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Quality Update - Healing the Handoff

Fall 2009

Healing the Handoff

Date: October 15, 2009

Investigators tackle the complex task of improving postsurgical handoffs.

A whirl of activity follows as a patient is wheeled from the operating room into the intensive care unit. The ICU nurse is preoccupied with transferring a patient’s lines and consequently retains little of the information that an anesthesiologist relays to her. Meanwhile, in a separate conversation, the surgeon updates the ICU attending on the patient’s condition. Consequently, neither the ICU nurse nor attending get the whole postoperative picture.

Such hectic scenarios—once common in the cardiac surgery intensive care unit (CSICU) at The Johns Hopkins Hospital—increased the risk of communication failures that can lead to patient harm. Lacking a clear procedure for handoffs to the CSICU, essential clinical data, including special instructions and lab values, might slip through the cracks.

Determined to prevent such breakdowns, clinicians in the Department of Anesthesia and Critical Care Medicine and the CSICU partnered with the Center for Innovation in Quality Patient Care to create a process to better communicate at transfers of care.

The result has been a system that had reduced the loss of vital information and increased care-team satisfaction and participation.

Compared to handoffs that occur at shift changes, postsurgical handoffs are even more complex, involving clinically unstable patients in transit, as well as caregivers from several disciplines. “Such transfers involve not only the exchange of information but also include the transfer of technology, including monitors, transducers, ventilators and lines,” says Michelle Petrovic, an attending anesthesiologist in the operating rooms and a project leader.

First, the group documented existing practices. “People were investing time and effort to perform the handoff but as a team they lacked a structured approach that helped them to communicate fully and clearly,” says Hanan Aboumatar, education and research associate with the Center for Innovation.

Preliminary research showed that significant information was missing from surgery and anesthesia reports during handoffs  to the CSICU. Key providers, themselves, were often absent during handoffs, as well. In a survey, 60 percent of ICU nurses expressed dissatisfaction with the transfer process.

 The group used its findings to create a postoperative handoff process tailored to the unit’s needs. Broken down into five sequential steps, the protocol, rolled out in March, requires a core team of providers to meet at bedside immediately after surgery. First, monitors and lines must be transferred so that all members can concentrate on the report from the surgeon and anesthesiologist and take notes.

 Following a postoperative checklist developed for the protocol, CSICU residents and nurses can ensure that the reports cover concerns ranging from what drains and tubes have been placed in a patient to what anesthetic procedures were used during surgery.   

Time for questions and answers is built into the protocol so that CSICU staff can clarify information.

Preliminary results were encouraging. In the weeks after the protocol was launched, all core team members were present at 68 percent of the handoffs, up from zero before the intervention. Nurses reported greater satisfaction with the new process and missing information from the surgery report has been reduced by half.

The investigators plan to customize the protocol for all of the hospital’s adult ICU’s and postanesthesia care units.