A new handoff protocol boosted communication while slashing errors among nurses, anesthesiologists and surgeons during the transfer of patients from the operating room (OR) to the PACU.

There was a dramatic decrease in lapses in the surgery and anesthesia reports after the rollout of the new handoff process at The Johns Hopkins Hospital, in Baltimore, a study concluded (J Clin Anesth 2015;27:111-119).

The number of defects per handoff dropped nearly threefold, to 3.68 after the new handoff procedure was implemented from 9.92 before its use, according to the study.

The average number of missing items on the surgery reports dropped to 1.2 after the new protocol, from 7.57 before, while the anesthesia reports saw a decline to 0.94 from 2.02 before the new protocol.

Also, there was a significant decrease in technical defects, which dropped to 0.10 after the new handoff protocol from 0.34 before.

“There is valuable information from all three arms—the nursing arm, the surgical arm and the anesthesia arm—and it is really important for it to be transmitted,” said Vinay Pallekonda, MD, assistant professor of anesthesiology/critical care and internal medicine at Wayne State University School of Medicine, in Detroit, and associate director, Surgical Critical Care, Harper Hospital Detroit Medical Center.

A Team Approach

Researchers at The Johns Hopkins Hospital examined a total of 103 handoffs of patients between May 2009 and March 2010. Fifty-three took place before the new protocol and 50 after the new procedures were put into place.

The study was unblinded, with clinical staff not only aware that the study was taking place but also having received extensive training on the new protocol before it was rolled out.

A trained observer remained in “close but unobtrusive proximity,” taking down data on a standardized observational form.

The research team was led by Michelle A. Petrovic, MD, of the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine, and the Center for Innovation in Quality Patient Care at The Johns Hopkins Hospital provided funding.

Under the new handoff protocol, all team members are required to be physically present at the patient’s bedside to give their reports. The anesthesiologist starts by announcing the patient’s name, stating his or her name, and then asking other team members to do the same.

The surgeon waits until the nurse completes the monitor setup before giving the first report. The surgeon then goes down his or her checklist, shares what is of most concern about the patient’s medical situation and takes questions.

The surgeon’s checklist includes chief complaint; surgery performed; surgical findings, complications and postsurgical diagnosis; drains and tubes; and special instructions and guidance on when to call for help or with questions.

The anesthesiologist and OR nurse follow with their reports, ticking off their respective checklists and then sharing their top concerns about the patient, followed by time for questions.

The anesthesiologist reviews the patient’s medical and surgical history, allergies, height/weight, and baseline vital signs and lab values. Other items include intraoperative procedures, invasive monitoring, venous access, fluid totals, paralytic status, narcotic totals and antibiotics.

The OR nurse reviews the type of surgery performed, isolation type, drains, and skin inspection and packing (rectal, vaginal, nasal). Special equipment, family information, and belongings and valuables are also checked off.

The ICU/PACU nurse then clarifies the remaining issues and formally announces that the “handoff is now complete.”

While developed at Johns Hopkins, the protocol is relatively simple and can be used at a wide range of hospitals, Dr. Pallekonda said.

“The beautiful thing about this particular protocol is that it can be implemented in every center, whether it’s a major academic medical center or a community hospital,” he said. “It’s a simple tool.”

Remaining Problems

Still, even with the new protocol and extensive checklists, anesthesiologists and surgeons still forgot to relay some key data.

Although the new handoff process significantly cut down on the amount of information lost in transit, some items proved to be more problematic than others.

Anesthesiologists most commonly forgot to include baseline physical exam and lab results on their reports, as well as allergies. Surgeons had more difficulty remembering to include anticipatory guidance statements or mention drains and tubes placed during the operation, the study noted.

The new protocol added about two minutes, on average, to the handoff time, increasing it to 11 minutes from nine minutes prior.

Still, the amount of time it took to get patients settled in the PACU after handoff dropped significantly, from 4.4 minutes before the new protocol to 2.9 minutes after, the researchers found.

Filling a Research Gap

The study helps fill a gap in research on the perioperative handoff to the PACU, the authors noted. Most of the current research on the perioperative handoff process has focused on cardiac patients being transferred to the ICU.

However, the handoff process to the PACU can be even more challenging, involving patients with a range of medical and surgical conditions who are undergoing a variety of procedures, not just cardiac cases.

Nurses in the PACU may have two to three patients to look after, compared with one in the ICU, while the length of stay is shorter.

That means it may be even more important “that accurate information and anticipatory guidance be effectively transmitted in the PACU handoff,” the study noted.

Tracking Satisfaction

Another key feature of the study was the focus on how well the new handoff protocol tested at Johns Hopkins was received by nurses, anesthesiologists and surgeons, all of whom were asked to complete a nine-question satisfaction survey.

PACU nurses agreed or strongly agreed with all nine questions on the survey. The nurses were particularly impressed with the anesthesiologists’ reports, the amount of information on potential problems with the patient and issues to follow up on, and the transfer of monitors and other equipment.

Anesthesiologists, who were already relatively happy with the handoff process in general, showed little change either way, the researchers pointed out. Surgeons gave the new protocol high marks in a couple of different areas, but only took part in the latter half of the study, making it difficult to judge before-and-after results.

Future Studies

Plans are in the works for a follow-up study, which will be a collaboration between the lead developer of the original handoff tool from Johns Hopkins, Dr. Petrovic, and Dr. Pallekonda and his team from NorthStar Anesthesia-Detroit Medical Center/Wayne State University.

The focus will be on whether improving communication in the handoff process can truly change the overall culture inside the institution and have an effect on patient outcomes. Such data are lacking in the current literature.

“There are so many checklists in medicine, in the surgical world and the anesthesia world,” Dr. Pallekonda noted. “Are they doing what they are supposed to be doing to change culture?

“It is important to come up with a fix to the problem, but implementation becomes just as important,” he said. “The work that Dr. Petrovic and I are currently working on will help answer this question.”