Improving health care safety is one of the top priorities of the U.S. health care system. A key element for health care safety is the elimination of sentinel events—unexpected occurrences involving death or serious physical or psychological injury, such as loss of limb or function—or even the risk.1 Problems in communication, continuity of care, and planning have been identified as the root cause in more than 80% of documented sentinel events.2 As a direct result, The Joint Commission (JC) added National Patient Safety Goal 2E, which instructs each organization to implement a standardized approach to patient handoff.1 According to the JC, the objective of a handoff is to “provide accurate information about a patient’s care, treatment, and services, current condition, and any recent or anticipated changesand must include open communication and opportunities for questions.”1,3 The JC identified the patient handoff from anesthesia providers to the Surgical Intensive Care Unit (SICU) and Postanesthesia Care Unit (PACU) an opportunity for an improvement.1,3
At the Memphis VAMC in Tennessee, there was no established protocol for patient handoff from anesthesia providers to the SICU and PACU. The Anesthesia and SICU staffs were frustrated by inconsistent and incomplete postsurgical handoffs. Issues identified by the anesthesia team included difficulty contacting SICU staff to give a report and inconsistent availability of staff on first arrival to SICU. The SICU staff felt communication was rushed and there were inconsistencies in length and quality of the reports, resulting in incomplete postsurgical handoffs.
A baseline survey showed only 75% of staff felt the handoff report was thorough, and 67% “felt like a team.” In response, a multidisciplinary safe patient handoff committee (SPHOC) was formed by representatives from the involved units to discuss issues and offer solutions. The SPHOC efforts were aided by the VA National Center for Patient Safety (NCPS).
This quality improvement project was implemented as part of the U.S. Army Graduate Program in Anesthesia Nursing (USAGPAN) and the Northeastern University doctorate of nursing practice curriculum. The goal was to develop a simple, reliable, easily trainable handoff protocol for implemententation. This goal aligned with the priorites of the Memphis VAMC, USAGPAN, and VA to establish a culture based on patient safety and continuity of care.4
Methods
Standardization of handoffs began with JC National Patient Safety Goal 2E. There has been a wealth of medical literature on the need for standardization of handoffs and the implementation of specific handoff protocols in the postoperative setting. The SPHOC completed a review of the literature supporting standardization of handoff protocols. After completion, a second literature search was completed to identify the concepts for the implementation phase of the project. A critical appraisal of the evidence was completed using the method described by Melnyk and Fineout-Overholt.5 Literature from January 2005 through March 2015 was obtained via the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Google Scholar. The search methods included the keywords handover, handoff, transfer, and safety combined with anesthesia, PACU, surgery, operating room, and intensive care. Articles about handoffs not originating in the operating room (OR) were excluded.
The 13 articles found in the literature review established an overall need for standardization of handoffs outside the OR. Four articles identified a correlation between adverse events and poor or incomplete handoffs.3,6-8 Multiple articles discussed the need to develop a standardized handoff protocol in order to increase team work and quality of care.3,6,7,9,10 Petrovic and colleagues reported a 10% decrease in missed information and a boost in staff satisfaction from 61% to 81% with a standardized handoff.9 Additionally, a decrease in handoff time by > 1 minute was noted.8 Two articles identified an increase in quality of care after the implementation of a standardized handoff protocol.8,10
The second phase of the literature review examined relevant handoff information, best practices for participation in the handoff, and established staff buy-in for the process. Segall and colleagues created a table with handoff strategies consistently identified in the literature.10 The most relevant of these were using a structured written checklist to guide communication, using protocols to standardize the process, and providing formal team training.10
Six articles identified a written checklist and standardized handoff process as successful strategies used to improve patient safety.11-16 Zavalkoff and colleagues discussed the use of a template sheet filled out by the anesthesia provider prior to the handoff for consistency and accuracy of report.16 Catchpole and colleagues drew correlations between a Formula 1 pit stop and anesthesia handoffs and discussed the teamwork portion of the handoff protocol relating to staff buy-in.14 After delegating roles and making a set protocol for the handoff process, the study group was able to meet their objectives of efficient and safe handoff.14
With the information provided from the literature review, the SPHOC established a standardized handoff for the postsurgical patient. The committee created a handoff sheet for the anesthesia provider to use for report. This also included standardizing the handoff process and delineating specific roles for each provider.
After completing a NCPS training workshop, goals were identified at a SPHOC meeting. The SPHOC discussed current barriers to safe patient transfer and suggestions to overcome the barriers. Initial interventions planned by SPHOC focused on the problems of unsafe handoffs and delays in transfer. First, SICU identified the best phone number to call, which was distributed to the anesthesia and OR staffs. Additionally, the committee began tracking the number of attempted calls to reach SICU and availability of the nurse to take the report.