1. QI Project: ED to OR Communication Initiative
Presented by: Erin Ross, Pete Ritchie, Leah Webb
For our QI project, we focused on communication from the ED to the OR related to patient transfers.

2. CASE ZERO
43 yo M with GSW to L calf. Evaluated by ED providers, Orthopedics, and TACS; spent 4 hours in the ED, then deemed in need of semi-emergent LLE fasciotomy. 
Charge RN was notified of need for OR. Charge RN then notified Anesthesia and OR RN of case. No further details were communicated by ED providers.
Unannounced, patient was brought INTUBATED to the OR, and left by the RN without report.
Room was unprepared and Anesthesia was not ready for case. Surgical staff was unavailable. 
Case completed with no issues and planned to extubate patient (HDS but still no information regarding reason for intubation and no notes by ED in chart yet). 
Extubation attempted but failed 2/2 inability to arouse and follow commands. Flumazenil given (received benzodiazepines in ED) without improvement. Patient was re-intubated in OR and taken to STICU.
Later discovered that patient endorsed methamphetamine use. He was stable, protecting airway, mentating with GCS 15, but was intubated prior to CTA and OR.

3. WHAT’S THE PROBLEM?
Patient safety is at stake with patients arriving directly to the OR from the ED without a defined provider-to-provider handoff process.
Our case demonstrates that patient safety is being risked without a provider-to-provider handoff occurring when the patient is transferred directly to the OR from the ED.

4. CONTRIBUTING FACTORS No formal handoff exists
ED providers need to buy in
No direct way for Anesthesia to contact ED providers
Limited time in urgent/emergent situations to discover information about patients
Distance between ED and OR prevents face-to-face interaction
There are many contributing factors to the problem including the fact that there is no existing handoff; there is a need for ED providers to be involved; there is no direct way for Anesthesia to contact the ED provider who cared for the patient; there is not time to “dig” for information on patients in these circumstances; and there’s a distance between the ED and OR that prevents face-to-face handoff and transition of care.

5. FACTOR INVESTIGATED ED providers’: Why?
Awareness of how to contact Anesthesia
Habits surrounding contact
Perception of importance of contact
Why?
First line solution: patient ownership transfer
A simple way to contact Anesthesia exists
We chose to investigate the ED providers and their awareness of how to contact Anesthesia; We asked about their habits and whether or not they felt it was important to contact Anesthesia in these types of cases. We focused on this factor because the ED providers are the initial step in the process as they are the first providers to care for the patient and they then transfer their care directly to Anesthesia. And because, there already exists an easy way for the ED to contact Anesthesia directly via the Charge phone.

6. PDSA: SCOPE OF PROBLEM Six question survey
Sent to ED Physicians and APPs via of web link
Results collected over one week
To determine the scope of the problem, we created a 6-question survey which we sent to ED providers. We collected results over 1 week.

7. RESULTS: Question 1
Are you aware of how to contact the Anesthesia Charge attending directly?
48% (11)
30% (7)
22% (5)
17% (4)
17% of those polled didn’t know that there is a Charge attending and 52% of people didn’t know how to contact them.

8. RESULTS—Question 2
How often do you call Anesthesia Charge to personally communicate handoff of patients coming directly to the OR?
A. 78% (18)
B. 22 % (5)
Nearly 80% of ED providers have never called and 20% rarely call with direct transfers.

9. RESULTS—Question 3 What is the direct number for Anesthesia Charge?
52% (12)
30% (7)
13% (3)
4% (1)
Only 30% of those polled knew the number for Charge anesthesia.

10. RESULTS—Question 4
Q4: Do you, personally, feel it is necessary to call Anesthesia Charge when transferring a patient direct to the OR?
13% (3)
87% (20)
What’s most concerning is that 87% of those polled do not think a call for handoff is necessary when directly transferring a patient.

11. RESULTS—Question 5
On Amion.com, under which subheadings will you find the number for Anesthesia Charge?
35% (8)
4% (1)
48 % (11)
More people did seem to know where to find the number for Charge, however a not insignificant portion think they will find the number under pain management, which is incorrect.

12. RESULTS—Question 6 Anesthesia Charge is available 24/7 by phone.
83% (19)
17% (4)
Despite the survey, 17% of people are unaware that Charge is indeed available 24/7.

13. NEXT STEPS...
Educated ED providers about ways to contact and availability of Anesthesia Charge.
Create handoff protocol to standardize procedure for direct transfer of care from ED to OR.
Work on improving culture and camaraderie between departments to facilitate communication.
For future PDSA cycles, we would advocate for education by sharing information about how to contact Charge and their availability. We would like to work with ED towards creating a standardized protocol for handoff that clearly outlines the process. Finally, it is ultimately important to foster respect and understanding between the two departments such that both are engaged in and motivated to keep the lines of communication open to facilitate the best patient care.

14. QUESTIONS?