Standardization of Post-Procedural Handoffs Between Anesthesia Providers and Cardiothoracic ICU Team Cara Crouch, MD and Joseph Morabito, DO Erin Flannery, DO and Jacob Loyd, MD Kimberley Duarte, MD, Nathaniel Strock, MD and Matthew Iacovetto, MD Patrick Henthorn, MSIV Faculty Advisors: Barb Wilkey, MD and Breandan Sullivan, MD University of Colorado Department of Anesthesiology May 1, 2018

Why is this important? Problem: Lack of communication of important information between the operative staff and the ICU staff during OR to CTICU handoffs. This is a daily occurrence that can potentially have significant impacts on patient care. Why this is a problem: (1) These patients are frequently hemodynamically unstable with significant cardiopulmonary pathology and potential ongoing blood loss (2) OR staff are frequently not available for questions postoperatively (need to return to OR for next case, etc) (3) without a formal sign-out process there is no consistency among the information communicated and the quality of the signout becomes dependent on the provider. Who are the stakeholders: ICU providers, ICU nursing staff, patients, surgery team

Fishbone Diagram

Does it really work? Joy et al., 2011 Single-center, pre/post of standardized handoff protocol in Pediatric CICU 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%.” Agarwal et al., 2012 Single-center, pre/post study of structured post-op handoff process implementation in Pediatric ICU: Nearly 50% decrease in CPR, ECMO, re-exploration, and incidence of metabolic acidosis Kaufman et al., 2013 Single center, pre/post study of structured post op handoff protocol implementaion in cardiac surgical ICU 60% decrease in unplanned intubations and 25% decrease in mean ventilator time

SMART AIM Statement Through the implementation of a handoff template in March 2018, we aim to enhance the communication of critical information during the transfer of care from the OR to the CTICU, which we will measure with a pre and post intervention survey of CTICU providers and nursing staff. Specific: Improve handoff from OR to CTICU via the use of a template Measurable: Pre and post-intervention surveys Achievable: Clear and concise template that is easy to follow Relevant: Multiple OR to CTICU handoffs occur daily, current method is unorganized Time-framed: Month trial during March 2018, survey results to guide further utilization

PDSA Cycle Objective: Prediction: Improve CTICU direct from OR handoffs to provider and nurse by formalizing the Anesthesia report with hope to ultimately decrease preventable handoff and communication errors. Prediction: Providers and nurses will have improved confidence and knowledge regarding the complexity of their patient and the plan along with immediate post-operative needs of the direct admit patients in the CTICU. Providers and nurses will be able to contact the Anesthesia provider directly if any questions or concerns arise.

PDSA Cycle Met with CTICU APPs to discuss current handoff process Develop handoff outline by incorporating elements from other OR to ICU guidelines plus necessary cardiothoracic surgical and anesthesia elements. Coordinate with nursing staff, PAs, and residents for implementation of formalized handoff. Test handoff process for one month March 2018. Assess implementation with follow-up survey from CTICU APPs in April 2018

PDSA Cycle

PDSA Cycle

PDSA Cycle

PDSA Cycle

PDSA Cycle

PDSA Cycle Add/Change particular items on handoff forms from CTICU provider feedback. Handoff forms to be incorporated for thoracic and vascular cases as well (all patients direct to CTICU). Maintain blank handoff forms in Cardiac and Thoracic ORs.

Discussion What we learned? Future Plans: Main Problems Identified Provider specific handoffs vary greatly New providers each month (some who have not been in CTICU) We can always improve patient safety during hand offs Future Plans: Edit handoff forms per CTICU provider specific requests Incorporate standardized Surgical signout 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 Agarwal, H. S., Saville, B. R., Slayton, J. M., Donahue, B. S., Daves, S., Christian, K. G., ... & Harris, Z. L. (2012). 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), 2109-2115. Kaufman, J., Twite, M., Barrett, C., Peyton, C., Koehler, J., Rannie, M., ... & Hyman, D. (2013). A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period. Joint Commission journal on quality and patient safety, 39(7), 306-311. 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.