Improving Perioperative Handoffs – A Case Study in Implementation May 7, 2017 International Anesthesia Research Society Annual Meeting Aalok Agarwala, M.D., M.B.A. Division Chief, General Surgery Anesthesia Associate Director, Quality and Safety Instructor in Anesthesia, Harvard Medical School

Outline About MGH Background Aim Our Critical Elements Measures of Success The Checklist Results Key Factors for Success

The Massachusetts General Hospital

Anesthesia at MGH Operating Rooms: 58 NORA Sites: 28 # Anesthetics/Year: ~70,000 Faculty: 135 Residents: 75 Fellows: 24 CRNAs: 50

Intraop Handoffs: Background Preventable errors & anesthetic mgmt. ~10% of errors involved a relief anesthetist ~1% could be attributed to the handoff process Cooper JB et al. Anesthesiology 1982;56:456-461 Previous handoff protocols at MGH Cooper JB. (J Clin Anesth 1989;1:228-31) Goldhaber-Fiebert, 2006 Rudolph JW, 2008 Still no standardized intraoperative handoff process in 2012

Improving Intraoperative Handoffs Aim: To improve the relay and retention of patient information by providing a simple, standardized structure for the handoff between anesthesia clinicians for intraoperative transfers of care

Our Critical Elements Small group of motivated front-line clinicians Training with quality improvement principles and tools Dedicated project planning time

The Team

Our Critical Elements Small group of motivated front-line clinicians Training with quality improvement principles and tools Dedicated project planning time Measures of success part of initial plan

Measures of Success Improvement in Information Relay - Measured by direct observation Improvement in Information Retention – Measured with specific questions Departmental Satisfaction - Survey about perceived handoff quality before and 8 months after introduction of the new process

Our Critical Elements Small group of motivated front-line clinicians Training with quality improvement principles and tools Dedicated project planning time Measures of success part of initial plan Leadership buy-in and support A QI “Coach” to help the team, regular check-ins Timeline for project completion

Timeline

Our Critical Elements Small group of motivated front-line clinicians Training with quality improvement principles and tools Dedicated project planning time Measures of success part of initial plan Leadership buy-in and support A QI “Coach” to help the team, regular check-ins Timeline for project completion Development of checklist/process by consensus Resources available to make checklist electronic

Electronic Handoff Checklist

Our Critical Elements Small group of motivated front-line clinicians Training with quality improvement principles and tools Dedicated project planning time Measures of success part of initial plan Leadership buy-in and support A QI “Coach” to help the team, regular check-ins Timeline for project completion Development of checklist/process by consensus Resources available to make checklist electronic Measurement and report-out to stakeholders

Results: Information Relay Item No checklist With checklist p-value Vasopressors 44% 85% <0.01 Antiemetics 15% 46 % <0.02 Antibiotics 63% 97% <0.001 Lines 80% 100% Blood loss 57% Urine output 52% Fluids administered 70% 90% =0.06 Potential concerns 92% <0.002 Postoperative plan 43% Introduction of anesthetist 3% 51%

Results: Information Retention Question Without Checklist With Checklist p-value Amount of fluid administered 72% 97% =0.008 Muscle relaxant used 63% =0.003 Antibiotic used 75% =0.020 Time next antibiotic dose due 39%

Results: Departmental Satisfaction Quality of Communication Before After p-value Outstanding/Good 63% 87% <0.001 Identification of Concerns 61% 85%

Results: Checklist Adoption Rate

Results: Maintenance

Conclusions The checklist improved relay and retention of critical information Use was associated with perception of improved communication Voluntary use remained steady Impact on improved patient outcomes not known

Why did it work this time? Front-line clinicians leading the effort Leadership support IT resources available Quality Improvement “Coach” Strict Timeline Measurable outcomes Results shared with department Key Factor: A group of motivated individuals

Acknowledgements Project Team: Guido Musch, MD, PhD, Paul Firth, MBChB, Lisa Warren, MD, Meredith Albrecht, MD, PhD Chief: Jeanine Wiener-Kronish, MD IT Support: Bill Driscoll and team Coach: Bob Gibbons, PhD – MIT Sloan Our predecessors: Jeff Cooper, PhD, Jenny Rudolph, PhD, Sara Goldhaber-Fiebert, MD Reference: Agarwala AV, Firth PG, Albrecht MA, Warren L, Musch G. An Electronic Checklist Improves Transfer and Retention of Critical Information at Intraoperative Handoff of Care. Anesth Analg 2015;120:96–104