Improving Intraoperative handoffs By Terry Easton, Matt Lyman, and Corey Tingey With help from Drs. Gravlee and Marshall

The Problem The focus of our project is intraoperative handoffs. We feel a standardized approach should be developed for the process of transferring information from one anesthesia caregiver to another. Handoffs are extremely variable and if done poorly, they can lead down a path of errors, harm, and even death. Done well, handoffs can be a safety net to ensure the patient is well cared for at all times.

Scope of the problem and solutions At the University Hospital, 20+ inpatient OR’s are running during each weekday. As a result, the number of intraoperative handoffs per day is significant. Within the last 2 years, a standardized method was developed in Epic to facilitate this information exchange. However, compliance with the Epic handoff system has been extremely low. As a group, we feel with a more robust handoff, the electronic handoff menu will have improved compliance among providers.

The Stakeholders The in-room anesthesia provider(s) The attending anesthesiologist Post-op nurses Operating surgeon The patient i. The in-room anesthesia provider – Their knowledge of the patient and what has occurred during the pre and intraoperative period will allow him/her to take better care of the patient and formulate a plan as to what should happen should a problem arise. ii. The attending Anesthesiologist – The attending, who may be needed in an urgent situation, may not know all of the intricacies of the case and may have to spend valuable time looking through the chart trying to learn what should have been handed off to the in-room provider. iii. Post-op nurses – The in-room providers cannot give a very thorough hand off to the post op nurses if they themselves have not received a thorough hand off and care of the patient can suffer. When post-op nurses have a thorough knowledge of what occurred in the case it allows them to prevent potential complications and trouble shoot problems quicker. iv. The Operating Surgeon – The operating team expects the in-room provider to know everything going on with the case at hand and knowledge gaps could lead to intraoperative delays or complications post op that the surgery team will have to manage. v. The Patient - There are numerous ways a patient’s care may suffer when a hand off is incomplete. A fixed hand off system should allow for optimal care of the patient throughout the perioperative period.

Environmental/Strategic Factors Patient Factors System/Process Epic checklist not useful Comorbidities (clinical condition) Existing institutional norms (culture) Complexity of surgical procedure Timing/appropriateness of hand off Lines, monitors, regional/neuraxial anesthesia Poor communication of essential patient information at the time of intraoperative handoffs. Poor compliance with standardized approach (checklist – Epic) at the time of intraoperative handoffs Variable process Awake patient ICU transport Safety culture Lack of motivation: “too much trouble” Disruptive to surgeon Reluctance to change Rapid movement/change in OR High turnover of employees Lack of defined leader Noise level Appropriate time in conduct of anesthetic Distraction from other tasks/people Comfort level of provider Staffing workload/hours Safe to relieve Staff Factors Environmental/Strategic Factors

Smart goals and objectives Area for improvement: Communication of essential elements at the time of intraoperative handoff Overall Goal: To standardize an approach to guide handoffs (checklist) Objectives: Improve communication, reduce variability, avoid errors and complications that may result in harm to the patient

Smart goals and objectives continued Area for improvement: Compliance and acceptance of handoff process Overall Goal: To ensure all members of the anesthesia team consistently employ a standardized approach (checklist) Objective: Improve compliance and monitor compliance rates through Epic

Smart goals and objectives continued Area for improvement: Operational considerations of safe and effective handoffs Overall goal: To perform intraoperative handoffs at an appropriate time during the anesthetic Objectives: Perform appropriate handoffs by an available, focused, and knowledgeable provider

Smart goals and objectives continued Area for improvement: Ease of use Overall goal: To make the handoff process concise, accessible, and Epic-friendly Objectives: Develop accessible handoff window that includes comprehensive yet concise information vital to handoff process

Process Flowchart Provider starts last case and prepares for an upcoming transfer of care Relief provider arrives: - Current provider available for a transfer of care? - Safe and appropriate time in case for transfer of care? If Yes: Perform handoff via Epic checklist Relief provider assumes responsibility for patient If No: Relief provider checks back later or assists current provider

POTENTIAL Next steps Modify how handoff window behaves in Epic during handoff process Default pop-up when changing staff Improve handoff window with SmartLinks for important, patient-specific information Train staff and monitor compliance

REferences McQueen-Shadfar L., Taekman J. Say what you mean to say: improving patient handoffs in the operating room and beyond. Simul Healthc. 2010;5(4):248– 253.[PubMed] Groah L. Hand offs—a link to improving patient safety. AORN J. 2006;83(1):227– 230.[PubMed] Rogers S. O., Jr, Gawande A. A., Kwaan M., et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140(1):25– 33.[PubMed] Bajaj P. What's new in patient safety and how it will affect your practice. Indian J Anaesth. 2007;51(5):363–364. Vidyarthi A. The Patient Handoff, Opportunities for Improvement. Webinar. Critical Care Trends: Today and Tomorrow series for AstraZeneca; Oct, 2007. Levitan D. Digital handoff smoothes flow between OR and ICU. Anesthesiology News. 2010;36(6):6.