Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach

Beyond the self: a novel framework to enhance non-technical team skills for anesthesiologists

Human factors and non-technical skills (NTS) have been identified as essential contributors to both the propagation and prevention of medical errors in the operating room. Despite extensive study and interventions to nurture and enhance NTS in anesthesiologists, gaps to effective team practice and patient safety remain. Furthermore, the link between added NTS training and clinically significant improved outcomes has not yet been demonstrated. We performed a narrative review to summarize the literature on existing systems and initiatives used to measure and nurture NTS in the clinical operating room setting. Controlled interventions performed to nurture NTS (N.=13) were identified and compared. We comment on the body of current evidence and highlight the achievements and limitations of interventions published thus far. We then propose a novel education and training framework to further develop and enhance non-technical skills in both individual anesthesiologists and operating room teams. We use the cardiac anesthesiology environment as a starting point to illustrate its use, with clinical examples. NTS is a key component of enhancing patient safety. Effective framing of its concepts is central to apply individual characteristics and skills in team environments in the OR and achieve tangible, beneficial patient outcomes.

An integrative review of human-centered design and design thinking for the creation of health interventions

BACKGROUND

In the United States, we have a healthcare system crisis with high rates of dissatisfaction among patients and providers. To transform health and healthcare, clinical providers must be proficient in the human-centered approach of design thinking (DT).

OBJECTIVE

To synthesize the human-centered design (HCD) and DT literature for the creation of health interventions.

METHODS

We performed an integrative literature review focused on how HCD and DT are used in the clinical healthcare setting. Four research databases were searched from inception through November 6, 2020. We analyzed the methodology used, who is using the frameworks, and the DT phases included.

RESULTS

Twenty-four articles were included in the final analysis. Of the 24 manuscripts, 6 (25%) were nurse-led and 15 (63%) had interdisciplinary first and last authors (e.g., Nursing and Medicine). Overall, 10/24 (42%) included all DT method. When analyzing the articles by approach or methodology, 12 (50%) stated they were using the HCD approach, 5 (21%) the DT methodology, and 7 (29%) stated they were using both the HCD approach and DT methodology.

CONCLUSION

There are inconsistencies in who uses DT and the phases used to create healthcare interventions.

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes

Anaesthesia handoffs are associated with negative outcomes (e.g. inappropriate treatments, post-operative complications, and in-hospital mortality). To minimise these adverse outcomes, federal bodies (e.g. Joint Commission) have mandated handoff standardisation. Due to the proliferation of handoff interventions and research, there is a need to meta-analyze anaesthesia handoffs. Therefore, we performed meta-analyses on the provider, patient, organisational, and handoff outcomes related to post-operative anaesthesia handoff protocols. We meta-analysed 41 articles with post-operative anaesthesia handoffs that implemented a standardised handoff protocol. Compared to no standardisation, a standardised post-operative anaesthesia handoff changed provider outcomes with an OR of 4.03 (95% CI 3.20-5.08), patient outcomes with an OR of 1.49 (95% CI 1.32-1.69), organisational outcomes with an OR of 4.25 (95% CI 2.51-7.19), handoff outcomes with an OR of 8.52 (95% CI 7.05-10.31). Our meta-analyses demonstrate that standardised post-operative anaesthesia handoffs altered patient, provider, organisational, and handoff outcomes. Practitioner Summary: We conducted meta-analyses to assess the effects of post-operative anaesthesia handoff standardisation on provider, patient, organisational, and handoff outcomes. Our findings suggest that standardised post-operative anaesthesia handoffs changed all listed outcomes in a positive direction. We discuss the implications of these findings as well as notable limitations in this literature base.

Implementation and 1-year follow-up of the cardiovascular ICU standardised handover

BACKGROUND

Miscommunication during clinical handover can lead to partial information transfer and healthcare provider dissatisfaction. We hypothesised that a quality improvement project to standardise the cardiovascular intensive care unit (CVICU) handover could improve healthcare provider satisfaction and reduce information omission.

METHODS

After institutional review board approval, the operating room (OR) to CVICU handover was audited prior, post and 1 year after standardisation implementation. The medical information transferred, healthcare provider participation and satisfaction, and patient outcome data were collected. Additionally, surveys were sent to the OR and CVICU staff by email.

RESULTS

There were 68 handover processes observed. The odds of greater satisfaction with handover for providers were 18 times higher with the process post implementation (p<0.0001) and 26 times higher 1 year after implementation (p<0.0001). There was statistically significant difference between intensive care unit resident presence (45% vs 76% vs 91%, p=0.004), surgical faculty presence (10% vs 36% vs 45%, p=0.034) and surgical fellow presence (15% vs 64% vs 62%, p=0.001) between the three time periods. More information related to the surgeon (5% vs 52% vs 27%, p=0.002), the medical history (65% vs 96% vs 91%, p=0.014) and the cardiopulmonary bypass (47% vs 88% vs 76%, p=0.017) was conveyed. The duration of mechanical ventilation was shorter after implementation (2.2±2.6 days vs 1.2±1.9 days vs 0.5±1.2 days, p=0.026).

CONCLUSIONS

One year after the OR to CVICU standardised handover implementation, the healthcare provider satisfaction remained increased, more team members participated and the information transfer increased. Although some clinical outcomes improved, further studies are recommended to prove causality.

Improving interprofessional handover on labor and delivery: A needs assessment study

Handover is the transfer of important clinical information between health providers. The current report describes a needs assessment of interprofessional labor and delivery handover at an urban hospital in Canada. The goal of this study was to explore the perceptions of the current handover meeting and opportunities for improvement. Using a constructivist paradigm, we conducted 28 semi-structured inter- views with handover participants. We used a recruitment grid to ensure we included the voices of participants representing each profession involved in interprofessional handover meetings. An inductive process was used to code the interview transcripts and theme the data. Major themes identified were: (1) Interprofessional handover contributes positively to team situational awareness, interprofessional relationships, and team communication; (2) Handover could be better if it had a more defined process; (3) Interprofessional handover can lead to feelings of intimidation; and (4) Interprofessional handovers on the labor and delivery unit in our setting need increased inclusivity of midwives. From these themes, continued development of interprofessional handover meetings on labor and delivery should be aimed at a formal definition of the scope and process for these meetings reducing feelings of intimidation, increased integration of Midwifery providers, and continued improvement of relationships between different professions and practitioners on labor and delivery.

An observational study of postoperative handoff standardization failures

BACKGROUND

Patient handoffs from an operating room (OR) to an intensive care unit (ICU) require precise coordination among surgical, anesthesia, and critical care teams. Although several standardized handoff strategies have been developed, their sustainability remains is poor. Little is known regarding factors that impede handoff standardization.

PURPOSE

Our objectives are three-fold: (1) highlight compliance failures with standardized handoffs; (2) identify factors contributing to compliance failures; and (3) develop guidelines for sustainable handoff interventions and processes.

METHODS

We used ethnographic data collection methods-general observations, handoff shadowing, and semi-structured clinician interviews-with 84 participants from OR, ICU, and telemedicine teams at a large academic medical center. We conducted thematic analysis supported by inductive and deductive coding using the Systems Engineering Initiative for Patient Safety (SEIPS) framework.

RESULTS

Post-operative handoffs can be characterized into four phases: pre-transfer preparation, transfer and setup, report preparation and delivery, and post-transfer care. We identified compliance failures with standardized handoff protocols and associated risk factors within the OR-ICU work system including limited teamwork, absence of handoff-specific tools, and poor clinician buy-in. To improve handoffs, clinicians provided suggestions for developing collaborative Electronic Health Record (EHR)-integrated handoff tools and re-engineering the handoff process.

CONCLUSIONS

Compliance failures are prevalent in all handoff phases, leading to poor adherence with standardization. We propose theoretically grounded guidelines for designing "flexibly standardized" bundled handoff interventions for ensuring care continuity in OR to ICU transitions of care.

Completeness of the operating room to intensive care unit handover: a matter of time?

BACKGROUND

Handovers of post-anesthesia patients to the intensive care unit (ICU) are often unstructured and performed under time pressure. Hence, they bear a high risk of poor communication, loss of information and potential patient harm. The aim of this study was to investigate the completeness of information transfer and the quantity of information loss during post anesthesia handovers of critical care patients.

METHODS

Using a self-developed checklist, including 55 peri-operative items, patient handovers from the operation room or post anesthesia care unit to the ICU staff were observed and documented in real time. Observations were analyzed for the amount of correct and completely transferred patient data in relation to the written documentation within the anesthesia record and the patient's chart.

RESULTS

During a ten-week study period, 97 handovers were included. The mean duration of a handover was 146 seconds, interruptions occurred in 34% of all cases. While some items were transferred frequently (basic patient characteristics [72%], surgical procedure [83%], intraoperative complications [93.8%]) others were commonly missed (underlying diseases [23%], long-term medication [6%]). The completeness of information transfer is associated with the handover's duration [B coefficient (95% CI): 0.118 (0.084-0.152), p<0.001] and increases significantly in handovers exceeding a duration of 2 minutes (24% ± 11.7 vs. 40% ± 18.04, p<0.001).

CONCLUSIONS

Handover completeness is affected by time pressure, interruptions, and inappropriate surroundings, which increase the risk of information loss. To improve completeness and ensure patient safety, an adequate time span for handover, and the implementation of communication tools are required.

Team performance during postsurgical patient handovers in paediatric care

Postsurgical handover of paediatric patients from operating rooms to intensive care units is a critical moment. This process is susceptible to errors and inefficiencies particularly if poor teamwork in this multidisciplinary and ad hoc collaboration occurs. Through combining provider- and observer-rated team performance, we aimed to determine agreement levels on team performance and associations with mental demands, disruptions, and stress. An observational and multisource study of provider and concomitant expert-observer ratings was established. In an Academic Paediatric Hospital, we conducted standardized observations of postsurgical handovers to PICU. We applied established observational and self-reported teamwork tools. Nested fixed and mixed models were established to estimate agreement within teams, between providers' and observer's ratings, as well as for estimations between team performance and mental demands, disruptions, and stress outcomes. Thirty-one postsurgical patient handovers were included with overall 109 ratings of involved providers. Provider-perceived team performance was rated high. Within the receiving sub-team, situation awareness was perceived lower compared to the handoff sub-team [F(df = 1) = 4.41, p = .04]. Inter-provider agreement on handover team performance was low for the overall team yet higher within handover sub-teams. We observed that high level of distractions during the handover was associated with inferior team performance rated by observers (B = - 0.72, 95% CI = - 1.44, - 0.01).Conclusion: We observed substantial disagreements on how involved professionals as well as observers rated teamwork during patient transfers. Investigations into paediatric teamwork and particular team-based handovers should carefully consider if concurrent provider and observer assessments are a valid and reliable way to evaluate teamwork in paediatric care. Common handover language should be established and mandatory before jointly evaluating this process. Our findings advocate also that handovers should be performed under low levels of distractions.What is Known:• Efficient teamwork during transfers of critically ill children is fundamental to quality and safety of handover practice.• Postoperative handovers are often performed by ad hoc teams of caregivers with multiple backgrounds and are prone to suboptimal team performance, communication, and information transfer.What is New:• Our provider and expert evaluations of team performance during OR-PICU handovers showed poor agreement for team performance. Our findings challenge previous results drawing upon single source assessments and inform future studies to carefully consider what approach of team performance assessments is required.• We further demonstrate that high levels of disruptions are associated with poor team performance during patient handovers and that efforts to ensure undisrupted handover practices in clinical care are necessary.

Motivations Influencing the Surgeon's Healthcare Unit Choice to Perform Surgery: A Confirmatory Study in Portugal

Quality surgical practice is a fundamental subject in health institutions, and it is important to understand the structural and organizational conditions of the operating room (OR). The present exploratory study sought to understand the motivations that underlie the choice of surgeons for the best healthcare unit to perform surgery, as well as the characteristics of those professionals regarding age, years of work experience, and sex. A questionnaire survey was administered to a convenience sample of 99 surgeons, 67.3% male and 32.7% female, aged 37 to 66 (M = 23.7; Std = 8.92). The results show that at the top of the surgeons' motivations to perform surgery is the 77.8% attributed to the human resources and equipment available and at the other extreme the 3% to the previous online visit to facilities. This study opens important clues to the development of more in-depth and comparative approaches, necessary for the continuous improvement of the healthcare provided in the context of surgical practice.

Interprofessional Care and Teamwork in the ICU

OBJECTIVES

We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care team, including patients and family members, and discusses quality improvement initiatives that require interprofessional collaboration for success.

DATA SOURCES

Studies were identified through MEDLINE search using a variety of search phrases related to interprofessional care, critical care provider types, and quality improvement initiatives. Additional articles were identified through a review of the reference lists of identified articles.

STUDY SELECTION

Original articles, review articles, and systematic reviews were considered.

DATA EXTRACTION

Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles.

DATA SYNTHESIS

"Interprofessional care" refers to care provided by a team of healthcare professionals with overlapping expertise and an appreciation for the unique contribution of other team members as partners in achieving a common goal. A robust body of data supports improvement in patient-level outcomes when care is provided by an interprofessional team. Critical care nurses, advanced practice providers, pharmacists, respiratory care practitioners, rehabilitation specialists, dieticians, social workers, case managers, spiritual care providers, intensivists, and nonintensivist physicians each provide unique expertise and perspectives to patient care, and therefore play an important role in a team that must address the diverse needs of patients and families in the ICU. Engaging patients and families as partners in their healthcare is also critical. Many important ICU quality improvement initiatives require an interprofessional approach, including Awakening and Breathing Coordination, Delirium, Early Exercise/Mobility, and Family Empowerment bundle implementation, interprofessional rounding practices, unit-based quality improvement initiatives, Patient and Family Advisory Councils, end-of-life care, coordinated sedation awakening and spontaneous breathing trials, intrahospital transport, and transitions of care.

CONCLUSIONS

A robust body of evidence supports an interprofessional approach as a key component in the provision of high-quality critical care to patients of increasing complexity and with increasingly diverse needs.

Impact of patient handover structure on neonatal perioperative safety

OBJECTIVE

To compare the incidence, severity, preventability, and contributing factors of non-routine events-deviations from optimal care based on the clinical situation-associated with team-based, nurse-to-nurse, and mixed handovers in a large cohort of surgical neonates.

STUDY DESIGN

A prospective observational study and one-time cross-sectional provider survey were conducted at one urban academic children's hospital. 130 non-cardiac surgical cases in 109 neonates who received pre- and post-operative NICU care.

RESULTS

The incidence of clinician-reported NREs was high (101/130 cases, 78%) but did not differ significantly across acuity-tailored neonatal handover practices. National Surgical Quality Improvement-Pediatric occurrences of major morbidity were significantly higher (p < 0.001) in direct team handovers than indirect nursing or mixed handovers.

CONCLUSIONS

NREs occur at a high rate and are of variable severity in neonatal perioperative care. NRE rates and contributory factors were homogenous across handover types. Surveyed clinicians recommend structured handovers for all patients at every transfer point regardless of acuity.

Improving transitions of care between the operating room and intensive care unit

Transitions of care between individual providers or teams of providers have a high potential for errors due to the incomplete transfer of critical information and the need for ongoing care. The transition from the operating room (OR) to the intensive care unit (ICU) is a particularly dangerous time for critically ill children. Hand-offs of care between the OR and ICU teams during this key transition period require detailed communication of complete and accurate patient information at a time when the patient is perhaps most vulnerable from a physiologic standpoint. Improving the safety of transitions from the OR to the ICU is an active area of investigation, though there are a few notable best practices that are commonly employed in a number of centers. These best practices include having the appropriate personnel at the bedside for the hand-off, the use of scripts and the "sterile cockpit rule", the use of checklists, double verification of post-operative orders, and maintaining an overall safety culture.

Handovers in Perioperative Care

Handovers around the time of surgery are common, yet complex and error prone. Interventions aimed at improving handovers have shown increased provider satisfaction and teamwork, improved efficiency, and improved communication and have been shown to reduce errors and improve clinical outcomes in some studies. Common recommendations in the literature include a standardized institutional process that allows flexibility among different units and settings, the completion of urgent tasks before information transfer, the presence of all members of the team for the duration of the handover, a structured conversation that uses a cognitive aid, and education in team skills and communication.

Developing a Standard Handoff Process for Operating Room-to-ICU Transitions: Multidisciplinary Clinician Perspectives from the Handoffs and Transitions in Critical Care (HATRICC) Study

BACKGROUND

Operating room (OR)-to-ICU handoffs place patients at risk for preventable harm. Numerous studies have described standardized handoff procedures following cardiac surgery, but no existing literature describes a general OR-to-ICU handoff system.

METHODS

As part of the Handoffs and Transitions in Critical Care (HATRICC) study, a postoperative handoff procedure was developed by conducting interviews and focus groups with staff routinely involved in OR-to-ICU patient transitions in two mixed surgical ICUs, which included nurses, house staff, and advanced practice providers. Transcripts were analyzed according to grounded theory. Surveys, attending physician interviews, and field notes further informed process development.

RESULTS

Interviews were conducted with 62 individuals, and three focus groups were held with 19 participants. Clinicians endorsed the importance of the OR-to-ICU handoff but identified several barriers to consistently achieving an ideal handoff-mainly, time pressure, unclear expectations, and confusion about other clinicians' informational needs. Participants were receptive to a standardized handoff process, provided that it was not overly prescriptive. Surveys (n = 132) revealed unreliable information transfer with current OR-to-ICU handoffs. These findings and preexisting OR-to-ICU handoff literature were used to develop a novel handoff process and information template suitable for standard use in a mixed surgical ICU.

CONCLUSION

OR and ICU teams agreed on handoffs' importance but expressed important barriers to consistently practicing ideal handoffs. Future work is needed to determine whether the handoff procedures developed by incorporating bedside provider perspectives improve patient outcomes.