Structured Patient Handoffs: The Movement Toward Adverse Event Reduction in the Perioperative Unit
This article appears in the July/August issue of PSQH.
By William L. Hamilton, MD, MBA
A patient handoff is the communication of pertinent patient information from one caregiver to another within a department, between departments in a healthcare facility, or between facilities. The purpose of handoffs is to coordinate patient continuity of care through an exchange of critical patient information.
The importance of handoffs and the type of information exchanged between clinicians began to surface after 2011. The Accreditation Council for Graduate Medical Education (ACGME) implemented rules to limit the number of hours worked consecutively per day and cumulatively per week for all residents. The goal was to improve patient safety by diminishing errors due to clinician fatigue; however, the duty hour restrictions also caused an increase in handoffs as clinicians required breaks and were unable to follow through on initiated patient care. These guidelines went into effect in July 2011 (AHRQ Patient Safety Network, 2016), and as a consequence, The Joint Commission identified communication as a leading root cause of anesthesia-related sentinel events.
Jayaswal et al. (2011) noted that information exchange during a care transfer could be the reason for adverse events, since such transfers occur on average five times per operating room per day. If a hospital has an average of 20 operating rooms, that results in 100 care transfers daily. Studies have shown that these anesthesia transfers increase patient in-hospital adverse events. Hudson, McDonald, Hudson, Tran, and Boodhwani (2015) established a 43% greater risk of in-hospital mortality and a 27% greater risk of major morbidity when anesthesia handoffs occur during a case. Saager et al. (2014) support Hudson’s finding, but also found that major in-hospital mortality/morbidity incidences further increased with each additional care transition, and that these incidences did not differ between types of anesthesia providers (attendings, residents, or CRNAs).
Lingard et al. (2004) identified a 30% failure rate in communication in the perioperative environment, and a recent study by Siddiqui et al. (2012) confirmed that failure to convey information deemed clinically important is common and occurs during all phases of the perioperative process.
In 2006, The Joint Commission identified patient handoffs as a National Patient Safety Goal for acute care facilities. It identified specific guidelines, which include implementation of a standardized approach to these communications, interactive communication with limited interruptions, accurate information, and a verification process with an opportunity to review or request additional historical information. Different variations of standardized tools have been developed and researched since the National Patient Safety Goal was identified, and several tools are discussed in more detail below.
Dharmadasa et al. (2014) created the Sick, At-risk, Follow-up and Epidural (SAFE) handoff tool used by anesthesia in obstetric cases to ensure the status of patients at risk was communicated during handoffs. The tool classified patients into one of four groups (sick, at-risk, follow-ups, and epidurals). After implementation of the SAFE tool, clinicians were four times more likely to conduct handoff communication with the tool than without it. This resulted in an increased use of handoffs from 49% to 79%, and the percentage of at-risk patients discussed effectively at handoff increased from 21% to 67%.
In other industries, such as aviation, the use of checklists is an established method for the reduction of adverse events. Checklists provide a standard for communication between two people when one individual assumes the responsibility of another. Potestio, Mottla, Kelley, and DeGroot (2015) developed a standard checklist for handoffs between anesthesia and the post-anesthesia care unit (PACU). Their checklist consists of three categories: items related to the patient, items related to the procedure, and communication related to the patient’s medications. Examples of patient items include patient identification, allergies, surgery/complications, ASA scoring, limb restriction, vitals, and type of anesthesia. Items related to the procedure include intubation, patient positioning, lines/catheters, and fluid management. Items in the medication category include antiemetics, medications administered in the PACU (antibiotics), the analgesia plan, and other intraoperative medications (e.g., antihypertensives, vasopressors). Additionally, a question at the conclusion of the handoff asks the oncoming caregiver, “Do you have any questions or concerns?”
Anesthesia providers (AP) were found to include more items in their handoff report with the use of a checklist, but they also spent more time in the handoff process (Salzwedel et al., 2013). The perioperative environment is time-pressured, so APs may be tempted to limit the handoff process duration due to juggling priorities. A clinician may choose which of the items on the checklist should be communicated when time is limited.
Robins and Dai (2015) developed a checklist specifically for handoffs in the postoperative care unit that focuses on patient information, medical history (allergies, past health conditions/surgeries), anesthesia (type, airway management, antibiotics, vascular access, and monitoring), intraoperative course (anesthesia events, analgesics, antiemetics, neuromuscular blockage/reversal, surgical events, intake and output, blood products, labs), and postoperative (patient status, infusions, postop analgesic/sedation plan, postoperative antiemetic plan, and disposition). They found that using a checklist created a focus on the critical patient items and, more importantly, lowered the rate of callbacks to the AP from the PACU nurse. Boat and Spaeth (2013) implemented a standardized checklist for handoffs of care in the operating room and PACU. They discovered that the protocol dramatically increased the quality and reliability of the handoff process.
Technology has been used to implement a standardized intraoperative handoff checklist tool (Man, Ajalat, Edwards, Lim, & Lin, 2017), including the capability to prepopulate information (e.g., delivered medications or allergies) into a handoff from the patient’s electronic health record. Kripalani (2011) noted that when such a tool was used for inpatient handoffs, there were time efficiency improvements, a reduction of medication discrepancies, and a reduction of deficits or missed communications in the handoff process.
While process improvements are also needed to formalize the use of the handoff report, the new technology holds the promise of providing accurate, real-time documentation and reporting. It also lays the foundation for further research and improvements between providers in the OR, and between anesthesia and PACU caregivers, particularly related to patient outcomes.
Future directions
The literature is robust with ideas and research on creating a handoff report tool that provides consistency of information, increases efficiency, and results in safer continuity of patient care. Computer technology has facilitated the development of these tools. Since prepopulated information drawn from an electronic record does not require human intervention, it is deemed more accurate and complete. Written checklists help to bridge the gap when an anesthesia information management system is not present in the perioperative environment. The one question that is left unanswered is the outcome of patient care as a result of including a handoff tool. There is opportunity to continue to learn from others, but there is still a challenge in shifting from suggestions on better handoff tools to an evidence-based handoff tool that demonstrates an improvement in patient outcomes.
Conclusion
The handoff report is a communication tool that conveys critical information pertinent for continued patient care from one clinician to another. An effective handoff report in anesthesia has the potential to decrease patient mortality and morbidity. The use of a standardized handoff tool can capture consistent information and increase efficiencies in care through the prepopulation of key data. The perioperative environment is an ideal location for further research on patient outcomes due to the high frequency of handoffs between caregivers.
William L. Hamilton, MD, MBA, is an anesthesiologist practicing at Intermountain Medical Center. He is the Immediate Past President of the Utah Medical Association (2015–2016). Hamilton has served as medical director for Intermountain Healthcare’s Central Regions Hospitals since 1996. From 1992 to 1996 he served on the Board of Directors of the American Society of Anesthesiologists. Until November 2012 he was a member, and Chair, of the Board of Directors of the American Medical Political Action Committee (AMPAC).
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