Deficits in information transfer between anaesthesiologist and postanaesthesia care unit staff: an analysis of patient handover

Trauma Bay Evaluation and Resuscitative Decision-Making

The reader of this article will now have the ability to reflect on all aspects of high-quality trauma bay care, from resuscitation to diagnosis and leadership to debriefing. Although there is no replacement for experience, both clinically and in a simulation environment, trauma clinicians are encouraged to make use of this article both as a primer at the beginning of a trauma rotation and a reference text to revisit after difficult cases in the trauma bay. Also, periods of reflection seem appropriate in the busy but, of course, rewarding career in trauma care.

An evidence synthesis on perioperative Handoffs: A call for balanced sociotechnical solutions

SIGNIFICANCE

Perioperative handoffs interconnect the preoperative, intraoperative, and postoperative phases underlying surgical care to maintain care continuity -yet are prone to coordination and communication failures.

OBJECTIVE

To synthesize evidence on factors affecting the safety and quality of perioperative handoff conduct and process.

MATERIALS AND METHODS

A search of PubMed, EMBASE, and CINAHL was conducted to include observational, descriptive studies of preoperative, intraoperative, and postoperative handoffs published in English language, peer-reviewed journals. Data analysis was informed by the Systems Engineering Initiative for Patient Safety (SEIPS) framework describing the relationship between the work-system, work processes, and outcomes. Study quality was assessed using the Quality Scoring System.

RESULTS

Twenty-three studies were included. Eighteen studies focused on postoperative handoffs, with one on preoperative, three on intraoperative and only one that looked at preoperative/postoperative handoffs combined. The SEIPS framework elucidated the complex inter-related factors (enablers and barriers) related to perioperative handoff safety. While some studies found that the use of standardized handoff tools and protocols and interdisciplinary teamwork were frequently-reported enablers, other studies identified the lack of structured handoff tools and protocols, poor teamwork and communication, and improper use of documentation tools were top-cited barriers affecting handoff quality. Suggestions to ensure handoff safety and quality included implementing structured handoff checklists and protocols and building interprofessional teamwork competencies for effective communication.

DISCUSSION AND CONCLUSION

Our review highlights an urgency to develop more holistic sociotechnical solutions that can create and sustain a balance between technical innovations in tools and technologies and the non-technical interventions/training needed to improve interpersonal relations and teamwork competencies - taken together, can improve the quality and safety of perioperative handoff practice.

Evaluation of a Paper-Based Checklist versus an Electronic Handover Tool Based on the Situation Background Assessment Recommendation (SBAR) Concept in Patients after Surgery for Congenital Heart Disease

(1) Background: we compare a new SBAR based electronic handover tool versus a paper-based checklist for handover in a pediatric intensive care unit (PICU). (2) Methods: this is a randomized, observational study of 40 electronic vs. 40 paper checklist handovers after pediatric cardiac surgery, with a 48 items checklist for comparison of reporting frequencies and notification of disturbances and noise. PICU staff satisfaction was evaluated by a 12-item questionnaire. (3) Results: in 14 out of 40 cases, there were problems with data processing (incomplete or no data processing). Some item groups (e.g., hemodynamics) were consistently reported at higher frequencies than other groups. Items not specifically asked for did not get reported. Some items, automatically processed in the SBAR handover page, did not get reported. Many handovers suffered a noisy and distracting atmosphere. There was no difference in staff satisfaction between the two handover approaches. Nurses were highly unsatisfied with the general approach by which the handover was performed. (4) Conclusions: human error appears to be a main factor for unreliable data processing. Software is still too complicated, and multitasking is a stressful and error prone event. Handover is a complex task with many factors required for a successful completion.

Implementation and 1-year follow-up of the cardiovascular ICU standardised handover

BACKGROUND

Miscommunication during clinical handover can lead to partial information transfer and healthcare provider dissatisfaction. We hypothesised that a quality improvement project to standardise the cardiovascular intensive care unit (CVICU) handover could improve healthcare provider satisfaction and reduce information omission.

METHODS

After institutional review board approval, the operating room (OR) to CVICU handover was audited prior, post and 1 year after standardisation implementation. The medical information transferred, healthcare provider participation and satisfaction, and patient outcome data were collected. Additionally, surveys were sent to the OR and CVICU staff by email.

RESULTS

There were 68 handover processes observed. The odds of greater satisfaction with handover for providers were 18 times higher with the process post implementation (p<0.0001) and 26 times higher 1 year after implementation (p<0.0001). There was statistically significant difference between intensive care unit resident presence (45% vs 76% vs 91%, p=0.004), surgical faculty presence (10% vs 36% vs 45%, p=0.034) and surgical fellow presence (15% vs 64% vs 62%, p=0.001) between the three time periods. More information related to the surgeon (5% vs 52% vs 27%, p=0.002), the medical history (65% vs 96% vs 91%, p=0.014) and the cardiopulmonary bypass (47% vs 88% vs 76%, p=0.017) was conveyed. The duration of mechanical ventilation was shorter after implementation (2.2±2.6 days vs 1.2±1.9 days vs 0.5±1.2 days, p=0.026).

CONCLUSIONS

One year after the OR to CVICU standardised handover implementation, the healthcare provider satisfaction remained increased, more team members participated and the information transfer increased. Although some clinical outcomes improved, further studies are recommended to prove causality.

An Examination of Nurses' Empowerment and Speaking Up During Postanesthesia Clinical Hand Overs

Hierarchical relationships can negatively affect nurses' psychological empowerment and interprofessional hand overs. We explored nurses' perceptions of their psychological empowerment, teamwork, and work engagement; relationships between these concepts during interprofessional clinical hand overs; and observed interactive communication behaviors during hand overs. We used surveys and observations of interprofessional clinical hand overs to collect data from 39 nurses in a postanesthesia care unit in Australia. Nurses reported high scores for psychological empowerment and work engagement. Relationships between empowerment and teamwork (r = 0.41, P = .01) and empowerment and work engagement (r = 0.65, P < .001) were positive and significant. Relationships between nurses' observed communication behaviors and perceptions of empowerment, teamwork, and work engagement were nonsignificant. Additional research is needed to better understand how empowerment, teamwork, and work engagement affect nurses' interactive communication behaviors during interprofessional clinical hand overs in the postanesthesia care unit.

Evidence-Based Guideline on Critical Patient Transport and Handover to ICU

The perioperative period is a time in which significant physiological change occurs. Improper transfer of information at this point can lead to medical errors. Planning and preparation for critical patient transport to ICU is vital to prevent adverse events. Critical patient transport to ICU must be as safe as possible and should not cause additional risks. It needs good communication, planning, and appropriate staffing with standard monitoring. Evidence shows inconsistency and variability on the use of standardized protocols during critical patient transfer and handover to the ICU. There is a variety of controversial approaches about the need of sedation, use of end-tidal CO₂ monitoring, and manual versus mechanical ventilation based on different evidence. The objective of this review was to recommend safer options of critical patient transfer to the ICU that help reduce patient morbidity and mortality. Methods. Google Scholars, PubMed through HINARI, and other search engines were used to search high-quality evidence that help reach appropriate conclusions. Discussion. Critical patient transfer and handover to ICU is a complex procedure that needs experienced hands, availability of appropriate team members, standard monitoring, and necessary emergency and patient-specific medications. Appropriate and adequate transfer of patient information to the receiving team decreases patient morbidity and mortality when the transfer team uses standardized checklist. Conclusion. Involvement of senior physicians, use of standard monitoring, and appropriate transfer of information have been shown to decrease critical patient morbidity and mortality.

Exploring postoperative handover quality in relation to patient condition: A mixed methods study

AIMS AND OBJECTIVES

To describe postoperative handover reporting and tasks in relation to patient condition and situational circumstances, in order to identify facilitators for best practices.

BACKGROUND

High-quality handovers in postoperative settings are important for patient safety and continuity of care. There is a need to explore handover quality in relation to patient condition and other affecting factors.

DESIGN

Observational mixed methods convergent design.

METHODS

Postoperative patient handovers were observed collecting quantitative (n = 109) and qualitative data (n = 48). Quantitative data were collected using the postoperative handover assessment tool (PoHAT), and a scoring system assessing patient condition. Qualitative data were collected using free-text field notes and an observational guide. The study adheres to the GRAMMS guideline for reporting mixed methods research.

RESULTS

Information omissions in the handovers observed ranged from 1-13 (median 7). Handovers of vitally stable and comfortable patients were associated with more information omissions in the report. A total of 50 handovers (46%) were subjected to interruptions, and checklist compliance was low (13%, n = 14). Thematic analysis of the qualitative data identified three themes: "adaptation of handover," "strategies for information transfer" and "contextual and individual factors." Factors facilitating best practices were related to adaptation of the handover to patient condition and situational circumstances, structured verbal reporting, providing patient assessments and dialogue within the handover team.

CONCLUSIONS

The variations in items reported and tasks performed during the handovers observed were related to patient conditions, situational circumstances and low checklist compliance. Adaptation of the handover to patient condition and situation, structured reporting, dialogue within the team and patient assessments contributed to quality.

RELEVANCE TO CLINICAL PRACTICE

It is important to acknowledge that handover quality is related to more than transfer of information. The present study has described how factors related to the patient and situation affect handover quality.

Completeness of the operating room to intensive care unit handover: a matter of time?

BACKGROUND

Handovers of post-anesthesia patients to the intensive care unit (ICU) are often unstructured and performed under time pressure. Hence, they bear a high risk of poor communication, loss of information and potential patient harm. The aim of this study was to investigate the completeness of information transfer and the quantity of information loss during post anesthesia handovers of critical care patients.

METHODS

Using a self-developed checklist, including 55 peri-operative items, patient handovers from the operation room or post anesthesia care unit to the ICU staff were observed and documented in real time. Observations were analyzed for the amount of correct and completely transferred patient data in relation to the written documentation within the anesthesia record and the patient's chart.

RESULTS

During a ten-week study period, 97 handovers were included. The mean duration of a handover was 146 seconds, interruptions occurred in 34% of all cases. While some items were transferred frequently (basic patient characteristics [72%], surgical procedure [83%], intraoperative complications [93.8%]) others were commonly missed (underlying diseases [23%], long-term medication [6%]). The completeness of information transfer is associated with the handover's duration [B coefficient (95% CI): 0.118 (0.084-0.152), p<0.001] and increases significantly in handovers exceeding a duration of 2 minutes (24% ± 11.7 vs. 40% ± 18.04, p<0.001).

CONCLUSIONS

Handover completeness is affected by time pressure, interruptions, and inappropriate surroundings, which increase the risk of information loss. To improve completeness and ensure patient safety, an adequate time span for handover, and the implementation of communication tools are required.

Audit of international intraoperative hemotherapy and blood loss documentation on anesthetic records

BACKGROUND

Anesthetic records facilitate information transmission to the next healthcare professional and should contain all relevant information of perioperative care. While most anesthesia societies provide guidelines for record content, important topics like hemotherapy and hemostatic therapy are not well represented. We considered the quality of anesthetic records with regard to the documentation options for hemotherapy and hemostatic therapy. A secondary objective was to examine guidelines for appropriate recommendations.

METHODS

Anesthetic records of international anesthesiology departments were evaluated for the presence of 20 defined fields associated with hemotherapy, hemostatic and fluid therapy as well as intraoperative diagnostics and monitoring. International guidelines were reviewed for appropriate recommendations.

RESULTS

A total of 98 anesthetic records from eight countries and guidelines of six anesthesia societies were analyzed. Data fields for red blood cell transfusion have been found in 29.3% (95% CI 0.20 to 0.38), ABO-testing in 6.1% (95% CI 0.01 to 0.11) and indication for transfusion in 2.0% (CI 0.00 to 0.05) of records. Most records contain fields for blood loss (94.4%; 95% CI 0.91 to 0.99) and diuresis (87.9%; 95% CI 0.81 to 0.94). International guidelines that were analyzed do not cover the topic of transfusion, but most give recommendations on basic monitoring, blood loss and fluid management documentation.

CONCLUSIONS

Most of the evaluated anesthetic records did not contain fields for relevant aspects of perioperative hemotherapy, hemostatic therapy and diagnostics. Guidelines and protocols for anesthetic documentation should include these topics to ensure information transfer and patient safety.

Handover Patterns in the PACU: A Review of the Literature

PURPOSE

Currently, there is no standardized handover pattern for patients undergoing general anesthesia when being transferred to the postanesthesia care unit (PACU).

DESIGN

A review of the literature.

METHODS

In this study, a review of the literature was conducted to analyze the PACU handover status, factors for poor handover, and commonly used handover patterns.

FINDINGS

Important handover information was often omitted during the handover of PACU patients, and there were many factors influencing postoperative patient handover quality. This study analyzed and compared several commonly used handover patterns for patients. Among these, the Situation-Background-Assessment-Recommendation tool is relatively mature. However, there is currently no unified standardized patient handover pattern, and the validity and applicability of tools still need to be verified.

CONCLUSIONS

PACU is an important place for the recovery of surgical patients. Anesthesia providers need to provide PACU nurses with complete and comprehensive postoperative handover information. A standardized handover model for clinical nurses is needed to improve patient safety management and work efficiency.

Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

Anaesthesia-specific checklists: A systematic review of impact

Checklists are recognised as powerful tools to prevent avoidable errors in high-reliability organisations. In healthcare, the perioperative area has been a leading field in the development of a wide range of checklists. However, clinical literature on this subject is still sparse and heterogeneous, producing results that are sometimes conflicting. This systematic review assesses the current literature on perioperative routine and crisis checklists. Literature searches did not use a date limit and included articles up to March 2019. The methodological heterogeneity precluded combining data from the individual studies into a quantitative meta-analysis. Data are presented by means of a qualitative comparison with the reference groups based on a content analysis approach. Of the 874 identified articles, 25 were included in this review. Most identified studies (23, 92%) have shown that the use of checklists in anaesthesia can decrease human error, improve patient safety and teamwork, and increase quality of care. Beyond the WHO surgical time-out, anaesthesia-specific checklists have been shown to be useful for provider handoffs, emergencies, and routine anaesthesia procedures. However, literature on anaesthesia-specific checklists is still limited and very heterogeneous. More large-scale studies are necessary to identify an ideal anaesthesia checklist and its most appropriate implementation method.

Quality in Postoperative Patient Handover: Different Perceptions of Quality Between Transferring and Receiving Nurses

BACKGROUND

A safe and efficient patient handover is important to ensure high-quality patient care and reduce the risk of patient harm. Few studies have explored handover activities beyond information transfer.

PURPOSE

The aims were to assess overall postoperative handover quality and relate quality assessments to handover circumstances, conduct, and teamwork and to compare transferring and receiving nurses' evaluations of handover quality.

METHOD

This was a cross-sectional study using the Norwegian Handover Quality Rating Form (N-HQRF). In addition, data were collected on nurses' evaluations of the patient condition, handover preparation, and participating nurses' clinical experience.

RESULTS

Although total perceived handover quality was high in a large majority of cases, there were significant differences between transferring and receiving nurses' evaluations of the same handover. Lower-quality handovers had a higher frequency of time pressure, uncertainty, and patient-related problems.

CONCLUSION

The findings point to the need to assess handover quality in a wider perspective. Handover circumstances might impact handover quality and should be considered when procedures for handover quality are designed and implemented.

Enhancing the Quality of the Anesthesia to Postanesthesia Care Unit Patient Transfer Through Use of an Electronic Medical Record-Based Handoff Tool

PURPOSE

Anesthesia to postanesthesia care unit (PACU) handoffs are often incomplete, imprecise, and highly variable with respect to information transfer, and therefore can jeopardize patient safety. A standardized anesthesia to PACU electronic medical record (EMR)-based patient handoff checklist was implemented and evaluated for its effect on the information transfer.

DESIGN

An observational preimplementation and postimplementation design was used.

METHODS

Assessment of the completeness and accuracy of information transfer during the PACU handoff was performed for a convenience samples of 100 patients preimplementation, 3 weeks postimplementation, and 3 months postimplementation.

FINDINGS

The mean percentage of total handoff checklist items addressed significantly increased 3 weeks and 3 months postimplementation compared with baseline.

CONCLUSIONS

The use of a standardized anesthesia to PACU EMR-based handoff checklist significantly increased the percent of accurate information transferred without considerably affecting the duration of the PACU handoff process.

The impact of standardised perioperative handover protocols

The handover of the care of patients is acknowledged as a vulnerable period in the perioperative patient journey, and handovers given within the perioperative environment present the risk of potentially harmful errors occurring. These errors can result from poor communication and inaccurate information transfer, and may be avoided through the implementation of standardised protocols. This article presents an in depth literature review and discussion allowing for the examination of best practice in the delivery of a handover within the perioperative environment, drawing clear conclusions and presenting recommendations for best practice.

Postoperative patient handovers-Variability in perceptions of quality: A qualitative focus group study

AIMS AND OBJECTIVES

(a) To explore the factors affecting quality in postoperative handovers as perceived by the different professional groups of clinicians involved. (b) To explore possible differences in perceptions of postoperative handover quality across professional groups and level of experience.

BACKGROUND

High quality patient handovers after surgery and anaesthesia are important to ensure patient safety. There is a paucity of research describing contextual factors related to handover quality and the perspectives of different professional groups involved.

DESIGN

A qualitative exploratory design was applied.

METHOD

A total of eight focus group interviews with 37 participants (29 nurses, eight doctors) were conducted. Anaesthesiologists, resident anaesthesiologists, nurse anaesthetists, postoperative care nurses and operating room nurses participated in the study. The interviews were conducted according to profession with two groups per profession: one with experienced clinicians and one with less experienced clinicians. The data were analysed using thematic analysis. The study adheres to the COREQ guidelines.

RESULTS

The data analysis identified the following factors affecting postoperative handover quality: "timing and concurrency conflicts," "handover structure," "patient conditions," "individual characteristics of clinicians involved" and "team composition." Differences across professional groups and level of experience were related to responsibility, structure and adaptation.

CONCLUSION

The professional groups involved describe the postoperative patient handover as a complex and variable process that needs to be carefully planned and executed according to the influencing factors. Variability exists across professional groups and level of experience.

RELEVANCE TO CLINICAL PRACTICE

Health care providers need to be aware that postoperative handovers are affected by a set of factors related to internal (patient conditions, individual characteristics of clinicians involved and team composition) and external (timing and concurrency conflicts, handover structure) characteristics. These issues need to be acknowledged when procedures and routines for handover quality are designed, implemented and used.

Handovers in Perioperative Care

Handovers around the time of surgery are common, yet complex and error prone. Interventions aimed at improving handovers have shown increased provider satisfaction and teamwork, improved efficiency, and improved communication and have been shown to reduce errors and improve clinical outcomes in some studies. Common recommendations in the literature include a standardized institutional process that allows flexibility among different units and settings, the completion of urgent tasks before information transfer, the presence of all members of the team for the duration of the handover, a structured conversation that uses a cognitive aid, and education in team skills and communication.

The postoperative handover: a focus group interview study with nurse anaesthetists, anaesthesiologists and PACU nurses

OBJECTIVES

To investigate different professionals' (nurse anaesthetists', anaesthesiologists', and postanaesthesia care unit nurses') descriptions of and reflections on the postoperative handover.

DESIGN

A focus group interview study with a descriptive design using qualitative content analysis of transcripts.

SETTING

One anaesthetic clinic at two hospitals in Sweden.

PARTICIPANTS

Six focus groups with 23 healthcare professionals involved in postoperative handovers. Each group was homogeneous regarding participant profession, resulting in two groups per profession: nurse anaesthetists (n=8), anaesthesiologists (n=7) and postanaesthesia care unit nurses (n=8).

RESULTS

Patterns and five categories emerged: (1) having different temporal foci during handover, (2) insecurity when information is transferred from one team to another, (3) striving to ensure quality of the handover, (4) weighing the advantages and disadvantages of the bedside handover and (5) having different perspectives on the transfer of responsibility. The professionals' perceptions of the postoperative handover differed with regard to temporal foci and transfer of responsibility. All professional groups were insecure about having all information needed to ensure the quality of care. They strived to ensure quality of the handover by: focusing on matters that deviated from the normal course of events, aiding memory through structure and written information and cooperating within and between teams. They reported that the bedside handover enhances their control of the patient but also that it could threaten the patient's privacy and that frequent interruptions could be disturbing.

CONCLUSIONS

The present findings revealed variations in different professionals' views on the postoperative handover. Healthcare interventions are needed to minimise the gap between professionals' perceptions and practices and to achieve a shared understanding of postoperative handover. Furthermore, to ensure high-quality and safe care, stakeholders/decision makers need to pay attention to the environment and infrastructure in postanaesthesia care.

Does Checklist Implementation Improve Quantity of Data Transfer: An Observation in Postanesthesia Care Unit (PACU)

BACKGROUND

Omission of patient information in perioperative communication is closely linked to adverse events. Use of checklists to standardize the handoff in the post anesthesia care unit (PACU) has been shown to effectively reduce medical errors.

OBJECTIVE

Our study investigates the use of a checklist to improve quantity of data transfer during handoffs in the PACU.

DESIGN

A cross-sectional observational study.

SETTING

PACU at Memorial Sloan Kettering Cancer Center (MSKCC); June 13, 2016 through July 15, 2016.

PATIENTS OTHER PARTICIPANTS

We observed the handoff reports between the nurses, PACU midlevel providers, anesthesia staff, and surgical staff.

INTERVENTION

A physical checklist was provided to all anesthesia staff and recommended to adhere to the list at all observed PACU handoffs.

MAIN OUTCOME MEASURE

Quantity of reported handoff items during 60 pre- and 60 post-implementation of a checklist.

RESULTS

Composite value from both surgical and anesthesia reports showed an increase in the mean report of 8.7 items from pre-implementation period to 10.9 post-implementation. Given that surgical staff reported the mean of 5.9 items pre-implementation and 5.5 items post-implementation without intervention, improvements in anesthesia staff report with intervention improved the overall handoff data transfer.

CONCLUSIONS

Using a physical 12-item checklist for PACU handoff increased overall data transfer.

Implementing situation-background-assessment-recommendation in an anaesthetic clinic and subsequent information retention among receivers: A prospective interventional study of postoperative handovers

BACKGROUND

Communication errors cause clinical incidents and adverse events in relation to surgery. To ensure proper postoperative patient care, it is essential that personnel remember and recall information given during the handover from the operating theatre to the postanaesthesia care unit. Formalizing the handover may improve communication and aid memory, but research in this area is lacking.

OBJECTIVE

The objective of this study was to evaluate whether implementing the communication tool Situation-Background-Assessment-Recommendation (SBAR) affects receivers' information retention after postoperative handover.

DESIGN

A prospective intervention study with an intervention group and comparison nonintervention group, with assessments before and after the intervention.

SETTING

The postanaesthesia care units of two hospitals in Sweden during 2011 and 2012.

PARTICIPANTS

Staff involved in the handover between the operating theatre and the postanaesthesia care units within each hospital.

INTERVENTION

Implementation of the communication tool SBAR in one hospital.

MAIN OUTCOME MEASURES

The main outcome was the percentage of recalled information sequences among receivers after the handover. Data were collected using both audio-recordings and observations recorded on a study-specific protocol form.

RESULTS

Preintervention, 73 handovers were observed (intervention group, n = 40; comparison group, n = 33) involving 72 personnel (intervention group, n = 40; comparison group, n = 32). Postintervention, 91 handovers were observed (intervention group, n = 44; comparison group, n = 47) involving 57 personnel (intervention group, n = 31; comparison group, n = 26). In the intervention group, the percentage of recalled information sequences by the receivers increased from 43.4% preintervention to 52.6% postintervention (P = 0.004) and the SBAR structure improved significantly (P = 0.028). In the comparison group, the corresponding figures were 51.3 and 52.6% (P = 0.725) with no difference in SBAR structure. When a linear regression generalised estimating equation model was used to account for confounding influences, we were unable to show a significant difference in the information recalled between the intervention group and the nonintervention group over time.

CONCLUSION

Compared with the comparison group with no intervention, when SBAR was implemented in an anaesthetic clinic, we were unable to show any improvement in recalled information among receivers following postoperative handover.

TRIAL REGISTRATION

Current controlled trials http://www.controlled-trials.com Identifier: ISRCTN37251313.

Inter-professional clinical handover in post-anaesthetic care units: tools to improve quality and safety

OBJECTIVES

To examine quality and safety in inter-professional clinical handovers in Post Anaesthetic Care Units (PACUs) and make recommendations for tools to standardize handover processes.

DESIGN

Mixed methods combining data from observations and focus groups.

SETTING

Three PACUs, one public tertiary hospital and two private hospitals.

PARTICIPANTS

Observations were made of 185 patient handovers from anaesthetists to nurses. Eight focus groups were conducted with 62 staff (15 anaesthetists and 47 nurses) across the study sites.

INTERVENTION

Inter-professional clinical handovers in PACU's.

MAIN OUTCOME MEASURES

Characteristics of the structure and processes that support safe inter-professional PACU handover practice.

RESULTS

Characteristics of the process, content, activities and risks during anaesthetist to nurse patient handover into the PACU were integrated into four steps in the PACU handover process summarized by the acronym COLD (Connect, Observe, Listen and Delegate), a verbal communication tool (ISoBAR), a checklist of critical information for safe patient transfer into PACU and a matrix of factors perceived to increase handover risk.

CONCLUSIONS

The standard structure and checklists for optimal content of patient handovers were derived from existing practices and consensus, hence, expected to provide ecologically valid and practical resources to improve quality and safety during clinical handovers in the PACU.

Improving the postoperative handover process in the intensive care unit of a tertiary teaching hospital

AIMS AND OBJECTIVES

The aim of this study was to improve the postoperative handover process and immediate postoperative patient outcomes. The objective was to implement a postoperative handover protocol in the neurosurgical intensive care unit of a tertiary teaching hospital.

BACKGROUND

Postoperative handover is a multidisciplinary collaborative medical activity that involves information transfer, sequenced tasks and high-quality teamwork. Evidence suggests that a lack of a standardised postoperative handover protocol adversely influences care quality and potentially compromises patient safety. As there is a lack of such protocols in China, there is an identified need for improvement.

DESIGN

This was a pretest/post-test study with follow-up after three months.

METHODS

A postoperative handover protocol that included a postoperative handover checklist, a standardised handover pathway and core team member involvement was developed based on research evidence and expert opinions and was then implemented and evaluated.

RESULTS

Following the implementation of this protocol, improved teamwork was achieved, surgeons were more frequently present at bedside handovers, the rate of transferring key messages increased, the rate of ventilator weaning within the first six hours of neurosurgical intensive care unit admission increased, and the ventilation duration per patient decreased without any clinical incident occurring in the first 24 hours after neurosurgical intensive care unit admission.

CONCLUSIONS

Following the implementation of a tailored standardised handover protocol, communication, teamwork and short-term patient outcomes were improved.

RELEVANCE TO CLINICAL PRACTICE

This clinically based research highlights the need for policy makers and administrators to create unit-specific protocols for improving postoperative handovers.

Perspectives of clinical handover processes: a multi-site survey across different health professionals

AIMS AND OBJECTIVES

To examine the perspectives of health professionals of different disciplines about clinical handover.

BACKGROUND

Ineffective handovers can cause major problems relating to the lack of delivery of appropriate care.

DESIGN

A prospective, cross-sectional design was conducted using a survey about clinical handover practices.

METHODS

Health professionals employed in public metropolitan hospitals, public rural hospitals and community health centres were involved. The sample comprised doctors, nurses and allied health professionals, including physiotherapists, social workers, pharmacists, dieticians and midwives employed in Western Australia, New South Wales, South Australia and the Australian Capital Territory. The survey sought information about health professionals' experiences about clinical handover; their perceived effectiveness of clinical handover; involvement of patients and family members; health professionals' ability to confirm understanding and to clarify clinical information; role modelling behaviour of health professionals; training needs; adverse events encountered and possibilities for improvements.

RESULTS

In all, 707 health professionals participated (response rate = 14%). Represented professions were nursing (60%), medicine (22%) and allied health (18%). Many health professionals reported being aware of adverse events where they noticed poor handover was a significant cause. Differences existed between health professions in terms of how effectively they gave handover, perceived effectiveness of bedside handover vs. nonbedside handover, patient and family involvement in handover, respondents' confirmation of understanding handover from their perspective, their observation of senior health professionals giving feedback to junior health professionals, awareness of adverse events and severity of adverse events relating to poor handovers.

CONCLUSIONS

Complex barriers impeded the conduct of effective handovers, including insufficient opportunities for training, lack of role modelling, and lack of confidence and understanding about handover processes.

RELEVANCE TO CLINICAL PRACTICE

Greater focus should be placed on creating opportunities for senior health professionals to act as role models. Sophisticated approaches should be implemented in training and education.

Quality of handover in a pediatric postanesthesia care unit

BACKGROUND

The quality of anesthetic handovers to postanesthesia care units (PACU) is known to be poor in adults, and only very limited reports are available regarding the quality of handovers in pediatric anesthesia. In particular, it is not known which and in what quality information is communicated. This current study investigated, therefore, the presence of any handover component as well as its consistency in a pediatric postanesthesia care unit.

METHODS

This prospective observational study evaluated postoperative anesthetic handovers to a pediatric PACU using a detailed checklist, comprising 55 possible items. The main outcome measure was the proportion of information verbally transmitted in relation to the written documentation within the anesthesia record.

RESULTS

Four hundred and forty-three handovers were observed with two handovers excluded due to missing data. Type of surgery (93% [95% CI 91-95]) and any intra-operative regional anesthesia (89% [95% CI 85-94]) were most frequently communicated. Items such as ASA-PS (3% [95% CI 2-5]) and fluid management (4% of cases [95% CI 2-6]) were rarely handed over. Eleven of the 55 items contained within the checklist were communicated in more than 70% of patients.

CONCLUSIONS

The observed handovers to PACU staff were incomplete and missing important information. However, omission of essential information potentially compromises patient safety. A standardized universal mandatory handover protocol following pediatric anesthesia is required.

The perioperative handoff protocol: evaluating impacts on handoff defects and provider satisfaction in adult perianesthesia care units

STUDY OBJECTIVE

To evaluate a new perioperative handoff protocol in the adult perianesthesia care units (PACUs).

DESIGN

Prospective, unblinded cross-sectional study.

SETTING

Perianesthesia care unit in a tertiary care facility serving 55,000 patients annually.

PATIENTS

One hundred three surgery patients.

INTERVENTIONS

During a 4-week preintervention phase, 53 perioperative handoffs were observed, and data were collected daily by a trained observer. Educational sessions were conducted to train perioperative practitioners on the new protocol. Two weeks after implementation, 50 consecutive handoffs were observed, and practitioners were surveyed with the same methodology as in the preintervention phase.

MEASUREMENTS

Type of information shared, type and duration of procedure, total duration of handoff, number and type of providers at the bedside, number of report interruptions, environmental distractions, and any other disruptive events. Observers also tracked technical/equipment problems to include malfunctioning or compromised operation of medical equipment, such as the cardiac monitor, transducer, oxygen tank, and pulse oximeter.

MAIN RESULTS

A total of 103 handoffs were observed (53 preintervention and 50 postintervention). The mean number of defects per handoff decreased from 9.92 to 3.68 (P < .01). The mean number of missed information items from the surgery report decreased from 7.57 to 1.2 items per handoff and from 2.02 to 0.94 (P < .01) for the anesthesia report. Technical defects reported by unit nurses decreased from 0.34 to 0.10 (P = .04). Verbal reports delivered by surgeons increased from 21.2% to 83.3%. Although the mean duration of handoffs increased by 2 minutes (P = .01), the average time from patient arrival at PACU to handoff start was reduced by 1.5 minutes (P = .01). Satisfaction with the handoff improved significantly among PACU nurses.

CONCLUSIONS

The perioperative handoff protocol implementation was associated with improved information sharing and reduced handoff defects.

Quality of post-operative patient handover in the post-anaesthesia care unit: a prospective analysis

BACKGROUND

Anaesthesiology plays a key role in promoting safe perioperative care. This includes the perioperative phase in the post-anaesthesia care unit (PACU) where problems with incomplete information transfer may have a negative impact on patient safety and can lead to patient harm. The objective of this study was to analyse information transfer during post-operative handovers in the PACU.

METHODS

With a self-developed checklist including 59 items the information transfer during post-operative handovers was documented and subsequently compared with patient information in anaesthesia records during a 2-month period.

RESULTS

A total number of 790 handovers with duration of 73 ± 49 s was analysed. Few items were transferred in most of the cases such as type of surgery (97% of the cases), regional anaesthesia (94% of the cases) and cardiac instability (93% of the cases). However, some items were rarely transferred, such as American Society of Anesthesiologists physical status (7% of the cases), initiation of post-operative pain management (12% of the cases), antibiotic therapy (14% of the cases) and fluid management (15% of the cases). There was a slight correlation between amount of information transferred and duration of post-operative handovers (r = 0.5).

CONCLUSION

The study shows that post-operative handovers in the PACU are in most cases incomplete. It appears useful to optimise the post-operative handover process, for example by implementing a standardised handover checklist.

Addressing the Mandate for Hand-off Education

The Accreditation Council for Graduate Medical Education requires that residency programs teach residents about handoffs and ensure their competence in this communication skill. Development of hand-off curricula for anesthesia residency programs is hindered by the paucity of evidence regarding how to conduct, teach, and evaluate handoffs in the various settings where anesthesia practitioners work. This narrative review draws from literature in anesthesia and other disciplines to provide recommendations for anesthesia resident hand-off curriculum development and evaluation.