Although a primary source of medical errors, handoffs between the ICU and the operating room (OR) can be improved through a structured process that does not negatively affect practitioner satisfaction. The structured handoff process both increased the quantity of information transferred and improved the efficiency of the process itself.
“Although a number of efforts have focused on implementing handoff protocols during postoperative handoffs, there was nothing in the literature when we started this project about trying to improve the care of critically ill patients prior to coming to the OR. Since then, there’s been one study published, which showed improvement in provider satisfaction and some process outcomes (Int J Health Care Qual Assur 2017;30[4]:304-311).”
Missing: Continuity
The current study began with baseline observations of 44 handoffs between ICU nurses and anesthesiologists at two of the institution’s surgical ICUs, using a detailed observation form. From there, the researchers initiated a multistage quality improvement project, which included:
- the introduction of a cognitive aid based on the I-PASS mnemonic (for Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver; Figure);
- education for anesthesiologists and ICU physicians and nurses; and
- the implementation of a policy requiring anesthetists to receive an in-person handoff from surgical ICU clinicians prior to transporting patients to the OR.
ICU  OR HANDOFF GUIDE
Huddle should include anesthetist, ICU RN, ICU clinician, and RT (if applicable)
|
Illness & Patient Summary
|
Access & Airway
Bleeding, Blood Products & Fluid BalanceMedications
Relevant ICU/OR Course |
Action List
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| Figure. Handoff guide based on the I-PASS mnemonic.
AED, automatic external defibrillator; A-line, arterial line; CVL, central venous line; ETT, endotracheal tube; HCP, healthcare provider; KCI, potassium chloride; PICC,peripherally inserted central catheter; PIV, peripheral IV
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“The old workflow—which is probably similar to that of most institutions—saw the patient prepped in the ICU by the nurse,” Dr. Agarwala said. “Separately, the OR anesthetist looked at the OR medical record and would go to the ICU where they may or may not have a conversation with anyone. The plan of care was often never communicated. There was often no continuity from what the ICU team was planning and what was happening in the OR.
“The new workflow started with a multidisciplinary huddle with the anesthetist, the ICU bedside nurse and the ICU clinical team,” he continued. “Then they needed to have a … ‘warm handoff,’ an actual communication with another person prior to bringing the patient to the OR, with time for questions.”
A total of 49 postimplementation handoffs were observed. Later, a second participant administered a provider satisfaction survey to the receiving anesthesiologist in the OR.
As Dr. Agarwala reported at the 2017 annual meeting of the American Society of Anesthesiologists (abstract A3097), one year after implementation of the new handoff process, ICU-to-OR handoffs were significantly more likely to include verbal confirmation of a number of important domains (Table). The handoffs were also rated as more ordered and inclusive by observers (35.9% before vs. 82.9% after; P=0.001).
| Table. Improvements in ICU-to-OR Handoff Information Sharing, Before and After Implementation of New Process | ||
| Information Domain | Percentage Accomplished, Before Versus After | P Value |
|---|---|---|
| Patient name | 40.9% vs. 93.8% | <0.0001 |
| Patient weight | 14.0% vs. 53.5% | 0.009 |
| Allergies | 50.0% vs. 83.3% | 0.036 |
| Illness severity | 36.4% vs. 89.6% | <0.0001 |
| Patient summary | 61.4% vs. 95.8% | 0.002 |
| Baseline physical exam | 25.6% vs. 85.4% | <0.0001 |
| Recent pertinent lab values | 53.7% vs. 87.2% | 0.032 |
| Action list | 56.1% vs. 97.7% | 0.0001 |
| Discussion of a plan | 67.6% vs. 100.0% | 0.001 |
| OR, operating room | ||
Of note, the average length of handoffs decreased by five minutes (14.8 vs. 9.8; P=0.007), and anesthesiologist satisfaction with handoffs was unchanged.
An important part of the project’s success was the development of a cognitive aid. “The first tool didn’t last very long because it was quite detailed,” Dr. Agarwala said. “After some feedback, we revised the tool to the form we use today. It’s quite a bit simpler, and really more of a prompt for discussion rather than a place where everything is written down.”
Similar results were reported by a group of Johns Hopkins Medicine researchers (abstract A3098), who also modified the I-PASS tool and standardized workflows in an attempt to improve the handoff of ICU patients about to undergo anesthesia.
The investigators collected preintervention data by retrospective interviews with staff anesthesiologists. After consultation with clinicians from anesthesia, ICU, nursing and respiratory therapy, they developed a transfer of care process that mandated physician-to-physician communication as well as use of the modified I-PASS tool to guide discussion.
Twenty-three handoffs were reviewed in the preimplementation phase, and 26 in the postimplementation phase. It was found that physician-to-physician communication improved from 35% to 77%. Furthermore, the number of I-PASS items discussed in the checklist increased for a number of domains, including identifying information, pertinent history, assessment, situational awareness and contingency plan.
Results like these, Dr. Agarwala noted, illustrate that improving patient care and safety is feasible, even in the busiest of institutions. “Our conclusion is that the implementation of a structured handoff process from the ICU to the OR can improve the thoroughness of information transfer, improve overall handoff readiness, decrease handoff length, and not impact clinician satisfaction negatively,” he said.
Dr. Agarwala’s audience had several questions about the process, including the timing of the handoff. “Did the handoff happen before or after the anesthesiologists had set up their room?” one asked.
“This was for nonemergent cases,” Dr. Agarwala replied. “They would set up the room first and then go up to the ICU to have the warm handoff before taking the patient down.”
“Do you think there would be any added value to having that warm handoff happen earlier, before they’re ready to take the patient to the OR, so that they can have the room better prepared?” the audience member asked.
“There are two issues with that,” Dr. Agarwala replied. “One problem is geographic. The ICUs are sometimes 10 floors away from where we operate. So you’d have to do the handoff, come back to the OR to get things set up, and then go back and pick up the patient. That’s probably difficult to make happen operationally. Or you can do it over the phone, but if you do it over the phone, getting everyone together is far more challenging than being present.”
Another person asked about the value of adding the handoff to the electronic medical record (EMR). “The EMR is a helpful tool, but it can’t be everything,” Dr. Agarwala said.
“The danger is you don’t want people to simply say, ‘Just look at the screen; everything is there.’ Because people don’t all look at the screen and they don’t look at all the information. You want there to be a warm communication because you hear what’s most important, whereas it’s just another line on the EMR screen that’s no different than anything else.”