Standardization of Post-Procedural Handoffs Between OR Staff and ICU Team Steven Antonovich, DO and Brennan McGill, MD Cara Crouch, MD and Laura Kirk, MD Ben Reynolds, MD Beth Benish, MD and Chris Lace, MD University of Colorado Department of Anesthesiology May 8, 2017

Adverse Event Patient taken directly from OR to ICU Anesthesia provider reported to RN at bedside RN to RN “handoff” Patient became hypertensive and tachycardiac (as sedation wore off) TOF performed and residual NMB diagnosed Results  Delayed extubation and potential patient harm (awareness)

Fishbone Diagram

UCH QI Entries “…no update regarding pressor requirements, code during procedure, temp pacer settings, paralytics, sedation, intubation etc.” “OR RN report consisted of ‘patient has aortic stenosis, had a TAVR, and has an IV.’” “Anesthesia exited without any report whatsoever” “Upon the RN’s formal assessment of the patient once the patient stabilized, a right- sided facial droop was noticed…however…this is the patient’s baseline but it was never communicated from anesthesia to the ICU RN!” “Patient has chronic respiratory failure and a tracheostomy at baseline. During a procedure, the anesthesiologist needed to intubate the patient and remove the trach. Post-procedurally, the patient’s trach was not replaced and no communication was provided to the accepting team regarding plans for replacing the trach…”

Does it really work? Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit (Pediatric Critical Care Medicine, 2011)1 “On average, 36-40% of handoff information is omitted in the absence of a standardized handoff process. After institution of a standardized process, information omissions drop by 50-66%.” Strengthening handover communication in pediatric cardiac intensive care (Pediatric Anesthesia, 2012) 2 All three phases of handover (pre-patient readiness, pre-handover readiness, and information conveyed) significantly improved with implementation of handover tool. There was no significant increase in the duration of the handover Changes in Medical Errors with a Handoff Program (NEJM, 2015)3 Medical error rate decreased by 23% and the rate of preventable adverse events decreased by 30% by introduction of a mneumonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program and a sustainability campaign.

SMART AIM Statement By the end of the 2016-2017 Academic year, we will improve care team transition for SICU patients by formalizing handoffs between the OR team and the receiving SICU team by formalizing the handoff. Improvement will be measured by evaluating differences between pre- and post-intervention surveys.” Specific: Formalize handoff Measurable: Pre- and post-intervention surveys Achievable: Simple intervention, minimal training required Relevant: Applies to all surgical, anesthesia and ICU personnel Time-Framed: By the end of the 2016-2017 Academic Year

PDSA Cycle Objective: Minimal people/services impacted Prediction: Improve SICU nursing and provider knowledge of direct admit patient care plans by formalizing the OR to SICU handoff process with hope to ultimately decrease preventable handoff and communication errors Minimal people/services impacted Prediction: Nurses and providers will have improved confidence and knowledge regarding the plan and post-operative needs of direct admit patients in the SICU

PDSA Cycle Met with SICU charge nurses/nurse education managers in January 2017 Developed handoff outline Distributed pre-intervention survey in January 2017 Coordinated with nursing staff, PAs, and residents for implementation of formalized handoff Began handoff process in February 2017 Assessed implementation with follow-up survey in March 2017

PDSA Cycle

PDSA Cycle Over the course of the past month, how often have you experienced patient care being compromised due to ineffective communication by the OR team during handoff of patients arriving to the SICU directly from the OR? Mean: 3.64 Mean: 4.05

PDSA Cycle Over the course of the past month, how often have the members of the OR team transferring patients to the SICU failed to introduce themselves during handoff? Mean: 2.36 Mean: 3.5

PDSA Cycle Over the course of the past month, how often has the OR team failed to provide their respective contact information so that the OR nursing team, surgical team, or anesthesia team can be contacted if additional questions arise after handoff? Mean: 2.28 Mean: 2.7

PDSA Cycle Over the course of the past month, how often have you felt unsure of the post-operative surgical plans and/or anesthetic needs of your patients brought to the SICU from the OR? Mean: 3.32 Mean: 4.2

PDSA Cycle What we learned? Future plans: Problems identified Lack of key personnel present Need for surgical team’s orders earlier Being helpful is important and does not go un-noticed Future plans: Reminder for surgical team to have orders in prior to leaving the OR Communicate our findings to all involved parties  spread the word! Mount large poster of handout on wall (will require marketing approval) Keep practicing We received good feedback (written and in person) regarding this project Repetition, repetition, repetition  make a habit of thorough/standardized sign outs Incoming classes will be exposed to this method from the beginning and can incorporate it into their own practice

Questions? References Joy, B. F., Elliott, E., Hardy, C., Sullivan, C., Backer, C. L., & Kane, J. M. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatric Critical Care Medicine. 2011 May; 12(3), 304-308. Craig, R., Moxey, L., Young, D., Spenceley, N. S., & Davidson, M. G. Strengthening handover communication in pediatric cardiac intensive care. Pediatric Anesthesia. 2012 Apr; 22(4), 393-399. Changes in Medical Errors with a Handoff Program. New England Journal of Medicine. 2015 Jan 29; 372(5), 490-491.