criteria◦Unplanned ICU admits from the OR

Outcomes/AnalysisOutcomes:

o Utilization: checklist use, personnel presento Effectiveness: information omission, interruptions,

provider contact, duration, discharge ready time (Student Audits)

o Knowledge Transfer (RN Surveys)o Domain Assessment (Handoff CEX)

Pre-post analysis for intervention utilization and effectiveness

Data Collection Tools

Audit Form Handover CEX

CEX + Phone Calls (n=201)PRE-IMPLEMENTATIONJanuary-March 2015

HMC OR-to-PACU Transfer-Of-Care

QI Initiative

UW Housestaff Quality and Safety Committee

PRE-IMPLEMENTATION

Pre-Study Data: RN survey (HMC)Knowledge transfer% respondents who occasionally,

rarely, or never knew the following:Post-operative plan – 43%Intra-operative events – 42%Patient-specific or procedure-specific call triggers – 83%

Pre-Study - Omission of Information

How often do you know who to call?

Very often Often Occasionally Rarely Never0%

5%

10%

15%

20%

25%

30%

35%

40%

Pre-Study - Anticipatory Guidance

How often do you know who to call?

Very often Often Occasionally Rarely Never0%

5%

10%

15%

20%

25%

30%

35%

40%

45.2%

Pre-Study - Anticipatory Guidance

Baseline Data: PACU RN survey

Call parameters for vitals

Call parameters for labs

Dressing change instructions

PO status

Activity status

Discharge/inpatient medications

Discharge/inpatient orders

Other

0% 10% 20% 30% 40% 50% 60% 70% 80%

If you had questions regarding patient care, what where they about?

Pre-Study - Omission of Information/Anticipatory Guidance

Power Analysis

Fixed sample size (n = 31), power 80%, alpha .05

Outcome variable Pre- Post-intervention (goals)Mean # calls/pages per patient 1.8 (1.3) 0.9 (relative 50% decrease)

‘Very often’ given post-op management plan (i.e. pain, wound care)

13.3% 48% (delta 34.7)

‘Very often’ given patient/procedure specific call triggers

3.3% 33% (delta 29.7)

‘Very often’ know who to call 19.4% 56% (delta 36.6)

Audit Data (n=76)PRE-IMPLEMENTATION January-March 2015

UW Housestaff Quality and Safety Committee

PENDING

PRE-IMPLEMENTATION

HMC OR-to-PACU Transfer-Of-Care

QI Initiative

Data Analysis – Audit Forms

Surgeon attendance: 57.0%Handover time: 3.8 +/- 0.3

minutesPACU LOS : 90.2 +/- 43.4

minutes(Phase 1 Admit Discharge Ready)

Call Triggers:2.5%Resident Contact Info: 1.2%

PRE-IMPLEMENTATION

Data Analysis – Audit Forms

Patient ID: 62.0%Medical History: 86.1%Diet: 11.4%

PONV: 41.0%Antibiotic Last Dose: 29.1%Pain Management Plan: 54.4%IV Access: 67.1%

PRE-IMPLEMENTATION

CEX + Phone Calls (n=201)PRE-IMPLEMENTATIONJanuary-March 2015

HMC OR-to-PACU Transfer-Of-Care

QI Initiative

UW Housestaff Quality and Safety Committee

PRE-IMPLEMENTATION

Data Collection ToolsPRE-IMPLEMENTATION

Data Analysis – Handoff CEXHandoff CEX Scores and Phone Calls –

Descriptive Statistics

PRE-IMPLEMENTATION

PRE-IMPLEMENTATION

PRE-IMPLEMENTATION

Data Analysis – Handoff CEX

A statistically significant difference was seen between Q1 (Setting) and Q3 (Communication) (p=0.03)

PRE-IMPLEMENTATIONPRE-IMPLEMENTATION

Data Analysis – Handoff CEXImpact of Auditor Presence on Handoff CEX Scores

Handoff CEX scores for provider-PACU RN interactions were greater in Group 2 handovers (i.e. with medical student auditors present) than in Group 1 handovers (i..e no observers)

PRE-IMPLEMENTATION

Chief Resident Survey – Current StateENT

◦Type of diet, location of incision, facial nerve monitoring, toradol

Neurosurgery◦Drains, VACs, intra-operative complications,

‘primary service doing orders’Orthopedics

◦ROM, weight bearing, positioning, pain management, drains & output call triggers

Checklist - OutlineIntroductionsSurgeon

◦ Surgical course◦ Post-operative management plan

Anesthesia◦ Anesthetic course◦ Current state/goals of care

Summary of plan & anticipatory guidanceQuestions/concerns

Checklist – Visual All Transfer-of-Care Participants (v3.0)

Checklist – Electronic PACU Nurse (v2.0)

Chief Resident Survey – Proposed Checklist

Specialty RepresentationCardiothoracic Surgery 1

Neurosurgery 1

General Surgery 4Plastic Surgery 1

Ophthalmology 1

Vascular Surgery 1

Anesthesiology 3

Otolaryngology 2

Orthopedic Surgery 2Urology 2

Chief Resident Survey – Proposed Checklist

Descriptive Statistics

Please rate 1-5 (1=strongly disagree; 5=agree)

Content - is what you want on here?Anticipatory Guidance – does this framework allow for a suitable management plan to be relayed to the PACU RN?Aesthetics/Familiarity – is this reminiscent of the OR-ICU checklist at UWMC?Organization/Efficiency – does the provider and information item sequence allow for the concise and logical reporting of perioperative events?

Implementation

Pocket cardsChief Resident Survey distributed to PACU RN and CRNA groupsRN “shift champions”Focus Group and Videography (April 15, 22)

◦Video clip demonstrating the proposed physical and electronic checklists being used

April 1 – May 31, 2015

Implementation

Videography 4.15.15PENDING

Audit +Handoff CEX DataPOST-IMPLEMENTATIONMay-October 2015

UW Housestaff Quality and Safety Committee

PENDING

POST-IMPLEMENTATION

HMC OR-to-PACU Transfer-Of-Care

QI Initiative

Timeline

Dec14 | Jan15 | Feb15 | Mar15 | April15 | May15 | June15 | July15

- Physical Checklist Implementation- Grant Funding Application

- Pre-intervention data collection:*PACU RN surveys*PACU handoff audits*LOS, PSNs

- Post-intervention data collection:*PACU RN surveys*PACU handoff audits*LOS, PSNs- Electronic Checklist Implementation

Winter 2014PACU RN meetingsFocus groups with leadershipChief resident surveysCoordination with IT

Summer/Fall 2015Presentation at QI MeetingsManuscript Preparation

Areas for ImprovementLoad time for electronic checklist?

◦NOT expected to affect workflowHandover time prolongation?

◦NOT expected with improved organizationPACU RN shift/location changes

◦Focus on PACU West

Future GoalsCombine with other institutional

handover initiatives◦Reporting of STOP-BANG score and

extubation risk assessment Brett Thomazin RRT, Aaron Joffe,

MD◦UW OR-ICU and OR-PACU Transfer Template Aalap Shah, MD, John Lang, MD,

Bala Nair, PhD◦Decrease # of handovers - HMC OR-ICU

Project Elizabeth Visco CRNA,

Future GoalsInstitutional-wide use

◦Encourage workflow changes and emphasize ownership in the changes (RN, MD, CRNA)

How does a good handover impact the medical/surgical team◦ Improved focus in subsequent cases?

II.UWMC OR-to-PACU –

Transfer Template (T2) Project

Project Goals

Process standardizationCreate anticipatory guidance

Improve Information Reporting

Interventions:1. Anesthesia Transfer Tool (T2)

Ultimate Goal:Replace Nursing SSHR (“Purple Sheet”) with Pre-Completed

Electronic Documentation with T2 information

Demographics

Anesthesia Transfer Tool (T2) for Handoff

DiagnosisProcedure

Labwork- ABG/VBG- CBC- Electrolytes- Glucose

Fluids/Products

Medications- Induction agents- NMBD + last

dose- Infusion status

Anesthesia Management- Attending

anesthesia concerns

- Airway note- IV access- Attending PMHx- Special notes

- i.e. CPB of/off

- EmergenceLast Vitals

Anesthesia team info

Pre-Study Data: Nursing (UWMC)

Name -- Airway management 3%

Status/Code 68% Induction Meds 16%

PMHx 36% Lines 24%

Home Rx 24% Resident name/pager 100%

Allergies 10% Anticipatory Guidance 82%

Omission of Information

March 27, 2014: Review of Surgical Services Handoff Report (“Purple sheet”)

in Main OR PACU (n=63 cases)

Study DesignProspective interventional RCT +

Crossover study of individual handoverso Intervention: Anesthesia Transfer Tool (T2)o Control: Provider-preferred written

information management system (i.e. notes)

Study DesignOR Anesthesia Computer designated to

either control or intervention armo Co-adaptive randomization of providerso Audio-tape recordings of handovers allow

the researcher to be blinded

Adaptive Randomization

RANDOMIZATION/ASSIGNMENT

CONTROL (- T2)

INTERVENTION(+ T2)

IN OR: Anesthesia Provider PC

OUT OF OR: Study Team Computer

Press “Leave OR”What do you see on your screen?

Operation

• Induce, Maintain, and Emerge from anesthesia as you normally would

Finish Case

This Nothing

Do as you normally would- Leave OR- Arrive in PACU, position patient

Handover• Use “Written Queue” sheet to initiate handover

Get printout from PACU printer

-Leave OR- Arrive in PACU, get printout- Position patient

Post-Handover Survey (CEX)

Workflow

Study DesignPrior to Handover (PACU)

◦Audio-tape recorder queued at bedside prior to provider/patient arriving with the patient in the PACU from the OR.

Post-Handover (PACU)◦Audio-tape recorder retrieved at bedside◦Handoff CEX distributed to Provider and

Recovery Room Nurse

Study DesignDuring the Handover: Data Colelctioj

Inclusion/ExclusionInclusion Criteria

◦Provider-Subjects: UW CRNAs + Senior Residents (CA2, CA3)

◦Patient-Subjects: ASA >= II Receiving elective surgery AND planned post-

operative inpatient admission to UWMCExclusion Criteria

◦Providers/cases involving an intraoperative handover

Outcomes/Analysis• Effectiveness (Audiotape Recordings)

o information omission, interruptions, provider contact, handover duration

o Data compared against Anesthesia Record (ORCA)o Scoring System

(0=missing, 0+E=present/incorrect, 1= present/correct)

• Domain Assessment (Handoff CEX)o Distributed to Provider and Recovery Room RN after

handover

• PACU Events o Collected from ORCA (IView)

Data Collection

Handoff CEXQuality: Domain Assessment

Audiotape RecordingsEffectiveness

AcknowledgmentsBala Nair, PhD Thomas Varghese, MDAnna Xue, MSIII Daniel Oh, MSIIIBarb DeWitt, RN SupervisorElizabeth Visco, CRNADan Harrington (IT)Dr. Michael Souter (Chief, Harborview

Anesthesiology)UW Housestaff Quality and Safety Committee

Thank youQuestions?

Appendix – UWMC OR-ICU

UWMC OR-ICU Handoff ChecklistAlan Artru, MDJohn Lang, MD

UWMC OR-ICU

Appendix: UWMC OR-ICUN=21

7 without the T2 (- T2; controls) CTICU = 4; SICU = 3

14 with the T2 (+T2, intervention) CTICU = 13; SICU = 1

Urine output: 3/14 (intervention) Vs. 3/7 (controls)

Blood loss: 5/14 (intervention) Vs. 4/7 (controls)

Fluids & infusions: 2/14 (intervention) Vs. 3/7 (control)

Patient status: 0/14 (intervention) Vs. 1/7 (control)

Hemodynamics: 0/14 (intervention) Vs. 1/7 (control)

Duration of the handoff process was similar for control and intervention cases.

The handoff tool was easily integrated into the clinical workflow to facilitate patient transfer without disruptions.

Appendix: The Donabedian Model

Health system structure:Academic Teaching Hospital- Varying provider

experience- Patient-provider dyad

interactions- Provider-PAC RN dyad

interactionsMultiple locations/Multiple ServicesCost-containment strategies- OR Turnover time- PACU Personnel- PACU ResourcesElectronic Health Record 3rd-party interfaceable programs

WHAT: Multidisciplinary Transition of Care (Verbal Handover)

HOW: Standardization

PROCESS MEASURES- % of handovers using checklist- “ “ with surgical resident present

BALANCE MEASURES- Handover time- PACU LOS

OUTCOME MEASURES- Nursing Surveys - # of post-handover calls/pages to care team- Third-Party Audit (Omission of information)

System factors

Processes of care

Health outcomes

Other ThoughtsIntervention Period spreading

knowledge of the initiative◦We don’t have social networks to disperse

and share information, but we work in a large academic center where we share copious knowledge between team members and between disciplines.

◦Positive reinforcement (i.e. voice how satisifed you are with a recent handover using the tool) can help involve stakeholders and improve participation down the food chain.