An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010;252:402-407. [PMID: 20647920 DOI: 10.1097/sla.0b013e3181e986df]

Pilot study to develop a pre-operative "Cardiothoracic Clinical Handover Tool" and its effect on handover quality

BACKGROUND

Clinical handover is an essential step in the surgical patient's hospital journey, but one that is not without risk. Within cardiothoracic surgery, endeavours to protocolise post-operative handover from cardiac theatre to cardiac intensive care units have resulted in enhanced patient safety, but little to no effort has focused on the pre-operative setting and the dissemination of information throughout the surgical team.

METHODS

We designed a pre-post study examining the quality of pre-operative cardiothoracic patient handovers before and after the introduction of an intra-departmentally designed "Cardiothoracic Clinical Handover Tool" based on the Royal College of Surgeons of England's guidelines for "Safe Handover".

RESULTS

Forty clinical handovers were assessed in each arm of the study. Handover quality improved from a score of 63.75% to 88.57% (p = < 0.001). This prolonged handover duration from a mean of 72.1 to 102.4 seconds per case (p = 0.003). Interruptions occurred in 27.5% of pre- and 25% of post-intervention handovers. Interruptions resulted in increased handover duration in both pre- and post-intervention groups (114.6 vs 77.7 seconds, p = 0.012) and poorer quality handovers in the pre-intervention group (51.28% vs 68.42%, p = 0.03) but failed to impact handover quality in the post-intervention group (88.57% vs 88.57%, p = 1).

CONCLUSIONS

Clinical handover tools have the potential to enhance the quality of pre-operative handover and protect against poor handover practices such as interruptions, safe-guarding patient welfare. We provide the first cardiothoracic specific pre-operative handover tool based on the RCSE guidelines.

Understanding Factors Associated with Paid Malpractice Claims in Plastic Surgery

BACKGROUND

Few studies have investigated malpractice broadly in the field of plastic surgery. The purpose of this analysis was to characterize plastic surgery malpractice cases and examine factors influencing malpractice case outcomes, thereby identifying areas of patient safety concern.

METHODS

The Candello database, which catalogs approximately 30% of all paid and unpaid malpractice claims in the United States, was used to obtain cases involving plastic surgery closed between 2009 and 2018. A total of 2674 cases were identified. A multivariable regression model was developed to analyze factors associated with a malpractice case closing with indemnity payment.

RESULTS

A total of 716 claims (26.8%) resulted in an indemnity payment. The clinical severity was determined to be high in 229 cases (8.6%). Emotional trauma [ n = 558 (20.9%)] was the most frequently cited injury category. Major differences between procedure groups were not observed, with consistent severity of injury across categories. Poor surgical technique, problems with communication among providers, inadequate informed consent, and deficient documentation were significant factors predictive of malpractice cases closing with payment. Issues with technical performance resulting in a known complication and patient factors were protective against paid claims.

CONCLUSIONS

The financial and clinical severity of malpractice claims in plastic surgery were relatively low overall. Multiple factors were found to be associated with a case closing with an indemnity payment. These data highlight the importance of the informed consent process and managing expectations in the clinical care of surgical patients.

The Quest for Excellence: A Quality Improvement Project on the Effects of a Standardized PACU/Phase II Bedside Report in a High Turnover Pediatric Ambulatory Surgery Center

PURPOSE

To evaluate the impact of an evidence-based standardized bedside report within a pediatric ambulatory surgery center on length of handoff time, registered nurse (RN) workflow, and patient and family satisfaction.

DESIGN

Quality improvement project using an evidence-based standardized bedside report intervention with pre- and postimplementation evaluation of process and outcome measures.

METHODS

In January 2019, a unit-based task force evaluated ways to improve current report process and consistency of communication between staff and families. Time from admit into Phase II until nursing handoff was measured pre- and postimplementation. Nursing workflow was measured by time to first RN assessment after admit to Phase II and the postimplementation nursing survey. Patient and family satisfaction were measured pre- and postimplementation from National Research Council Health.

FINDINGS

Postimplementation, average handoff times decreased by 30%; average time from admit to the Phase II unit until the nursing handoff decreased by 28%. From the postimplementation RN survey, 100% RNs: (1) felt standardized bedside report had a positive impact on their workflow, (2) expressed confidence in giving and receiving reports, and (3) reported they had critical information to safely care for patients. Overall patient satisfaction was measured by How likely would you be to recommend this facility to your family and friends; 11.6% improvement over baseline scores was reported. Improved percentages of score improvement from baseline included: nurses explained things (4.42%), nurses listened carefully (4.3%), patient and family received consistent information (2.46%), care providers explained things (2.22%), and patient and family trusted nurses with care (1.74%).

CONCLUSIONS

Implementation of standardized bedside report resulted in (1) more expeditious times to handoff and first RN assessment, (2) overall positive impact on nursing workflow, and (3) improvements in patient and family satisfaction.

The Cognitive Basis for Human Error and the Best Practices to Reduce Error

A great deal of knowledge exists about how to make health care safer than it is currently. The tools exist but all too often, they are not implemented. All anesthesia providers need to understand what safety best practices are and continue to advocate for them in their workplaces.

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.

Implicit expression of uncertainty in medical students during different sequences of clinical reasoning in simulated patient handovers

BACKGROUND

Dealing with medical uncertainty is an essential competence of physicians. During handovers, communication of uncertainty is important for patient safety, but is often not explicitly expressed and can hamper medical decisions. This study examines medical students' implicit expression of uncertainty in different sequences of clinical reasoning during simulated patient handovers.

METHODS

In 2018, eighty-seven final-year medical students participated in handovers of three simulated patient cases, which were videotaped and transcribed verbatim. Sequences of clinical reasoning and language references to implicit uncertainty that attenuate and strengthen information based on a framework were identified, categorized, and analyzed with chi-square goodness-of-fit tests.

RESULTS

A total of 6358 sequences of clinical reasoning were associated with the four main categories "statement", "assessment", "consideration", and "implication", with statements occurring significantly (p<0.001) most frequently. Attenuated sequences of clinical reasoning occurred significantly (p<0.003) more frequently than strengthened sequences. Implications were significantly more often attenuated than strengthened (p<0.003). Statements regarding results occurred significantly more often plain or strengthened than statements regarding actions (p<0.0025).

CONCLUSION

Implicit expressions of uncertainty in simulated medical students' handovers occur in different degrees during clinical reasoning. These findings could contribute to courses on clinical case presentations by including linguistic terms and implicit expressions of uncertainty and making them explicit.

Sustained Improvement in Quality of Patient Handoffs After Orthopaedic Surgery I-PASS Intervention

PURPOSE

The I-PASS tool has been shown to decrease medical errors in patient handoffs in nonorthopaedic surgery fields. We prospectively studied the implementation of a version of this handoff tool modified for orthopaedic surgery patients in an academic practice at two level I trauma centers.

METHODS

This was a prospective study of a multicenter handoff improvement program. Handoffs were evaluated preintervention and at 1, 6, 9, and 18 months postintervention for key data elements defined by I-PASS. Rates of adverse clinical outcomes were compared before and after the handoff intervention.

RESULTS

Seven hundred five electronic patient handoffs were analyzed. From preintervention to the 18-month time point, notable improvement was observed in 8 of 9 targeted quality elements. In Poisson regression analysis, adherence to the standardized handoff format was sustained at markedly improved levels throughout all postintervention time points. No statistically significant differences were observed between rates of 30-day readmission, 90-day readmission, urinary tract infection, pulmonary embolism/deep vein thrombosis, surgical site infection, or delirium before and after the intervention.

CONCLUSION

Introduction of an orthopaedic-specific I-PASS tool produced sustained adherence from a group of over 50 orthopaedic providers. Objective quality of handoffs improved markedly as defined by the I-PASS standard, and 86% of the providers supported the ongoing use of the tool. Despite the improvement in handoff quality, we were unable to demonstrate a notable change in measured clinical outcomes. Methods for the development and implementation of the orthopaedic-specific I-PASS tool are described. Orthopaedic residency programs should consider using a version of I-PASS to standardize care.

Failure to Rescue Deteriorating Patients: A Systematic Review of Root Causes and Improvement Strategies

OBJECTIVES

"Failure to rescue" (FTR) is the failure to prevent a death resulting from a complication of medical care or from a complication of underlying illness or surgery. There is a growing body of evidence that identifies causes and interventions that may improve institutional FTR rates. Why do patients "fail to rescue" after complications in hospital? What clinically relevant interventions have been shown to improve organizational fail to rescue rates? Can successful rescue methods be classified into a simple strategy?

METHODS

A systematic review was performed and the following electronic databases searched between January 1, 2006, to February 12, 2018: MEDLINE, PsycINFO, Cochrane Library, CINAHL, and BNI databases. All studies that explored an intervention to improve failure to rescue in the adult population were considered.

RESULTS

The search returned 1486 articles. Eight hundred forty-two abstracts were reviewed leaving 52 articles for full assessment. Articles were classified into 3 strategic arms (recognize, relay, and react) incorporating 6 areas of intervention with specific recommendations.

CONCLUSIONS

Complications occur consistently within healthcare organizations. They represent a huge burden on patients, clinicians, and healthcare systems. Organizations vary in their ability to manage such events. Failure to rescue is a measure of institutional competence in this context. We propose "The 3 Rs of Failure to Rescue" of recognize, relay, and react and hope that this serves as a valuable framework for understanding the phases where failure of patient salvage may occur. Future efforts at mitigating the differences in outcome from complication management between units may benefit from incorporating this proposed framework into institutional quality improvement.

Standardised handover process with checklist improves quality and safety of care in the postanaesthesia care unit: the Postanaesthesia Team Handover trial

BACKGROUND

Miscommunication is a leading cause of preventable incidents in healthcare. A number of checklists have been created in an attempt to improve patient outcomes with only a small impact. However, the 2009 WHO Surgical Safety Checklist demonstrated benefits in terms of reduced morbidity and mortality. Our aim was to determine whether use of a Postanaesthesia Team Handover (PATH) checklist would reduce hypoxaemic events in the postanaesthesia care unit (PACU).

METHODS

This single-centre, prospective, pre-/post-implementation study was conducted between February 2019 and July 2020 in the PACU of Versailles Private Hospital, Paris, France. Pre-PATH implementation data were collected for 294 consecutive adult patients (≥18 yr old) admitted to the PACU and post-PATH implementation data were collected for 293 consecutive patients. The primary outcome was the rate of hypoxaemic events post-surgery during PACU stay.

RESULTS

The rates of hypoxaemic events were 4.1% (11/267 [95% confidence interval {CI}: 2.3-7.2%]) before the PATH checklist was introduced and 0.8% (2/266 [95% CI: 0.2-2.7%]) after. Patients in the PATH group were 5.6 times (odds ratio [OR] [95% CI: 1.3-33.6], P=0.041) less likely to have a hypoxaemic event than those in the control group. The handover process in the PATH checklist group also had significantly less interruptions (38.6% control vs 20.7% PATH; OR=2.5 [95% CI: 1.7-3.7]; P<0.0001).

CONCLUSIONS

Implementation of the PATH checklist in adult patients post-surgery was associated with a reduction in the rate of hypoxaemic events in the PACU. These findings support standardisation of the handover process with checklists following anaesthesia and surgery.

CLINICAL TRIAL REGISTRATION

NCT03972423.

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.

Pain Management and Education for Ambulatory Surgery: A Qualitative Study of Perioperative Nurses

BACKGROUND

Ambulatory surgery presents unique challenges regarding adequate pain management and education. Studies have documented issues with transfer of information and patient comfort. Our objective was to explore perioperative nurses' perspectives of current practices and challenges with pain management and education.

MATERIALS AND METHODS

We used a qualitative descriptive design and conducted four focus group interviews, with 24 total participants from two perioperative areas of an academic medical center, using a standardized script. Using qualitative analysis software, two investigators reviewed the data and coded major themes and subthemes. The consolidated criteria for reporting qualitative studies guidelines were followed for reporting the data.

RESULTS

We identified four major themes impacting current perioperative pain management and education practices: communication among the perioperative care team, sources of nurses' frustrations in the perioperative setting, patient expectations for pain, and nurse-driven pain management and education. Nurses highlighted their work became easier with adequate information transfer and trust from physicians. Frustrations stemmed from surgeon, system, and patient factors. Nurses often use their clinical experience and judgment in managing patients throughout the perioperative period. Furthermore, nurses felt patients have limited pain education and stressed education throughout the surgical care pathway could improve overall care.

CONCLUSIONS

Perioperative pain management, assessment, and education practices are inconsistent, incomplete, and sources of frustrations according to participants. Participant experiences highlight the need for improved and standardized models. Patient pain education should use a multidisciplinary approach, beginning at the point of surgery scheduling and continuing through postoperative follow-up.

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.

How to communicate between surgeon and intensivist?

PURPOSE OF REVIEW

Communication and teamwork are essential to enhance the quality of care, especially in operating rooms and ICUs. In these settings, the effective interprofessional collaboration between surgeons and intensivists impacts patients' outcome. This review discusses current opinions and evidence for improving communication strategies and the relationship between surgeons and intensivists/anesthesiologist.

RECENT FINDINGS

Effective teamwork has been demonstrated to improve patient outcome and foster healthier relationships between professionals.With the expansion of new medical superspecialist disciplines and the latest medical developments, patient care has been put through a progressive fragmentation, rather than a holistic approach. Operating theaters and ICU are the common fields where surgeons and anesthesiologists/intensivists work. However, communication challenges may frequently arise. Therefore, effective communication, relational coordination, and team situation awareness are considered to affect quality of teamwork in three different phases of the patient-centered care process: preoperatively, intraoperatively, and postoperatively.

SUMMARY

Although limited, current evidence suggests to improve communication and teamwork in patient perioperative care. Further research is needed to strengthen the surgeon-intensivist relationship and to deliver high-quality patient care.

The Elephant in the Room: Nurses' Views of Communication Failure and Recommendations for Improvement in Perioperative Care

Perioperative communication failures endanger patient safety and may reduce efficiency. The objective of our phenomenological research study was to determine the reasons for and consequences of perioperative communication failures and to seek recommendations for improvement. Fourteen perioperative nurses participated in this study. We conducted in-depth interviews with a semi-structured questionnaire following Colaizzi's seven-step methodology to extract themes. We organized the themes into categories: causes, consequences, and recommendations for preventing communication failure. Some themes for causes were inadequate time for preoperative preparation, lack of personnel, and disruptive behaviors of physicians. Consequences of communication failure were decreased staff retention, avoidance of colleagues, threats to patient safety, and intra-team violence. Two recommendations included enforcing institutional regulations and creating team spirit. The study revealed that nurses believe that institutional regulations should not only be present but enforced. Further, nurses believe that strengthening employees' interpersonal skills is essential to preventing communication issues.

Psychometric properties of an instrument measuring communication within and between the professional groups licensed practical nurses and registered nurses in anaesthetic clinics

BACKGROUND

The most common cause of clinical incidents and adverse events in relation to surgery is communication error. There is a shortage of studies on communication between registered nurses and licenced practical nurses as well as of instruments to measure their perception of communication within and between the professional groups. The aim of the present study was to evaluate the psychometric properties of the Swedish version of the adapted ICU Nurse-Physician Questionnaire, designed to also measure communication within and between two professional groups: licensed practical nurses and registered nurses. Specifically, the aim was to examine the instrument's construct validity using confirmatory factor analysis and its internal consistency using Cronbach's Alpha.

METHODS

A cross-sectional and correlational design was used. The setting was anaesthetic clinics in two Swedish hospitals. A total of 316 questionnaires were delivered during spring 2011, of which 195 were analysed to evaluate the psychometric properties of the questionnaire. Construct validity was assessed using confirmatory factor analysis and internal consistency using Cronbach's Alpha. To assess items with missing values, we conducted a sensitivity analysis of two sets of data, and to assess the assumption of normally distributed data, we used Bayesian estimation.

RESULTS

The results support the construct validity and internal consistency of the adapted ICU Nurse-Physician Questionnaire. Model fit indices for the confirmative factor analysis were acceptable, and estimated factor loadings were reasonable. There were no large differences between the estimated factor loadings when comparing the two samples, suggesting that items with missing values did not alter the findings. The estimated factor loadings from Bayesian estimation were very similar to the maximum likelihood results. This indicates that confirmative factor analysis using maximum likelihood produced reliable factor loadings. Regarding internal consistency, alpha values ranged from 0.72 to 0.82.

CONCLUSIONS

The tests of the adapted ICU Nurse-Physician Questionnaire indicate acceptable construct validity and internal consistency, both of which need to be further tested in new settings and samples.

TRIAL REGISTRATION

Current controlled trials http://www.controlled-trials.com Communication and patient safety in anaesthesia and intensive care. Does implementation of SBAR make any differences? Identifier: ISRCTN37251313, retrospectively registered (assigned 08/11/2012).

Cross-Disciplinary Care: A Systematic Review on Teamwork Processes in Health Care

As health care delivery moves toward more complex, team-based systems, the topic of medical teamwork has gained considerable attention and study across disciplines. This systematic review integrates empirical research on teamwork and health care to identify broad trends. We identified and coded 1,818 relevant, English, and peer-reviewed journal articles using a teamwork processes rubric. Several themes emerged. The health care teamwork literature has grown substantially over the past 20 years. Approximately half of the studies were descriptive (rather than interventional or psychometric); the majority relied on quantitative methods. Health care teamwork was also studied in thematically distinct manners. Interpersonal processes were most commonly studied across fields. Of all disciplines, medicine focused most on transition processes, whereas those from team science centered more highly on action processes. There were also finer grained disciplinary differences in content areas of communication and collaboration. Interprofessional journals represent a potential area for interdisciplinary efforts. Implications and future directions are discussed.

The impact of patient safety culture on handover in rural health facilities

BACKGROUND

Effective handover is crucial for patient safety. Rural health care organisations have particular challenges in relation to handover of information, placing them at higher risk of adverse events. Few studies have examined the relationship between handover and patient safety in rural contexts, particularly in Australia. This study aimed to explore the effect of handover on overall perceptions of patient safety and the effect of other patient safety dimensions on handover in a rural Australian setting.

METHODS

A cross-sectional online survey using The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was implemented across six rural Local Health Districts in NSW, Australia and resulted in 1587 respondents. Hierarchical multiple linear regression analysis was conducted to account for the nested nature of the data. Models were developed to assess the effect of handover on patient safety perceptions, and the effect of other patient safety culture composites on handover variables. Open-ended questions about patient safety were inductively analyzed for themes. Quotes from the handover theme are presented.

RESULTS

All models were significant overall (p < .001), with explanatory powers ranging from 29 to 48%. Within rural health settings, effective handover is significantly related to patient safety perceptions (R2 = .29). A strong teamwork culture and management support culture was found to enhance effective handover of patient information (R2 = .47), and effective handover of personal responsibility (R2 = .37). A strong teamwork, management support, and open communication culture enhances handover of department accountability (R2 = .41). Despite the implementation of standardised communication tools and frameworks for handover, patient safety is compromised by inadequate coordination, poor or absent documentation between departments, between other health care agencies and in transfer of care from acute facilities to primary/community care.

CONCLUSION

Approaches to handover need to consider the particular challenges associated with rurality and strengthening elements found to be associated with increased safety, such as a strong teamwork and management culture and good reporting practices. Research is required to examine how communication at transition of care, particularly between facilities, is conducted and ways in which to enhance patients' and families' participation.

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.

Variations in the Delivery of Emergency General Surgery Care in the Era of Acute Care Surgery

BACKGROUND

Acute care surgery (ACS) was proposed to improve emergency general surgery (EGS) care; however, the extent of ACS model adoption in the United States is unknown. A national survey was conducted to ascertain factors associated with variations in EGS models of care, with particular focus on ACS use.

METHODS

A hybrid mail/electronic survey was sent in 2015 to 2,811 acute care hospitals with an emergency room and an operating room. If a respondent indicated that the approach to EGS was a dedicated clinical team whose scope encompasses EGS (± trauma, ± elective general surgery, ± burns), the hospital was considered an ACS hospital.

RESULTS

Survey response was 60.1% (n = 1,690); 272 (16.1%) of these hospitals reported having used an ACS model of care for EGS patients. Teaching status and general hospital practices (for example, interventional radiology available within one hour) were associated with ACS use. In bivariate analyses, ACS use was associated with many EGS-specific practices (40.1% of ACS hospitals freed their surgeons of daytime clinical responsibilities after operating overnight vs. 4.7% of general surgeon on call (GSOC) hospitals; p < 0.0001).

CONCLUSION

There are wide variations in EGS practices in the United States, with use of an ACS model of care being relatively low despite reported benefits of ACS models of care on EGS access, quality, and costs. Hospital factors associated with using ACS models are overall size and higher level of existing resources. These findings could be applied to the development of centers of excellence for EGS care.

The feasibility, acceptability and preliminary testing of a novel, low-tech intervention to improve pre-hospital data recording for pre-alert and handover to the Emergency Department

Background

Poor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Data used in handover is not always easily recorded using ambulance based tablets, particularly in time-critical cases. Paramedics have therefore developed pragmatic workarounds (writing on gloves or scrap paper) to record these data. However, such practices can conflict with policy, data recorded can be variable, easily lost and negatively impact on handover quality.

Methods

This study aimed to measure the feasibility and acceptability of a novel, low tech intervention, designed to support clinical information recording and delivery during pre-alert and handover within the pre-hospital and ED setting. A simple pre and post-test design was used with a historical control. Eligible participants included all ambulance clinicians based at one large city Ambulance Station (n = 69) and all nursing and physician staff (n = 99) based in a city Emergency Department.

Results

Twenty five (36%) ambulance clinicians responded to the follow-up survey. Most felt both the pre-alert and handover components of the card were either ‘useful-very useful’ (n = 23 (92%); and n = 18 (72%) respectively. Nineteen (76%) used the card to record clinical information and almost all (n = 23 (92%) felt it ‘useful’ to ‘very useful’ in supporting pre-alert. Similarly, 65% (n = 16) stated they ‘often’ or ‘always’ used the card to support handover. For pre-alert information there were improvements in the provision of 8/11 (72.7%) clinical variables. ​ Results from the post-test survey measuring ED staff (n = 37) perceptions of handover demonstrated small (p < 0.05) improvements in handover in 3/5 domains measured.

Conclusion

This novel low-tech intervention was highly acceptable to ambulance clinician participants, improving their data recording and information exchange processes. However, further well conducted studies are required to test the impact of this intervention on information exchange during pre-alert and handover.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0168-3) contains supplementary material, which is available to authorized users.

Improving cardiac operating room to intensive care unit handover using a standardised handover process

Handovers from the cardiovascular operating room (CVOR) to the cardiovascular intensive care unit (CVICU) are complex processes involving the transfer of information, equipment and responsibility, at a time when the patient is most vulnerable. This transfer is typically variable in structure, content and execution. This variability can lead to the omission and miscommunication of critical information leading to patient harm. We set out to improve the quality of patient handover from the CVOR to the CVICU by introducing a standardised handover protocol. This study is an interventional time-series study over a 4-month period at an adult cardiac surgery centre. A standardised handover protocol was developed using quality improvement methodologies. The protocol included a handover content checklist and introduction of a formal 'sterile cockpit' timeout. Implementation of the protocol was refined using monthly iterative Plan-Do-Study-Act. The primary outcome was the quality of handovers, measured by a Handover Score, comprising handover content, teamwork and patient care planning indicators. Secondary outcomes included handover duration, adherence to the standardised handover protocol and handover team satisfaction surveys. 37 handovers were observed (6 pre intervention and 31 post intervention). The mean handover score increased from 6.5 to 14.0 (maximum 18 points). Specific improvements included fewer handover interruptions and more frequent postoperative patient care planning. Average handover duration increased slightly from 2:40 to 2:57 min. Caregivers noted improvements in teamwork, content received and patient care planning. The majority (>95%) agreed that the intervention was a valuable addition to the CVOR to CVICU handover process. Implementation of a standardised handover protocol for postcardiac surgery patients was associated with fewer interruptions during handover, more reliable transfer of critical content and improved patient care planning.

A qualitative study of patient and provider experiences during preoperative care transitions

AIMS AND OBJECTIVES

To explore the issues and challenges of care transitions in the preoperative environment.

BACKGROUND

Ineffective transitions play a role in a majority of serious medical errors. There is a paucity of research related to the preoperative arena and the multiple inherent transitions in care that occur there.

DESIGN

Qualitative descriptive design was used.

METHODS

Semistructured interviews were conducted in a 975-bed academic medical centre.

RESULTS

A total of 30 providers and 10 preoperative patients participated. Themes that arose were as follows: (1) need for clarity of purpose of preoperative care, (2) care coordination, (3) interprofessional boundaries of care and (4) inadequate time and resources.

CONCLUSION

Effective transitions in the preoperative environment require that providers bridge scope of practice barriers to promote good teamwork. Preoperative care that is a product of well-informed providers and patients can improve the entire perioperative care process and potentially influence postoperative patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Nurses are well positioned to bridge the gaps within transitions of care and accordingly affect health outcomes.

Assessing written communication during interhospital transfers of emergency general surgery patients

BACKGROUND

Poor communication causes fragmented care. Studies of transitions of care within a hospital and on discharge suggest significant communication deficits. Communication during transfers between hospitals has not been well studied. We assessed the written communication provided during interhospital transfers of emergency general surgery patients. We hypothesized that patients are transferred with incomplete documentation from referring facilities.

METHODS

We performed a retrospective review of written communication provided during interhospital transfers to our emergency department (ED) from referring EDs for emergency general surgical evaluation between January 1, 2014 and January 1, 2016. Elements of written communication were abstracted from referring facility documents scanned into the medical record using a standardized abstraction protocol. Descriptive statistics summarized the information communicated.

RESULTS

A total of 129 patients met inclusion criteria. 87.6% (n = 113) of charts contained referring hospital documents. 42.5% (n = 48) were missing history and physicals. Diagnoses were missing in 9.7% (n = 11). Ninety-one computed tomography scans were performed; among 70 with reads, final reads were absent for 70.0% (n = 49). 45 ultrasounds and x-rays were performed; among 27 with reads, final reads were missing for 80.0% (n = 36). Reasons for transfer were missing in 18.6% (n = 21). Referring hospital physicians outside the ED were consulted in 32.7% (n = 37); consultants' notes were absent in 89.2% (n = 33). In 12.4% (n = 14), referring documents arrived after the patient's ED arrival and were not part of the original documentation provided.

CONCLUSIONS

This study documents that information important to patient care is often missing in the written communication provided during interhospital transfers. This gap affords a foundation for standardizing provider communication during interhospital transfers.

A Defined Esophagectomy Perioperative Clinical Care Process Can Improve Outcomes and Costs

Esophagectomy (EG) is a high-risk therapy for esophageal cancer and end-stage benign disease. This study compares the results of EG before and after implementation of a perioperative clinical care process including a health provider education program (EP) and institutional uncomplicated postoperative clinical pathway (POP) for purpose quality improvement. This is a single institution retrospective cohort study. The EP was provided to critical care and telemetry unit nurses and the POP was imbedded in the electronic health record. Patients undergoing elective EG with reconstruction with the stomach for benign disease or cancer were included from 2005 to 2011. Cohorts were pre- and postimplementation (PreI and PostI) of an EP and 8-day POP (August 2008). Patient, tumor and peri/postoperative-specific variables were compared between cohorts, as well as resource utilization and hospital costs. We identified 33 PreI and 41 PostI patients. Both cohorts had similar patient demographics, preoperative comorbidities, majority cancer diagnosis, and for cancer patients, majority adenocarcinoma and IIB/III pathologic stage. Both groups had one death and similar rate of discharge to home. The PostI cohort demonstrated reduced 30-day readmission rate (2.4% vs 24.2%); P < 0.05. In regard to clinical outcomes, the PostI group exhibited reduced deep venous thrombosis/pulmonary emboli (2.4% vs 18.2%); P < 0.05. The PostI group demonstrated significantly reduced radiographic test utilization and costs, as well as total overall 30-day readmission costs. A defined perioperative clinical process involving educating the patient care team and implementing a widely disseminated POP can reduce complications, 30-day readmission rates, and hospital costs after EG.

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.

The impact of an integrated nursing handover system on nurses' satisfaction and work practices

AIMS AND OBJECTIVES

This study examined the impact of an Integrated Nursing Handover System--structured content, a minimum data set and an electronic module within the patient clinical information system--on nurses' satisfaction with handover and changes to practice.

BACKGROUND

Poor transfer of patient information between clinicians at handover has been associated with adverse patient outcomes.

DESIGN

A mixed methods pre-post evaluative approach was used.

METHODS

The Integrated Nursing Handover System was introduced and evaluated within an Australian hospital. Changes to nurses' satisfaction were measured using the modified Bradley Clinical Handover Survey (n = 40 pre, n = 80 post). Three focus groups with clinicians (2) and mangers and educators (1) examined changes to clinical practice. The location of handover was observed.

RESULTS

Nurses' satisfaction with handover was improved. A two stage approach to handover emerged: nurses received handover of all patients within meeting rooms followed by handover delivered at the bedside. Major categories identified through content analysis included: implementation and the transition, work practice changes and bedside handover, accessible and standardised patient information, accountability for information transfer and a central repository of patient information.

CONCLUSION

An integrated system has been implemented with positive outcomes of: improved nurse satisfaction with handover, nurses being informed about all patients, enhanced patient transfers and improved patient information for all health professionals. Further research into the potential use of stored patient handover data for research is recommended.

RELEVANCE TO CLINICAL PRACTICE

This comprehensive system of nursing handover represents the first integrated system of this nature ever reported in the nursing and health literature. This integrated nursing handover system has been successfully implemented resulting in delivery of more comprehensive, logical and standardised patient information at handover.

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 Escalation of Care: Development and Validation of the Quality of Information Transfer Tool

OBJECTIVE

To develop and provide validity and feasibility evidence for the QUality of Information Transfer (QUIT) tool.

BACKGROUND

Prompt escalation of care in the setting of patient deterioration can prevent further harm. Escalation and information transfer skills are not currently measured in surgery.

METHODS

This study comprised 3 phases: the development (phase 1), validation (phase 2), and feasibility analysis (phase 3) of the QUIT tool. Phase 1 involved identification of core skills needed for successful escalation of care through literature review and 33 semistructured interviews with stakeholders. Phase 2 involved the generation of validity evidence for the tool using a simulated setting. Thirty surgeons assessed a deteriorating postoperative patient in a simulated ward and escalated their care to a senior colleague. The face and content validity were assessed using a survey. Construct and concurrent validity of the tool were determined by comparing performance scores using the QUIT tool with those measured using the Situation-Background-Assessment-Recommendation (SBAR) tool. Phase 3 was conducted using direct observation of escalation scenarios on surgical wards in 2 hospitals.

RESULTS

A 7-category assessment tool was developed from phase 1 consisting of 24 items. Twenty-one of 24 items had excellent content validity (content validity index >0.8). All 7 categories and 18 of 24 (P < 0.05) items demonstrated construct validity. The correlation between the QUIT and SBAR tools used was strong indicating concurrent validity (r = 0.694, P < 0.001). Real-time scoring of escalation referrals was feasible and indicated that doctors currently have better information transfer skills than nurses when faced with a deteriorating patient.

CONCLUSIONS

A validated tool to assess information transfer for deteriorating surgical patients was developed and tested using simulation and real-time clinical scenarios. It may improve the quality and safety of patient care on the surgical ward.

Interface transition checklists in spinal surgery

ISSUE

Recently, quality tools have been promoted to improve patient safety and process efficiency in healthcare. While surgeons primarily focused on surgical issues, like infection rates or implant design, we introduced pre-admission and preoperative checklists in the early 2000s.

INITIAL ASSESSMENT

To assess the efficiency of these tools in a neurosurgical department, we performed a survey of all spinal instrumentation patients operated in 2011 (n = 147). The results revealed several problems.

CHOICE OF SOLUTION

We consequently redesigned the checklists accompanied by flanking measures, such as written  and online accessible standards. Furthermore, the staff was trained to use the updated quality tools.

IMPLEMENTATION

The measures were implemented in 2012.

EVALUATION

Results were re-evaluated in a second survey in 2013 (n = 162). We found that the use of pre-admission checklists significantly increased from 47 to 96%, while the use of preoperative checklists significantly decreased from 86 to 75%. Within the same period, the quality and completeness of the checklists did, however, increase, so that in 2013, 43% of the patients had a completely processed preoperative checklist, compared to 29% in 2011.

LESSONS LEARNED

The introduction of checklists alone did not in itself guarantee an improved workflow. The introduction must be accompanied by other measures, like written standards and regular training of employees. Otherwise, the positive effect wears off quickly. Nevertheless, we could show that the stringent application of quality tools can induce a sustainable change. Our data further suggest that the clear and traceable delegation of responsibilities is of high importance.

The role of the nurse and the preoperative assessment in patient transitions

Transitions in care in the perioperative environment are numerous and should be considered high-risk endeavors. The preoperative area is the first transition in care for a surgical patient and should be considered a critical dimension of care transition. The purposes of this study were to identify nursing's contributions to transitions in care in the perioperative environment and to identify the role of the preoperative assessment in this transition. Qualitative descriptive design was used. Focus groups were conducted with 24 nurses in a 975-bed medical center. The themes that arose in the focus groups were: (1) understanding patient vulnerabilities, (2) multidimensional communication, (3) managing patients' expectations, and (4) nursing's role in compensating for gaps. We conclude that the nurse's role in the preoperative assessment during the transition of preoperative care is that of advocate who identifies the patient's needs and risk factors that may be affected by the surgical experience. This study suggests that the nursing preoperative assessment can be useful in identifying and defining patients' risk factors not just for surgery, but for the entire perioperative care trajectory.

Patient handoffs in surgery: Successes, failures and room for improvement

Patient handoffs are transitions where communication failures may lead to errors in patient care. Face-to-face handoffs are preferred, however may not always be feasible. Different models and strategies have been described, yet there are few experimental studies. Expanding the problem, the on-call surgeon may be responsible for many patients, few or none that they admitted. Effective handoffs improve the quality of care and result in fewer errors. Herein we review different models of patient handoffs, comment on common pitfalls, and suggest areas for new research.

Safety hazards in abdominal surgery related to communication between surgical and anesthesia unit personnel found in a Swedish nationwide survey

Background

Many adverse events occur due to poor communication between surgical and anesthesia unit personnel. The aim of this study was to identify strategies to reduce risks unveiled by a national survey on patient safety.

Methods

During 2011–2015, specially trained survey teams visited the surgery departments at Swedish hospitals and documented routines concerning safety in abdominal surgery. The reports from the first seventeen visits were reviewed by an independent group in order to extract findings related to routines in communication between anesthesia and surgical unit personnel.

Results

In general, routines regarding preoperative risk assessment were safe and well- coordinated. On the other hand, routines regarding medication prior to surgery, reporting between the different units, and systems for reporting and providing feedback on adverse events were poor or missing. Strategies with highest priority include: 1. a uniform national health declaration form; 2. consistent use of admission notes; 3. systems for documenting all important medical information, that is accessible to everyone; 4. a multidisciplinary forum for the evaluation of high-risk patients; 5. weekly and daily scheduling of surgical programs; 6. application of the WHO check list; 7. open dialog during surgery; 8. reporting based on SBAR; 9. oral and written reports from the surgeon to the postoperative unit; and 10. combined mortality and morbidity conferences.

Conclusion

One repeatedly occurring hazard endangering patient safety was related to communication between surgical and anesthesia unit personnel. Strategies to reduce this hazard are suggested, but further research is required to test their effectiveness.

Optional real-time display of intraoperative neurophysiological monitoring in the microscopic field of view: avoiding communication failures in the operating room

BACKGROUND

The use of intraoperative neurophysiological monitoring (IONM) in neurosurgery has improved patient safety and outcomes. However, a pitfall in the use of IONM remains unsolved. Currently, there is no feasible way for surgeons to interpret IONM waves themselves during operations. Instead, they have to rely on verbal feedback from a neurophysiologist. This method is prone to communication failures, which can lead to delayed or false interpretation of the data. Direct visualization of IONM waves is a way to alleviate this problem and make IONM more effective.

METHODS

Microscope-integrated IONM (MI-IONM) was used in 163 cranial and spinal cases. We evaluated the feasibility, system stability and how well the system integrated into the surgical workflow. We used an IONM system that was connected to a surgical microscope. All IONM modalities used at our institution could be visualized as required, superimposed on the surgical field in the eyepiece of the microscope without obstructing the surgeon's field of vision.

RESULTS

Use of MI-IONM was safe and reliable. It furthermore provided valuable intraoperative information. The system merely required a short learning curve. Only minor system problems without impact on surgical workflow occurred. MI-IONM proved to be especially useful in surgical cases where careful monitoring of nerve function is required, e.g., cerebellopontine angle surgery. Here, direct assessment of surgical action and IONM wave change was provided to the surgeon, if necessary (on-off control).

CONCLUSION

MI-IONM is a useful extension of conventional IONM that provides optional real-time functional information to the surgeon on demand.

General principles of medical interconsultation for hospitalised patients

Medical interconsultation for hospitalised patients is a regular activity among internal medicine specialists. However, despite its growing impact and importance, a model that defines its characteristics, objectives and information has not been established. This study, conducted by the Shared Care and Interconsultations Group of the Spanish Society of Internal Medicine, proposes a number of general recommendations concerning the method for requesting and responding to hospital medical interconsultations, as well as a format for these interconsultations.

Towards the next frontier for simulation-based training: full-hospital simulation across the entire patient pathway

OBJECTIVE

To evaluate the efficacy of an entire hospital simulation in imparting skills to expert healthcare providers, encompassing both retention and transfer to clinical practice.

BACKGROUND

Studies demonstrating the effectiveness of simulation do not concentrate upon expert multidisciplinary teams. Moreover, their focus is confined to a single clinical setting, thereby not considering the complex interactions across multiple hospital departments.

METHODS

A total of 288 participants (Attending surgeons, anesthesiologists, physicians, and nurses) completed this largest simulation study to date, set in the UK Defence Medical Services' Hospital Simulator and the conflict zone in Afghanistan. The simulator termed "Hospital Exercise" (HOSPEX) is a fully immersive live-in simulation experience that covers the entire environment of a military hospital with all departments. Participants undertook a 3-day training program within HOSPEX before deployment to war zones. Primary outcome measures were assessed with IMPAcT (the Imperial Military Personnel Assessment Tool). IMPAcT measures crisis management, trauma care, hospital environment, operational readiness, and transfer of skills to civilian practice. Reliability, skills learning, and retention in the conflict zone were assessed statistically.

RESULTS

Reliability in skills assessment was excellent (Cronbach α: nontechnical skills = 0.87-0.94; environment/patient skills = 0.83-0.95). Pre/post-HOSPEX comparisons revealed significant improvements in decision making (M = 4.98, SD = 1.20 to M = 5.39, SD = 0.91; P = 0.03), situational awareness (M = 5.44, SD = 1.04 to M = 5.74, SD = 0.92; P = 0.01), trauma care (M = 5.53, SD = 1.23 to M = 5.85, SD = 1.09; P = 0.05), and knowledge of hospital environment (M = 5.19, SD = 1.17 to M = 5.42, SD = 0.97; P = 0.04). No skills decayed over time when assessed several months later in the real conflict zone. All skills transferred to civilian clinical practice.

CONCLUSIONS

This is the first study to describe the value of a full-hospital simulation across the entire patient pathway. Such macrosimulations may be the way forward for integrating the complex training needs of expert clinicians and testing organizational "fitness for purpose" of entire hospitals.

Systemwide change of sedation wean protocol following pediatric laryngotracheal reconstruction

IMPORTANCE

Pediatric laryngotracheal reconstruction (LTR) remains the standard surgical technique for expanding a stenotic airway and necessitates a multidisciplinary team. Sedation wean following LTR is a critical component of perioperative care. We identified variation and communications deficiencies with our sedation wean practice and describe our experience implementing a standardized sedation wean protocol.

OBJECTIVE

To standardize and decrease length of sedation wean in pediatric patients undergoing LTR.

DESIGN, SETTING, AND PARTICIPANTS

Using Institute for Healthcare Improvement (IHI) methodology, we implemented systemwide change at a tertiary care center with the goal of improving care based on best practice guidelines. We created a standardized electronic sedation wean communication document and retrospectively examined our experience in 29 consecutive patients who underwent LTR before (n = 16, prewean group) and after (n = 13, postwean group) wean document implementation.

INTERVENTIONS

Implementation of a standardized sedation protocol.

MAIN OUTCOMES AND MEASURES

Presence of sedation wean document in the electronic medical record, length of sedation wean, and need for continued wean after discharge.

RESULTS

The sedation wean document was used in 92.3% patients in the postwean group. With the new process, the mean (SD) length of sedation wean was reduced from 16.19 (11.56) days in the prewean group to 8.92 (3.37) days in the postwean group (P = .045). Fewer patients in the postwean group required continued wean after discharge (81.3% vs 33.3%; P = .02).

CONCLUSIONS AND RELEVANCE

We implemented a systemwide process change with the goal of improving care based on best practice guidelines, which significantly decreased the time required for sedation wean following LTR. Our methodological approach may have implications for other heterogeneous patient populations requiring a sedation wean.