Just like in the operating room (OR), patient handoffs in an ambulatory surgery center (ASC) are commonly derailed by communication distractions, which put patients’ safety at risk, according to investigators at the Cooper Medical School of Rowan University (CMSRU) in Camden, N.J.
“We had previously looked into barriers to handoff communication in our hospital’s operating room,” said Erin W. Pukenas, MD, study author and assistant professor of anesthesiology at CMSRU. “The natural progression was to look at handoff patterns in other settings, too. And in our institution—as in others—there’s a real focus on efficiency in the ambulatory surgery center. So we thought it important to characterize the quality of handoffs in that setting, too.”
With that in mind, the researchers collected audio recordings of 80 ASC handoffs over a six-week period. Trained observers rated the quality of each handoff, documented distractions and noted secondary task activity during the handoff. The handoffs were timed for completion of patient care and information exchange. Satisfaction surveys were also completed and sent to the information senders and receivers in every handoff.
The researchers found that 40% (28) of handoffs were associated with communication distractions. Perhaps not surprisingly, information exchange times were significantly longer in the presence of distractions: 2.3 versus 1.5 minutes (P<0.001). Handoffs with communication distractors were rated lower in overall quality (P<0.05) by trained observers and associated with a greater number of errors, which were defined as a transfer of incorrect information. Handoff satisfaction scores rated by the sender were significantly lower in handoffs with distractions (P<0.05).
Monitors and equipment were the most common distractors, comprising 19% of instances. Direct patient care, transient staff and patient communication were the next most common distractors, at 16% each. Other barriers to handoff communication included staff conversation (12%), auditory distraction (9%), role clarity (6%), charting (3%) and family communication (3%).
“We took a close look at the auditory distractions and found that alarms played a huge role,” Dr. Pukenas said “Even in some of our audio recordings there was so much alarm noise that we had to throw a few out of the study because we couldn’t hear the handoff.”
The study also revealed that human behavior played a part in impeding handoffs, too.
“Sometimes the anesthesia staff would arrive in the PACU postanesthesia care unit and would have to wait several minutes for a nurse to be freed up, or it would be lunch time and nobody was sure who was covering the patient,” she said. “In essence, if someone’s standing there waiting for even just a few minutes, it’s an opportunity to improve efficiency, especially in the context of a surgery center where the goal for turnover is seven to 10 minutes. Two minutes can make a big difference.”
The researchers concluded that nearly 50% of the distractions recorded in this study might have been preventable.
“I would like people to know that distracted communication is not only a predictor for poor handoffs, but also has a significant impact on getting your patients back in the OR for the next case,” Dr. Pukenas said.
Dr. Pukenas said improving handoff quality begins with identifying and minimizing distractions within postoperative care environments. So the researchers took the study’s results to the hospital administration at Dr. Pukenas’ institution “to put processes in place so we could prevent these distractions from happening.”
“The benefit for the hospital is that we can get the anesthesia provider back to the OR more quickly, so the next case can get started,” she said. “So now we have structure. We have someone assigned to each bed in the PACU, despite fluctuating levels of staff and acuity, and they have a process of handing off to each other during break time. We’re trying to minimize noise, too.”
Taral Patel, MD, study co-investigator, said handoff problems exist in institutions of all types.
“I think this has been an issue with a lot of hospitals,” Dr. Patel said. “And it’s especially acute for residents, because we’re the ones doing most of the handoffs.”
The researchers said more research on handoff communication in all settings is needed to ultimately improve safety and efficiency for patients.
The findings were originally presented at the American Society of Anesthesiologists’ annual meeting (abstract A3165) last fall.