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What Is the Best Method for Perioperative Handoffs?
INTRODUCTION
A handoff is defined as a transfer of care of a patient between health care providers. This definition includes communication about the condition of the patient and relevant patient history and also may involve the physical transfer of the patient from one part of the hospital to another. Handoffs are of particular interest because of the association between communication deficits and adverse events in patient health care. , The Joint Commission (TJC) reports that more than half of sentinel events can be attributed to communication errors, with the majority of communication errors related to patient handoff. This alarming statistic led TJC to add the following to its National Patient Safety Goals Requirement 2E: “Implement a standardized approach to ‘hand off’ communications, including an opportunity to ask and respond to questions.”
All anesthesia providers are familiar with the fundamental concepts of patient handoff (also referred to as handover, signout, or transitions of care). In general, there are three main types of perioperative handoffs, summarized in Fig. 61.1 . Perioperative handoffs occur in three phases: preoperative handoff, intraoperative handoff, and postoperative handoff. Preoperative handoff occurs between preoperative holding room nursing staff and anesthesia providers, intraoperative handoff may occur between anesthesia providers, and postoperative handoff occurs between anesthesia providers and nursing staff in the postanesthesia care unit (PACU). If the patient is transferred directly to the intensive care unit (ICU) setting, a multidisciplinary ICU handoff should occur between anesthesia providers, ICU nursing staff, ICU physician staff, and surgeons or proceduralists (i.e., gastroenterologist, cardiologist).
It should be noted that perioperative handoffs are unique compared with other types of handoffs in medicine. Unlike the shift-to-shift handoffs that occur two to three times per day in hospital wards, several unique handoff events occur per patient encounter in the perioperative setting. These handoffs occur among providers of different disciplines (e.g., anesthesiology, critical care medicine, surgery, operating room [OR] nursing, critical care nursing, PACU nursing) and occur while the patient is unable to participate. In addition, the surgical patient population is a heterogeneous group with differing levels of acuity and variable nursing requirements, and therefore, identifying the needs of a particular patient requires active thought and communication rather than a reliance on rote processes. The immediate postoperative period is particularly challenging because emergence from anesthesia is the period of care with the highest risk for pulmonary and cardiac complications.
Despite the obvious importance of perioperative handoff, there is no universal standard for what information and processes should be included in a handoff. Efforts to establish a standard list of information exchanged during a perioperative handoff are specific to the phase of perioperative care, with postoperative handoff being the most robustly studied.
Handoff research has focused on interventions designed to improve the handoff process. These interventions could be as simple as introducing a handoff tool such as a mnemonic or checklist of information exchanged or could include a step-by-step protocol dictating the entire handoff process. , , Interventions designed to improve perioperative handoffs focus on process improvement, with few studies measuring the intervention’s effect on adverse events or mortality. The current chapter reviews the evidence for structure and content of perioperative handoffs.
OPTIONS/THERAPIES
Perioperative handoff interventions can be thought of as occurring on a spectrum from least to most structured. The less structured processes, such as checklists and mnemonics, allow providers the freedom to introduce elements of the handoff that they deem important and are easier to implement and scale across health care systems. On the other hand, more structured processes or protocols enable a thorough and consistent handoff process and give less room for providers to tailor the handoff to a specific patient.
Different handoff interventions also have slightly different aims. Mnemonics and checklists add structure to the information exchange and encourage a shared mental model. Protocols, in addition to adding structure to the information exchange, also add structure or “choreograph” to the process of the handoff.
Does Using a Mnemonic Such as SBAR Increase Exchange of Information?
Mnemonics are the simplest way to add structure to the handoff process. For providers partaking in a handoff, a mnemonic may increase memory of important steps and provide a structured process to follow.
SBAR is a mnemonic originally developed by the United States Navy to facilitate information transfer that was adopted for use in medicine by the Kaiser Permanente group. Along with being the most widely recognized handoff mnemonic, it is recommended by safety-oriented organizations, such as the Institute for Healthcare Improvement and the Agency for Healthcare Research and Quality. In a systematic review of handoff literature in all parts of the hospital, the SBAR (Situation, Background, Assessment, Recommendations) mnemonic was used most often (69.2%). Its popularity may be attributed to its incorporation of personal assessment and suggestion of the situation in the “Recommendations” portion.
Because many perioperative handoffs involve a change in location of the patient, handoff communication may take place over the phone. The SBAR mnemonic has also been shown to improve nurse–physician communication and reduces unexpected death when used in telephone communication about a deteriorating patient in the ICU.
One of the challenges with implementing SBAR or other similar mnemonics is the tendency for providers to view the mnemonic as a document rather than a verbal tool. Many institutions pair the mnemonic with educational sessions and visual cues, , but decreased fidelity has been shown to occur over time.
Does Using a Checklist Increase Exchange of Information?
Mnemonics and checklists have several distinguishing characteristics. Mnemonics are mental tools to structure the handoff process, whereas a checklist is a physically tangible tool. Checklists also have the additional benefit of leaving a physical or electronic vestige of the handoff process that can be saved by the receiving provider for future reference.
In a single pediatric cardiac intensive care unit (PCICU) at a large academic hospital in the United States, Agarwal and colleagues developed a comprehensive handoff tool that aimed to prevent loss of information and decrease immediate postoperative complications. The handoff tool development process is representative of similar processes described in other research. The authors evaluated the current handoff process both by observing handoffs in the PCICU and by surveying the entire clinical team to assess for loss of information and limitations with the current process.
They used this information to create a structured handoff process that consisted of two steps: a telephone handoff 30 minutes before patient arrival and an in-person handoff upon patient arrival to the unit. Both of these processes were structured around a checklist. The telephone handoff was scripted with a checklist that functioned as a data transfer sheet and was filled out by the receiving PCICU nurse. The bedside handoff was guided by a handover checklist that acted as a visual prompt for the verbal handoff that occurred at bedside.
Implementing these two checklist-guided processes in the PCICU led to significantly increased transfer of information between providers, as reported by providers. These processes also led to decreased immediate postoperative complications, including a statistically significant decrease in metabolic acidosis, early extubation, and incidence of cardiopulmonary resuscitation during the first 24 hours after transfer from the OR to PCICU.
Salzwedel and colleagues implemented a laminated checklist prompt as part of the OR to PACU handoff. They video-recorded handoffs and in the analysis by two independent evaluators found an increase in information exchanged from 32% to 49% of checklist items. Although the checklist was comprehensive, less than half of checklist items were exchanged during the handoff despite its use. It is unclear why participants had such low compliance even while being video-recorded and having the visual prompt of a checklist. Interestingly, this study group found only a slight increase in the duration of PACU handoff, from 86 seconds to 121 seconds with inclusion of the checklist. The study provides evidence that a small increase in the amount of time spent in PACU handoff can lead to a significant increase in the information exchanged.
Should the Handoff Process Be Choreographed?
Many groups have decided to implement entire protocols for perioperative handoffs. A protocol is a more structured approach to standardization of a handoff; it requires not only a tool for guidance but also a structure and format to follow so that, ideally, every handoff follows the same steps and happens the same way.
Implementation of a protocol is labor intensive and requires both individual effort and institutional support. Of all perioperative handoffs, the postoperative handoff is the most complex, occurring among multiple services (surgical, anesthesia, OR staff), including a change in location (from OR to PACU or ICU) and during emergence from anesthesia, when patients are most likely to suffer respiratory and cardiac complications. Not coincidentally, most studies of handoff protocol implementation are focused on the postoperative handoff.
To date, the most robust perioperative handoff process implemented is the protocol established by the HATRICC study group. HATRICC is a Type 1 hybrid effectiveness-implementation trial designed to test the effectiveness of a standardized OR-to ICU handoff process while collecting data about process implementation. It is a parallel mixed methods study with simultaneous collection of qualitative and quantitative data. The findings from the needs assessment phase were adapted to test the standard handoff process. The study took place in two mixed surgical ICUs in a major academic urban health system.
In addition to initiating a dynamic process for evaluation and implementation of OR to ICU handoff, this study group was able to collect qualitative data on staff perspective of the handoff process. This qualitative data was obtained from clinician interviews, clinician sentiments toward existing and ideal handoff practices from surveys, and field notes. The feedback yielded a choreography of the handoff process and a structured written template.
The final handoff process established includes prearrival communication between OR and ICU, role identification, identification of immediate care needs such as hemodynamic support and mechanical ventilation, a dedicated time to transfer to ICU monitoring equipment, a template that clinicians complete with pertinent information, and verbal handoff among clinicians. Finally, the ICU provider leads a focused, systems-based discussion of the patient’s clinical concerns, confirming understanding of the information relayed by the OR team. Contact information is provided and the team disperses after all questions are answered.
Can Handoffs Be Structured Electronically?
Incorporating the handoff process into the electronic medical record (EMR) can improve workflow and enhance usability. The EMR also provides the added benefit of prepopulating information to offload some of the information recall required. EMR integration is ideal for one-to-one handoffs such as nursing shift handoff and intraoperative handoff between anesthesia providers. More complicated handoffs such as the postoperative handoff to PACU or ICU involve multiple services and active patient care. EMR integration of handoff process has not been studied in these perioperative handoffs.
Agarwala et al. introduced an electronic checklist that was used on a voluntary basis as a framework to structure permanent intraoperative handoffs between anesthesiologists. The checklist included a minimum number of essential items and appeared automatically when the provider clicked the “transition of care” icon in the Anesthesia Information Management System (AIMS). With this simple electronic tool, significantly more information was exchanged and the receiving anesthesiologists were able to recall more relevant information, such as antibiotic information, muscle relaxant name and dose, and fluids administered.
An EMR integrated checklist tool has also been used successfully in PACU handoff with similar increase in information exchanged.
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