Standardizing Anesthesia Handoffs

Educational Objectives

The goal of this program is to improve the quality of communications during handoffs. After hearing and assimilating this program, the clinician will be better able to:

1. Implement protocols for structured handoffs.

Summary

Background: in 2009, Joint Commission declared ineffective communication most common reason for sentinel events

Handoff: involves transfer of care, information, responsibility, authority, and accountability; intraoperative change of shift or permanent relief among most important handoffs; studies found that morbidity and mortality increase with increasing numbers of handoffs; Saager et al (2014) found risk for major morbidity and mortality 8.8% with one provider (no handoffs) and 21.2% with ≥4 handoffs; Terekhov et al (2016) found no association between handoffs and morbidity and mortality but noted that short breaks associated with 6.7% improvement in morbidity and mortality rates; Cooper et al (1989) found short breaks associated with identification of potential areas of concern and near misses

National Patient Safety Goals (Joint Commission, 2009): included implementation of standardized approach to communications during handoff, including opportunity to ask and respond to questions

Potential benefits of standardized communications: addition of detailed structure can help to organize care of complex patients, minimize overload of information, reduce errors of omission and commission, and aid in communications in cases of poor human-computer interactive design

Preprocedure: Caruso et al (2017) showed standardized handoffs from intensive care unit (ICU) to operating room increased communication without delaying surgery and improved satisfaction among anesthesia providers; Lorinc et al (ASA abstract) showed reduction in missed items during handover from pediatric preoperative nurse to anesthesia provider after implementation of standardized handover; Agarwala et al (2015) showed improvement in transfer of information during intraoperative handoffs after implementation of electronic checklist

Postoperative transfer to ICU: multiple institutions found decrease in omissions, improvement in readiness and transfer of information, and improved pain scores

Postoperative transfer to postanesthesia care unit (PACU): Weinger et al (2015) found acceptable handoffs improved from 3% to 87% over 3 yr among providers trained to use standardized transfer; also found improvement among providers who did not receive training, suggesting changes in culture can lead to overall improvements among staff

Segall et al (2012): performed systematic review including 31 studies; recommendations included standardization of process (eg, checklists, protocols), completion of urgent clinical tasks before handover, requirement that all relevant members of team be present, allowance of only patient-specific discussions during handover, and provision of training in team skills and communication

Outcomes: some very small studies show benefit for clinical outcomes; most studies unable to show benefit

Checklists: merely instrument; effective use requires competence among clinicians and selection of correct instrument; handoffs differ; single checklist not appropriate for every type of handoff; not all information equally important (emphasis must be placed on appropriate items); risks associated with checklists include skipping items already on electronic handoff report and skipping items because information not known

Limitations of technology: new technology does not necessarily eliminate error; computer cannot provide recommendations or assessments

Speaker’s recommendation: use electronic handoff report when available (provides important information and opportunity to verify correctness of chart)

Experience at speaker’s institution: before implementation, average of 33% of 25 items communicated during handoff to PACU; after implementation, average increased to 75% among clinicians who used tools for handoffs and 46% among those who did not use tools despite training; satisfaction increased among nurses in PACU; use of checklists did not increase time needed for turnover

Readings

Agarwala AV et al: An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care. Anesth Analg 2015 Jan;120(1):96-104; Caruso TJ et al: Standardized ICU to OR handoff increases communication without delaying surgery. Int J Health Care Qual Assur 2017 May 8;30(4):304-11; Cooper JB: Do short breaks increase or decrease anesthetic risk? J Clin Anesth 1989;1(3):228-31; Lorinc AN et al: Pediatric preoperative handovers: does a checklist improve information exchange? 2016. www.asaabstracts.com/strands/asaabstracts/abstract.htm%20%20?year=2016&index=15&absnum=4884. Accessed June 19, 2018; Saager L et al: Intraoperative transitions of anesthesia care and postoperative adverse outcomes. Anesthesiology 2014 Oct;121(4):695-706; Segall N et al: Can we make postoperative patient handovers safer? a systematic review of the literature. Anesth Analg 2012 Jul;115(1):102-15; Terekhov MA et al: Intraoperative care transitions are not associated with postoperative adverse outcomes. Anesthesiology 2016 Oct;125(4):690-9; Weinger MB et al: A multimodal intervention improves postanesthesia care unit handovers. Anesth Analg 2015 Oct;121(4):957-71.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Staples was recorded at the 68th Annual Postgraduate Symposium on Anesthesiology, held April 27-29, 2018, in Kansas City, MO, and presented by the University of Kansas Medical Center Department of Anesthesiology and the Department of Continuing Education and Professional Development. For information about upcoming CME opportunities from the University of Kansas Medical Center Department of Continuing Education and Professional Development, please visit kumc.edu/community-­engagement/ce. The Audio Digest Foundation thanks the speakers and the University of Kansas Medical Center for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AN603202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.