6/4/2019

1

Handoffs in the ICU: Opportunities for Better Care

Jose L. Pascual MD, PhD, FRCS(C), FACS, FCCM

Associate Professor of Surgery

Perelman School of Medicine, University of Pennsylvania 

Trauma, Emergency Surgery, Surgical and Neuro Critical Care

OR‐to‐ICU handoffs can be problematic

Potential problems• Patient movement

• Technology movement

• Multiple teams

• Different disciplines

• Different priorities

• Time pressure

Consequences• Physical injuries

• Physiologic deterioration

• Medication errors

• Missed information

• Poor team functioning

Nagpal et al. Failures in communication and information transfer across the surgical care pathway, BMJ Qual Saf (2012)

6/4/2019

2

Standardizing OR‐to‐ICU handoffs works

• Information exchange improves

• Provider satisfaction improves

• Handoff duration is unchanged or shorter

• Medical errors may decrease

• Goals (e.g. extubation) may be reached earlier

Craig et al. Strengthening handover communication in pediatric cardiac intensive care. Paediatr Anaesth 2012; 22(4):393-9

Common features of published OR to ICU 

handoff protocols

Lane‐Fall et al. Handoffs and transitions in critical care (HATRICC), BMC Surgery (2014)

0

10

20

30

40

50

60

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Number of pap

ers

Year

Published papers on OR‐to‐ICU handoffs (Scopus)

6/4/2019

3

What OR to ICU handoffs should look like

SurgeonICU provider

ICU nurse (1°)

Anesthetist

Respiratory therapist

ICU nurses (2°)

BackgroundMedical errors extremely common

Communication errors 2 out of 3 sentinel events, most serious events

Omission and incorrect transfer of critical information

More handoffs due to shorter resident workhours, APPs

As of 2010 ACGME: Compulsory to provide curriculum

But curricula are home‐grown: few critically evaluated

Landrigan CP et al, NEJM 2010Joint Commission, 2013

6/4/2019

4

BackgroundPrevious Single Center Study developed I‐PASS (iterative) @ Boston Children'sIllness severityPatient summary

Action listSituational awareness & contingency planSynthesis by receiver

Multicenter Trial to broadly test curriculum effect on medical errors – interns + seniors

Methods9 pediatric residency programs (USA & Canada)

6 months pre‐intervention

6 months intervention

6 months post‐intervention (matched –time of year)

Data collectedMedical errors Quality of oral and written handoffs Demographics and medical complexity of unit patients All residents – analysis only on consented residents Cookies gift cards 

MethodsNo sites had preexisting standardized handoff processesNo ICUsCurriculum (I‐PASS Bundle) 2hr didactic communication session (AHRQ/DOD) TeamSTEPPS, Team Strategies, Tools to Enhance Performance and PS I‐PASS handoff techniques

1hr role playing & simulation sessionOnline module Faculty development Toolkit for feedback to residentsMarketing campaign: posters, logos, advertising 

6/4/2019

5

MethodsWritten handoff: Implemented into EMR (7/9 – 2/9 MS word)

Medical errors Incident reportingNurse review of EMR 5days/wk

Solicited reports from nurses and post call residents (surveys)

Two blinded MDs classified events  Adverse event (harm due to medical care)

Near miss/error (little potential for harm)

Exclusion (neither medical error nor adverse event)

Handoff quality, resident workflow & satisfactionKey elements analyzed (rates of inclusion)

Written handoff list (every morning and evening)  ‐random sample analyzed (432)

Audiotaped oral handoff report (AM and PM) Random sample (207)

Research staff followed residents for 8‐12hrs

12 Major & 114 minor activities

End of rotation survey

Results10 740 patient admissions

5516 pre, 5224 post 

Errors, LOS, complexity, demographics

876 residents consented (94.5%)

Survey responses  pre 93.1%, post 93.3%

6/4/2019

6

Medical errors

↓ 23%↓ 30%↓ 21%

Non preventable adverse events: no difference

Written handoff quality

Oral handoff quality

6/4/2019

7

Resident Workflow patterns & satisfaction8128 time‐motion hours collected (pre and post)

No Δ patient/family contact time (11.8 vs 12.5%)

No Δ time @computer creating/editing list (1.6 vs 1.3%)

No Δ time @computer overall (16.2 vs 16.5%)

No Δ time editing written document (0.5 vs 0.6%)

Resident reporting handoff training (60.3 vs 98.9%, p<0.001)

Resident assessment of quality of their Handoff (27.8 vs 72.2%, p<0.001)

Discussion I‐PASS Improved process written and oral handoffs (9/9 sites)

Reduction of med errors (6/9 sites)

Without increase in resident time spent on handoff

Without decrease in time with patients

QuestionsWhy 3/9 sites did not have reduction of errors?

Data collectors clearly not blinded

How was baseline handoff education 60%?

No discussion of non‐resident providers (NP, PA)

What about off hours and weekends?

6/4/2019

8

Handoffs in the Intensive Care Unit: Worse During Off Hours?

ME Barry, BR Hochman, MB Lane-Fall, SR Allen, DN Holena, L Kaplan, JL Pascual

Division of Traumatology, Surgical Critical Care, & Emergency Surgery

Perelman School of Medicine of the University of Pennsylvania

Introduction

Communication failures common and problematic• Adverse events• Malpractice events• Complexity of OR-to-ICU handoffs

Handoffs and “weekend effect” Hypotheses: (1) OR-to-ICU bedside handoff quality diminishes

on nights and weekends (2) bedside handoff practices inconsistent between

high and moderate volume ICUs The Joint Commission. Sentinel Event Data. Available at: http://www.jointcommission.org/assets/1/18/Root_Cuses_by_Event_Type_2004‐2Q2013.pdf [accessed 23 January 2014].Carr et al. Weekend and Night Outcomes in a Statewide Trauma System. Arch Surg. 

( )

6/4/2019

9

Methods

• Bedside handoffs assessed in a high volume (210 admits/month) and a moderate volume (125 admits/month) surgical ICU

• Handoff assessment metric:- Duration and number of people in room- Number of content items omitted- Quality of teamwork, transmitter delivery, professionalism- Number of receiver passive and active listening skills- Receiver physical exam

• T-tests and chi square analysis:- Weekday (0700-1700, M-F) vs. night/weekend within ICUs- High vs. moderate volume ICU

High Volume ICU Weekdays vs. Nights/Weekends

**p<0.01

Results

High Volume vs. Moderate Volume ICU

*p<0.05, **p<0.01

Results

6/4/2019

10

Conclusions

1) Bedside handoff practices on nights and weekends are not worse

2) Bedside handoff practices are better in a high volume ICU

3) Specific handoff practices merit evaluation and training implementation to improve ICU processes of care

ICU OR‐to‐ICU Handoffs on Weekdays vs. Nights/Weekends

**

Hochman et al, Am J Med Quality, 2015

OR‐to‐ICU Handoffs in ICU1 (↑Vol.) vs. ICU2 (↓Vol)

Hochman et al, Am J Med Quality, 2015

6/4/2019

11

OR-to-ICU Handoffs Captured on Video: Are Transitions at Night More Dangerous?

M Barry, B Hochman, M Lane-Fall, D Zappile, D Holena, S Allen, N Martin, P Reilly, J Pascual

Division of Traumatology, Surgical Critical Care & Emergency Surgery

Perelman School of Medicine of the University of Pennsylvania

Introduction

Communication failures• Adverse events• Malpractice events• Complexity of OR-to-ICU handoffs

ACGME handoff requirement

Handoffs and “weekend effect”

The Joint Commission. Sentinel Event Data. [accessed 23 January 2015].Carr et al. Weekend and Night Outcomes in a Statewide Trauma System. Arch Surg. 2011.Nasca et al. The New Recommendations on Duty Hours from the ACGME Task Force N Engl J Med 2010

6/4/2019

12

Hypothesis

OR-to-ICU bedside handoff quality diminishes on nights and weekends

compared to that of weekdays

Methods

Video-recorded 32 OR-to-surgical ICU bedside handoffs

Videos evaluated offline:• Number of people in room, time providers spent in room• Timing/length of reports, who delivered to whom• Presence of patient exam

• Reports: delivery skills, passive/active listening skills, engagement• Teamwork parameters• Interruptions

6/4/2019

13

Weekday (0700-1700, M-F) vs. night/weekend

Handoff characteristics (32 handoffs)• T-tests, Chi Square analysis

Handoff quality measures (42 handoff assessments)• Scores converted to value relative to observer’s average• T-tests

Results

Basic Handoff Characteristics

WeekdaysNights & Weekends

P-value

Number of people in room 6.8 6.8 0.92

Total time in room

Anesthesia 9m 21s 8m 23s 0.45

Surgery 3m 26s 4m 15s 0.43

Receiving ICU Provider 8m 38s 8m 54s 0.99

Time to first handoff report 1m 11s 1m 15s 0.83

Time to room empty of providers

12m 14s 11m 53s 0.60

6/4/2019

14

WeekdaysNights & Weekends

P-value

Handoff Report Length

Anesthesia 3m 46s 2m 58s 0.50

Surgery 1m 34s 2m 8s 0.25

Total 4m 42s 5m 20s 0.52

Handoff Report Type

Anesthesia to ICU Provider 56% 56%

Anesthesia to RN 81% 81%

Surgeon to ICU Provider 50% 53% 0.47

Surgeon to RN 50% 75% 0.14

Physical Examination

ICU Provider 50% 44% 0.83

RN 63% 56% 0.60

Either Provider or RN 75% 81% 0.67

Basic Handoff Characteristics

WeekdaysNights & Weekends

P-value

Teamwork

Task Prioritization 0.72 1.14 0.47

Clear Role Identification 0.97 1.02 0.76

Attention to Reports 0.79 1.18 0.21

Coordination of Reports 0.81 1.14 0.058

Transmitter Collaboration 0 1.74 0.025

Sum 0.80 1.15 0.03

Engagement

Anesthesia 1 1

Surgery 0.69 1.26 0.017

ICU Provider 0.87 1.12 0.10

RN 0.84 1.14 0.28

Quality Outcome Measures

WeekdaysNights & Weekends

P-value

Report Delivery

Anesthesia 1.05 0.96 0.73

Surgery 0.5 1.5 < 0.001

All 0.79 1.2 0.029

Listening Skills

Eye Contact 1.07 0.94 0.062

Affirmatory Statements 0.99 1.01 0.88

Head Nodding 0.94 1.04 0.35

Note Taking 1.01 0.99 0.91

Questions / Interactive Comments 1.02 0.99 0.79

Interruptions 1.03 0.98 0.89

Quality Outcome Measures

6/4/2019

15

Discussion

Bedside handoff practices on nights and weekends are potentially better Video recording may be a useful tool

for monitoring handoff quality Specific handoff practices merit

evaluation and training implementation to improve ICU processes of care

Primary question:

Does handoff standardization improve OR-to-ICU handoff communication in a mixed surgical population?

Secondary question:

What factors influence the successful implementation of a standardized OR to ICU handoff process?

Research questions

HATRICC measures

Data type

Measure type

Effectiveness Implementation

Qualitative • Handoff quality• Teamwork quality

• Acceptability• Appropriateness• Fidelity• Sustainability

Quantitative

• Information omissions• Handoff accuracy• Handoff duration• Team members present• Teamwork quality• Professionalism• Diagnostic test utilization• ICU length of stay• ICU mortality• In-hospital mortality

• Acceptability• Cost• Fidelity

6/4/2019

16

Pre-intervention observations

94 “handoffs” observed in total 62 single‐observer

16 dual‐observer

Does not count practice observations

Final sample after de‐duplication: 68

64 handoffs observed

4 “missing in action”

Four observers, 502 hours

Exploration:“Was that a handoff?”

Interviews and focus groups

Data type Team

Clinician type InterviewFocus group Survey OR ICU

HousestaffAnesthesia (n=12) X X X X XSurgery* (n=22) X X X X X

CRNAs (n=16) X X XNPs, PAs (n=6) X X XICU nurses (n=18) X X XAttending physicians

Anesthesia (n=4) X X X XSurgery (n=5) X* X X X

*general surgery, orthopedics, otorhinolaryngology, plastic surgery, thoracic surgery, trauma, and urology

Lane-Fall et al. Joint Commission Journal 2018, 44(9): 514-525

6/4/2019

17

Themes from interviews and focus groups Frequently reported barriers: Low prioritization Time constraints

Handoff quality affected by:  Professionalism Teamwork 

Frustrating aspects of handoff: Inconsistent provider presence Insufficient resident knowledge of patient/case

Lane-Fall et al. Joint Commission Journal 2018, 44(9): 514-525

Why don’t post‐op handoffs work? An advanced practitioner’s perspective “So there are some people that just bring the patient in and basically run away, like one of my colleagues.  He does not give a good sign‐out.  He does not tell you anything unless you specifically ask a question of him.  He will not tell you if the aorta fell apart and you had to reconstruct.”

Why might someone run away?

“I think that they are not comfortable in the ICU, and if something happened, they don't want to be responsible for it, so they leave the patient and they go, because they don't want to be caught up in this.  

I think that sometimes it's because unfortunately you have another case or you're getting called into another room.  

I think sometimes some people are hungry and they just kind of toss and run.

And also, there's one person that doesn't like one of the physicians that takes care of the hearts, Dr. X, so if he sees him, he doesn't stay long in the unit.  They don't get along.”

Simulation helped build the new handoff process

Changes after simulation: added physical exam | clarified necessary participants | changed template

6/4/2019

18

A new handoff process developed with clinician input

Lane-Fall et al. Joint Commission Journal, 2018.

Handoff protocol improved information exchange and team outcomes

• Information omissions decreased 21%

• Providers more consistently at bedside

• Handoff duration increased (3.5 min 8 min)

• No change in unit-level patient outcomes

Lane-Fall MB et al, in press, Annals of Surgery

How to read this heat map: 

• Green = favorable  • Yellow = intermediate• Red = unfavorable  

One row = one observation

Observations are sorted by number of information omissions, then by teamwork and professionalism ratings

Lane-Fall MB et al, in press, Annals of Surgery

6/4/2019

19

Lane-Fall MB et al, in press, Annals of Surgery

Lane-Fall MB et al, in press, Annals of Surgery

Lane-Fall MB et al, in press, Annals of Surgery

Fidelity (adherence)to HATRICC protocol

6/4/2019

20

“I think, ultimately, we have to be clinicians and do what we think is best for the patient and not follow a checklist just because that’s present.”

‐ Anesthesia resident

Mixing methods gives additional insight

qualitativequantitative

Lane‐Fall et al, unpublished data

“All disciplines equate that term with handoff - it’s a great catch word that stuck. It’s the norm to say in the patient’s room ‘Ok let’s HATRICC.’ Or ‘Is everyone ready for HATRICC?’ It’s very interesting because you never hear the phrase ‘Ok, are we ready for handoff?’”

- ICU nurse manager

We assessed acceptability in multiple ways

said the new process was acceptable

always or usually used the new process

said the new process made patient care betteror much better

125/160(78.1%)

136/152 (89.5%)

107/156(68.7%)

Acceptability ratings (surveys):

We assessed acceptability in multiple ways

Interview-based assessments:“All disciplines equate that term with handoff - it’s a great catch word that stuck.

It’s the norm to say in the patient’s room ‘Ok let’s HATRICC.’ Or ‘Is everyone ready for HATRICC?’ It’s very interesting because you never hear the phrase ‘Ok, are we ready for handoff?’”

6/4/2019

21

Lane‐Fall M, Pascual J et al, Ann Surg, (accepted for publication)

Education & Choreography in Multidisciplinary Handoffs (OR‐to‐ICU) HATRICC

Lane‐Fall M, Pascual J et al Ann Surg

Lane‐Fall M, Pascual J et al Ann Surg

6/4/2019

22

Attribute Pre‐intervention (n=64) Post‐intervention (n=97) P‐value

Teamwork, number (%) of handoffs with feature

Surgeon present 49/64 (76.6%) 95/97 (97.9%) <0.001

Anesthetist present 56/64 (87.5%) 97/97 (100%) <0.001

Nurse present 46/64 (71.9%) 94/97 (96.9%) <0.001

ICU provider* present 47/64 (73.4%) 86/97 (88.7%) 0.019

All 4 representatives** present 25/64 (39.1%) 81/97 (83.5%) <0.001

Quality of information transfer***

Superior

Satisfactory

Unsatisfactory

11/62 (17.7%)

36/62 (58.1%)

15/62 (24.2%)

22/97 (22.7%)

66/97 (68.0%)

9/97 (9.3%)

0.041

Teamwork***

Superior

Satisfactory

Unsatisfactory

10/64 (15.6%)

25/64 (39.1%)

29/64 (45.3%)

26/97 (26.8%)

53/97 (54.6%)

18/97 (18.6%)

0.001

Professionalism***

Superior

Satisfactory

Unsatisfactory

37/64 (57.8%)

11/64 (17.2%)

16/64 (25.0%)

30/97 (30.9%)

60/97 (61.9%)

7/97 (7.2%)

<0.001

Handoff duration (minutes) 3.3 (n=53) 8.0 (n=89) <0.001

Clinicians in room during handoff, 

maximum number

11.8 9.7 0.137

Patient transfers with no observable 

in person handoff

4/68 (5.9%) 0/97 (0.0%) 0.027Lane‐Fall M, Pascual J et al Ann Surg)

Handoffs PearlsEngage the multidisciplinary and multiprofessional teams

Teach a “best practice way”Choreograph the bedside interaction/transition of careThis will definitely improve the process

This will likely improve provider satisfaction

Improvement in patient safety Reducing medical errors Reducing near misses Leave provider time with family unaltered

Assess your institution’s quality of handoffsBeware of modifiers (volume, off‐hours)