Handoffs in the Postoperative Anesthesia Care Unit: Use of a Checklist for Transfer of Care Holly-May Robins, CRNA, DNAP, MBA Feng Dai, MS, PhD Information loss can occur during all phases of care. The transfer of care (handoff) from the operating room to the postoperative anesthesia care unit (PACU) is an especially susceptible time. Information loss can lead to an increase in medication errors, sentinel events, and poor patient outcomes. High-reliability organizations, such as the aviation industry, use checklists to decrease errors and improve safety. As the healthcare industry becomes more complex, it is in the interest of patient safety to develop, validate, and use similar objective procedures as those used in high-reliability organizations. The purpose of this research was to H ealthcare, especially during the perioperative period, has become complex. This increasing complexity helps to create additional opportunities for errors to be made. The risks associated with administering an anesthetic do not end when the patient emerges from anesthesia; the potential for complications continues during the transfer of care from the operating room to the postoperative anesthesia care unit (PACU). On arrival to the PACU, a transfer of care occurs between the anesthesia provider and the PACU registered nurse (RN). The handoff is usually completed at the patient’s bedside, with the anesthesia provider verbally reporting to the PACU RN. Important details related to the patient’s medical history, intraoperative events, and postoperative plan are detailed in the discussion. The PACU RN then assumes care of the patient. This information, exchanged between providers, is vulnerable to content loss and miscommunication. The Joint Commission estimates that 80% of medical errors are due to communication failure during the handoff process.1 Handoff communication is defined as the “transfer of information with authority and responsibility during transitions in care across the continuum for the purpose of ensuring the continuity and safety of the patient’s care.”2 A handoff includes the exchange of pertinent medical information and occurs throughout all phases of care, including transfers from one institution to another.3 During a handoff, information is at risk of degradation and miscommunication.4 Information loss and misunderstanding are contributing factors linked to an increase in sentinel events, medication errors, and poor patient outcomes.5 Communication errors have also 264 AANA Journal „ August 2015 „ Vol. 83, No. 4 determine if the utilization of a formulated checklist with objective measures during the handoff from the operating room to the PACU decreased information loss, the need for information clarification, and anesthesia providers’ time spent in transfer of care, with improved adequacy of the handoff. Specific metrics were monitored before and after implementation to assess for information loss, information clarification, anesthesia providers’ time, and to rate the adequacy of the report. Keywords: Checklist, handoff, information loss. been associated with a decrease in patient satisfaction and increased length of hospital stay.6 The Joint Commission has recommended improvements to the handoff process as a national goal to improve patient safety.7 To improve the handoff process, institutions have made efforts to decrease the number of handoffs for each patient. Limiting the number of handoffs is a difficult task in the hospital setting, however. Nursing shifts, operating room schedules, and resident work hours require multiple patient handoffs. The Accreditation Council for Graduate Medical Education guidelines on resident physicians’ duty hours have required institutions to limit the work hours of residents.8 The effort to decrease errors associated with fatigue and sleep deprivation have resulted in an increased number of handoffs. This is especially evident in the operating room, where the anesthesia provider who starts the case may not be the same provider who finishes the case and transports the patient to the PACU. Information is particularly vulnerable to degradation during frequent handoffs, as is often seen in these cases of multiple providers. In addition to the problem of multiple providers, communication styles can also alter or affect the information exchanged. Communication styles vary among providers and affect how the information is exchanged. The tone, volume, and speed of the communication can affect the handoff. The provider may not deliver all the pertinent information, or the receiver may misunderstand the message.9 A lack of standardization, coupled with varied communication styles, further compounds the issue. The environment in which the handoff exchange occurs plays an important role in the process. Distractions and ex- www.aana.com/aanajournalonline cessive noise can contribute to difficulty in hearing the information.9 Noise levels in a PACU can exceed the recommended standard of the National Institute for Occupational Safety and Health.10 This may make it difficult to hear the information correctly. The culture of an institution can also contribute to communication difficulties. In an institution where increased productivity is highly valued, allowing the time necessary to complete a handoff may be problematic. Production pressure can create a sense of urgency, causing the handoff process to be hurried so that the providers can immediately leave the PACU to begin the next case. Hierarchical divisions between nurses and physicians may influence the ability to question information among staff.11 According to the American College of Surgeons closed claims database, breakdowns in verbal communication account for 85% of adverse events.12 Clear communication is necessary to decrease information loss and prevent unfavorable outcomes. Another contributing factor to communication error is the lack of standardization in the handoff process. Lack of standardization increases the risk of information loss by depending on the communication abilities of the providers exchanging the information.13 The anesthesia provider must recall all the pertinent information of the patient’s operative course, and relay this information in a concise manner. It is difficult for an anesthesia provider to perform this task reliably each time. Human factors contribute to the inability of an individual to function without error. A systems approach can help provide a mechanism for the provider to relay information accurately in a standardized fashion.14 A systems approach focuses on the entire process, not just the provider. In high-reliability organizations, such as the aviation industry, checklists, repeating the information received, and communication strategies are used to increase safety.15 This, however, is not the standard in most PACUs, which rely predominantly on subjective verbal communication as the means to transfer information and do not routinely use checklists and other communication strategies that could improve accuracy. The purpose of this research was to determine whether utilization of a formulated checklist, with the objective measures we developed for the handoff in the PACU, decreases information loss, improves adequacy of the handoff, decreases the need for information clarification, and decreases time spent in transfer of care. Materials and Methods Our research protocol was first submitted to the institutional review board (IRB) for approval according to the hospital standards. IRB determined that the research project met the criteria of a quality improvement project. Approval was then obtained from the anesthesiology departmental chairperson and was confirmed by the IRB. • Creation of Checklist. A checklist (Figure 1) was www.aana.com/aanajournalonline ASSESS READINESS Are you ready for report? YES TIME OUT NO STOP Both parties ask for a time-out for information exchange. START HANDOFF • IDENTIFYING INFORMATION Patient name Verify name on ID band Procedure Surgeon • MEDICAL HISTORY Past health conditions Past surgeries Allergies • ANESTHESIA Type of anesthesia Airway management/concerns Antibiotics Vascular access: size/location Invasive monitoring • INTRAOPERATIVE COURSE Anesthetic events/treatment/concerns Analgesics Antiemetic Neuromuscular blockade/reversal Surgical events/concerns Intake/output/EBL Blood products Yes/No Labs • POSTOPERATIVE Patient status Airway/O2/Ventilator settings Infusions Postoperative analgesic/sedation plan Postoperative antiemetic plan Disposition CLARIFICATION: Do you have any questions? END HANDOFF 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Figure 1. Handoff Checklist Abbreviations: EBL, estimated blood loss; ID, identification; labs, laboratory tests; O2, oxygen. created by a workgroup that included input from the PACU RNs, a team of Certified Registered Nurse Anesthetists (CRNAs), and members of the patient safety committee. After the checklist was created, it was laminated into a card that the anesthesia provider received before the start of the case. Then, face and content validity of the checklist was performed in a pilot study, in which 29 PACU RNs and 29 CRNAs were asked to evaluate the clarity and representativeness of various key contents. Key content included identifying information, medical history, anesthesia, intraoperative course, and postoperative information. All the participants reported that the information on the checklist was clear, representative, and easy to use. They also reported that the checklist highlighted key elements necessary for postoperative patient care. AANA Journal „ August 2015 „ Vol. 83, No. 4 265 • Research Hypotheses. We hypothesized that the use of a standardized and formulated checklist during handoff would improve communication between the anesthesia provider and the receiver (eg, RN), resulting in reduced information loss during report, higher adequacy of report, lower rate of callbacks for information clarification, and reduced time in the PACU for the anesthesia provider. • Randomization. A computer-generated list of random numbers was used for participant allocation in a 1:1 ratio on the day of surgery to 2 groups. In group 1, the anesthesia provider performed the PACU handoff using the formulated checklist. In group 2, the anesthesia provider performed the PACU handoff without using the checklist. All anesthesia providers were instructed on how to use a checklist but were blinded to the content of the real checklist (see Figure 1) until they were enrolled in the checklist group (group 1). In the morning, each anesthesia provider participating in the study received a sealed envelope that contained a randomized group assignment, and the checklist was given only to those assigned to the checklist group. The checklists were collected immediately after the handoff occurred to prevent circulation into the nonchecklist group. All PACU nurses assigned to the adult inpatient and outpatient areas were eligible to participate as receivers in the study. Depending on group assignment, the anesthesia provider delivered a verbal report either with a checklist or without a checklist after the patient arrived at the PACU. After the handoff was completed, a sealed data collection sheet (Figure 2) was given to the PACU RN. The PACU RNs were prompted at the beginning of each shift, during morning rounds, to complete the data collection sheets. The data collection sheet was filled out immediately after the verbal handoff occurred and was collected by the data collector every hour. Patient-identifiable information was removed before data analysis, and medical record numbers were kept on an encrypted hospital computer. • Sample Size Justification. An a priori power analysis was performed to determine the needed sample size. From a previous pilot study, we estimated that receivers (ie, RNs) during handoff from the nonchecklist anesthesia provider group had a success rate of 67% (4 of 6*100%) of correctly identifying 6 key elements of the checklist. A sample size of 26 per group was estimated to have 80% power to detect a difference of 28% (ie, those receiving from the checklist anesthesia provider group would have a success rate of 95%) at a 2-sided significance level of .05. To account for 10% missing data, we enrolled and randomized a 60 anesthesia providers (30 per group) into the study. • Data Collection. The following sections highlight the 4 measures or components recorded in the data collection sheet (see Figure 2). 266 AANA Journal „ August 2015 „ Vol. 83, No. 4 To be completed by the PACU RN receiving report PATIENT MRN: Report with Checklist? YES /NO KEY ELEMENTS Please circle yes or no if the information listed was given in the handoff: 1. Patient identified: YES / NO 2. Patient allergy information given: YES / NO 3. Antibiotic information given: YES / NO 4. Intake and output: YES / NO 5. EBL information: YES / NO 6. Pain management discussed: YES / NO HANDOFF QUESTIONS 1. Did you need to clarify information or call back the provider after the anesthesia provider completed the handoff? YES / NO 2. Was the handoff adequate: YES / NO ______________________________________________________ To be completed by the data collector Information score: Clarification/Callback: Yes (1)/No (2) Report adequate: Yes (1)/No (2) Time in PACU: Anesthesia End: TOTAL TIME: Figure 2. PACU Data Collection Sheet Abbreviations: EBL, estimated blood loss; MRN, medical record number; RN, registered nurse; PACU, postanesthesia care unit. 1) Information score: The PACU RN attempted to recall 6 key elements of the handoff after a report was given. A numerical rating score on a scale of 0 through 6 was calculated, with 0 representing that none of 6 key elements was correctly recalled and 6 being the highest score, wherein all 6 key elements were correctly recalled. The 6 key elements were defined as follows: • Patient identification using the patient’s name band • Patient allergy information • Antibiotic information • Intake and output • Estimated blood loss • Pain management 2) Handoff adequacy: The PACU RN rated the handoff as adequate or inadequate in a yes or no question format. Definition of an adequacy rating was discussed in a staff meeting with the PACU nurses and managers present. An adequate report was defined as a verbal report that allowed the PACU RN to begin direct patient care without having to look up additional information. This included performing a clinical assessment, administering medications, and patient positioning. All PACU RNs received instructions orally as well as by written communications sent electronically through the hospital email system. 3) Information clarification: The rate of callbacks for information clarification was determined by the PACU www.aana.com/aanajournalonline Outcome Score ratingc 6
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