New PACU Handoff Checklist Improves Information Exchange

Twenty-six seconds: That’s the average amount of extra time it might take an anesthesia resident to exchange up to 20% more information when using a new PACU handoff checklist developed by researchers at MedStar Georgetown University Hospital, a new study suggests.

The PACU is a “high-risk environment” where health care providers are multitasking rapidly to prioritize care, according to Christopher Potestio, MD, lead study author and CA-3 resident at the hospital, in Washington, D.C. Communication errors between health care providers during PACU handoffs can occur and jeopardize patient safety, according to the researchers. So they developed a new 20-item checklist that they hope can be used at any institution to boost the amount of information exchanged between anesthesia residents and PACU nurses (Figure).

“[It’s] important for us to do a standardized, organized, expedited transition of care,” Dr. Potestio said. “Our goal was to create a checklist that’s going to be reproducible and accepted by our colleagues.”

The study included 14 anesthesia residents (CA-1 to CA-3). The researchers observed the residents over a three-month period to compare PACU handoffs before and after the checklist was implemented as part of standard practice. The main measures were differences in amount of items discussed on the checklist and the time needed to exchange that information after checklist implementation.

“We found that our anesthesia providers actually exchanged 20% more information,” Dr. Potestio said. “Of the 20 items we found that were significant, at baseline our providers gave 50% to 60% of that information. It went up to about 80% with implementing our checklist.”

The checklist has three parts. The patient section includes medical history, anesthesia complications and surgery performed. The procedure section includes data on patient position, intubation conditions, lines or catheters used and fluid management. The medication portion contains a patient’s analgesia plan, antiemetics administered and medications used during PACU stay.

The checklist initially contained 42 items selected from the medical literature and observations of handoffs. This was eventually pared down to 20 items to keep the checklist as succinct as possible. Dr. Potestio said the final item (“Do you have any questions or concerns?”) on the checklist is crucial to any handoff of care.

“We want this to be a two-way handoff. We find that the best, most successful handoffs are two-way,” he said.

The researchers found that standing medications, preoperative cognitive function, complications, patient positioning, limb restriction and preoperative activity level were “handed off with significantly higher frequency when residents used the checklist.” They noted that the checklist increased the time residents used on the handoff: 126.4±52.25 seconds compared with 100.86±36 seconds at baseline (P=0.011).

Dr. Potestio said the time difference is minor compared with the potential improvement in patient safety and care in the PACU. “It’s 20% more information in 20 more seconds. I think it’s a pretty good tradeoff for us.”

He said the checklist can be tailored slightly to fit the needs of any institution. The next step is to include input from surgeons for a multidisciplinary handoff.

The findings were presented at the 2015 annual New York State Society of Anesthesiologists PostGraduate Assembly in Anesthesiology (poster P-9007).

 

PACU Handoff Checklist

Patient Identification (Nameband check)

Time In

Allergies

Surgical Procedure and Reason for surgery

Type of anesthesia (GA, TIVA, regional)

Surgical or anesthetic complications

Patient PMH and ASA scoring

Preoperative cognitive function

Preoperative activity level (METs)

Limb Restriction

Preop vitals

Positioning of patient (if other than supine)

Intubation conditions (grade of view, airway, quality

of bag mask ventilation, bite block?)

Procedure        Lines/catheters (IV’s, a-lines, CVLs,

foley, chest tubes, surgical drains, VP shunt)

Fluid management

Fluids =

EBL =

UO =

Analgesia plan – during case, postop orders

Antiemetics administered

Medications    Medications due during PACU (antibiotics, etc.)

Other intra-op medications (steroids, antihypertensives)

Do you have any questions or concerns?

ASA, American Society of Anesthesiologists; CVLs, central venous lines; EBL, estimated blood loss; GA, general anesthesia; METs, metabolic equivalent; PMH, past medical history; TIVA, total intravenous anesthesia; UO, urine output; VP, ventriculoperitoneal