Communication: Critical to Preventing Errors in Pediatric Peri-Operative Care Jennifer Schoonover CPNP-AC, PC Pediatric Anesthesia Associates

Objectives List, describe, and understand the key elements of the perioperative handoff. Identify barriers to communicating important details. Make a plan to integrate changes in handoffs for your personal or institutional practices.

com·mu·ni·ca·tion kəˌmyo͞onəˈkāSHən/ noun 1.the imparting or exchanging of information or news.

The goal of the peri-operative handoff is to exchange information about the surgical patient to the team that will be taking care of them. The hand off definition: – “the transfer of information in care across the continuum for the purpose of ensuring the continuity and safety of the patient’s care” AORN

Key Elements of the Handoff Specific information about the patient: name, age, weight, allergies. Procedure performed Preoperative conditions: developmental delays, medical history, pertinent chronic medications Intra operative review: airway management, IV access and fluids given, intraoperative medications given Intra operative complications Postoperative concerns: pain management, nausea prevention, any further follow up with labs or any other procedures Surgical site issues, dressings

Who reports what? Anesthesia provider may report: Patient name, gender, age, procedure, physician History of present illness History of chronic illness Relevant pre-op lab tests Type of anesthesia administered Patient response to anesthesia agents Duration of anesthesia Reversal agents Narcotics Antibiotics Fluid replacement and type (I & O) Invasive monitoring line Vital signs Allergies Other conditions Medications given Complications related to the procedure Orders Surgeon may report: Immediate orders Diagnostic tests for PACU Interventions needed in PACU Perioperative nurse may report: Baseline patient assessment Positioning during procedure Skin prep ESU pad placement and removal assessment Use of special equipment (laser, endoscope) Intraoperative irrigation fluids Administration of medications or dyes from surgical field Implants, transplants, explants Dressing Drains, stents, catheters Sensory or motor limitations Prosthesis presence Pressure ulcer risk assessment Other pertinent patient information Information about the family or others waiting for the patient Cooper, A. Applying Evidence-Based Information to Improve Hand-Off Communication in Perioperative Services, Back to the Basics, OR Connection file:///C:/Users/NHB2LIBU07/Downloads/Hand-OffCommunication.PDF

What makes relaying this information difficult? Stabilizing the patient after transfer in the PACU and preparing the patient in preoperative Lack of time: hurried report, rushing to the next case, computerized charting, patient needing pain medicine, etc. Multiple people giving the handoff: circulating RN, anesthesia, surgeon Making assumptions (this was an ear tube case, no airway or line was placed) Failure of mode of communication (speaking softly, non verbal cues) Resistance of change among all team members

Example of Poor Communication It’s just rude!

Why does it matter? Sentinel Events can occur…death, dismemberment, infections, chronic health issues, etc. “A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness.”The Joint Commission “The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these root cause data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of root causes or trends in root causes over time.”

One Nurses Experience Silence Kills -(or maims)

Sentinel Event Data Root Causes by Event Type 2004 –2Q 2014 Joint Commission reviews all reported sentinel events and their root cause analysis to determine what causes are more likely. They make goals and recommendations for hospitals and institutions to focus on based on this information.

Joint Commission Joint Commission ranks communication as one of the highest contributors to sentinel events. They define communication as “oral, written, electronic, among staff, with/among physicians, with administration, with patient or family” The majority of sentinel events have multiple root causes, communication is often in the top 3.

Communication Rankings in Root Cause Analysis Transfer related events: # 2 20/27 (74%) Wrong site, wrong procedure events: #2 726/1071 (71%) Unintended retention of foreign objects: # 3 584/932 (63%) Op/Postop complications: # 2 434/823 (53%) Anesthesia related events: # 4 55/104 (53%)

We want to do what we can to prevent these events

In 2006, a national patient safety goal was added regarding communication “The organization implements a standardized approach to hand off communications, including an opportunity to ask and respond to questions.”

Joint Commission looks for these attributes in hand offs: Interactive communication Up to date information exchange A method to verify (repeat back) A review of the chart by the receiver Uninterrupted report (or minimized) a standardized process is recommended

Current Standardized Processes I PASS the Baton I SBAR PACE Five “P”s It doesn’t matter which one you use, or if you make one of your own up as an institution

SBAR Example

Effective Handoff Tips Two way communication, both participants taking joint responsibility for ensuring accurate relay of information. Face to face handoffs are best Uninterrupted time, as much as needed Use verbal and written means of communication

Cincinnati’s review of their perioperative handoff system (2013) They did not have a standardized reporting system. They evaluated two handoffs: intraoperative anesthesia handoffs and the anesthesia handoff to PACU Then they instituted a standardized system and reevaluated. The reliability of intraoperative handoffs increased from 20%-100% The reliability of the PACU handoff increased from 59%-90%

KCH Recovery Room Data We are currently looking at key components of our handoffs – Stabilizing airway/vital signs, name, age, weight, allergies, procedure, relevant medical history including developmental delay, type of airway management, IV access/fluids, medications given, intraoperative complications, postoperative concerns – Also asking: Is the nurse ready for report? Any questions? Did the nurse feel they received all the information needed to care for the patient?

KCH Recovery Room Data Our recovery room is fast paced with the number of surgeries recovered daily averaging 30 to 50. A strict schedule is adhered to as best as possible. Patient care is our number one concern. The PACU nurse is bombarded with stabilizing the patient and getting the handoff from both the anesthesia provider and the perioperative/circulating RN at the same time.

KCH Recovery Room Data Observed 57 handoffs Handoffs are given as a team approach including a circulating RN and an anesthesia provider – The circulating RN is a part of the handoff team 100% of the time – Attending anesthesiologists participate in the handoff 29.8% of the time – CRNA 54.4% of the time – SRNA 31.6% of the time – Resident 5.3% of the time – 29.8 % of the time the handoff is given by multiple anesthesia providers (2)

KCH Recovery Room Data Our average for meeting all of the key components for handoffs was 59% We found we were really good at: stabilizing the airway/VS (100%), reporting procedure (95%), medications given (98%), relevant medical history (91%), and developmental delays (93%) We found that we were not so good at: reporting the patients’ age (23%), weight (28%), and asking the PACU RN if they had any questions (35%)

KCH Recovery Room Data continued PACU RN’s are utilizing our computerized charting system to get the information they need prior to the patients’ arrival in the PACU Of all observations, RN's felt they got all the information they needed from their OR handoff team 90% of the time.

KCH Recovery Room Handoff Evaluation Plans Data collection (observing handoffs). Discussion of findings with the entire team (PACU RN’s, circulating RN’s, anesthesia providers). Implementation of an agreed upon standardized tool for handoffs-institutional specific (February 2015). Reevaluation of tool approximately 8 weeks after implementation. Evaluation of intraoperative handoffs (this is more difficult because they do not happen at an appointed time).

How does this relate to your institution? The same process can be repeated in your institution (if you go through the process you will have buy in from all team members). Your team will feel empowered. Your team will be encouraged to be accountable for reporting all pertinent information. Your patients’ will transfer through your area with a higher level of safety. Your institution will meet JCAHO standards

How does this relate to your personal practice? The process of change begins with ourselves. We can not control others, but we do have power over how we communicate. You can be sure that you are giving the best possible handoff you can You can ask questions to the person giving you the handoff to clarify the information you are gathering. Attend a communication seminar/conference

References Boat AC & Spaeth JP. Handoff checklists improve reliability of patient handoffs in the operating room and postanesthesia care unit. Pediatric Anesthesia 23 (2013) The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL: The Joint Commission, Joint Commission on Accreditation of Health-care Organizations. Sentinel Event Data; root causes by event type. The Joint Commission, 2013 retrieved from and nt_Type_2004-2Q_2014.pdf nt_Type_2004-2Q_2014.pdf file:///C:/Users/NHB2LIBU07/Downloads/Hand- OffCommunication.PDF file:///C:/Users/NHB2LIBU07/Downloads/Hand- OffCommunication.PDF