Promoting Patient Safety With Perioperative Hand-off .
Promoting Patient Safety WithPerioperative Hand-off CommunicationNancy Leighton Robinson, DNP, MSN, RN, LHRM, CCMEffective perioperative hand-off communication is essential for patientsafety. The purpose of this quality improvement project was to demonstrate how a structured hand-off tool and standardized process could increase effective perioperative communication of essential elementsof care and assist in the timely recognition of patients at risk forclinical deterioration in the initial postoperative period. A team-basedpilot project used the Iowa Model of Evidence-Based Practice and theprinciples of Lean Six Sigma to implement Perioperative PEARLS, aperioperative specific hand-off communication tool and a standardized framework for hand-off communication. The implementation ofa structured hand-off tool and standardized process supports compliance with regulatory standards of care and eliminates waste from thehand-off process. A review of pre-implementation and post-implementation data revealed evidence of safer patient care. Evidence-based perioperative hand-off communication facilitates expedited patientevaluation, rapid interventions, reduction in adverse events, and asafer perioperative environment.Keywords: hand-off communication, perioperative, evidence-basedpractice, patient safety, Lean Six Sigma.Ó 2016 by American Society of PeriAnesthesia NursesEFFECTIVE COMMUNICATION OF INFORMATION between health care providers is a fundamental principle of patient care. Efficient nursingcommunication is the foundation that ensuressafe patient care during times of transition. Lackof complete, accurate communication betweenthe caregiver and the receiver of patient information at points of transition is a major issue affectingthe quality and safety of patient care in the currenthealth care system. The focus of this qualityimprovement project was to promote best handoff practice for perioperative nurses.Nancy Leighton Robinson DNP, MSN, RN, LHRM, CCM,Director, Sacred Heart Health System Clinical Education, Pensacola, FL.Address correspondence to Nancy Leighton Robinson,Director of Clinical Education, Sacred Heart Health System,5151 N. Ninth Ave., Pensacola, FL 32504; e-mail address:nrobinsondnp12@gmail.com.Ó 2016 by American Society of PeriAnesthesia Nurses1089-9472/ Background and SignificanceThe process of hand-off communication has threeobjectives: transferring of the responsibility ofcare, establishing an audit or end point in care between providers, and conveying knowledge tofacilitate continuation of patient care.1 Communication failures are a leading cause of preventableadverse events that a hospitalized patient experiences in the modern American health caresystem.2 Each transition of care when patient information is communicated from one provider to thenext is a high-risk period for communicationbreakdown where information can be lost and/ormisinterpreted.In the postanesthesia care unit (PACU), frequent,brief, and complex handoffs occur. Handoffs aretypically succinct and informal, without writtendocumentation of the content. Handoffs involveclinical tasks, the transfer of information, and responsibility for patient care. Owing to the clinicalJournal of PeriAnesthesia Nursing, Vol 31, No 3 (June), 2016: pp 245-253Downloaded from ClinicalKey.com/nursing at Anne Arundel Medical Center - JCon June 23, 2016.For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.245
NANCY LEIGHTON ROBINSON246instability of the postoperative patient, the PACUnurse simultaneously performs patient care taskswith information transfer from the operatingroom (OR) and anesthesia staff. The combinationof nursing care tasks with information transfermakes communication of intraoperative information susceptible to loss and error. Effectivecommunication is adversely impacted by distractions and interruptions. Given the complexity ofsurgery, it is critical that adequate patient information is communicated during transitions of care.Effective and standardized communication between care providers at perioperative handoffpoints helps to facilitate patient safety, anticipate,and limit complications. Ineffective handoffs cancontribute to gaps in patient care and failures inpatient safety. National and state accreditationand regulatory entities have recognized the significance of hand-off communication.The purpose of this quality improvement projectwas to demonstrate how a structured hand-offtool and standardized process can increase effective perioperative communication of essential elements of care and assist in the timely recognitionof patients at risk for clinical deterioration in theinitial postoperative period (phase one). This project supports compliance with established regulatory standards for hand-off communication andeliminates waste from the hand-off process.Evidence Used for the Practice ChangeThere is no universal approach to hand-offcommunication. A handoff in care occurs whenaccountability and responsibility for a patient aretransferred from one health care provider toanother.3 The primary function of the handoff isto communicate essential patient data to providesafe, contiguous care. The health care providersassuming care of the patient require up-to-date patient information to make informed decisions andprovide seamless care.An analysis of sentinel events by The JointCommission identified communication as thetop contributing factor to medical error, withhandoff playing a distinct role in an estimated80% of serious preventable adverse events.4 National Patient Safety Goal 2E, initiated in 2009, isnow Element of Performance 2 for StandardPC.02.02.01. (‘‘The hospital coordinates the patients’ care, treatment, and services based on thepatients’ needs.’’)5 The safety standard for handoff communication requires communication thatis timely, accurate, completely unambiguous, andunderstood by the recipient. The redesign of theperioperative hand-off processes in this projectmet The Joint Commission standard and promotessafe patient care.5Critical Appraisal of the EvidenceThe current format of postoperative handovers inthe PACU did not meet the primary purpose of ahandoff, which is the accurate transfer of information about a patient’s state and care plan to ensurethe safety and continuity of patient care.6 The literature has described perioperative handoff usingterms such as brief, inconsistent, unstructured,incomplete information transfer, and informal.Disparity exists with the expectations of the JointCommission that handoffs follow the structuredformal approach of communication that is seenin highly reliable industries such as the airlineand nuclear power industry.7The lack of a standardized perioperative hand-offprocess creates the potential for error. The PACUenvironment is filled with distraction, concurrentactivities and interruptions that influence theattention of nurses during handoff. Different members of the PACU are involved transiently in thecare of the patient, so the primary care nurse isnot clearly identifiable.1 In the perioperativesetting, a premium is placed on efficiency. Thereare strict schedules that must be kept despite constant interruptions from emergencies, add-ons, delays, and complications. Time becomes a barrier tocommunication. Rushing the handoff can lead tosmall, yet critical mistakes that can ultimatelyharm patients.8 When insufficient time is allottedfor handoffs, time constraints lead to omission ofpertinent patient details.9The current recommendation is a guided,structured communication process for patienthand-off communication. Several standardizedframeworks for generic hand-off communicationare available. The SBAR (situation, background,assessment, and recommendation) communication tool is one of the most well established.The SBAR tool provides a focus to the hand-offDownloaded from ClinicalKey.com/nursing at Anne Arundel Medical Center - JCon June 23, 2016.For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
PERIOPERATIVE HANDOFFprocess by establishing what information will becommunicated and how it will be communicated,which helps to promote teamwork and improvesthe culture of patient safety.9 A structured tool establishes guidelines and standardizes the communication of pertinent content during handoff. Theactual content of the information to be includedin the perioperative hand-off protocol should bedeveloped from surveying the managers and staffmembers of the departments involved to meet theneeds of the end user and promote compliance.10Current literature lacks a perioperative specificcommunication tool, which could improve theunique handoff between health care professionalsin the immediate postoperative period.Perioperative Hand-off Project PlanThis quality improvement project was conductedin an acute care community hospital located in asuburb of a large metropolitan area. The facilityhas eight ORs and a 12-bed PACU. Owing to the nature of this practice change project, the directorof surgical services determined that participationby all perioperative registered nurses (RNs) wasrequired. No inclusion or exclusion criteria wereapplied to the postoperative patient populationassociated with the practice change project. Thefacility institutional review board approved thepractice change as an expedited project, followinginitial review by the nursing research andevidence-based council.Iowa Model of Evidence-Based PracticeThe Iowa Model of Evidence-Based Practice11 wasused as the framework to facilitate the perioperative hand-off communication project. The IowaModel was chosen for this project for its application to facilitate organization and establish amethod for communication with the perioperativeteam. The model integrates a team approach tocollaborate and communicate on project decisions. The Iowa Model is initiated with anemphasis on either knowledge or problem-based‘‘triggers’’11,12 that establish the projecttrajectory. This project was based on theproblem-focused trigger of the need for consistentpatient information to be communicated in a structured manner that met regulatory requirements.These issues supported the project as a priorityfor perioperative practice. A multidisciplinary247team was formed to address the issue and includeda doctor of nursing practice student, OR nursechampion, PACU nurse champion, Certified Registered Nurse Anesthetist (CRNA) champion, director of surgical services, OR and PACU clinicalsupervisors, and a Lean Six Sigma master blackbelt. The evidence obtained from the literature review demonstrated sufficient findings to restructure the hand-off communication process anddevelop a perioperative specific hand-off communication tool.Lean Six Sigma MethodologyThe foundation of Lean Six Sigma is based on thecore principles of standardized work and continuous improvement. Standardized work is the current best way to safely complete an activity withthe proper outcome and the highest quality. Standardized work is the method for developing bestpractices. Analysis of the work helps to definethe best way of doing the work.13The multidisciplinary team met to identify thecomponents of handoff that are prone to error,delay, and redundancy. These issues classified aswaste include: any activity that consumes resources but does not add value to patient care.13Lean Six Sigma initiatives focus on eliminatingwaste or nonvalued activities in a process toachieve sustainable improvement. A value streammap is a structured diagram that identifies all ofthe specific actions required during the entireend-to-end process for patient care or patientflow.13 The team met to complete an ‘‘as is’’ (current state) value stream map (Figure 1) of perioperative handoff (OR to PACU). The goal was toidentify waste in the hand-off process. The team reconvened to review the ‘‘as is’’ value stream map.The development of a ‘‘future/ideal state’’ (idealstate; Figure 2) value stream map demonstratedwaste elimination from the perioperative handoff process. Implementation of the ‘‘future/idealstate’’ map was adopted as the process for handoff,after staff education.Perioperative PEARLSStandardizing the hand-off content ensures thateach member of the team understands the significant clinical information. To facilitate an individual’s comprehension of what is communicated,Downloaded from ClinicalKey.com/nursing at Anne Arundel Medical Center - JCon June 23, 2016.For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
NANCY LEIGHTON ROBINSON248Figure 1. OR PACU handoff - present state map. CRNA, Certified Registered Nurse Anesthetist; EBL, estimatedblood loss; OR, operating room; PACU, postanesthesia care unit; Pt, patient.information must be organized in a format that therecipient is prepared to process. The use of achecklist as a memory aid serves two purposes:first, it ensures that critical information necessaryfor patient care is not omitted; and second, itprovides a consistent order in which informationshould be communicated.A literature search did not yield a perioperativespecific hand-off tool. Many hand-off tools usethe SBAR acronym. Owing to the nature of theperioperative environment, it was determinedthat SBAR might not be the most effective acronymto use for handoff. A review of the AmericanSociety of PeriAnesthesia Nurses (ASPAN) standards, a literature review, and results of the OR,PACU, and CRNA questionnaires contributed tothe development of the hand-off tool PerioperativePEARLS (Table 1). Although PEARLS is not anacronym like SBAR, each letter in the word PEARLScorresponds with essential elements of careunique to the perioperative patient population.Pilot ProjectThe pilot project was implemented in phases. Theinitial phase included the completion of a perioperative hand-off communication audit tool(Table 2) pre-implementation. Direct observationof handoff from the OR to PACU is a criticalelement in the establishment of a facility appropriate hand-off tool.A four-point Likert scale questionnaire on perioperative hand-off content was developed. The questionnaire included aspects of nurse-to-nursecommunication, intraoperative patient information such as position, special devices, drains, packing, tubes, and types of dressing. Adequacy of timefor handoff and the need for a more comprehensive report were also assessed. The results of thequestionnaire assisted in the development of theperioperative specific hand-off tool, PerioperativePEARLS.One week before the practice change implementation, flyers announcing Perioperative PEARLSwere strategically placed in the OR and PACUareas. A PowerPoint educational presentationand opportunities for perioperative hand-off simulation to reinforce the application of the hand-offcommunication process were provided for allperioperative RNs. Content included background information on hand-off communicationtheory, regulatory requirements, the ‘‘future/idealstate’’ value stream map, and the hand-off tool,Downloaded from ClinicalKey.com/nursing at Anne Arundel Medical Center - JCon June 23, 2016.For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
PERIOPERATIVE HANDOFFPatient in OR249OR Circ callsPACU with 5min noticeBay assignmentand responsibleRN is given toOROR Circ placespt in bay.Primary PACURN comes to ptbedsideOR Circ may discuss specialequipment: vent, isolation,& T-pieceConnecting tomonitors bysecondaryPACU RNOR Circ beginproviding reportto PACUprimary RNOR Circcompletes reportand leavesPACUPerioperative PEARLSCRNA givesreportCRNAcompletesdocumentationCRNA remainsuntil first set ofvital signs andpt is stableIncludes med history,airway, medications,vital signs, type ofanesthesiaFigure 2. OR PACU handoff - huture state map. CRNA, Certified Registered Nurse Anesthetist; OR, operatingroom; PACU, postanesthesia care unit; RN, registered nurse.Perioperative PEARLS. Content included therevised process for the patient trajectory fromthe OR to PACU, which incorporated the regulatory requirements for handoff and a more comprehensive patient admission process (Figure 3). Awritten quiz and evaluation were completed toensure competency. Laminated signs of Perioperative PEARLS were posted in all of the ORs, PACUbays, staff lounges, nurse stations, and anesthesiaworkroom.Evaluation MethodEvaluations were completed using a precomparison and/or postcomparison of knowledge andprocess. There were two areas of evaluation.First, the perioperative nursing staff completeda competency assessment to provide validationof understanding of hand-off communicationand the proper use of Perioperative PEARLS. Second, data from hand-off observation audits werecompared for 1 month before and after the implementation of Perioperative PEARLS and the LeanSix Sigma ‘‘future state’’ value stream map. Closemonitoring of perioperative hand-off practiceprovided opportunities for re-education, clarification of any questions or concerns, and effectiveness of the practice change. An extensiveliterature search was conducted to locate an established tool that would facilitate evaluation ofperioperative hand-off communication. The literature lacked sufficient perioperative specific toolsthat would enable the outcome measurement ofhand-off effectiveness. It was necessary to selfdevelop a perioperative specific hand-off audittool that incorporated the essential elements ofthe hand-off process. Expert opinion of a PhDprepared nurse researcher was used to ensurethe hand-off audit tool met project design andoutcome specifications. The outcomes measuredrelated to the improved effective communicationof essential clinical information in the immediatepostanesthesia period (1 to 2 hours aftercompletion of surgical procedure). The toolalso measured the standardized communicationbetween perioperative care providers andDownloaded from ClinicalKey.com/nursing at Anne Arundel Medical Center - JCon June 23, 2016.For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
NANCY LEIGHTON ROBINSON250Table 1. Perioperative PEARLScomponents of regulatory requirements for handoff communication. Although quality of handoffwas not a direct focus of this project, a surveytool ‘‘the Coordination of Handoff EffectivenessQuestionnaire’’ has been validated for measuringhand-off quality and evaluating the tangiblehand-off interventions in the context of local,unit-level norms. The Coordination of HandoffEffectiveness Questionnaire assesses two core elements of a handoff: (1) quality of informationtransfer and (2) quality of the interaction process.14 Trend analysis compared pre-implementation and post-implementation perioperativehand-off communication audit data. The trendanalysis was presented in a graph format thatdemonstrated comparative outcomes of the perioperative hand-off communication practicechange. The results were presented to the perioperative nurse council to determine the justification and sustainability of the perioperative handoff communication pilot.OutcomesThe desired outcomes of this quality improvement project were multidimensional. The firstdesired outcome was improved communicationof essential elements of care in the immediateDownloaded from ClinicalKey.com/nursing at Anne Arundel Medical Center - JCon June 23, 2016.For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
PERIOPERATIVE HANDOFF251Table 2. Hand-off Communication Audit ToolCriteriaYesNoN/ACommentsWas structured handoff process used (PEARLS)?Was handoff communication interactive?Was there an opportunity for questions/clarification during handoff?Were interruptions limited during handoff?Was patient identification verified?Was there a comprehensive review of essential patient i
Perioperative Hand-off Communication Nancy Leighton Robinson, DNP, MSN, RN, LHRM, CCM Effective perioperative hand-off communication is essential for patient safety. The purpose of this quality improvemen
A healthy perioperative practice environment can be defined as a practice setting that is safe, healing, humane, and respectful of the rights, responsibilities, needs, and contributions of all members of the perioperative team. 1 Members of a highly functioning perioperative team
hyperglycemia, and the management of diabetes in the perioperative period including preoperative evaluation, day of surgery management, and postoperative care. Pathophysiology of perioperative hyperglycemia There are many factors that contribute to hyperglycemia in the perioperative setting. Surgical stress increases secretion of counter regulatory
novice perioperative nurse according to that survey was at least 30,000 to 50,000. The same survey estimated the costs of orientation for an experienced perioperative nurse at 10,000 to 15,000. Perioperative nurse executives and educators need to drill down to a very fine level to determine the true costs of orientation for new employees.File Size: 1MB
and management reporting. Centricity Perioperative Anesthesia An industry-leading Anesthesia Information Management System (AIMS), Centricity Perioperative Anesthesia streamlines the capture, flow, and management of patient data throughout your facility. It can help provide more predictable patient care, enable more
Perioperative Medication Safety Practices In 2011, AORN released a new “Recommended practices for medication safety.” The recommendations are fully achievable and are intended to reflect current knowledge that promotes optimal levels of practice. Perioperative registered nurses (RNs) are encouraged to adopt these
Carol Petersen, RN, BSN, MAOM, CNOR Perioperative Nursing Specialist AORN, Inc Denver, Colo Lori Plante-Mallon, RN, CNOR Perioperative RN Strong Memorial Hospital University of Rochester Medical Center Rochester, NY Kristy Robinson, RN, BSN, CNOR Perioperative RN Tampa General Hospital Tampa,
may be substantially higher (James, 2013, JPS) Crossing the Quality Chasm: A New Health System . National Patient Safety Goals IHI’s 100K lives Campaign 2004 2005 Patient Safety . Patient Quality & Safety Movement: Worldwide 2000 An Organization with a Memory NHS forms National Patient Safety Agency 2001 NPSF’s launches Patient Safety .
Cambridge IGCSE Accounting is accepted by universites and employers as proof of an understanding of the theory and concepts of accounting, and the ways in which accounting is used in a variety of modern economic and business contexts. Learners focus on the skills of recording, reporting, presenting and interpreting inancial information; these form an ideal foundation for further study, and for .
