Combined Handover Presentation
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Transcript of Combined Handover Presentation
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Process Improvements and Healthcare IT:
OR-to-PACU Transfer-Of-Care
Aalap Shah, MDChair, Surgical Services Committee
UW Housestaff Quality and Safety Committee
Mentor: Thomas Varghese, MD
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Handover - Definition“Transfer of information,
responsibility, and authority from one health care provider to another.”
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BackgroundTransfers of information represent
high-risk, error-prone patient care episodes1
Relationship between handovers and patient outcomes2,3
Standardization with protocols or checklists are recommended1,4
1Segall, 20122Greenberg, 20073Kulger, 20024Moller, 2013
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Background• Gawande 2003
• Review of 100 incident reports from 45 surgeons• 60% of events in OR+PACU• 43% due to communication failure; of
which 2/3 were due to inadequate handoffs.
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• Joint Commission 2006 –o Requirement for standardized handoff
approach at accredited institutions• Joint Commission + WHO 2008 –
o Highlighted role for standardized processes to identify and reduce handoff-related errors
• Institute of Medicine 2008 – o Increased focus on handoff processes to
improve patient safety• ARRA 2009 –
• $19.2B (of $>170B) stimulus package allocated to Healthcare IT
Background
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Current Obstacles at HMCLack of institutional standardization5,6
◦When should the handoff take place No established order
◦Who should be present Surgeon presence not required until recent
◦How the handover should be recorded Purple Sheet (UWMC), Pieces of Paper (HMC) No concurrent, matching documentation of handover
in EHR◦Where should handover process improvements
be targeted UW OR-ICU, HMC OR-ICU, but not elsewhere
5Chen, 20096Catchpole, 20077Smith, 20088Joy, 20119Nagpal 2011
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Current Obstacles at HMCPoor Quality7
◦Organization◦ Interruptions8
◦Absence of essential personnelInformation omission9
◦What information is relevant to the patient & case
Lack of anticipatory guidance8
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HMC Postoperative
Un-planned
ICU
1. Bay Assigned2 Arrive in PACU,
Handover- Attach O2- Monitors- Positioning- MD: Verbal
handoff, +/- anticipatory guidance, +/- surgical plan
- RN: SSHR filled
Stable for Dispo?
(Aldrete)***
Monitor in PACU
CODE/still unstable?
Home
Floor Txor
Planned ICUOrders in?
Bed avail?
Yes! To floor
Yes! Go home
Outpt Rx ready?
No No
Limbo
Limbo
RN-RN hand-over
RN-RN hand-over
Post-Handover- Providers leave
immediately
- RN checks post-op orders afterwards,
pages if incomplete
- Pt. wakes up, +/- pain, +/- PONV, +/- cardio-respiratory
issues
- Call for additional post-op orders or
dose changes
Additional MED-SURG Admission Guidelines
****
PASS
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Project Goals
Process standardizationCreate anticipatory guidance
Control the settingIncrease Stakeholder Involvement
Improve Information Reporting Interventions:
1. Visual Checklist (MD/CRNA) large/laminated, at each PACU bay
2. PowerNote Checklist (RN) becomes part of the EHR matches the visual checklist
Ultimate Goal:Replace Nursing Written Handover Notes with Electronic
Documentation
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Study DesignProspective interventional study with
pre-/post-implementation comparison◦ Interventions:
Standardized transfer of care checklist (March 2015) Electronic checklist in EMR (April 2015)
Setting: HMC PACU West
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Study DesignAuditors observe post-operative
handovers in PACU West using Audit Form◦ Information compared against Anesthesia
Record◦ Information collected and stored in REDCap
Post-Handover, the PACU RN voluntarily completes the Handoff CEX
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Inclusion/ExclusionInclusion Criteria
◦Patients receiving elective surgery AND planned post-operative inpatient admission to HMC
Exclusion Criteria◦Unplanned ICU admits from the OR
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Outcomes/AnalysisOutcomes:
o Utilization: checklist use, personnel presento Effectiveness: information omission, interruptions,
provider contact, duration, discharge ready time (Student Audits)
o Knowledge Transfer (RN Surveys)o Domain Assessment (Handoff CEX)
Pre-post analysis for intervention utilization and effectiveness
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Data Collection Tools
Audit Form Handover CEX
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CEX + Phone Calls (n=201)PRE-IMPLEMENTATIONJanuary-March 2015
HMC OR-to-PACU Transfer-Of-Care
QI Initiative
UW Housestaff Quality and Safety Committee
PRE-IMPLEMENTATION
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Pre-Study Data: RN survey (HMC)Knowledge transfer% respondents who occasionally,
rarely, or never knew the following:Post-operative plan – 43%Intra-operative events – 42%Patient-specific or procedure-specific call triggers – 83%
Pre-Study - Omission of Information
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How often do you know who to call?
Very often Often Occasionally Rarely Never0%
5%
10%
15%
20%
25%
30%
35%
40%
Pre-Study - Anticipatory Guidance
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How often do you know who to call?
Very often Often Occasionally Rarely Never0%
5%
10%
15%
20%
25%
30%
35%
40%
45.2%
Pre-Study - Anticipatory Guidance
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Baseline Data: PACU RN survey
Call parameters for vitals
Call parameters for labs
Dressing change instructions
PO status
Activity status
Discharge/inpatient medications
Discharge/inpatient orders
Other
0% 10% 20% 30% 40% 50% 60% 70% 80%
If you had questions regarding patient care, what where they about?
Pre-Study - Omission of Information/Anticipatory Guidance
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Power Analysis
Fixed sample size (n = 31), power 80%, alpha .05
Outcome variable Pre- Post-intervention (goals)Mean # calls/pages per patient 1.8 (1.3) 0.9 (relative 50% decrease)
‘Very often’ given post-op management plan (i.e. pain, wound care)
13.3% 48% (delta 34.7)
‘Very often’ given patient/procedure specific call triggers
3.3% 33% (delta 29.7)
‘Very often’ know who to call 19.4% 56% (delta 36.6)
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Audit Data (n=76)PRE-IMPLEMENTATION January-March 2015
UW Housestaff Quality and Safety Committee
PENDING
PRE-IMPLEMENTATION
HMC OR-to-PACU Transfer-Of-Care
QI Initiative
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Data Analysis – Audit Forms
Surgeon attendance: 57.0%Handover time: 3.8 +/- 0.3
minutesPACU LOS : 90.2 +/- 43.4
minutes(Phase 1 Admit Discharge Ready)
Call Triggers:2.5%Resident Contact Info: 1.2%
PRE-IMPLEMENTATION
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Data Analysis – Audit Forms
Patient ID: 62.0%Medical History: 86.1%Diet: 11.4%
PONV: 41.0%Antibiotic Last Dose: 29.1%Pain Management Plan: 54.4%IV Access: 67.1%
PRE-IMPLEMENTATION
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CEX + Phone Calls (n=201)PRE-IMPLEMENTATIONJanuary-March 2015
HMC OR-to-PACU Transfer-Of-Care
QI Initiative
UW Housestaff Quality and Safety Committee
PRE-IMPLEMENTATION
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Data Collection ToolsPRE-IMPLEMENTATION
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Data Analysis – Handoff CEXHandoff CEX Scores and Phone Calls –
Descriptive Statistics
PRE-IMPLEMENTATION
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PRE-IMPLEMENTATION
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PRE-IMPLEMENTATION
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Data Analysis – Handoff CEX
A statistically significant difference was seen between Q1 (Setting) and Q3 (Communication) (p=0.03)
PRE-IMPLEMENTATIONPRE-IMPLEMENTATION
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Data Analysis – Handoff CEXImpact of Auditor Presence on Handoff CEX Scores
Handoff CEX scores for provider-PACU RN interactions were greater in Group 2 handovers (i.e. with medical student auditors present) than in Group 1 handovers (i..e no observers)
PRE-IMPLEMENTATION
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Chief Resident Survey – Current StateENT
◦Type of diet, location of incision, facial nerve monitoring, toradol
Neurosurgery◦Drains, VACs, intra-operative complications,
‘primary service doing orders’Orthopedics
◦ROM, weight bearing, positioning, pain management, drains & output call triggers
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Checklist - OutlineIntroductionsSurgeon
◦ Surgical course◦ Post-operative management plan
Anesthesia◦ Anesthetic course◦ Current state/goals of care
Summary of plan & anticipatory guidanceQuestions/concerns
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Checklist – Visual All Transfer-of-Care Participants (v3.0)
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Checklist – Electronic PACU Nurse (v2.0)
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Chief Resident Survey – Proposed Checklist
Specialty RepresentationCardiothoracic Surgery 1
Neurosurgery 1
General Surgery 4Plastic Surgery 1
Ophthalmology 1
Vascular Surgery 1
Anesthesiology 3
Otolaryngology 2
Orthopedic Surgery 2Urology 2
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Chief Resident Survey – Proposed Checklist
Descriptive Statistics
Please rate 1-5 (1=strongly disagree; 5=agree)
Content - is what you want on here?Anticipatory Guidance – does this framework allow for a suitable management plan to be relayed to the PACU RN?Aesthetics/Familiarity – is this reminiscent of the OR-ICU checklist at UWMC?Organization/Efficiency – does the provider and information item sequence allow for the concise and logical reporting of perioperative events?
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Implementation
Pocket cardsChief Resident Survey distributed to PACU RN and CRNA groupsRN “shift champions”Focus Group and Videography (April 15, 22)
◦Video clip demonstrating the proposed physical and electronic checklists being used
April 1 – May 31, 2015
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Implementation
Videography 4.15.15PENDING
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Audit +Handoff CEX DataPOST-IMPLEMENTATIONMay-October 2015
UW Housestaff Quality and Safety Committee
PENDING
POST-IMPLEMENTATION
HMC OR-to-PACU Transfer-Of-Care
QI Initiative
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Timeline
Dec14 | Jan15 | Feb15 | Mar15 | April15 | May15 | June15 | July15
- Physical Checklist Implementation- Grant Funding Application
- Pre-intervention data collection:*PACU RN surveys*PACU handoff audits*LOS, PSNs
- Post-intervention data collection:*PACU RN surveys*PACU handoff audits*LOS, PSNs- Electronic Checklist Implementation
Winter 2014PACU RN meetingsFocus groups with leadershipChief resident surveysCoordination with IT
Summer/Fall 2015Presentation at QI MeetingsManuscript Preparation
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Areas for ImprovementLoad time for electronic checklist?
◦NOT expected to affect workflowHandover time prolongation?
◦NOT expected with improved organizationPACU RN shift/location changes
◦Focus on PACU West
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Future GoalsCombine with other institutional
handover initiatives◦Reporting of STOP-BANG score and
extubation risk assessment Brett Thomazin RRT, Aaron Joffe,
MD◦UW OR-ICU and OR-PACU Transfer Template Aalap Shah, MD, John Lang, MD,
Bala Nair, PhD◦Decrease # of handovers - HMC OR-ICU
Project Elizabeth Visco CRNA,
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Future GoalsInstitutional-wide use
◦Encourage workflow changes and emphasize ownership in the changes (RN, MD, CRNA)
How does a good handover impact the medical/surgical team◦ Improved focus in subsequent cases?
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II.UWMC OR-to-PACU –
Transfer Template (T2) Project
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Project Goals
Process standardizationCreate anticipatory guidance
Improve Information Reporting
Interventions:1. Anesthesia Transfer Tool (T2)
Ultimate Goal:Replace Nursing SSHR (“Purple Sheet”) with Pre-Completed
Electronic Documentation with T2 information
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Demographics
Anesthesia Transfer Tool (T2) for Handoff
DiagnosisProcedure
Labwork- ABG/VBG- CBC- Electrolytes- Glucose
Fluids/Products
Medications- Induction agents- NMBD + last
dose- Infusion status
Anesthesia Management- Attending
anesthesia concerns
- Airway note- IV access- Attending PMHx- Special notes
- i.e. CPB of/off
- EmergenceLast Vitals
Anesthesia team info
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Pre-Study Data: Nursing (UWMC)
Name -- Airway management 3%
Status/Code 68% Induction Meds 16%
PMHx 36% Lines 24%
Home Rx 24% Resident name/pager 100%
Allergies 10% Anticipatory Guidance 82%
Omission of Information
March 27, 2014: Review of Surgical Services Handoff Report (“Purple sheet”)
in Main OR PACU (n=63 cases)
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Study DesignProspective interventional RCT +
Crossover study of individual handoverso Intervention: Anesthesia Transfer Tool (T2)o Control: Provider-preferred written
information management system (i.e. notes)
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Study DesignOR Anesthesia Computer designated to
either control or intervention armo Co-adaptive randomization of providerso Audio-tape recordings of handovers allow
the researcher to be blinded
Adaptive Randomization
RANDOMIZATION/ASSIGNMENT
CONTROL (- T2)
INTERVENTION(+ T2)
IN OR: Anesthesia Provider PC
OUT OF OR: Study Team Computer
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Press “Leave OR”What do you see on your screen?
Operation
• Induce, Maintain, and Emerge from anesthesia as you normally would
Finish Case
This Nothing
Do as you normally would- Leave OR- Arrive in PACU, position patient
Handover• Use “Written Queue” sheet to initiate handover
Get printout from PACU printer
-Leave OR- Arrive in PACU, get printout- Position patient
Post-Handover Survey (CEX)
Workflow
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Study DesignPrior to Handover (PACU)
◦Audio-tape recorder queued at bedside prior to provider/patient arriving with the patient in the PACU from the OR.
Post-Handover (PACU)◦Audio-tape recorder retrieved at bedside◦Handoff CEX distributed to Provider and
Recovery Room Nurse
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Study DesignDuring the Handover: Data Colelctioj
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Inclusion/ExclusionInclusion Criteria
◦Provider-Subjects: UW CRNAs + Senior Residents (CA2, CA3)
◦Patient-Subjects: ASA >= II Receiving elective surgery AND planned post-
operative inpatient admission to UWMCExclusion Criteria
◦Providers/cases involving an intraoperative handover
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Outcomes/Analysis• Effectiveness (Audiotape Recordings)
o information omission, interruptions, provider contact, handover duration
o Data compared against Anesthesia Record (ORCA)o Scoring System
(0=missing, 0+E=present/incorrect, 1= present/correct)
• Domain Assessment (Handoff CEX)o Distributed to Provider and Recovery Room RN after
handover
• PACU Events o Collected from ORCA (IView)
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Data Collection
Handoff CEXQuality: Domain Assessment
Audiotape RecordingsEffectiveness
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AcknowledgmentsBala Nair, PhD Thomas Varghese, MDAnna Xue, MSIII Daniel Oh, MSIIIBarb DeWitt, RN SupervisorElizabeth Visco, CRNADan Harrington (IT)Dr. Michael Souter (Chief, Harborview
Anesthesiology)UW Housestaff Quality and Safety Committee
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Thank youQuestions?
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Appendix – UWMC OR-ICU
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UWMC OR-ICU Handoff ChecklistAlan Artru, MDJohn Lang, MD
UWMC OR-ICU
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Appendix: UWMC OR-ICUN=21
7 without the T2 (- T2; controls) CTICU = 4; SICU = 3
14 with the T2 (+T2, intervention) CTICU = 13; SICU = 1
Urine output: 3/14 (intervention) Vs. 3/7 (controls)
Blood loss: 5/14 (intervention) Vs. 4/7 (controls)
Fluids & infusions: 2/14 (intervention) Vs. 3/7 (control)
Patient status: 0/14 (intervention) Vs. 1/7 (control)
Hemodynamics: 0/14 (intervention) Vs. 1/7 (control)
Duration of the handoff process was similar for control and intervention cases.
The handoff tool was easily integrated into the clinical workflow to facilitate patient transfer without disruptions.
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Appendix: The Donabedian Model
Health system structure:Academic Teaching Hospital- Varying provider
experience- Patient-provider dyad
interactions- Provider-PAC RN dyad
interactionsMultiple locations/Multiple ServicesCost-containment strategies- OR Turnover time- PACU Personnel- PACU ResourcesElectronic Health Record 3rd-party interfaceable programs
WHAT: Multidisciplinary Transition of Care (Verbal Handover)
HOW: Standardization
PROCESS MEASURES- % of handovers using checklist- “ “ with surgical resident present
BALANCE MEASURES- Handover time- PACU LOS
OUTCOME MEASURES- Nursing Surveys - # of post-handover calls/pages to care team- Third-Party Audit (Omission of information)
System factors
Processes of care
Health outcomes
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Other ThoughtsIntervention Period spreading
knowledge of the initiative◦We don’t have social networks to disperse
and share information, but we work in a large academic center where we share copious knowledge between team members and between disciplines.
◦Positive reinforcement (i.e. voice how satisifed you are with a recent handover using the tool) can help involve stakeholders and improve participation down the food chain.