Handover of responsibility for the anaesthetised patient - opinion and practice

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.

A Multidisciplinary QI Initiative to Improve OR-ICU Handovers

: Background: Handover from the operating room (OR) staff to the ICU staff is a critical transition time for patients, in which the potential for error and miscommunication is high. Therefore, minimization of extraneous interruptions during the exchange of crucial information between the anesthesia and surgical teams and the nursing, respiratory therapy, and medical teams is imperative.

OBJECTIVES

The aim of this quality improvement (QI) initiative was, first, to examine the impact of a standardized handover process between the OR and the ICU on process and information-sharing errors, and second, to examine provider satisfaction with the handover process.

METHODS

We conducted prospective observations of the handover process before and after implementation of the QI initiative. In the pre-process improvement period, 38 cardiothoracic patients were observed during handover. In the post-process improvement period, 38 patients were observed after implementation of the newly developed, standardized handover process and communication template. Provider satisfaction surveys were distributed at each observation during the pre- and post-process improvement periods.

RESULTS

Compared with the pre-process improvement period, there was a significant decrease in interruptions during report in the post-process improvement period (1.7 ± 1.1 to 0.13 ± 0.34). There were also significantly fewer handover process errors (6.1 ± 2.8 to 1.7 ± 1.5), and fewer information-sharing errors (5.2 ± 2.7 to 2.3 ± 1.5). Average report time increased slightly, from 13.2 ± 6.8 minutes to 14.6 ± 3.8 minutes, but the increase was not significant. A total of 211 provider satisfaction surveys were completed in the pre-process improvement period and 95 in the post-process improvement period. Providers in all disciplines completed surveys in both time periods, and there was no significant difference in the percentage of respondents from any discipline. Responses to the following survey items showed significant improvement in the post-process improvement period: surgery report was satisfactory, anesthesia report was satisfactory, could hear all the report, pre-op anesthesia information was helpful, and start and end of handover were clear. Post-process improvement as well, more respondents disagreed that the person handing off the patient was under time pressure and that the person taking on responsibility for the patient was under time pressure.

CONCLUSION

A standardized OR-ICU handover process developed by a multidisciplinary team decreased handover process and information-sharing errors and increased provider satisfaction, with no significant increase in handover time.

The effect of a checklist on the quality of patient handover from the operating room to the intensive care unit: A randomized controlled trial

PURPOSE

Handover of patient care is a potential safety risk for the patient due to loss of information which may result in adverse outcome. We hypothesized that a checklist for handover from the operating room (OR) to the intensive care unit (ICU) will lead to an increase of quality regarding information transfer compared with a nonstandardized handover procedure.

MATERIALS AND METHODS

The study was conducted as a prospective, randomized trial in a university hospital. The quality of handovers with checklist was compared with handovers without checklist. Handovers were recorded by digital voice recorder and analyzed using an individual rating sheet for each patient. This enabled to discriminate between items that "must be handed over" (red items) and items that "should be handed over" (yellow items).

RESULTS

A total of 121 patient handovers from OR to ICU were included. Significantly more red items were handed over in the study group compared with the control group (study group: median 87.1%, 25-27 percentile 77.1%-90.0%; control group: median 75.0%, 25-75 percentile 66.7%-88.6%; P < .01).

CONCLUSIONS

This study gives first evidence that the use of a standardized checklist for patient handover from OR to ICU increases the quantity and quality of transmitted medical information.

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.

A preliminary study of the impact of a handover cognitive aid on clinical reasoning and information transfer

OBJECTIVES

To assess the impact of a written cognitive aid on expressed clinical reasoning and quantity and the accuracy of information transfer during resident doctor handover.

METHODS

This study was a randomised controlled trial in an academic paediatric intensive care unit (PICU) of 20 handover events (10 events per group) from residents in their first PICU rotation using a written handover cognitive aid (intervention) or standard practice (control). Before rounds, an investigator generated a reference standard of the handover event by completing a handover aid. Resident handovers were then audio-recorded and transcribed by a blinded research assistant. The content of this transcript was inserted into a blank handover aid. A blinded content expert scored the quantity and accuracy of the information in this aid according to predetermined criteria and these information scores (ISs) were compared with the reference standard. The same expert also blindly scored the transcripts in five domains of clinical reasoning and effectiveness: (i) effective summary of events; (ii) expressed understanding of the care plan; (iii) presentation clarity; (iv) organisation; (v) overall handover effectiveness. Differences between intervention and control groups were assessed using the Mann-Whitney test and multivariate linear regression.

RESULTS

The intervention group had total ISs that more closely approximated the reference standard (81% versus 61%; p < 0.01). The intervention group had significantly higher clinical reasoning scores when compared by total score (21.1 versus 15.9 points; p = 0.01) and in each of the five domains. No difference was observed in the duration of handover between groups (7.4 versus 7.7 minutes; p = 0.97).

CONCLUSIONS

Using a novel scoring system, our simple handover cognitive aid was shown to improve information transfer and resident expression of clinical reasoning without prolonging the handover duration.

The effect of a checklist on the quality of post-anaesthesia patient handover: a randomized controlled trial

OBJECTIVE

Patient handover is an important element of continuity, quality and safety in patient care. Handover without standardized protocols is prone to information loss and might be a possible danger to patient safety. Checklists are established methods that help to structure complex processes in other high-risk fields such as aviation. In the past few years, their implementation has attracted research interest in medicine. We hypothesize that a checklist for handover between anaesthesiologist and post-anaesthesia care unit nurse will increase the amount of information transfer during patient handover after anaesthesia.

DESIGN AND SETTING

A total of 120 post-anaesthesia patient handovers were recorded on video and analyzed. Forty handovers before the implementation of the checklist and 80 after the implementation of the checklist, randomized into two groups: with and without the use of the checklist.

MAIN OUTCOME MEASURES

An overall number of items handed over, handover of specific items and duration of the handover were analyzed.

RESULTS

With the use of the written checklist, the overall items handed over increased significantly from a median of 32.4-48.7%. The duration of handover increased from a median of 86-121 s. Instructions about items that should be included in handovers, but without the use of a written checklist, was not associated with an increase in the number of items handed over or duration of the interview.

CONCLUSIONS

This study suggests that the use of a checklist for post-anaesthesia handover might improve the quality of patient handover by increasing the information handed over.

[Patient safety in anesthesiology and intensive care medicine. Measures for improvement]

Technical improvements as well as various strategies for error detection and error prevention have made intensive care medicine and anesthesiology a safe medical specialty. Due to the introduction of "Patient safety in the ICU: the Vienna declaration" of the European Society of Intensive Care Medicine (ESICM) from October 2009 and the "Helsinki declaration on patient safety" of the European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology (EBA) from June 2010, there are now specific recommendations for all hospitals in Europe concerning the safety measures that are considered to be of essential importance. Many of today's well-known safety strategies have been originally developed in non-medical environments, as for instance civil aviation. Such high reliability organizations may serve as examples in the medical domain. Critical incident reporting systems, crisis resource management and checklists, e.g. the World Health Organization (WHO) checklist, are safety approaches of this kind. In addition to these, standardized drug labelling, hand disinfection, techniques for patient handover and simulation-based training have been exemplarily selected for this article as measures that can increase patient safety.

An Analysis of Computer-Assisted Pre-Screening Prior to Elective Surgery

In order to assess the potential utility of guided patient self-assessment as an early preoperative triage tool, a computer-assisted questionnaire delivered by a non-clinician via telephone was 1) compared to face-to-face interview and examination by anaesthetists in outpatient clinics and 2) evaluated as a mechanism to stream patients to day of surgery assessment.

In total, 514 patients scheduled for elective surgery in two tertiary public hospitals were assessed initially by telephone and then in an outpatient clinic. Both forms of assessment were marked by panels of specialist anaesthetists, who also provided an opinion on which patients would have been suitable to bypass preoperative anaesthetic outpatient assessment based upon information provided by the telephone interview.

Overall, the quality of assessment provided by non-clinician telephone interview was comparable to face-to-face interview by anaesthetists, although more complex issues required face-to-face assessment. Panel review considered that 398 patients (60%) would not have required evaluation by an anaesthetist until the day of surgery, thus avoiding the need to separately attend a preoperative outpatient clinic. The sensitivity of telephone interview provided information to correctly classify patients as suitable for day of surgery evaluation was 98% (95% confidence interval 96 to 99%) with a specificity of 97% (95% confidence interval 92 to 98%).

This study demonstrates that remote computer-assisted assessment can produce quality patient health information and enable early patient work-up and triage with the potential to reduce costs through more efficient use of resources.

[Medical handovers in ICU: a snapshot of practice in the South West of France]

INTRODUCTION

Medical handover is critical for quality of care in ICU. Time assigned to medical handovers can vary across different units, with significant impact on the organization of medical work. We aimed to study the time spent for medical handover in ICU and its variation across academic, general and private hospitals in the area of the South West of France, the Midi-Pyrénées region.

METHODS

Between August and October 2010, we questioned by phone, 86 physicians issued from 19 different ICUs. This prospective observational study mainly focused on four items: unit's characteristics, health diaries organization, medical handovers procedures, and self-assessment of satisfaction for medical handover (numeric scale from 0 to 10).

RESULTS

Eleven general hospital centers, three private hospitals, five university hospitals were concerned by the survey. The mean time spent for medical handover was 59±35 min on monday morning, significantly longer than other days, evening, and to weekend handovers (P<0.001 for all comparisons). When reporting it to the number of ICU bed, the time spent for handover per patient was significantly shorter in private hospital compared to general and academic hospital (P<0.05 for all comparison).

CONCLUSION

Time spent for medical handover is important, with an approximate total time of 1h 30 min on monday, and 1h the other days. Physician in private hospitals spend less time for medical handovers. This fact should be considered for medical timework organization, especially in academic hospital and in hospital with large ICU.

Interaction between anaesthetists, their patients, and the anaesthesia team

Communication is a key skill for anaesthetic practice. The 'non-informational' aspects of communication, such as non-verbal elements and the degree to which the style of communication reflects the implied relationship between the sender and the recipient, are relevant to interactions both between anaesthetists and patients and to interactions with other members of staff in the team. Communication and interaction between members of the anaesthesia team in isolation has received less attention than communication in the operating theatre during surgery. Most aspects of such communication are informally learned and developed with experience. Studies of communication at induction of anaesthesia have used qualitative methods to identify a range of styles of talk. This is nominally directed at the patient but also serves to unite and co-ordinate the team to ensure the patient's smooth, safe progress into anaesthesia. In particular, the use of positive words and phrases seems to benefit patient comfort and safety. On emergence, a more limited range of communication styles is found. Handover of the recently anaesthetized patient to recovery room staff is often brief and distracted by concurrent patient-related activities. Both information about the patient, and responsibility for the patient's continuing care, have to be transferred. The handover event also serves as an opportunity to review the care the patient has received and plan for further progress. Anaesthetists and nurses use unspoken and implicit negotiation strategies to achieve the aims of handover without compromising future collaborative work. This is in contrast to the more formalized handover approaches in other safety-critical settings.

Incidents in anaesthesia: past occurrence and future avoidance

This article is a revised version of an analysis of reported incidents related to anaesthesia, originally published in the journal Anaesthesia (Catchpole et al 2008a) and undertaken on behalf of the National Patient Safety Agency. The purpose was to examine the range, types, frequencies and causes of reported patient safety incidents associated with anaesthesia. First we examined anaesthetic incidents as a sub-set of the total number of reported incidents; then we examined pre-surgery assessment, epidural anaesthesia, and anaesthetic awareness incidents, as they were identified as being frequent and of potential concern. To our knowledge it was the first paper to analyse and present results of the NPSA's database in a clinical academic journal. Here, we take the opportunity to re-present and review the findings in light of subsequent progress in understanding and improving patient safety and quality of care.

Burns surgery handover study: trainees' assessment of current practice in the British Isles

INTRODUCTION

Effective handover of clinical information between working shifts is essential for patient safety. The aim of this study was to identify current practice and trainees' assessment of handover in the burns units of the British Isles.

METHODS

A telephone questionnaire was conducted to trainee burns surgeons (at junior and senior grades) currently working at all 30 burns surgery units in the British Isles. Information regarding timing, location, duration, participation and quality of handover was collated anonymously. Trainees commented on satisfaction with current practice and its perceived safety.

RESULTS

A 100% response from all 30 units was obtained. 23/30 units (76.7%) had junior to junior trainee handovers. 17/30 (56.7%) had senior to senior trainee handovers. 19/30 units (63.3%) reported that handover took place with more than one grade of doctor present (range 1-4 grades). 3/30 (10%) reported that handover was bleep-free. 3/30 (10%) had received formal training on good burns handover. 5/30 (16.7%) were working in a unit that operated a "burns surgeon of the week" pattern of emergency cover. Mean satisfaction level was 3.8 out of 5. Those working in "surgeon of the week" teams had significantly higher scores, 4.4 versus 3.68 (p=0.037). Other healthcare professionals were present at only 4/30 (13.3%) handovers. Overall 26/30 (86.7%) of trainees judged their current handover practice "safe" (100% in "surgeon of week" group and 84% in the remaining group, p=0.289).

CONCLUSIONS

Effective handover remains a keystone in safe and effective communication between doctors. The study highlights areas for improvement in handover practice, including greater involvement of an integrated multidisciplinary team. Those working under the "surgeon of the week" pattern are more satisfied.

Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room

BACKGROUND

We aimed to describe how anaesthetists hand over information and professional responsibility to nurses in the operating theatre recovery room.

METHODS

We carried out non-participant practice observation and in-depth interviews with practitioners working in the recovery room of an English hospital and used qualitative methods to analyse the resulting transcripts.

RESULTS

We observed 45 handovers taking place between 17 anaesthetists and 15 nurses in the recovery room of the operating theatre suite. These took place in an environment that is event-driven, time-pressured, and prone to concurrent distractions. Anaesthetists and nurses often had differing expectations of the content and timing of information transfer. The point at which transfer of responsibility for the patient occurred during the handover process was variable and depended not only on the condition of the patient but also on the professional relationship between the nurse and doctor concerned. Handover also provided an 'audit point' in care where the patient's intraoperative progress was reviewed and plans were made for further management. Here, as in the transfer of responsibility, we found evidence that nurses play a greater role in defining the limits of anaesthetists' practice than might be expected.

CONCLUSIONS

Patient handovers in the recovery room are largely informal, but nevertheless show many inherent tensions, both professional and organizational. Although formalized handover procedures are often advocated for the promotion of safety, we suggest that they are likely to work best when the informal elements, and the cultural factors underlying them, are acknowledged.

Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System

The incident reporting database at the National Patient Safety Agency was interrogated on the nature, frequency and severity of incidents related to anaesthesia. Of 12,606 reports over a 2-year period, 2842 (22.5%) resulted in little harm or a moderate degree of harm, and 269 (2.1%) resulted in severe harm or death, with procedure or treatment problems generating the highest risk. One thousand and thirty-five incidents (8%) related to pre-operative assessment, with harm occurring in 275 (26.6%), and 552 (4.4%) related to epidural anaesthesia, with harm reported in 198 (35.9%). Fifty-eight occurrences of anaesthetic awareness were also examined. This preliminary analysis is not authoritative enough to warrant widespread changes of practice, but justifies future collaborative approaches to reduce the potential for harm and improve the submission, collection and analysis of incident reports. Practitioners, departments and professional bodies should consider how the information can be used to promote patient safety and their own defensibility.

Patient handover: Time for a change?

BACKGROUND

Receiving a patient handover from an ambulance crew occurs many times during the day across the country. Handover has major implications for subsequent patient care but there has been little investigation of the handover process between ambulance and emergency department staff.

METHODS

Four emergency departments and one ambulance service were included within one geographical area in the UK. The research was based on a quantitative approach using a descriptive, non-experimental cross-sectional survey. A questionnaire was distributed to a convenience sample of ambulance paramedics and emergency department nurses and doctors. The questionnaire was constructed using mainly closed questions with some qualitative date collected through open questions. Data was analysed using SPSS version 11.5.

RESULTS

Of the 101 questionnaires distributed, a total of 80 (68%) participants contributed towards the study. The results indicated emergency department staff need to appreciate that a lack of active listening skills can lead to frustration for ambulance staff. Ambulance staff must expect to repeat their handover, especially for patients in the resuscitation room. Handovers for critically ill patients should be delivered in two phases, with essential information given immediately and again thereafter to give further information when initial treatment has been undertaken.

RECOMMENDATIONS

Suggestions are made for improving handovers by developing national guidelines and by incorporating handover in emergency department education.

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality

BACKGROUND

We aimed to improve the quality and safety of handover of patients from surgery to intensive care using the analogy of a Formula 1 pit stop and expertise from aviation.

METHODS

A prospective intervention study measured the change in performance before and after the implementation of a new handover protocol that was developed through detailed discussions with a Formula 1 racing team and aviation training captains. Fifty (23 before and 27 after) postsurgery patient handovers were observed. Technical errors and information omissions were measured using checklists, and teamwork was scored using a Likert scale. Duration of the handover was also measured.

RESULTS

The mean number of technical errors was reduced from 5.42 (95% CI +/-1.24) to 3.15 (95% CI +/-0.71), the mean number of information handover omissions was reduced from 2.09 (95% CI +/-1.14) to 1.07 (95% CI +/-0.55), and duration of handover was reduced from 10.8 min (95% CI +/-1.6) to 9.4 min (95% CI +/-1.29). Nine out of twenty-three (39%) precondition patients had more than one error in both technical and information handover prior to the new protocol, compared with three out of twnety-seven (11.5%) with the new handover. Regression analysis showed that the number of technical errors were significantly reduced with the new handover (t = -3.63, P < 0.001), and an interaction suggested that teamwork (t = 3.04, P = 0.004) had a different effect with the new handover protocol.

CONCLUSIONS

The introduction of the new handover protocol lead to improvements in all aspects of the handover. Expertise from other industries can be extrapolated to improve patient safety, and in particular, areas of medicine involving the handover of patients or information.

Emergency physician intershift handovers: an analysis of our transitional care

The emergency department intershift transfer of patient care is a universal event. Despite the frequency of its occurrence and complexity of issues surrounding the exchange, emergency department patient handover is insufficiently explored in our literature. This article reviews the effectiveness and efficiencies of the handover practice. The authors provide personal opinion regarding favorable parameters for the prehandover, intershift meeting, and posthandover activities.

Analysis of surgical errors in closed malpractice claims at 4 liability insurers

BACKGROUND

The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical error and identify opportunities for prevention.

METHODS

We retrospectively reviewed 444 closed malpractice claims, from 4 malpractice liability insurers, in which patients alleged a surgical error. Surgeon-reviewers examined the litigation file and medical record to determine whether an injury attributable to surgical error had occurred and, if so, what factors contributed. Detailed descriptive information concerning etiology and outcome was recorded.

RESULTS

Reviewers identified surgical errors that resulted in patient injury in 258 of the 444 (58%) claims. Sixty-five percent of these cases involved significant or major injury; 23% involved death. In most cases (75%), errors occurred in intraoperative care; 25% in preoperative care; 35% in postoperative care. Thirty-one percent of the cases had errors occurring during multiple phases of care; in 62%, more than 1 clinician played a contributory role. Systems factors contributed to error in 82% of cases. The leading system factors were inexperience/lack of technical competence (41%) and communication breakdown (24%). Cases with technical errors (54%) were more likely than those without technical errors to involve errors in multiple phases of care (36% vs 24%, P = .03), multiple personnel (83% vs 63%, P < .001), lack of technical competence/knowledge (51% vs 29%, P < .001) and patient-related factors (54% vs 33%, P = .001).

CONCLUSIONS

Systems factors play a critical role in most surgical errors, including technical errors. Closed claims analysis can help to identify priority areas for intervening to reduce errors.

A national survey of obstetric anaesthetic handovers

The handover of patient information between shifts enables continuity of care and increases patient safety. We surveyed UK practice during handovers in obstetric anaesthesia. A questionnaire was sent to 239 lead consultant obstetric anaesthetists to record routine practice in their unit and individual opinion about handover procedures. Responses were received from 168 anaesthetists, a 70% response rate. Handover policies were available in 10% of units. Most (76%) responding units had an allocated time for handover. In most units (76%), the duration of handover was reported as being < 15 min but the actual duration and depth of any discussion involved were not specified. Handovers were rarely documented in writing (7%). Consultant anaesthetists were most likely to be present at the morning handover and few handovers were multidisciplinary. Four percent of units reported critical incidents following inadequate handovers in the past 12 months. We identify features in handover procedures that could be improved.