Operating Room Nurse to Post Anesthesia Care Unit Nurse Handoff: Implementation of a Written SBAR Intervention Erin Long BSN, RN, DNP Student The unique setting of the perioperative area is subject to particular barriers to communication including noise, interruptions, and a high rate of patient arrival and discharge. The operating room (OR) nurse must handoff in a timely manner in order to maintain a busy operative schedule while the Post Anesthesia Care Unit (PACU) nurse must care for several patients in need of various levels of care. A lack of structure to the handoff between these nurses places surgical patient safety at risk as miscommunication is more common when handoff protocol is not standardized (Abraham, Kannampallil & Patel, 2014; Kalkman, 2010; Petrovic, Aboumatar & Scholl et al., 2014; Petrovic, Martinez & Aboumatar, 2012; Riesenberg, Leitzsch & Cunningham, 2010; Riesenberg, Leitzsch & Little, 2009; The Joint Commission, 2015). The purpose for this evidence based practice project was to reduce communication errors and reduce patient risks during the handoff communication between operating room (OR) and PACU nurses by standardizing communication with the tested mnemonic tool SBAR. Background Mnemonic Phrase Aids nurse memory (Riesenberg, Leitzsch & Little, 2009) Associated with a handoff checklist (Holly & Poletick, 2013; Kalkman, 2010; Riesenberg, Leitzsch, & Cunningham, 2010) Standardized Protocol Decreases handoff variability (Ong & Coiera, 2014; Riesenberg, Leitzsch & Cunningham, 2010) Reduces communication errors risking patient safety (Abraham, Kannampallil, & Patel, 2012; Greenberg et al., 2007; Holly & Poletick, 2013; Kalkman, 2010; Ong & Coiera, 2011; Petrovic, Aboumatar, & Scholl, 2015; Riesenberg, Leitzsch & Little, 2009; Riesenberg, Leitzsch, & Little, 2012) Recommendations from the Literature Handoff Evaluation Form Statistical Testing & Results Phase One Phase Two Phase Three Frequencies No Significant items across Phases One-Three Mean Scores PACU (M = 8.14, SD = 3.2) PACU (M = 8.31, SD = 3.4) PACU (M = 7.57, SD = 3.25) OR (M = 8.87, SD = 4.15) Paired-Samples t Test OR SBAR Handoff & PACU Handoff Evaluation Independent-Samples t Test Item Result NPO PACU (M = 2.71, SD = 0.46) PACU (M = 2.71, SD = .46) OR (M = 1.5, SD = 0.86) OR (M = 1.50, SD = 0.86) (t(41) =7.51, p < 0.00) (t(82) = 8.061, p = 0.00) Skin PACU (M = 2.98, SD = 0.15) PACU (M = 2.98, SD = .15) OR (M = 2.62, SD = 0.77) OR (M = 2.62, SD = 0.76) (t(41) = 2.93, p < 0.006) (t(82) = -2.97, p = 0.004) Shift PACU (M = 1.24, SD = 0.62) PACU (M = 1.24, SD = .62) OR (M =1.02, SD = 0.15) OR (M = 1.02, SD = 0.15) (t(41) = 0.04, p < 0.037) (t(82) = 2.18, p = 0.032) ANOVA PACU Handoff Evaluation Form No Significant Results (No Post Hoc Testing) PACU Mean Scores No Significant Results (F(66,68) = .21, p = .81) Project Design: Three, 2 week phases for a project duration of 6 weeks Education Session: Handoff PowerPoint ® provided between phases one & two for all perioperative nurses, presented during staff meeting Intervention: 1-page SBAR Handoff form attached to patient charts for nurse use during patient transfer from OR to PACU, measuring 24 items; used by OR nurses in phases two and three Handoff Evaluation Form: 1-page form attached to patient charts and used to evaluate the received handoff, measuring 24 items; used by PACU nurses during all three phases & OR nurses during phase one Safety Attitudes Questionnaire (SAQ): 36 item self-report Likert scale with 6 subscales, 2 of which measure perioperative nurse perceptions of patient safety and teamwork Implementation PICOT PICOT In perioperative nurses, how will the implementation of a written SBAR Handoff Form affect the content of handoffs between OR and PACU nurses and impact the perceptions of teamwork and patient safety of perioperative nurses over the course of three months when compared to current oral report practice? SBAR Handoff Statistical Testing & Results Phase Two Phase Three Statistical Significance Frequencies No Significant items across Phases Two-Three Mean Scores (M = 12.38, SD = 3.69) (M = 11.5, SD = 3.48) (t(82) = 1.81, p = 0.241) Independent-Samples t Test Items Result Implants (M = 0.92, SD = 0.28) (M = 0.57, SD = 0.51) (t(25) = 2.19, p < 0.038) Data Analysis Review of the Literature Databases: CINAHL, ProQuest, Medline (PubMed), Medline (EbscoHOST), Cochrane Library, & Joanna Briggs Institute Keywords: periop*, intraop*, handoff*, handover* Appraisal: Critical Appraisal Skills Programme (CASP) & Checklist for Evidence-Based Clinical Practice Guidelines (CASP, 2013; Melnyk & Fineout-Overholt, 2011) Literature Search SAQ Statistical Testing & Results Pretest Posttest Independent-Samples t Test Item Results Ask Questions   OR (M = 2.70, SD = 1.16) Family OR (M = 4.43, SD = 0.79) PACU (M = 3.86, SD = 1.07) PACU (M = 3.00, SD = .71) (t(15) = -2.14, p = 0.050) (t(10) = 3.227, p = 0.009) Good Job B OR (M = 2.20, SD = 1.87) Daily Efforts B OR (M = 2.86, SD = 1.46) PACU (M = 4.29, SD = 0.95) PACU (M = .00, SD = .00) (t(15) = -2.69, p = 0.017) (t(10) = 4.03, p = 0.002) Problem Personnel B  OR (M = 1.20, SD = 1.03) Compromise Patient Safety B OR (M = 3.57, SD = 1.81) PACU (M = 3.57, SD = 0.79) (t(15) = -5.11, p = 0.000) (t(10) = 4.34, p = 0.001) Timely Info B OR (M = 2.0, SD = 1.69) OR (M = 3.29, SD = 1.70) PACU (M = 4.0, SD = 0.82) (t(10) = 4.25, p = 0.002) (t(15) = -2.87, p = 0.012) Problem Personnel B OR (M = 2.00, SD = 1.63) (t(10) = 2.70, p = 0.022) Pretest & Posttest Timely Info B OR (M = 3.00, SD = 1.53) Paired-Samples t Test (t(10) = 4.33, p = 0.001) Support Pretest (M = 4.58, SD = 0.67) Level of Staffing OR (M = 3.14, SD = 1.07) Posttest (M = 3.92, SD = 0.90) PACU (M = 1.60, SD = .89) (t(11) = 2.60, p = 0.025) (t(10) = 2.63, p = 0.025) Commun-ication Breakdowns OR (M = 2.71, SD = 0.76) PACU (M = 1.40, SD = 1.14) (t(10) = 2.42, p = 0.036) Definition: process used by nurses to file risk reports Result: No reported events following implementation; no change in reported events related to perioperative patient safety when comparing 4 week periods before and after education session Patient Safety MIDAS Audit Conclusions Implementation of a written SBAR Handoff form was not successful in standardizing perioperative nurse Handoff from the OR to the PACU Handoff Evaluation Forms: Phases One-Two revealed promising trends in mean scores, but overall project statistical testing showed only 3/24 items improved with the intervention SBAR Handoff Forms: Mean scores decreased from Phase Two- Three and the Implants item decreased in handoff inclusion SAQ: Perioperative nurse perceptions of Teamwork and Patient Safety showed variations in individual items Ranking & Appraisal of the Evidence Source Type Level Appraisal Score Qualitative Quantitative Good Fair Systematic Reviews X I V Single Studies VI Expert Opinions VII Recommendations Literature supports the use of a mnemonic phrase and standardized handoff protocol during nurse handoff to reduce risks to patient safety Repeating the project during a time when fewer changes are happening simultaneously and for a longer duration are recommended Acknowledgements: Thank you to Dr. Kessler for her continual support and guidance throughout this EBP project. Also many thanks to the perioperative nurses who graciously agreed to participate in this project.