Handoffs and Transitions of Care: Lessons from Lens

1. Handoffs and Transitions of Care:Lessons from Lens Elizabeth A. Martinez, MD, MHS Associate Professor Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Harvard Medical School Cardiovascular Surgical Translational Study Armstrong Institute for Patient Safety and Quality Content Call: April 18, 2013

2. Objectives • Define transitions of care and handoffs • To recognize effective vs. ineffective handoffs • To identify the components of an effective handoff • To understand the importance of communication during transitions of care • Understand ASA quality metric for transitions of care

3. Communication Breakdowns are frequently the root cause of… undesirable outcomes

4. Analysis of errors reported by surgeons Gawande AA, et al. Surgery 2003; 133(6):614

5. The Joint Commission:The Importance of Communication National Patient Safety Goals • Improve the communication among caregivers • Read-back • Handoff • Accurately and completely reconcile medications and other treatments across the continuum of care • Address specifically during handoff • Encourage the active involvement of patients and their families in the patient’s care, as a patient safety strategy

6. Sign-offs: Transitions of Care • Joint Commission Patient Safety Goal #2 • vulnerable time in the care of patients since communication failures and environmental barriers often characterize such handoffs • “Implement a standardized approach to ‘hand off’ communications, including an opportunity to ask and respond to questions”.

7. Communication Process

8. Standards of Effective Communication • Complete • Communicate all relevant information • Clear • Convey information that is plainly understood • Brief • Communicate the information in a concise manner • Timely • Offer and request information in an appropriate timeframe • Verify authenticity • Validate or acknowledge information (closing the loop)

9. Why does communication break down? • Cognitive workload • Complexity increasing • Implicit assumptions • Authority gradients/Hierarchy • Diffusion of responsibility • Environmental factors • Production pressures • Competing priorities/Interruptions

10. Characteristics of High-reliability Communication Tactics • Are easy to understand and follow • Offer consistency & predictability: • Standardization • Feature redundancy • Incorporate forcing functions • Ensure that people cannot work around the system • Minimize reliance on human memory

11. Lessons from LENS • Locating Errors Through Networked Surveillance • Methods: • Observations, Contextual inquiry, Interviews, Surveys, • Observations included the transition of care from the OR to ICU as a key time point • In addition to intraop transitions and preop discussions that might have taken place • Hazards were coded

12. LENS Domains Human Factors Engineering Health Services Research Organizational Sociology Industrial Psychology Cardiovascular Clinical Care

13. Taxonomy Potential Failure Mode Gurses et al;BMJQualSaf 2012;21(10):810-8.

14. Lessons from LENS • Locating Errors Through Networked Surveillance • Methods: • Observations, Contextual inquiry, Interviews, Surveys, • Observations included the transition of care from the OR to ICU as a key time point • In addition to intraop transitions and preop discussions that might have taken place • Hazards were coded **While some of the observations identify a specific provider type, we know these are not unique to that provider type. The goal of the next few slides are to share real-life examples of hazards and to have us begin to think about how these are related to our individual provider types and teams – and how we can eliminate them.**

15. Lesson from LENS*:Organization • NO standardization • Variability within and between sites on how information and technology were transferred between team members • No evidence of standard handoffs intraop or postop • Purchasing decisions • In multiple settings either the OR or ICU team needed to change over the pumps during critical times for patients while vasoactive agents were being infused • “In OR, they use only pump A. In PACU, they use both pump A and pump B. In ICU they use only pump B.”  • “they swicth the infusion pumps over before leaving the OR to the pumps that will be used in the OR” (Can be done by a single practitioner including junior resident) • Policies • “When the patient is transported to the PACU the drips are all changed over; this is especially true for drips that are made up peri- and intraoperatively by the anesthesiologist. RNs in the PACU will only use drips that come from the pharmacy.” • “  …gtts are different concentration than ICU uses. ‘Nurse won’t use our drips’ – either dif concentration, not from pharmacy or poorly labeled”.  • Staffing patterns • Little to no assistance during transfer: Anesthesia single team member preparing the patient to leave the OR. Focusing on equipment, etc…. While monitoring the patient. *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you.

16. Lesson from LENS*:Patient characteristics • We did not collect patient level data • However….. These patients are obviously complex and this impacts the transitions of care and the information shared (or not shared) • Multiple medical problems • Can be on multiple drips and have received multiple intraop meds • Have multiple lines, drains and tubes • May be paced with/without intraop issues • Mechanical support • Hemodynamic lability needing to be addressed prior to complete transfer of information *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you.

17. Lesson from LENS*:Physical Environment • Layout • Distances needing to be traveled to post op setting • Waiting for elevators • “Anesthesia resident, perfusionist and nurse transported the patient up 5 floors to the ICU. There was a long wait as no one has a key to divert the elevator for fresh post-op cases regardless of acuity” • Ease of traveling down a hallway • Construction at one site • “[The postop setting] is down a long corridor that includes turns, doors, and carts lining the hallway. There appear to be many opportunities for trouble when pushing the stretcher, monitor, pole, etc. from the OR to the CVPACU.”  *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you.

18. Lesson from LENS*:Provider • Professionalism • “Fellow to nurse.” That’s all you get to know!”  • “The attending in the PACU did not get up from the desk for report. The anesthesiologist reported to the PACU attending while nurses changed lines, etc. they were not near the anesthesiologist and could not over hear the handoff report.” • Knowledge/Experience • “The anesthesia residents leave at 2pm. If a case is on-going at 2pm a CRNA comes in and covers for the anesthesia resident. The anesthesia attending perceive that this practices causes issues with handoff, professional responsibility, and role.”  • Performance • “[Mid level] gave a short handoff report (medium level structure): No allergies. Heart rate was between 50s and 60s.,, You probably know history. Smoker. … Do you have any questions?” *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you.

19. Lesson from LENS*:Tasks • Standardization – Lack of • PR team member to ICU: “I would keep pressure close to 100. She got a dose of Insulin on the pump. 1 PRBC unit post pump. 1 unit PRBC on the pump. She had 1 gram of vanco after case. I turned the pacer down to 82 from 90. Phenylephrine is hanging.”  • No Standard/Systematic approach to sharing information with new team • Not much information shared about intraop course or guidance for post op care. • Competing priorities • Simultaneous transfer of information and technology • Preparation • “Respiratory therapy had to be paged. Didn't have temp probe connection ready. Had to go find one.” *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you.

20. Lesson from LENS*:Team • Communication • Incomplete report • Not all team members present/give report • “The surgeon stopped by asked the BP, look at chest tube and left. NO surgical report given”  • “There was no sign out [information shared verbally] between nurses when the nurse was relieved for lunch” • Report is shared with some team members • “The handoff was not very in depth and [was in]complete. AR made handoff to the nurses and the ICU resident. The surgery fellow was present but gave handoff to the surgical resident out in the hall.”  • “The [postop] attending … did not get up from the desk for report. The anesthesiologist [and surgeon] reported to the … attending while nurses changed lines, etc. they were not near the anesthesiologist and could not over hear the handoff report.”  • Notification/Preparation • “Circulator did not notify ICU team that the patient was coming” • “Nurse who was giving break did not know the last name of the nurse for whom she was giving a break which resulted in delay and increased tension since it took longer to page her when she was needed to operate a piece of equipment.”  • Knowledge • “Intensivist asked about hematoma. No explanation by anyone that was by the bedside. ” • Distractions • “Unrelated personal conversations rather than a formal sign out ….”  • “Another nurse called into the room about another patient”  • “ICU wasn’t prepared for second A-line. This was not the routine and they were not notified ”  • Debriefings did not occur in the OR *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you.

21. Lesson from LENS*:Tools and Technology • Man-machine interface (Heuristics) • At each of the institutions, following at least one case, the transport monitor was not functioning and it was difficult for the providers to troubleshoot. • Communication • “Brief report consisted of: Procedure, products, H/O AVR, Ventricle is good, info about peripherals. Problem with report is that the anesthesia team didn't have a record to read off the history since it was electronic.” • Lines/tubes/drains • “Brought bed in room (nursing) and got tangled in suction tubing. Couldn’t get the foley temp connector undone, was knotted” • Frequently we know that it is a challenge to transfer central lines/PA catheter *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you.

22. Teamwork Across Units and Handoffs “We do this Poorly”* Data from Hospital Survey of Patient Safety (HSOPS) Site 1 Site 2 Site 3 Site 4 Site 5 All Sites Percent reporting a positive response *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you.

23. Potential Failure Mode Need to switch to Smart pump in the ICU Patient becomes extremely hypotensive Organization did not Purchase smart pump technology for all OR pumps Patient arrests and dies Patient receives inadvertent bolus of nitroglycerin

24. Potential Failure Mode Need to switch to New drips in the ICU Patient becomes extremely hypotensive Anesthesiologists make up their own drips and use their own concentrations Patient arrests and dies Patient receives inadvertent bolus of nitroglycerin

25. Adverse Consequences • Antiplatelets not restarted appropriately • Patient had an MI • ICD not turned on and patient discharged to floor/home • Diabetic patient had glucose checked on PACU admission per routine • Hyperglycemia treated by nurse • Patient had received insulin in the or and not given in report **Not LENS data

26. Adverse Consequences • Patient with difficult intubation was extubated with only junior house officer available • Required immediate, emergent reintubation • Difficult airway not noted in report. • Patient required am emergent cric • Off-service patient had a complication • Nobody took responsibility • No clearly defined primary service **Not LENS data

27. Implementation of Periop Handoff Protocol • Focus groups and survey of practitioners: what is wrong with our process? • SENDERS: Surgery, anesthesia, nursing • RECEIVERS: ICU, PACU • Protocol elements: • Require all practitioners be at the bedside • Standardized the process • Single person speaking at a time • Technology transfer • Information transfer • Checklists for sender and receivers • Clearly state when the handover is complete with opportunity for questions • Education of all practitioners on handover process Petrovic MA, et al. J CardiothoracVascAnesth 2012 Petrovic MA, et al. Joint Commission Journal 2012.

28. Objectives • Define transitions of care and handoffs • To recognize effective vs. ineffective handoffs • To identify the components of an effective handoff • To understand the importance of communication during transitions of care • Understand ASA quality metric for transitions of care

29. OR Debriefing: Step #1

30. Petrovic MA, et al. J CardiothoracVascAnesth 2012 Petrovic MA, et al. Joint Commission Journal 2012.

31. Surgery Checklist • Actual procedure performed • Surgical findings (anticipated and unanticipated) • Surgical complications • Drains/tubes (location, number, type) • Special instructions (NGT, chest tubes, extubation) • Patient disposition • Responsible primary service • Who to page Petrovic MA, et al. J CardiothoracVascAnesth 2012 Petrovic MA, et al. Joint Commission Journal 2012.

32. Anesthesia Checklist • Preop • Intraop • Postop guidance • PMH and PSH • Allergies and Code status • Medications – what was taken prior to surgery • Baseline vitals, exam, labs • Airway • Lines • Fluid totals (ins and outs) • Paralytic status • Labs and Meds (Antibiotics) • Key events • Drips • Respiratory: vent settings, etc… • Other • Conclusion:“The thing that I am most concerned about in the periop setting is “ Petrovic MA, et al. J CardiothoracVascAnesth 2012 Petrovic MA, et al. Joint Commission Journal 2012.

33. Nursing Checklist • Actual surgery performed • Isolation type • Lines • Drains • Skin Inspection • Packing • Special equipment/Others • Family information • Belongings and valuables • Events/Concerns Petrovic MA, et al. J CardiothoracVascAnesth 2012 Petrovic MA, et al. Joint Commission Journal 2012.

34. Impact of Standardized Handoff in CSICU On average, handoff increased by 1 minute (NS) Petrovic MA, et al. J CardiothoracVascAnesth 2012

35. Formula 1 Pit-stop Catchpole KR, et al. Paediatr Anaesth 2007; 17(5):470-8

36. Formula 1 in Pediatric Cardiac Surgery Catchpole KR, et al. PaediatrAnaesth 2007; 17(5):470-8

37. Impact of Formula 1 Approach Regression analysis identified an interaction between teamwork and the number of technical errors in the post-phase. Catchpole KR, et al. PaediatrAnaesth 2007; 17(5):470-8

38. American Society of Anesthesiologists • Transfer of Care Workgroup • Committee for Performance and Outcome Metrics • Developed handoff metric for-OR to-ICU • approved by the ASA Board of Directors • Can be used for internal QI programs • Key classes of elements defined

39. ASA Transition of Care Metric Use of a Protocol or Checklist and include the following elements: • Identification of patient • Identification of responsible practitioner (primary service) • Discussion of pertinent medical history • Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed) • Intraoperative anesthetic management and issue/concerns to include things such as airway, hemodynamic, narcotic, sedation level and paralytic management and intravenous fluids/blood products and urine output during the procedure, pertinent labs. • Expectations/Plans for the early post-procedure period to include things such as the anticipated course (anticipatory guidance), complications, need for laboratory or ECG and next antibiotic dosing time. • Opportunity for questions and acknowledgement of understanding of report from the receiving post-procedure team **Similar measures for Intraop and Postop**

40. Segall, Systematic Review AnesthAnalg, 2012. 115:102-15

41. Segall, Systematic Review AnesthAnalg, 2012. 115:102-15

42. Next Steps • Begin to look at your transitions of care through new lenses • Bring your thoughts to the Face-to-Face • Updates from Dr. Gurses and the CSTS team • Data from the CSTS site visits • Transitions across the continuum • Hazards and Good Practices • Begin to answer “What should handoffs look like across the continuum of CV surgery care?”

43. Thank you Martinez.Elizabeth@mgh.harvard.edu

44. References 1. Agarwal HS, Saville BR, Slayton JM, et al. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance*. Critical care medicine;40(7):2109-15. 2. Kalkman CJ. Handover in the perioperative care process. Current opinion in anaesthesiology;23(6):749-53. 3. Li P, Ali S, Tang C, et al. Review of computerized physician handoff tools for improving the quality of patient care. J Hosp Med. 4. Petrovic MA, Aboumatar H, Baumgartner WA, et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. Journal of cardiothoracic and vascular anesthesia 2012;26(1):11-6. 5. Petrovic MA, Martinez EA, Aboumatar H. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Joint Commission journal on quality and patient safety / Joint Commission Resources 2012;38(3):135-42. 6. **Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesthesia and analgesia 2012;115(1):102-15. 7. Tan JA, Helsten D. Intraoperative handoffs. International anesthesiology clinics 2013;51(1):31-42. 8. Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatricanaesthesia 2007;17(5):470-8. 9. Chen JG, Mistry KP, Wright MC, et al. Postoperative handoff communication: a simulation-based training method. Simul Healthc;5(4):242-7.