It happens to us every day…
“I took over this case about 30 minutes ago. We’ll be done in 10. Intraoperative sign-out was straightforward: 76-year-old male with known CAD for open prostatectomy, NIDDM, CKD, easy airway & lines, 3 L crystalloids, 1L EBL, 150 ml of urine prior to clamping ... I look at the EKG: ST depression in II and V5 lead – is that new? How did it look when I took over? HR 85; BP stable. Hmm ... let’s see if there’s a printout of the EKG strip prior to induction – negative; I’ll give some esmolol and order an EKG for the PACU – smooth emergence, vitals unchanged, patient appears comfortable, off to PACU.
I’m paged for a STAT airway in the ICU just as I arrive in the PACU. I need to give a quick sign-out to the PACU RN before dashing off to the ICU. The PACU nurses are busy putting the patient back on monitors. Do I really have their attention? It’s difficult to tell who will be the primary nurse for this patient. How short and quick can my report be? What’s the standard? What’s safe?”
Handovers can be defined as the structured process for transferring information, primary responsibility, authority and accountability from one caregiver (team) to another.1-3 In doing so, the receiving individual or team is able to quickly get a “story” of the situation. Although we often think of this structure within our professional responsibilities, a handover caregiver can also be the patient or patient’s family, particularly at admission and discharge.
Handovers are extremely variable. Done well, they can be a safety net (new eyes and ears picking up on something that has fallen through the cracks), a missed symptom for a diagnosis, missed lab or fixation error (e.g., low blood pressure being treated as blood loss when it is sepsis). Done poorly, they can lead us down a path of errors, complications, harm and even death.2,4
The Joint Commission’s 2006 National Patient Safety Goal requiring “a standardized approach” for handovers is now scored as a standard.5 Specific to the O.R.-PACU transition, the ASA standard is: “upon arrival in the PACU, the patient shall be re-evaluated and a verbal report provided to the responsible PACU nurse by a member of the anesthesia care team who accompanies the patient.”6 Patterson et al. share 21 important handoff strategies.1 We highlight nine strategies in Table 1 as particularly important to consider in the perioperative environment.
Handovers should never be a one-way street data dump. The first three strategies emphasize this point. As with any patient safety tool that improves situational awareness (e.g., huddles, WHO briefings and debriefings), this is a dialog that allows the team to improve its problem-recognition, problem-solving and sense-making. Interactive questioning is key; some organizations encourage read-back/repeat-back strategies to verify information and hardwire the two-way communication.
Safety science informs us that structuring handovers improves reliability and resilience. Strategies IV- VI emphasize this. Standardized expectations minimize the possibility that information will fail to be conveyed or be forgotten. It cues a forgotten mention of the last antibiotic dose, a patient’s preexisting one-sided weakness or, as in our “case,” pre-existing ST changes. Transferring information on the patient’s preoperative condition is articulated in the ASA standards.
Strategies IV-VI also remind us that handovers are not just about the current snapshot. Robust handovers include knowledge from the previous team as well as anticipated “what-ifs.”
Interruptions during handovers should be limited as articulated in strategies VII and VIII. The aviation industry describes it as a “sterile cockpit rule,” emphasizing the critical nature of the process.
Safety science tells us to standardize what we can (read: not everything). This means that we need to adapt to the complexity of the situation without trying to jam a square peg into a round hole. Highly effective handovers operate like an accordion – expanding and contracting when necessary. Avoid the pitfall of “commission of information” – an over-comprehensive handover of information.
“While I intubate a new patient in the ICU, I wonder if I mentioned my EKG order and concerns about my previous patient in the PACU. Whether or not I did, the RN will surely see it and page me if there’s a concern ... 30 minutes later I check in the PACU. My EKG is done, but nobody paged me about the findings: new ST depression and frequent PVCs …”
Strategy IX emphasizes that handovers are not just about information. Role clarity is critically important. Catchpole et al. extrapolated the Formula 1 pit-stop model to develop clear roles and responsibilities during O.R. to pediatric ICU transfers and found striking improvements in both technical and information handover.7
Other “roles” that should be clear in a handover are responsibility and authority. Giving and taking over of the responsibility role between two health care workers/teams within the care continuum is one of the most important components of an effective handover to ensure a patient is well cared for at all times. This transfer of responsibility needs to be an active and clearly defined part of the handover process. To emphasize this importance, at Oregon Health & Science University, we conclude the handover process with a question-and-answer section followed by verbal acknowledgement that the patient’s care has now been transferred (“my patient-your patient”). An additional nuance to responsibility is the authority of care. The anesthesia team may transfer the responsibility of pain management to the PACU nurse but maintain the authority of orders regarding pain management.
In our case, who is responsible for getting the EKG done? Whose responsibility is it to have the EKG interpreted? Who has the authority to act on the EKG findings? Is it clearly defined in your practice?
The message is clear: high-performance teams use handovers with structure, standardization and adaptation to ensure that nothing is lost in translation.
So what about a checklist? ...
Common sense might suggest a standardized “checklist” to improve the safety and quality of perioperative handovers. Standardized perioperative and discharge checklists have been effectively implemented into the surgical arena.8,9 Yet a “transfer of care checklist” between anesthesia providers and PACU nursing is rare.
Utilizing checklists to improve uniformity and communi-cation can be a key tool in effecting safe patient handovers. There are significant hurdles to adapting such a checklist into real-time clinical practice. The scope and variety of practice venues lend themselves to difficulties in uniform policy implementation.
Resources, templates and examples of success are available so we don’t have to reinvent the wheel.10-13 For example, the Joint Commission has made available its targeted solutions tool (TST) for handoff communications – a customizable tool that measures the effectiveness of handoffs within an organization.12 Segall et al. provide a systematic review of the current literature on postoperative handovers, identifying common elements to improve safety.10
Mnemonics can foster reliable implementation of a standardized handover.14 The PUTS PATIENT FIRST mnemonic (see table on page 26) is used in one of the authors’ institutions (CC). By adapting to specific environments, the mnemonic has been successfully applied to the hospital, ASC and even remote anesthetizing locations.
For example, in a fast-paced, rapid-turnover ASC, there is the inherent risk that relevant details may not be communicated in an effort to maintain efficiency. The mnemonic checklist provides a tool to rapidly relay pertinent information without sacrificing time or efficiency.
While developing a new policy and practice, some colleagues are reluctant to participate in a mandated protocol. Overcoming these obstacles is a challenge that must be anticipated prior to implementation. Streamlining checklists prior to introduction for your specific practice and seeking input from all key players will facilitate acceptance. Introducing any new checklists, policies and practice in concert with teamwork training has also been found to be a key factor for success.10 Finally, when implementing a checklist as part of a structured handover, don’t let compliance overtake the commitment of ensuring a handover is done accurately and effectively. Compliance audits help us understand barriers to implementation, but over-focus on compliance can undermine the overarching intention of the handover.15
“The RN asks me about the patient’s current code status. Don’t remember having talked about that during intraoperative sign-out. Now I dig through the EHR again … wishing we had an automated report incorporated in the EHR to assist with the handover in the PACU …”
With increasing adoption of electronic health records (EHR), it is important to smartly integrate a handover process into our daily routine.16 Implementation of a computer-based sign-out process that includes patient information and automated fields (such as vital signs and labs) has been shown to improve reporting quality, continuation of care and safety.17,18 It would seem obvious to use EHR reports for the extraction of key information needed for effective handover in the PACU or ICU, because a majority of data is documented in real time in the anesthesia record and could support the verbal handover. With increasing reliance on electronic functionality, it is also important to have a procedure in place for network/system downtimes.
As we move forward, it will be key to smartly combine EHR reports to assist in the data transfer and verbal communication of our handovers in the PACU and ICU. In the end, handovers are the act of transferring information, responsibility and authority from one entity to another. Doing it right every time is our duty to our patients, their families and our colleagues.
Della M. Lin, M.D., M.S. is AlternateDirector, Hawaii, Senior Fellow, Patient Safety Leadership, Estes Park Institute, Senior Fellow, Patient Safety, AHA-HRET, State Coordinating Lead, Hawaii Safer Care, Surgical Safety Collaborative, Honolulu.
Charles J. Chase, D.O. is Medical Director, Orlando Center for Outpatient Surgery, Orlando Health, Orlando, Florida.
Matthias J. Merkel, M.D., Ph.D. is Associate Professor, APOM Chief Safety Officer, Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland.
1. Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125-132
2. Beach C. Lost in transition. AHRQ, WebM&M, Cases & Commentaries website. http://www.webmm.ahrq.gov/case.aspx?caseID=116. Published February, 2006. Accessed March 19, 2014.
3. Jeffcott SA, Evans SM, Cameron PA, Chin GS, Ibrahim JE. Improving measurement in clinical handover. Qual Saf Health Care. 2009;18(4):272-277.
4. Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204(4):533-540.
5. The Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission Resources; 2014.
6. American Society of Anesthesiologists Committee on Surgical Anesthesia. Guidelines for patient care in anesthesiology. ASA website. https://www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx. Last amended October 19, 2011. Accessed March 19, 2014.
7. Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17(5):470-478.
8. Weiser TG, Haynes AB, Lashoher A, et al. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care. 2010;22(5):365-370.
9. Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth. Analg. 1970;49(6):924-934.
10. Segall N, Bonifacio AS, Schroeder RA, et al.; Patient Safety Center of Inquiry. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth. Analg. 2012;115(1):102-115.
11. Patient hand-off too kit. AORN: Association of periOperative Registered Nurses website. http://www.aorn.org/Clinical_Practice/ToolKits/Patient_Hand_Off_Tool_Kit/Patient_Hand_Off_Tool_Kit.aspx. Published, 2012. Accessed March 20, 2014.
12. Facts about the Hand-off Communications Project. Joint Commission Center for Transforming Healthcare website. http://www.centerfortransforminghealthcare.org/assets/4/6/CTH_HOC_Fact_Sheet.pdf. Accessed March 20, 2014.
13. Boat AC, Spaeth JP. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Paediatr Anaesth. 2013;23(7):647-654.
14. Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual. 2009;24(3):196-204.
15. Rydenfält C, Ek Å, Larsson PA. Safety checklist compliance and a false sense of safety: new directions for research. BMJ Qual Saf. 2014;23(3):183-186.
16. Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010; 252(2):402-407.
17. Kim SW, Maturo S, Dwyer D, et al. Interdisciplinary development and implementation of communication checklist for postoperative management of pediatric airway patients. Otolaryngol Head Neck Surg. 2012;146(1):129-134.
18. Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg. 2005;200(4):538-545.