Patient Hand-Offs

1. Patient Hand-Offs Sheri S. Crow, MD, MS Assistant Professor of Pediatrics Critical Care Medicine Mayo Clinic Rochester, MN

2. Intensive-care medicine has become the art of managing extreme-complexity ……and a test of whether such complexity can, in fact, be humanly mastered. NewYorker 2007

3. Hand-Off Statistics • During 24 ICU hours the average patient experiences: • 178 individual actions per day • Nurse/doctor errors in 1% of these actions • 2 errors/day/patient • Handover failures account for: • 20% of U.S. malpractice claims • Half of sentinel events involving communication breakdowns (Joint Commission Report) • Post-operative handovers: common area for communication breakdown.

4. Requirement for Success “hold the odds of doing harm low enough for the odds of doing good to prevail”

5. http://www.youtube.com/watch?v=YS_llfT2kQc http://www.youtube.com/watch?v=xQ4SVzxbp7Y&feature=related

6. Formula One Pit Stops • A multi-professional team comes together as a single unit to effectively perform a complex task.

7. Overcoming the Odds Do Checklists Really Work????

8. An ICU Fairy Tale

9. Checklist intervention • Peter Pronovost: Johns Hopkins • Goal: Reduce central line infections • Central line checklist: • Wash hands with soap • Clean the patients skin with chlorhexadine antiseptic • Use sterile drapes • Wear sterile mask, gown, gloves • Place sterile dressing over catheter site.

10. Checklist Implementation • Month 1: Observation • Nurses document checklist compliance • At least 1 missed step > 1/3 of procedures • Month 2: Intervention • Nurses authorized to stop doctors violating protocol steps • Nurses asked each day if lines could be removed

11. Results • Significant decline in line infections: • After 1 year: 11% to 0. • After 2 years: 1 line infection/year • Prevention of 43 infections and 8 deaths • Savings of 2 million dollars • Next project: Ventilator associated pneumonia (VAP) • Non-compliance with VAP prevention protocols decreased from 70% to 4% • Pneumonia dropped by 25% • 21 fewer patients died than previous year • ICU length of stay dropped by half

12. Keystone Initiative • Within 3 months: • Infection rate decreased by 60% • Michigan ICU infection rates: Worst national rates to top 10%. • Within 18 months saved: • 175 million dollars • 1500 lives • Success persists almost 4 years later

13. Why they work? • Assist with memory recall • Specify the minimum expected steps in a complex process.

14. Intra-operative Checklist

16. Haynes AB et al. N Engl J Med 2009;360:491-499

17. Operative Theatre to ICUHand-Offs

18. Three Parts to a Successful Handover • Equipment and Technology Handover • Information Handover • Discussion and Plan Catchpole et al Pediatric Anesthesia 2007

19. Patient information: Patient details Medical history Allergy status Name of procedure Current status of patient Anesthetic information Type of anesthesia Intraop anesthetic course Anticipated post-op problems Monitoring and range for physiological parameters Analgesia plan Plan for IV fluids Anesthesia contact number Surgical information Intra-operative surgical course Blood loss Antibiotic plan Medication plan-drugs to be restarted DVT prophylaxis Plan for tubes and drains NG tube and feeding plan Post-operative investigations Surgical contact number Sample Checklists: Post-op Handover

20. Clinical Applications for Checklists • Central Line Placement • Compliance with Clinical Practice Guidelines: Ventilator associate pneumonia • Operative Theatre to ICU handovers • Change of Shift handovers • Hospital to hospital transfer

21. Questions/Discussion