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Handoffs and Transitions of Care:
Lessons from Lens
Elizabeth A. Martinez, MD, MHS
Associate Professor
Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Harvard Medical School
Cardiovascular Surgical Translational Study
Armstrong Institute for Patient Safety and Quality
Content Call: April 18, 2013
1
Objectives
• Define transitions of care and handoffs
• To recognize effective vs. ineffective handoffs
• To identify the components of an effective
handoff
• To understand the importance of
communication during transitions of care
• Understand ASA quality metric for transitions
of care
2
Communication
Breakdowns are frequently
the root cause of…
undesirable outcomes
3
Analysis of errors
reported by surgeons
Gawande AA, et al. Surgery 2003; 133(6):614
4
The Joint Commission:
The Importance of Communication
National Patient Safety Goals
• Improve the communication among
caregivers
– Read-back
– Handoff
• Accurately and completely reconcile medications and
other treatments across the continuum of care
– Address specifically during handoff
• Encourage the active involvement of patients and their
families in the patient’s care, as a patient safety strategy
5
Sign-offs: Transitions of Care
• Joint Commission Patient Safety Goal #2
– vulnerable time in the care of patients since
communication failures and environmental barriers
often characterize such handoffs
– “Implement a standardized approach to ‘hand off’
communications, including an opportunity to ask
and respond to questions”.
6
Communication Process
7
Standards of
Effective Communication
• Complete
– Communicate all relevant information
• Clear
– Convey information that is plainly understood
• Brief
– Communicate the information in a concise manner
• Timely
– Offer and request information in an appropriate timeframe
– Verify authenticity
– Validate or acknowledge information (closing the loop)
8
Why does communication break
down?
– Cognitive workload
– Complexity increasing
– Implicit assumptions
– Authority gradients/Hierarchy
– Diffusion of responsibility
– Environmental factors
– Production pressures
– Competing priorities/Interruptions
9
Characteristics of High-reliability
Communication Tactics
• Are easy to understand and follow
• Offer consistency & predictability:
– Standardization
• Feature redundancy
• Incorporate forcing functions
• Ensure that people cannot work around the
system
• Minimize reliance on human memory
10
Lessons from LENS
• Locating Errors Through Networked Surveillance
• Methods:
– Observations, Contextual inquiry, Interviews, Surveys,
• Observations included the transition of care from
the OR to ICU as a key time point
– In addition to intraop transitions and preop
discussions that might have taken place
• Hazards were coded
11
LENS Domains
Human Factors
Engineering
Health Services
Research
Organizational
Sociology
Industrial
Psychology
Cardiovascular
Clinical Care
Slide 12
Taxonomy
Potential Failure Mode
Gurses et al;BMJ Qual Saf 2012;21(10):810-8.
Slide 13
Lessons from LENS
• Locating Errors Through Networked Surveillance
• Methods:
– Observations, Contextual inquiry, Interviews, Surveys,
• Observations included the transition of care from the OR to
ICU as a key time point
– In addition to intraop transitions and preop discussions that might
have taken place
• Hazards were coded
**While some of the observations identify a specific provider type,
we know these are not unique to that provider type. The goal of the
next few slides are to share real-life examples of hazards and to have
us begin to think about how these are related to our individual
provider types and teams – and how we can eliminate them.**
14
Lesson from LENS*:
Organization
• NO standardization
– Variability within and between sites on how information and technology were transferred
between team members
• No evidence of standard handoffs intraop or postop
• Purchasing decisions
– In multiple settings either the OR or ICU team needed to change over the pumps during critical
times for patients while vasoactive agents were being infused
• “In OR, they use only pump A. In PACU, they use both pump A and pump B. In ICU they use only
pump B.”
• “they swicth the infusion pumps over before leaving the OR to the pumps that will be used in the
OR” (Can be done by a single practitioner including junior resident)
• Policies
– “When the patient is transported to the PACU the drips are all changed over; this is especially
true for drips that are made up peri- and intraoperatively by the anesthesiologist. RNs in the
PACU will only use drips that come from the pharmacy.”
– “ …gtts are different concentration than ICU uses. ‘Nurse won’t use our drips’ – either dif
concentration, not from pharmacy or poorly labeled”.
• Staffing patterns
– Little to no assistance during transfer: Anesthesia single team member preparing the patient to
leave the OR. Focusing on equipment, etc…. While monitoring the patient.
*Unpublished data; Data and presentation to be used for
educational purposes within your institution only. Thank you.
15
Lesson from LENS*:
Patient characteristics
• We did not collect patient level data
• However….. These patients are obviously complex
and this impacts the transitions of care and the
information shared (or not shared)
–
–
–
–
–
–
Multiple medical problems
Can be on multiple drips and have received multiple intraop meds
Have multiple lines, drains and tubes
May be paced with/without intraop issues
Mechanical support
Hemodynamic lability needing to be addressed prior to complete
transfer of information
*Unpublished data; Data and presentation to be used for
educational purposes within your institution only. Thank you.
16
Lesson from LENS*:
Physical Environment
• Layout
– Distances needing to be traveled to post op setting
– Waiting for elevators
– “Anesthesia resident, perfusionist and nurse transported the
patient up 5 floors to the ICU. There was a long wait as no one
has a key to divert the elevator for fresh post-op cases
regardless of acuity”
• Ease of traveling down a hallway
– Construction at one site
– “[The postop setting] is down a long corridor that includes
turns, doors, and carts lining the hallway. There appear to be
many opportunities for trouble when pushing the stretcher,
monitor, pole, etc. from the OR to the CVPACU.”
*Unpublished data; Data and presentation to be used for
educational purposes within your institution only. Thank you.
17
Lesson from LENS*:
Provider
• Professionalism
– “Fellow to nurse.” That’s all you get to know!”
– “The attending in the PACU did not get up from the desk for report. The
anesthesiologist reported to the PACU attending while nurses changed lines,
etc. they were not near the anesthesiologist and could not over hear the
handoff report.”
• Knowledge/Experience
– “The anesthesia residents leave at 2pm. If a case is on-going at 2pm a CRNA
comes in and covers for the anesthesia resident. The anesthesia attending
perceive that this practices causes issues with handoff, professional
responsibility, and role.”
• Performance
– “[Mid level] gave a short handoff report (medium level structure): No
allergies. Heart rate was between 50s and 60s.,, You probably know history.
Smoker. … Do you have any questions?”
*Unpublished data; Data and presentation to be used for
educational purposes within your institution only. Thank you.
18
Lesson from LENS*:
Tasks
• Standardization – Lack of
– PR team member to ICU: “I would keep pressure close to 100.
She got a dose of Insulin on the pump. 1 PRBC unit post pump. 1
unit PRBC on the pump. She had 1 gram of vanco after case. I
turned the pacer down to 82 from 90. Phenylephrine is
hanging.”
• No Standard/Systematic approach to sharing information with new team
• Not much information shared about intraop course or guidance for post
op care.
• Competing priorities
– Simultaneous transfer of information and technology
• Preparation
– “Respiratory therapy had to be paged. Didn't have temp probe
connection ready. Had to go find one.”
*Unpublished data; Data and presentation to be used for
educational purposes within your institution only. Thank you.
19
Lesson from LENS*:
Team
• Communication
– Incomplete report
• Not all team members present/give report
–
–
“The surgeon stopped by asked the BP, look at chest tube and left. NO surgical report given”
“There was no sign out [information shared verbally] between nurses when the nurse was relieved for lunch”
• Report is shared with some team members
–
–
“The handoff was not very in depth and [was in]complete. AR made handoff to the nurses and the ICU resident. The surgery
fellow was present but gave handoff to the surgical resident out in the hall.”
“The [postop] attending … did not get up from the desk for report. The anesthesiologist [and surgeon] reported to the …
attending while nurses changed lines, etc. they were not near the anesthesiologist and could not over hear the handoff
report.”
– Notification/Preparation
• “Circulator did not notify ICU team that the patient was coming”
• “Nurse who was giving break did not know the last name of the nurse for whom she
was giving a break which resulted in delay and increased tension since it took
longer to page her when she was needed to operate a piece of equipment.”
– Knowledge
• “Intensivist asked about hematoma. No explanation by anyone that was by the bedside. ”
• Distractions
– “Unrelated personal conversations rather than a formal sign out ….”
– “Another nurse called into the room about another patient”
– “ICU wasn’t prepared for second A-line. This was not the routine and they were not notified ”
• Debriefings did not occur in the OR
*Unpublished data; Data and presentation to be used for
educational purposes within your institution only. Thank you.
20
Lesson from LENS*:
Tools and Technology
• Man-machine interface (Heuristics)
– At each of the institutions, following at least one case, the transport monitor
was not functioning and it was difficult for the providers to troubleshoot.
• Communication
– “Brief report consisted of: Procedure, products, H/O AVR, Ventricle is good,
info about peripherals. Problem with report is that the anesthesia team
didn't have a record to read off the history since it was electronic.”
• Lines/tubes/drains
– “Brought bed in room (nursing) and got tangled in suction tubing. Couldn’t
get the foley temp connector undone, was knotted”
– Frequently we know that it is a challenge to transfer central lines/PA
catheter
*Unpublished data; Data and presentation to be used for
educational purposes within your institution only. Thank you.
21
Teamwork Across Units and Handoffs
“We do this Poorly”*
Data from Hospital Survey of Patient Safety (HSOPS)
46%
Teamwork Across
Hospital Units
56%
46%
59%
68%
56%
30%
40%
35%
44%
Hospital Handoffs
& Transitions
49%
Site 1
Site 2
Site 3
Site 4
Site 5
All Sites
40%
0%
20%
40%
60%
80%
100%
Percent reporting a positive response
*Unpublished data; Data and presentation to be used for
educational purposes within your institution only. Thank you.
22
Potential Failure Mode
Need to switch to
Smart pump in the ICU
Patient becomes extremely
hypotensive
Organization did not
Purchase smart pump technology
for all OR pumps
Patient arrests and dies
Patient receives inadvertent
bolus of nitroglycerin
23
Potential Failure Mode
Need to switch to
New drips in the ICU
Patient becomes extremely
hypotensive
Anesthesiologists make up their
own drips and use their own
concentrations
Patient arrests and dies
Patient receives inadvertent
bolus of nitroglycerin
24
Adverse Consequences
• Antiplatelets not restarted appropriately
– Patient had an MI
• ICD not turned on and patient discharged to
floor/home
• Diabetic patient had glucose checked on PACU
admission per routine
– Hyperglycemia treated by nurse
– Patient had received insulin in the or and not
given in report
**Not LENS data
25
Adverse Consequences
• Patient with difficult intubation was extubated
with only junior house officer available
– Required immediate, emergent reintubation
– Difficult airway not noted in report.
– Patient required am emergent cric
• Off-service patient had a complication
– Nobody took responsibility
– No clearly defined primary service
**Not LENS data
26
Implementation of Periop Handoff
Protocol
• Focus groups and survey of practitioners: what is
wrong with our process?
– SENDERS: Surgery, anesthesia, nursing
– RECEIVERS: ICU, PACU
• Protocol elements:
– Require all practitioners be at the bedside
– Standardized the process
•
•
•
•
•
Single person speaking at a time
Technology transfer
Information transfer
Checklists for sender and receivers
Clearly state when the handover is complete with opportunity for
questions
– Education of all practitioners on handover process
Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012
Petrovic MA, et al. Joint Commission Journal 2012.
27
Objectives
• Define transitions of care and handoffs
• To recognize effective vs. ineffective handoffs
• To identify the components of an effective
handoff
• To understand the importance of
communication during transitions of care
• Understand ASA quality metric for transitions
of care
28
OR Debriefing:
Step #1
29
Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012
Petrovic MA, et al. Joint Commission Journal 2012.
30
Surgery Checklist
•
•
•
•
•
Actual procedure performed
Surgical findings (anticipated and unanticipated)
Surgical complications
Drains/tubes (location, number, type)
Special instructions (NGT, chest tubes,
extubation)
• Patient disposition
• Responsible primary service
• Who to page
Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012
Petrovic MA, et al. Joint Commission Journal 2012.
31
Anesthesia Checklist
• Preop
• Intraop
• Postop guidance
–
–
–
–
PMH and PSH
Allergies and Code status
Medications – what was taken prior to surgery
Baseline vitals, exam, labs
–
–
–
–
–
–
Airway
Lines
Fluid totals (ins and outs)
Paralytic status
Labs and Meds (Antibiotics)
Key events
– Drips
– Respiratory: vent settings, etc…
– Other
•Conclusion: “The thing that I am most concerned about in the periop setting is “
Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012
Petrovic MA, et al. Joint Commission Journal 2012.
32
Nursing Checklist
•
•
•
•
•
•
•
•
•
•
Actual surgery performed
Isolation type
Lines
Drains
Skin Inspection
Packing
Special equipment/Others
Family information
Belongings and valuables
Events/Concerns
Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012
Petrovic MA, et al. Joint Commission Journal 2012.
33
Impact of Standardized Handoff
in CSICU
Presence of core team
PrePost
intervention intervention
0%
68%
P<0.05
% age of missed information
(surgery report)
26%
16%
P<0.03
% age of missed information
(anesthesia report)
19%
17%
NS
Satisfaction (ICU nurses)
61%
81%
P<0.05
On average, handoff increased by 1 minute (NS)
Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012
34
Formula 1 Pit-stop
Catchpole KR, et al. Paediatr Anaesth 2007; 17(5):470-8 35
Formula 1 in Pediatric Cardiac Surgery
Catchpole KR, et al. Paediatr Anaesth 2007; 17(5):470-8 36
Impact of Formula 1 Approach
Preintervention
Post
intervention
Technical
errors
5.42
(95%CI ± 1.24)
3.15
(95%CI ± 0.71)
Information
omissions
2.09
(95% CI ± 1.14)
10.8 minutes
(95% CI ± 1.6
min)
Duration
P<0.05
1.07
P<0.05
(95%CI ± 0.55)
9.4 minutes
NS
(95% CI± 1.29 min)
Regression analysis identified an interaction between
teamwork and the number of technical errors in the postphase.
Catchpole KR, et al. Paediatr Anaesth 2007; 17(5):470-8 37
American Society of Anesthesiologists
• Transfer of Care Workgroup
• Committee for Performance and
Outcome Metrics
– Developed handoff metric for-OR to-ICU
• approved by the ASA Board of Directors
• Can be used for internal QI programs
• Key classes of elements defined
38
ASA Transition of Care Metric
Use of a Protocol or Checklist and include the following elements:
1. Identification of patient
2. Identification of responsible practitioner (primary service)
3. Discussion of pertinent medical history
4. Discussion of the surgical/procedure course (procedure, reason
for surgery, procedure performed)
5. Intraoperative anesthetic management and issue/concerns to
include things such as airway, hemodynamic, narcotic, sedation
level and paralytic management and intravenous fluids/blood
products and urine output during the procedure, pertinent labs.
6. Expectations/Plans for the early post-procedure period to include
things such as the anticipated course (anticipatory guidance),
complications, need for laboratory or ECG and next antibiotic
dosing time.
7. Opportunity for questions and acknowledgement of
understanding of report from the receiving post-procedure team
**Similar measures for Intraop and Postop**
39
Strategies for Safe and Effective
Postoperative Handovers
•Prepare monitor, alarms, equipment & fluids before
patient arrival
•Complete urgent care tasks before the verbal handover
•Set aside time for handover communication. Avoid
performing other tasks and limit conversations
•Use “sterile cockpit” – only patient specific conversations
are allowed
•All relevant members of the OR and Post op Receiving
teams should be present
•Only one care provider should speak at a time
Segall, Systematic Review Anesth Analg, 2012. 115:102-15
40
Strategies for Safe and Effective
Postoperative Handovers
•Provide opportunity to ask questions and voice
concerns
•Document the handover
•Use supporting documentation for labs, anesthetic
info, etc….
•Use structured checklist to guide communication and
ensure completeness (reference forms or cards as
reminders)
•Use protocols to standardize the process
•Provide formal team or handover training
Segall, Systematic Review Anesth Analg, 2012. 115:102-15
41
Next Steps
• Begin to look at your transitions of care
through new lenses
– Bring your thoughts to the Face-to-Face
– Updates from Dr. Gurses and the CSTS team
• Data from the CSTS site visits
• Transitions across the continuum
• Hazards and Good Practices
• Begin to answer “What should handoffs look
like across the continuum of CV surgery care?”
42
Thank you
[email protected]
43
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Agarwal HS, Saville BR, Slayton JM, et al. Standardized postoperative handover process improves outcomes
in the intensive care unit: a model for operational sustainability and improved team performance*. Critical
care medicine;40(7):2109-15.
Kalkman CJ. Handover in the perioperative care process. Current opinion in anaesthesiology;23(6):749-53.
Li P, Ali S, Tang C, et al. Review of computerized physician handoff tools for improving the quality of patient
care. J Hosp Med.
Petrovic MA, Aboumatar H, Baumgartner WA, et al. Pilot implementation of a perioperative protocol to guide
operating room-to-intensive care unit patient handoffs. Journal of cardiothoracic and vascular anesthesia
2012;26(1):11-6.
Petrovic MA, Martinez EA, Aboumatar H. Implementing a perioperative handoff tool to improve
postprocedural patient transfers. Joint Commission journal on quality and patient safety / Joint Commission
Resources 2012;38(3):135-42.
**Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A
systematic review of the literature. Anesthesia and analgesia 2012;115(1):102-15.
Tan JA, Helsten D. Intraoperative handoffs. International anesthesiology clinics 2013;51(1):31-42.
Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula
1 pit-stop and aviation models to improve safety and quality. Paediatric anaesthesia 2007;17(5):470-8.
Chen JG, Mistry KP, Wright MC, et al. Postoperative handoff communication: a simulation-based training
method. Simul Healthc;5(4):242-7.
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