1. Operating Room Nurse to Post Anesthesia Care Unit Nurse Handoff: Implementation of a Written SBAR Intervention
Erin Long BSN, RN, DNP Student
The unique setting of the perioperative area is subject to particular barriers to communication including noise, interruptions, and a high rate of patient arrival and discharge. The operating room (OR) nurse must handoff in a timely manner in order to maintain a busy operative schedule while the Post Anesthesia Care Unit (PACU) nurse must care for several patients in need of various levels of care. A lack of structure to the handoff between these nurses places surgical patient safety at risk as miscommunication is more common when handoff protocol is not standardized (Abraham, Kannampallil & Patel, 2014; Kalkman, 2010; Petrovic, Aboumatar & Scholl et al., 2014; Petrovic, Martinez & Aboumatar, 2012; Riesenberg, Leitzsch & Cunningham, 2010; Riesenberg, Leitzsch & Little, 2009; The Joint Commission, 2015).
The purpose for this evidence based practice project was to reduce communication errors and reduce patient risks during the handoff communication between operating room (OR) and PACU nurses by standardizing communication with the tested mnemonic tool SBAR.
Background
Mnemonic Phrase
Aids nurse memory (Riesenberg, Leitzsch & Little, 2009)
Associated with a handoff checklist (Holly & Poletick, 2013; Kalkman, 2010; Riesenberg, Leitzsch, & Cunningham, 2010)
Standardized Protocol
Decreases handoff variability (Ong & Coiera, 2014; Riesenberg, Leitzsch & Cunningham, 2010)
Reduces communication errors risking patient safety (Abraham, Kannampallil, & Patel, 2012; Greenberg et al., 2007; Holly & Poletick, 2013; Kalkman, 2010; Ong & Coiera, 2011; Petrovic, Aboumatar, & Scholl, 2015; Riesenberg, Leitzsch & Little, 2009; Riesenberg, Leitzsch, & Little, 2012)
Recommendations from the Literature
Handoff Evaluation Form Statistical Testing & Results
Phase One
Phase Two
Phase Three
Frequencies
No Significant items across Phases One-Three
Mean Scores
PACU (M = 8.14, SD = 3.2)
PACU (M = 8.31, SD = 3.4)
PACU (M = 7.57, SD = 3.25)
OR (M = 8.87, SD = 4.15)
Paired-Samples t Test
OR SBAR Handoff & PACU Handoff Evaluation Independent-Samples t Test
Item
Result
NPO
PACU (M = 2.71, SD = 0.46)
PACU (M = 2.71, SD = .46)
OR (M = 1.5, SD = 0.86)
OR (M = 1.50, SD = 0.86)
(t(41) =7.51, p < 0.00)
(t(82) = 8.061, p = 0.00)
Skin
PACU (M = 2.98, SD = 0.15)
PACU (M = 2.98, SD = .15)
OR (M = 2.62, SD = 0.77)
OR (M = 2.62, SD = 0.76)
(t(41) = 2.93, p < 0.006)
(t(82) = -2.97, p = 0.004)
Shift
PACU (M = 1.24, SD = 0.62)
PACU (M = 1.24, SD = .62)
OR (M =1.02, SD = 0.15)
OR (M = 1.02, SD = 0.15)
(t(41) = 0.04, p < 0.037)
(t(82) = 2.18, p = 0.032)
ANOVA
PACU Handoff Evaluation Form
No Significant Results (No Post Hoc Testing)
PACU Mean Scores
No Significant Results (F(66,68) = .21, p = .81)
Project Design: Three, 2 week phases for a project duration of 6 weeks
Education Session: Handoff PowerPoint ® provided between phases one & two for all perioperative nurses, presented during staff meeting
Intervention: 1-page SBAR Handoff form attached to patient charts for nurse use during patient transfer from OR to PACU, measuring 24 items; used by OR nurses in phases two and three
Handoff Evaluation Form: 1-page form attached to patient charts and used to evaluate the received handoff, measuring 24 items; used by PACU nurses during all three phases & OR nurses during phase one
Safety Attitudes Questionnaire (SAQ): 36 item self-report Likert scale with 6 subscales, 2 of which measure perioperative nurse perceptions of patient safety and teamwork
Implementation
PICOT
PICOT
In perioperative nurses, how will the implementation of a written SBAR Handoff Form affect the content of handoffs between OR and PACU nurses and impact the perceptions of teamwork and patient safety of perioperative nurses over the course of three months when compared to current oral report practice?
SBAR Handoff Statistical Testing & Results
Phase Two
Phase Three
Statistical Significance
Frequencies
No Significant items across Phases Two-Three
Mean Scores
(M = 12.38, SD = 3.69)
(M = 11.5, SD = 3.48)
(t(82) = 1.81, p = 0.241)
Independent-Samples t Test
Items
Result
Implants
(M = 0.92, SD = 0.28)
(M = 0.57, SD = 0.51)
(t(25) = 2.19, p < 0.038)
Data Analysis
Review of the Literature
Databases: CINAHL, ProQuest, Medline (PubMed), Medline (EbscoHOST), Cochrane Library, & Joanna Briggs Institute
Keywords: periop*, intraop*, handoff*, handover*
Appraisal: Critical Appraisal Skills Programme (CASP) & Checklist for Evidence-Based Clinical Practice Guidelines (CASP, 2013; Melnyk & Fineout-Overholt, 2011)
Literature Search
SAQ Statistical Testing & Results
Pretest
Posttest
Independent-Samples t Test
Item
Results
Ask Questions
OR (M = 2.70, SD = 1.16)
Family
OR (M = 4.43, SD = 0.79)
PACU (M = 3.86, SD = 1.07)
PACU (M = 3.00, SD = .71)
(t(15) = -2.14, p = 0.050)
(t(10) = 3.227, p = 0.009)
Good Job B
OR (M = 2.20, SD = 1.87)
Daily Efforts B
OR (M = 2.86, SD = 1.46)
PACU (M = 4.29, SD = 0.95)
PACU (M = .00, SD = .00)
(t(15) = -2.69, p = 0.017)
(t(10) = 4.03, p = 0.002)
Problem Personnel B 
OR (M = 1.20, SD = 1.03)
Compromise Patient Safety B
OR (M = 3.57, SD = 1.81)
PACU (M = 3.57, SD = 0.79)
(t(15) = -5.11, p = 0.000)
(t(10) = 4.34, p = 0.001)
Timely
Info B
OR (M = 2.0, SD = 1.69)
OR (M = 3.29, SD = 1.70)
PACU (M = 4.0, SD = 0.82)
(t(10) = 4.25, p = 0.002)
(t(15) = -2.87, p = 0.012)
Problem Personnel B
OR (M = 2.00, SD = 1.63)
(t(10) = 2.70, p = 0.022)
Pretest & Posttest
Timely Info B
OR (M = 3.00, SD = 1.53)
Paired-Samples t Test
(t(10) = 4.33, p = 0.001)
Support
Pretest (M = 4.58, SD = 0.67)
Level of Staffing
OR (M = 3.14, SD = 1.07)
Posttest (M = 3.92, SD = 0.90)
PACU (M = 1.60, SD = .89)
(t(11) = 2.60, p = 0.025)
(t(10) = 2.63, p = 0.025)
Commun-ication Breakdowns
OR (M = 2.71, SD = 0.76)
PACU (M = 1.40, SD = 1.14)
(t(10) = 2.42, p = 0.036)
Definition: process used by nurses to file risk reports
Result: No reported events following implementation; no change in reported events related to perioperative patient safety when comparing 4 week periods before and after education session
Patient Safety MIDAS Audit
Conclusions
Implementation of a written SBAR Handoff form was not successful in standardizing perioperative nurse Handoff from the OR to the PACU
Handoff Evaluation Forms: Phases One-Two revealed promising trends in mean scores, but overall project statistical testing showed only 3/24 items improved with the intervention
SBAR Handoff Forms: Mean scores decreased from Phase Two- Three and the Implants item decreased in handoff inclusion
SAQ: Perioperative nurse perceptions of Teamwork and Patient Safety showed variations in individual items
Ranking & Appraisal of the Evidence
Source
Type
Level
Appraisal Score
Qualitative
Quantitative
Good
Fair
Systematic Reviews X I V
Single
Studies VI
Expert Opinions
VII
Recommendations
Literature supports the use of a mnemonic phrase and standardized handoff protocol during nurse handoff to reduce risks to patient safety
Repeating the project during a time when fewer changes are happening simultaneously and for a longer duration are recommended
Acknowledgements: Thank you to Dr. Kessler for her continual support and guidance throughout this EBP project. Also many thanks to the perioperative nurses who graciously agreed to participate in this project.