Transitions of Care (OR-PACU) - Aalap Shah , MD

Aalap Shah, MDClinical Fellow in Anesthesia,

Boston Children’s HospitalHarvard Medical School

***April 2016 Update***

I have no relevant financial relationships to disclose.

Evaluate systems-wide limitations to improving current handover practice

Understand the major outcome measures associated with handover research

Recognize common themes in handover research in different settings

Familiarize with Institutional initiatives in standardizing and optimizing handover practices

17th century originMeeting of Europeans and Chinese

Described as replete with “confusion” and “ incomprehensibility”

Created a sense of inability to understand China’s culture and worldview

Metonymy seen in other cultures and indigent expressions

"It's all Greek to me”

“It’s Double Dutch” “That’s a Volapuk thing”

“It’s German to me”

“Boheman villages!”

Rosenberg 1979 – concluded that Chinese was the “hardest language” to learn

Wikipedia: 22of 50 languages with expression regarding difficulty learning the Chinese language

TelephoneRussian scandal, whisper down the lane, broken telephone, operator, grapevine, gossip, don’t drink the milk, the messenger game

Why isn’t there a single term?Handoff, Handover, Dropoff, Transfer-of-Care, TransitionsIn Reality: Handoff ≠ Transition-of Care

Many Definitions!JCAHO 2010

“The process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver.”

“Your patient is my patient”

Transfers of information represent high-risk, error-prone patient care episodes that are closely related to patient outcomes

Standardization with protocols or checklists are recommended

Joint Commission 2006 WHO 2008 Institute of Medicine 2008 BMA 2004

BEME 2003

Literature Review 223 PubMed/MEDLINE CITATIONS as of March 2015

205 / 554 errors due to nurse-physician communication errors

44,000 to 98,000 preventable deaths each year, with an associated cost of $17 to $29 billion.

Donchin 2003

CriCO (February 2016) –- 1744 patient deaths / 5 years- 1.7 billion in malpractice costs (30% of cases) CriCO 2016

Gawande 2003 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.

Other landmark papers: Adamski 2007, Patterson 2010

Wakefield 1999, Donchin 1995, Hempel 2015

Formula1: Pit Stops (2004)

Beer 2015: ISBAR Patient Safety

Beer 2015: ISBAR Patient Safety

• Informal/Brief Roughton 1996, Bomba 2005), Kalkman 2010, Mazzocco 2009, Kitch 2008, Nagpal 2010,

Hom 2004, Cohen 2010, Bomba 2005, Alvarado 2006, McFertridge 2007

• Setting Cluttering

Small patient pods, limited space

Noise level in PACU Sidebars, adjacent pod conversations, monitors

Cultural/setting differences Delrue 2013, Behara 2005), Wong 2007

• Lack of attendance

• Interruptions / Shift change (Staggers 2011, Donchin 2003)

RN, Attendees, Other

To OR - SCOAP- Incision- PACU orders

placed intraop

PACU

ICU

IIa. Day before Surgery

Pt. arrives on DOS

IIb. Day of Surgery

Providers assigned

cases

I. Pre-operative data collection and plan formation- PAC Note- Cerner- OSH Records- ?EpicII. D/w attending

Need to see:- Preop Nurse- Surgeon- Anesthesia- OR Nurse Decide

Dispo**

DOS cancellation?

Pre-Op Issues?*

Cancel; off pathway

IntraopHandover?

MD-MD handover

- PACU Orders placed

- Surg Orders placed

- Case finish, emergence, extubation

- Surg ICU Orders placed

- Nurses call report and for ICU bed

- RT brings bent to ANES

- Techs bring monitors + O2 to anes

Reschedule

1. Anes2. OR Nurse3. +/- Surgery

1. Anes2. OR Nurse

3. Surgery

Pre-Op IntraOp

Un-planned ICU

1. Bay

Assigned

2 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

Tx

or

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

Post-Op [PACU]

• Information Omission/”Overload”Anwari 2002, Arora 2007, Lauterbach 2009, Welsh 2010, Horwitz 2008, Kitch 2008, McCloughen 2008, Thomas 2012, McCloughen2008

• Multiple Intra-operative Handovers• Saager 2014 - N=138932

Morbidity Incidence of 8.8, 11.6, 14.2, 17.0, and 21.2% for patients with 0, 1, 2, 3, and ≥4 transitions; odds ratio 1.08

• Inadequate pre-operative preparation Kluger 2000

• Level of experience Van Eaton 2005, Van Eaton 2010, Chang 2010, Borowitz 2008, Lofgren 1990,

Gandhi 2005

• No anticipatory guidance Bump 2011, Horwitz 2008, Ilan 2012, Kitch 2008, Philibert

2009, Thomas 2012, Hinami 2009

• No accepted content structure/agreement on content categories (Collins 2011)

• Content-related data standards (CCD) C48 Referral Summary Health Information Technology Standards Panel (HITSP)

• Clinical Care Classification System (3C) American Society for Testing and Materials International (ASTM) Continuity of Care Record (CCR) Health Level 7 (HL7)

• SNOMED-CT• Unified Medical Language System (UMLS)• Integrating the Health Enterprise Cross-Enterprise Document

Sharing of Medical Summaries (IHE XDS-MS)• International Classification of Nursing Practice (ICPN) Dykes 2009

• Intraoperative Agarwala 2015

• Post-Operative PACU Anwari 2002, Weinger 2015, van Rensen 2012

ICU Agarwal 2012, Hom 2004, Nagpal 2010, Sabir 2006, Agarwala, Salzwedel 2013, Petrovic 2012, Joy 2011, Zavalkoff 2011,

Catchpole 2006,

• Anesthesia-based literature Hom 2004, Nagpal 2010, Sabir 2006, Agarwala 2015,

Salzwedel 2013, Smith 2008, Weinger 2015, van Rensen 2012, Segall 2012

STUDY SETTING1 of 2

• Shift-to-Shift Bump 2011, Horwitz 2008, Ilan 2012, Kitch 2008, Philibert 2009, Thomas 2012,

Hinami 2009, Arora 2007, Lauterbach 2009, Welsh 2010, Horwitz 2008, Kitch 2008, McCloughen 2008, Thomas 2012, McCloughen 2008, Chung 2011, Clark 2009, Wilson 2007, Christie 2009, Jukkala 2012, Raies 2007, Nelson 2010, Roberts 2012, Baldwin 1994, Kalisch 2007, Wentworth 2012, Riesenberg 2010, Flanagan 2009, Ferran 2008, Stahl 2009, Cheah 2005, Wayne 2008, Anderson 2010, Frank 2005, Van Eaton 2005, Van Eaton 2010, Wohlaeur 2012, Rabinovich 2009, Ryan 2011, Raptis 2009, Barnes 2011, Campion 2007, Campion 2010, Palma 2011), (Bigham 2014,, Bittner 2012, Catchpole 2007, Ferran 2008, Ryan 2011, Salemo 2009, Jukkala 2012, Stahl 2009, Govier 2012), Ram 1992, Raptis 2009, Wayne 2008, Anderson 2010, Barnes 2011, Palma 2011, Wohlauer 2012, Singer 2006, Wolff 2004, Alvarado, Cohen 2010, Maxson 2012

• Age Group (Pediatrics) Chen 2011, Zavalkoff 2011, de Laval 2000, Catchpole

2006, Singer 2006

• Interdepartmental Handoffs Joy 2011, Christie 2009, Delrue 2013,

McFertridge, Beckmann 2004

• Inter-hospital/Post-hospital Wong 2008, Gandara 2010, Helloso

2005, Anderson 1993, Anderson 1993, Anderson 1995

STUDY SETTING2 of 2

• RN-to-RN Chung 2011, Clark 2009, Wilson 2007, Christie 2009, Jukkala 2012, Raies 2007, Nelson 2010,

Roberts 2012, Baldwin 1994, Kalisch 2007, Wentworth 2012, Riesenberg 2010, O’Connell 2008, Patterson 1995, Berkenstadt 2008, Miller 2009, Chaboyer 2010, Lamond 2000, McFetridge 2007, Welsh 2010, McLane 2009, Staggers 2009, Currie 2002, Lally 1999, Sexton 2004, Nelson 2010, Fenton 2006, Block 2010, Sherlock 1995, Mascioli 2009

• MD-to-RN Rabinovich 2009, Ryan 2011, Raptis 2009, Barnes 2011, Campion 2007, Campion 2010, Palma

2011, Agarwal 2012

• MD-to-MD Flanagan 2009, Ferran 2008, Joy 2011, Stahl 2009, Cheah 2005, Wayne 2008, Anderson

2010, Frank 2005, Van Eaton 2005, Van Eaton 2010, Wohlaeur 2012, Solet 2005, Agarwala 2015

• Other members Respiratory Therapists, NP, Assisting RN

STUDY MEMBERS

• Prospective Observational Interventional (Pre-/Post) Bigham 2014, Agarwala 2015, Agarwal 2012, Bittner 2012, Catchpole 2007, Chung 2011,

Ferran 2008, Joy 2011, Ryan 2011, Salemo 2009, Jukkala 2012, Stahl 2009, Govier 2012), Ram 1992, Raptis 2009, Wayne 2008, Anderson 2010, Barnes 2011, Palma 2011, Wohlauer 2012, Kochendorfer, Salerno, Gakhar, Pickering, Van Eaton, Chu, Alem, Nabors, Cheah, Delrue 2013, Edozien 2011, Maxson 2012, Bhabra 2007, Petrovic 2015, Starmer 2013, Starmer 2014

• Prospective Survey/Interviews Anwari 2002, Flanagan 2009, Rabinovich

2009, Clark 2009, Wilson 2007, Basu 2011, Christie 2009, Raines 2007, Stahl 2009, Cheah 2005, Nelson 2010, Roberts 2012, Baldwin 1994, Kalisch 2007, Bernstein 2010, Campion 2007, Frank 2005, Wentworth 2012, Campion 2010, Sidlow 2006) Ye, Horwitz, Solet, Apker, Smith 2008, Rayo 2014

• Prospective RCT Lee 1996, Van Eaton 2005, Van Eaton 2010, Salzwedel 2013

• Systematic Reviews Abraham 2014, Collins 2010, Arora 2009, Riesenberg 2009, Risenberg

2010, Flemming 2013, Cohen 2010, Nagpal 2010, Gordon 2011, Hesselink 2012, Moller 2013, Segall 2012, Li 2012

STUDY DESIGN

STUDY MEDIUM / INTERVENTIONS

• In-patient verbal handover Patterson 2004, Bhabra 2007

• EMR-based tools Flanagan 2009, Anderson 2010, Barnes 2011, Palma 2011, Van Eaton 2010,

Wentworth 2012, Wohlauer 2012, Sidlow 2006, Benham-Hutchin 2008, Blouin 2011, Collins 2011

• Third-party software Rabinovich 2009, Cheah 2005, Nelson 2010, Ram 1992, Wayne

2008, Baldwin 1994

• Paper Tools: Clark 2009, Joy 2011, Salermo 2009, Raines 2007,

Checklists Berkenstadt , Alem, Ferran, Gakhar, Hart, Wolff

Guides/cognitive aids Fenton, Block, Chaboyer, Nelson 2010, Lee 1996,

Edozien 2011

1 of 2

Agarwala 2012Vanderbilt University

Petrovic 2015Johns Hopkins HospitalReprinted with permission

• Structured handover order Simmons 2000, Chu, Catchpole 2007, Sower 2008

(Formula One), Edozien 2011, Talbot 2007, Maxson 2012, Joy 2011, Ferran 2008, Petrovic 2015

• Formula1 in ICU Catchpole 2007, Sower 2008

• Electronic handovers Ram, Nabors, Kochendorfer, Cheah, Van Eaton, Salerno, Ryan

2011, Rabinovitch 2009

• Direct Supervision Nabors

• Multidisciplinary Projects/ Simulation Delrue 2013, Shah

2016, Broehuis 2007, Klaber 2009, Edozien 2005, Chaboyer 2009), Delrue 2013, Jettcott 2009, Shah 2016, Katzenbach 1993, Awad 2005, Lingard 2006, Millery 2011, IHI, Chang 2010, Van Eaton 2010), Weinger 2015, Petrovic 2015, Nadzam 2009, Mistry 2008. Berfeenstadt 2008, Weinger 2015, Clancy 2008

STUDY MEDIUM / INTERVENTIONS2 of 2

• Surveys/Scoring Criteria/Thematic Assessments

• Pt. Complications Agarwal 2012 – decrease in 24-hr major complication rate [CPR, ECMO, severe metabolic acidosis])

• Successful extubation in PCICU within 24hrs: 50% vs 43.2%; (p< .04).

• Completion of healthcare-related tasks,Missed medications, delay in subspecialist notification

STUDY OUTCOME CATEGORIES1 of 2

• Item Reporting/Technical Errors Agarwala 2015, Catchpole 2007,

Flanagan 2009, Chung 2011, Govier 2012, Ferran 2008, Wilson 2007, Raptis 2009, Joy 2011*, Van Eaton 2010* Chen 2011, Hughes 2008, Horwitz, Lamond, Staggers 2009, Cheah 2005,

• Missing Corrobrative Information in EMR Patterson

2010, Sexton 2004, Shah 2016, Lauterbach 2009

Palma 2011: 5 extra minutes spent correcting handoff information

• PACU LOS/Readmissions: Salzwedel 2013, Ryan 2011, Bittner 2012, Patterson

2010

Bittner 2012 (Finding: Non-linear relationshipbetween Quality Score, Spearman rho=0.258)

• Interruptions/Handover DurationWentworth 2012, Chen 2011, Alvarez 2006, Van Eaton 2005, 2010, Pezzolesi 2010

STUDY OUTCOME CATEGORIES2 of 2

• Shah 2016• Targeted Obstacle: No structured post-

operative handover

0% 20% 40% 60% 80%

Call parameters for vitals

Call parameters for labs

Dressing change instructions

PO status

Activity status

Discharge/inpatient medications

Discharge/inpatient orders

Other

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

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

https://drive.google.com/file/d/0B2uK7WoIRnTyc2pTcWR3SDFjQjQ/view

• Required surgical representative to give report before anesthesia report

• Laminated Tabletop/Bedside Checklist Cards

• Grand Rounds Presentations/Weekly E-mails

• Instructional Simulated Video on Intranet

• Prospective interventional study • Post-Operative Elective Procedures w/

Inpatient Stay (non-ICU)• Information Omission, LOS, Handover

Length• Observers (2) observe post-operative

handovers in PACU West using Audit Form• Auditors (2) independently record

information items from EHR

Table 1a: Pre-vs Post-Implementation Data – “Matched Reporting”

Table 2a: Pre-vs Post-Implementation Data – “Reporting Errors”

Table 1b: Pre-vs Post-Implementation Data – “Matched Reporting”

• EHR/Clinical Pathway Integration Bernstein 2008, KalkMan 2010

• Templates Co 2010, Whipple 2007, Benham-Hutchins 2008, Blouin 2011, Collins 2011, Fielsten 2006,

Siebens 2001, Gardner 2013, Gandra 2010, Hayrinen 2008, Henry 1997, Shah 2016, Swinglehurst 2012, Vawdrey 2008

Vawdrey 2008: Need to guarantee usability• 793 / 1699 templates in use (Mt. Sinai)• Most common: free text note called “Miscellaneous

Nursing Note

• Institutional Reporting Standards Bonney 2013, Bosmans 2012,

Gandara 2010

• Content Overlap Dykes 2009, Collins 2011

• EBL format (Resilience Theory/Convergence Science) Delrue 2013, Jettcott 2009, Shah 2016, Katzenbach 1993, Awad 2005, Lingard 2006, Millery 2011, IHI

Student/Junior Trainee Education Chang 2010, Van Eaton 2010

High-Reliability Training: Wilson 2005

• Coordinate Institutional Initiatives (i.e. BCH I-PASS) Decreasing # of handovers – Surgical Home I-PASS

• Starmer 2014 (NEJM)Medical errors dropped by 23 percent when nine other pediatric hospitals implemented I-PASS

• Weinger 2015: - standardized electronic handover report form, - a didactic webinar, mandatory simulation training focused on improving

interprofessional communication- post-training performance feedback

• Display Adoption Metrics (p-charts)

• Quality Improvement Projects• Anticipate multiple revisions• Get the stakeholder’s input• Identify shift champions• PDSA Cycles

• Improve intraoperative handovers Tscholl 2014, Saaeger 2014

• Delegate representative to attend the handover shared mental model/teamwork

• Cognitive Aids (Videos, Handout cards) SBAR Haig 2006

• Situational awareness Simons 2000

identify common overlap items first

• Interactive Questions, Receiver Summary Rayo

2014