Handoffs and Transitions of Care: Lessons from Lens Elizabeth A. Martinez, MD, MHS Associate...
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Handoffs and Transitions of Care: Lessons from Lens Elizabeth A. Martinez, MD, MHS Associate Professor Anesthesia, Critical Care and Pain Medicine Massachusetts
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 1
Slide 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 2
Slide 3
Communication Breakdowns are frequently the root cause of
undesirable outcomes 3
Slide 4
Analysis of errors reported by surgeons Gawande AA, et al.
Surgery 2003; 133(6):614 4
Slide 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 patients care, as a patient
safety strategy 5
Slide 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. 6
Slide 7
Communication Process 7
Slide 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) 8
Slide 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
9
Slide 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 10
Slide 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
11
Slide 12
Slide 12 LENS Domains Human Factors Engineering Organizational
Sociology Industrial Psychology Cardiovascular Clinical Care Health
Services Research
Slide 13
Slide 13 Taxonomy Potential Failure Mode Gurses et al;BMJ Qual
Saf 2012;21(10):810-8.
Slide 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.** 14
Slide 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 wont 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. 15
Slide 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. 16
Slide 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. 17
Slide 18
Lesson from LENS*: Provider Professionalism Fellow to nurse.
Thats 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.
18
Slide 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. 19
Slide 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 wasnt 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. 20
Slide 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. Couldnt 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. 21
Slide 22
Teamwork Across Units and Handoffs We do this Poorly* Site 5
All Sites Site 4 Site 3 Site 2 Site 1 Percent reporting a positive
response Data from Hospital Survey of Patient Safety (HSOPS)
*Unpublished data; Data and presentation to be used for educational
purposes within your institution only. Thank you. 22
Slide 23
Potential Failure Mode Organization did not Purchase smart pump
technology for all OR pumps Need to switch to Smart pump in the ICU
Patient receives inadvertent bolus of nitroglycerin Patient becomes
extremely hypotensive Patient arrests and dies 23
Slide 24
Potential Failure Mode Anesthesiologists make up their own
drips and use their own concentrations Need to switch to New drips
in the ICU Patient receives inadvertent bolus of nitroglycerin
Patient becomes extremely hypotensive Patient arrests and dies
24
Slide 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 25
Slide 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 26
Slide 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 Cardiothorac Vasc Anesth 2012 Petrovic MA, et al. Joint
Commission Journal 2012. 27
Slide 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 28
Slide 29
OR Debriefing: Step #1 29
Slide 30
Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012 Petrovic
MA, et al. Joint Commission Journal 2012. 30
Slide 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 Cardiothorac Vasc Anesth 2012 Petrovic
MA, et al. Joint Commission Journal 2012. 31
Slide 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 Cardiothorac Vasc Anesth 2012 Petrovic MA, et al.
Joint Commission Journal 2012. 32
Slide 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 Cardiothorac Vasc Anesth 2012 Petrovic MA, et al. Joint
Commission Journal 2012. 33
Slide 34
Impact of Standardized Handoff in CSICU Pre- intervention Post
intervention Presence of core team0%68%P