Handovers From the OR to the ICU

Alberto S. Bonifacio, BSN, MHA*
Durham Veterans Affairs Medical Center Durham, North Carolina

Noa Segall, PhDw
Duke University Medical Center Durham, North Carolina

Atilio Barbeito, MD, MPHwzz
Durham Veterans Affairs Medical Center Durham, North Carolina

Jeffrey Taekman, MDw
Duke University Medical Center Durham, North Carolina

Rebecca Schroeder, MD, MMCiwzz
Durham Veterans Affairs Medical Center Durham, North Carolina

Jonathan B. Mark, MDwzz
Durham Veterans Affairs Medical Center, Durham, North Carolina

The case was long and difficult—a redo sternotomy and coronary artery bypass grafting procedure on a fragile 82-year-old patient. While you are pushing the bed down the hallway, you move cautiously toward the intensive care unit (ICU) because the patient is hemodynamically unstable and receiving high doses of inotropes and intra-aortic balloon pump support. Upon rounding a corner, equipment temporarily being stored in the hallway forces you to swerve forcefully disconnecting the helium tubing from the balloon pump. Alarms chiming, you quickly make it to your assigned ICU bed space to find the receiving ICU nurse absent. She left the bedside to look for a missing pressure cable. You handover the bag-mask system to the respiratory therapist, and she asks whether you had any problems with intubation or ventilation. You want to tell her that intubation was difficult, but you notice that the arterial pressure is very low. “Please don’t disconnect the a-line yet,” you ask the
FROM THE *PATIENT SAFETY CENTER OF INQUIRY ; zDEPARTMENT OF ANESTHESIOLOGY AND wDEPARTMENT OF ANESTHESIOLOGY REPRINTS: JONATHAN B. MARK, MD, DEPARTMENT OF ANESTHESIOLOGY, DURHAM VETERANS AFFAIRS MEDICAL CENTER, 508 FULTON STREET DURHAM, NC 27705. E-MAIL: JONATHAN.MARK@DUKE.EDU
INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 51, Number 1, 43–61 r 2013, Lippincott Williams & Wilkins

www.anesthesiaclinics.com | 43

2. You would love to hear.1 are the processes that span the gaps between critical junctures and ensure that continuity of care is maintained.] These transfers of care. handover failures account for half of the sentinel events rooted in “communication failures” as reported by the Joint Commission9 and also for 20% of all malpractice claims in the United States. have been shown to be fraught with technical and communication errors2–4 that have been linked to adverse events and patient harm. We gave him 2000 mL of crystalloid.com .10 In response to these and a growing number of similar findings. but gets interrupted by the nurse who asks “Is he really supposed to be on 15 units per hour of insulin?” ’ Introduction The problems caused by ineffective patient handovers are well known and common—we have all experienced them. the ICU resident.anesthesiaclinics. Patient handovers. for example. Twenty minutes later.11 www. you walk out. and accountability between individuals and teams. but the TV is on (looks like it may rain tomorrow). “That was a tough case. Last ACT was 106. treatment areas. The Joint Commission. now alone.11 and increased regulatory demand to improve health care performance and outcomes. now requires health care providers to “implement a standardized approach to handover communications including an opportunity to ask and respond to questions” (National Patient Safety Goal 02. interest in patient handovers has grown significantly. the safety of our patients depends upon the seamless transitions of care between clinical care teams. and support systems. In today’s increasingly complex and integrated health care system. the surgeon is talking to the ICU attending in the hallway and giving details of the procedure.07 mcg/kg/min of epinephrine. defined as the transfer of information. At the desk.5–8 For example. you gather your paperwork and deliver your report to the patient’s primary ICU nurse: “He is on 0.” The nurse takes notes on the back of her insulin sheet. however. Meanwhile.01). new resident workload restrictions. professional responsibility.” the surgeon comments as he accompanies you out the door. carrying the monitor and the oxygen tank. [The terms handover and handoff are used interchangeably in the medical literature to describe the transitions in patient care as defined above.44 ’ Bonifacio et al resident as you push 5 mcg of intravenous epinephrine and administer a fluid bolus. is trying to figure out why the patient needs to be ventricularly paced.05. His EF was low to start with. With the balloon pump working and vital signs recovering. We prefer the term handover (and use it in this chapter) because we feel it conveys a clearer sense of teamwork and continued commitment to the seamless care of the patient.

Handovers From the OR to the ICU ’ 45 The Accreditation Council for Graduate Medical Education. Although more complex than within-unit or shift handovers. Commonly called “sign-out. The first is a handover that is usually performed at the end of a shift when a provider who is caring for several patients transfers information about each patient to his or her replacement. nurses in an intensive care unit (ICU). Fewer than 25 articles have been published since 1999 that focus specifically on OR to ICU patient handovers. Most transfers that require a change in level of care (eg.”14 this handover ends with a formal or informal transfer of responsibility for the care of these patients.” or “within-unit. This type of handover usually occurs between 2 clinicians of similar disciplines such as house officers on a medicine ward. The second type of handover is the transfer of a patient from 1 location in the hospital to another with a different team assuming care for that patient. they remain high-risk. and the common presence of invasive monitoring. etc. ’ Types of Handovers A clear distinction is beginning to emerge between distinct types of intrafacility handovers. ICU to step-down or emergency to ward.15 Of these.13 Despite these robust efforts to improve the safety of handovers. ensure and monitor structured handover processes.) involve “betweenunit” handovers. etc.12 requires residency programs to design clinical assignments to minimize the number of care transitions. this handover involves some unique qualities such as a delivering team comprised of 2 services (anesthesia and surgery) instead of 1. and vulnerable points in the continuum of care. the need to communicate details about a recent and significant event (the surgical procedure). postoperative handovers have received relatively little attention. or between 2 consultant physicians who cross-cover each other at different times during the week. the few that tested specific interventions have limited generalizability owing to small sample sizes. recognizing the impact of resident work hour mandates. but also a physical transfer of the patient. a focus on 1 population type (pediatric cardiac surgery).anesthesiaclinics. Unlike the other between-unit handovers. These “between-unit” handovers not only involve a transfer of information and responsibility. tubes and drains.com . and ensure that trainees are competent in communicating with team members during handover. ’ The Operating Room (OR) to ICU Handover A variant of the “between-unit handover” is the transfer of postoperative patients from the OR to a postoperative care area such as the ICU handover or postanesthesia care unit. error-prone. and absence of www.

elevators. and nonstandardized19 and.4. Upon arriving in the ICU. and monitoring cables that easily tangle and disconnect. In this process. provide strategies to improve handover safety and reliability. ’ Characteristics of the OR to ICU Handover The OR to ICU handover is dynamic and complex. www. life-threatening complications at any time during the transfer process. Physical Transfer Acutely ill or physically compromised patients recovering from highrisk procedures may experience rapid. it is evident how handovers give rise to so many procedural and communication errors. defibrillators. an OR team is charged with transporting a patient and support equipment while simultaneously monitoring and performing any needed therapeutic tasks such as manual ventilation. Movement of the patient from the OR table to a hospital bed may cause physiological disturbances related to positional changes and shifts in blood volume leading to cardiopulmonary instability. crowded hallways. and critical personnel. we will describe the 3 crucial components of OR to ICU handovers: (1) the physical transfer of the patient. Free-rolling equipment transported with the patient such as intravenous poles or circulation assist devices are often difficult to maneuver and add to the task saturation for transport teams. unstructured. and (3) the transfer of responsibility and care. assessing.com .16–18 This chapter will describe current knowledge about OR to ICU handovers. (2) the transfer of information. and poor coordination of the bed movement are common sources of technical and attention errors. the patient is especially vulnerable as essential emergency resources such as suction.anesthesiaclinics. and offer guidance on implementing change and sustaining improvements in care. lines. as a result. In the next sections. may be unavailable. and initiating care plans for the patient. the OR team joins a separate ICU team to transfer monitoring and support equipment to local systems while important information about the patient’s status and plan of care is transmitted. drains. Furthermore. A complex surgical patient may be connected to >2 dozen tubes.2. The process is further complicated as delivering team members with correspondingly different perspectives on the course of the surgery must transmit information to a second team that is often simultaneously stabilizing. Separation of these cumbersome pieces from the bed because of insufficient personnel. As such.46 ’ Bonifacio et al outcome data. In transit. Physically moving the patient also raises the risk for displacement or dislodgement of critical lines and tubes. this process is often informal. inconsistent and highly variable.

critical team members may be functionally excluded from the report even if physically present such as when a surgeon and anesthesiologist speak privately with the ICU physician. and a lack of structure further confound the process and contribute to communication failures.Handovers From the OR to the ICU ’ 47 Patient transport also presents an opportunity for significant periods during which the patient may be inadequately monitored.15 For example. Interestingly.22 Another barrier to effective communication is the absence of key team members from the handover. whereas the ICU nurse is busy performing clinical tasks. Information Transfer Because of the condition of the postsurgical patient.” receivers disagreed 60% of the time. Poor preparation of equipment (missing cables or dysfunctional components).) because it is the information with which he or she is most familiar and considers most important.21 Another descriptive study reported that anesthesiologists failed to transfer all of the essential information in 67% of OR to postanesthesia care unit handovers. airway difficulties. but the transfer occurs between 2 highly specialized teams that work in functionally disparate environments.20 Chang and colleagues reported that although deliverers of a handover thought their report contained “the most important piece of information. thereby increasing the likelihood of information omissions or inaccuracies related to surgical details and plan of care. intake and output. For example.com . may likewise lead to poor patient monitoring. or distraction related to multitasking. Differences in communication style. intraoperative analgesia) was reported most often while surgeryrelated information (eg. an anesthesiologist may focus on the “anesthesia data set” (eg. the study also noted that information related to anesthesia (eg. hierarchical constraints. Postoperative care transitions routinely require a minimum of 2 interruptions in monitoring: (1) a transfer from the fixed OR to a mobile transport system. accidental disconnections.anesthesiaclinics. the anesthesia provider may be left to communicate all of the intraoperative information. and delayed transfer because of tangled cables may prolong unmonitored periods.19 Furthermore. Not only is this data set extensive and significant. and (2) a transfer from the mobile to the fixed ICU monitoring system. Although www. The result is often a lengthy but incomplete transfer of disorganized information from which the receiving team must extract those points in which they are most interested. the quantity and complexity of information exchange may be great. Inattention of the transport team. Members of the delivering team may prioritize and share information based upon their clinical roles and make inaccurate assumptions about what the members of the receiving team need or wish to hear. course of surgery) was reported least often. etc. if the surgeon is not present.

For example. Like the physical and information transfer.23 Finally. the transfer of authority and responsibility is usually informal rather than explicitly articulated. These factors combine to place handovers at high risk for communication failure. Transfer of Responsibility The formal transfer of responsibility for the patient is most often the final step in the handover occurring after the information is delivered. however. This may also occur if the report delivered is inaudible because of soft speech or a noisy environment.com . duplication. Concentration and attention from both the deliverers and receivers of critical information are essential for a successful exchange. a nurse attempting to calibrate an invasive blood pressure transducer while simultaneously receiving report may have difficulty comprehending and retaining the information delivered. time pressure related to OR scheduling or shift changes may cause unnecessary abbreviation or even deferral of the handover altogether.24 This presents yet another opportunity for patient harm because of uncertainty about patient care goals. Another common error and handover failure mode is inattention caused by the concurrent performance of tasks while attempting to receive information. who is ultimately responsible for the care of the patient. and patient harm. they are often surrounded by auditory and visual distractions such as alarming monitors. exclusion from the report may lead to data omission. and to whom questions or instructions should be directed. and sometimes even patient televisions. Regardless of reason.48 ’ Bonifacio et al present. Furthermore. the body of literature offering insight and recommendations for OR to ICU www. adverse events. or inaccuracy as team members are unable to cross-check and verify patient information. intercom announcements. The distraction-rich environment of an ICU is yet another barrier to effective handovers. The nurse must then cognitively reassemble abstracted bits of information or later request the information from a team member who received it (yet another handover and opportunity for miscommunication). the nurse becomes effectively excluded from the exchange of information. Also common are cognitive disruptions caused by staff interrupting the information exchange to discuss issues unrelated to the handover. errors may also occur with the physical task (calibrating the blood pressure transducer) as the nurse switches attention between the 2 tasks.anesthesiaclinics. ’ A Practical Guide to Improving Postoperative Handovers Although variable in quality and lacking in strong evidence.

 Provide training in team skills and communication. Endsley25 has formally defined SA as “the perception of the elements in the environment within a volume of time and space. In other words.15 Each recommendation will be discussed in further detail in the following sections. Establishing a scalable and flexible yet standardized protocol for the OR to ICU handover will enhance the situational awareness (SA) of all team members.  Complete urgent clinical tasks before the information transfer.  Standardize the process. In addition to recommendations for physical and information transfer. Segall and colleagues identified 24 articles that offered recommendations for improving handovers.” the cognitive demand on working memory will decrease resulting in an improved understanding and retention of information. As team members become comfortable with the “routine. In a recent literature review. and detect potential process failures improves.  Allow only patient-specific discussions during verbal handovers.15 Incorporating these concepts into the design of handovers has the potential for improving handover safety and reliability by addressing many of the modes of failure mentioned earlier. the www.anesthesiaclinics. anticipate each other’s actions.” Defining roles and responsibilities will enable the concurrent completion of numerous tasks while ensuring that important items are not forgotten. The matrix depicted in Figure 1 is an example of a standardized process for the transfer of the patient upon arrival to the ICU. Figures 2. many authors emphasized the importance of effective teamwork skills during handovers. 3 are sample diagrams of staff positions and suggestions for task allocation for receiving surgical patients in the ICU.com . Handover Teamwork and Structure Five strategies to improve OR to ICU handovers have been broadly recommended in the recent literature. with roles on the y-axis and time/events on the xaxis. Standardizing the process is important as it will provide all handover participants with a broad understanding and clear expectations as to how the process should work. It is read like a musical score. the ability of individuals to cross-monitor each other.Handovers From the OR to the ICU ’ 49 handovers is growing and improving.  Require that all relevant team members be present. it is a plan that gets everyone on the “same page. Fourteen of these supported their interventions with some level of evidence with 4 describing interventionbased studies. As teams become more familiar and adept at executing a standardized process such as the one we describe. Codifying the standard into a formal protocol will further enhance efforts by improving compliance thereby reducing variability in the process.

” This definition breaks the concept of SA into 3 distinct levels: (1) level 1—perception of the environment. For example. (2) level 2—comprehension of the meaning of this information. nasogastric tube. enabling them to perceive what is happening. asking team members to “call out” vital signs as they appear on the ICU monitor display or other pieces of information (eg. The handover leader will facilitate smooth execution of the process by initiating and concluding the handover and determining when to deviate from the www. PAP . With a good sense of SA. SA can be enhanced by using effective team communication strategies. SPO2. endotracheal tube. NGT. team members are highly “in tune” with what is occurring around them. noninvasive blood pressure. thermodilution cardiac output. RN.anesthesiaclinics.50 ’ Bonifacio et al Figure 1. BP indicates blood pressure. TDCO. pulmonary arterial pressure. electrocardiogram. CVP . MD. certified registered nurse anesthetist. Designating a handover leader may also be helpful. The handover roles are identified on the y-axis while the time course of events is depicted on the x-axis.com . pulse oximeter oxygen saturation. ECG. anticipate what may occur. OR. registered nurse. ETT. Time 0 indicates the arrival of patient to the intensive care unit (ICU). central venous pressure. NIBP . comprehension of their meaning and the projection of their status in the near future. CRNA. and create a plan of how to react. operating room. Standardized process for handover at bedside. and (3) level 3—projection of events or actions in the future based on the perception and comprehension. identification of an unexpected hemorrhage or a change in infusion rates during handover) will get all members on the same page without disrupting the performance of their individual tasks. medical doctor.

it will. routine (eg.anesthesiaclinics. in cases with unexpected patient deterioration or critical equipment failure).27 Physical Transfer At times it seems that Murphy’s Law. Stop)26. I am Uncomfortable. RN indicates registered nurse. Upon arrival to the ICU. the handover teams first establish monitoring and complete critical tasks before transferring information. Initial team positions and tasks upon patient arrival in the intensive care unit (ICU). ensuring the receiving team is ready to receive report before information delivery. “if anything can go wrong.com . These include allowing only 1 person to speak at a time.” is the only constant in the transport of critically ill patients. or Crew Resource Management’s 3W’s (What I see.Handovers From the OR to the ICU ’ 51 Figure 2. A variety of validated programs offer teamwork strategies such as Team STEPPS (Team STEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety) CUS (I am Concerned. RT. receiving team. Personnel not directly involved in the initial transfer of monitor and equipment are asked to remain away from the bedside (behind the “hot line”) until needed. The handover leader will also be charged with mediating interpersonal conflicts and setting the tone for effective teamwork and cooperation. Strategies should be implemented to www. What I I’m concerned about. What I want). and establishing a common language or method to address conflict. Other teamwork skills that may enhance the process include the establishment and enforcement of communication ground rules. especially when furthest away from help.

Depending on the distance to be traveled and availability of code carts along the way. During the physical transfer of the patient. See text for more detail. The Guidelines for the Interand Intra-hospital Transport of Critical Ill Patients published by the Society of Critical Care Medicine describes good strategies relevant to OR to ICU handovers. and developing contingency plans. receiving team. for example. The sterile cockpit concept describes a bedside environment that is free of any distractions that may interfere with the transfer of clinical communication. prevent mishaps and mitigate their effects when they occur. www.anesthesiaclinics.52 ’ Bonifacio et al Figure 3. prohibit the disassembly of OR monitor and ventilation systems (eg. handover team members must anticipate and be prepared to manage life-threatening postoperative complications. functional bag-valve mask ventilation devices. etc. The remaining team members may listen while they complete any remaining noncritical (secondary) tasks such as measuring the urine output.28 Equipment issues are common during patient handovers. RT. it is important to ensure that necessary equipment is in good working order (ie. Once the patient is properly monitored and critical tasks are completed. OR ventilator circuit) until the patient is determined to be safe for transport. Team positions and roles for information transfer after initial tasks are completed.).29 Before transport. Some handover models. nurturing a proactive mindset. RN indicates registered nurse. batteries for infusion pumps. full oxygen cylinders. it may be advisable to travel with a transport kit with basic resuscitation and airway equipment and drugs. the relevant parties of the delivering and receiving teams gather at the foot of the bed in a sterile cockpit23 to conduct the transfer of information.com . functional monitor. These include meticulous preparation of equipment. intravenous pole wheels.

Providing the ICU with a list of expected patients allows unit managers to plan for bed and staffing needs. Phone calls are then made by OR personnel near surgical wound closure and just before patient transport to update the receiving team of any significant changes or special instructions. This bedside report should adequately describe the patient’s current status. or in writing.). The flow of information should begin as soon as the surgery schedule is published or the decision is made to admit a patient to the unit. and (3) provide care consistent with the overall care plan upon assuming responsibility. A list of handover www. spacing. Information Transfer Information communicated by the delivering team must enable the receiving team to perform 3 vital tasks: (1) prepare the staff. accurately. should contain sufficient information to allow the receiving team to develop a clinical picture of the patient. and inform the receiving team of any special considerations. isolation. The appropriate type and amount of information should be communicated clearly.Handovers From the OR to the ICU ’ 53 It is also helpful to familiarize transport teams with the location of code carts. ICU and OR staff collaboratively developed the form for the specific purpose of preparing the ICU physical environment and staff expectations for patient arrival. outline a plan of care. Figure 4 is an example of a manually completed worksheet intended to prepare the ICU for patient arrival. Sending a person in advance to reserve an elevator or clear the hallway of equipment or people is often helpful as well. and other resources for patient arrival. ventilators. A number of health information systems now provide real-time electronic anesthesia records that enable the ICU staff to monitor the patient’s clinical status during surgery. alternate treatment areas. and visual depictions to enhance usability and comprehension. Before the patient’s arrival to the ICU.anesthesiaclinics. etc. borders. communicated verbally. and efficiently. This preliminary report was designed for the OR circulating nurse and anesthesia provider to complete at a convenient time during the case (usually 45 to 60 min before patient transfer). (2) provide immediate medical care upon patient arrival. It is not intended to provide detailed clinical information or to duplicate data that will be handed over after patient arrival. a patient-specific report will help the ICU prepare for the patient’s arrival. A detailed verbal report should be provided to the receiving team after arrival to the ICU. appropriately prepare space and equipment (eg. and manage staff and workload. and means of summoning help in case it is needed. The form makes use of colors. this mode of communication has the potential to offer the ICU team a very detailed view of the patient’s condition during surgery. environment. This “preliminary” report. Although not formally evaluated in the OR to ICU handover literature. electronically.com .

patient. It is not intended to provide detailed clinical information or to duplicate data that will be handed over after patient arrival. Although most have intrinsic face validity. SSN. MRSA. HIV . Figure 5 is an example of such a checklist organized in a modified SBARQ (SBARQ is an acronym for a technique used to communicate information in a standardized and easily understood www. operating room. IV . a minimum data set should be created that will satisfy the informational needs of the delivering OR and receiving ICU teams. ICU. A single. estimated time of arrival. incisions. date of birth. infusions. The report is to be completed by the anesthesiology provider and circulator at a convenient time during the case. Gtts. interactive discussion at the patient’s bedside that involves all relevant team members is a powerful strategy to improve handovers. drains. OGT/NGT. nitroglycerin. Pt. patient or social security number. Anes indicates anesthesiology provider. Example of a hand-written report intended to prepare the ICU staff for patient arrival. it may prove impractical or even detrimental to include them all. orogastric tube/nasogastric tube.com . ETA. and any active therapy being delivered such as vasoactive drug infusions. RN. tubes. registered nurse. DOB. Participation from all team members enables crosschecking and validation of information transferred and creates an opportunity to rapidly perform a joint physical scan of the patient to verify the location and condition of lines. methicillinresistant Staphylococcusaureus. Preliminary report.anesthesiaclinics. Instead. past medical history. VRE. HEP . “Read and verify” checklists may be used as quick memory aids to provide logical structure to the report and ensure that all important items have been addressed. vancomycin-resistant enterococcus. information items frequently cited in the literature can be found in the Table 1. hepatitis. intensive care unit. OR. face-to-face. Intravenous Line. human immunodeficiency virus.54 ’ Bonifacio et al Figure 4. PMHX. NTG.

Handover Information Items Frequently Recommended in the Literature15 Patient Information Name Age Allergies Diagnosis Procedure performed Medical history Anesthesia information Type of anesthesia and course Intraoperative medications (dose and time) IV fluids administered Blood products administered (type and amount) Estimated blood loss Tubes/lines/wires Surgical information Surgical course Surgical site information (dressing. limiting speakers to one at a time). drains) Surgical complications and interventions CPB/circulatory arrest/cross clamp/other procedure durations Current status Assessment of hemodynamic stability Care plan Anticipated recovery and problems Postoperative management plan Postoperative orders and investigations Monitoring plan with parameters Analgesia plan Plan for IV Fluid.23. and Questions23) format.anesthesiaclinics. medications.31 By sharing and reviewing vital information as a complete team.7.30.”32 In the context of an OR to ICU handover. The critical meeting between the delivering and receiving teams optimally occurs in a “sterile cockpit. tubes. format. intravenous.” a concept adapted from the Federal Aviation Industry that prohibits “any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties. www. IV. Recommendation. safety will improve as errors can be better detected and their effects mitigated. Background. establishing clear roles and responsibilities. and prohibiting discussions unrelated to the transfer of the patient. Assessment. a sterile cockpit can be created by eliminating distractions (eg. antibiotic. the receiving team must be given an opportunity to ask questions to ensure that they have a complete and accurate understanding of the information delivered. turning the television off.com .Handovers From the OR to the ICU ’ 55 Table 1. Before the conclusion of the handover. deep venous thrombus prophylaxis Nasogastric feeding CBP indicates cardiopulmonary bypass. The acronym stands for: Situation.

CT. EBL. converting them into enduring. vital signs. and evaluate processes. One helpful approach is to use an established quality improvement model. intensive care unit. RN. Read and verify checklist. chest tubes. systems improvement using observable. history. and employing a cyclical process of continuous improvement. such as Lean Six Sigma. Example of a cognitive aid developed for use during the bedside transfer of information. intravenous. The checklist is intended to reduce error by providing a general structure to the delivery of information and as a reminder to prevent the omission of important items. ’ Change Management Although these recommendations to improve handovers may sound simple. institutional practice is challenging. Responsibility Transfer The final component of the handover is the formal transfer of responsibility and accountability from the delivering OR team to the receiving ICU team. IV . registered nurse. ICU.33 Plan-Do-Study-Act.56 ’ Bonifacio et al Figure 5.25 Although each model offers a unique framework to systematically study.com . including the importance of active engagement from executive and front-line leaders. they have specific principles in common. Hx. A/V wires indicates arterial/ventricular wires. estimated blood loss. measurable data.anesthesiaclinics. www. improve. VS. The transfer must be an explicit verbal (and eventually documented) acknowledgment from the receiving team that responsibility for care has been accepted and assumed.34 or Team STEPPS.

piloting on live patients can be conducted. Including stakeholders in this effort will promote a sense of ownership and generate support for the proposed changes. investigators can draw upon the experiences. and ideas of handover team members to gain deeper insight into the process and develop solutions that may better meet the needs of its end users. and focus groups. or simulating the new handover process in a controlled environment. from formal leaders at all levels gives the project legitimacy and establishes expectations from subordinate leaders. Before implementation. it will be important to gain the support and active engagement of leaders and other key stakeholders. modified based on facts learned. and then reexamined to determine if the desired outcomes were achieved. identify subtle or rare events not captured because of a small sample size. and decipher differences between perceptions and reality. and not proximal causes of errors. Implementation Many would agree that strategy development is easy when compared with implementation and sustainment. The only published study known that examined the sustainability of a postoperative handover intervention reported that only partial compliance with strategies to www. 1 or 2 trained observers can collect data that can be compiled to create process maps or other visual depictions of the current handover system. A deeper understanding may be gained by combining this “snapshot” with contextual data collected from those involved in the handover. increasing the likelihood that new strategies address root.Handovers From the OR to the ICU ’ 57 Before beginning a project to improve patient handovers. Once the new process is sufficiently refined through iterative testing in simulation. By adding context to what is observed. At the heart of any quality improvement framework lies a systematic cycle of continuous improvement where processes are methodically examined. Their support will be essential to overcoming barriers to change. the sense of ownership and buyin fostered through staff participation will play importantly during implementation. The type and amount of data collected will depend on the scope of the project and the resources available. Using an observation checklist. An objective and detailed description of current handovers can be achieved by direct field observations. can facilitate the detection of faults in the design. investigators will be better able to recognize patterns in handovers. process modeling. Consequently. By first studying a process.anesthesiaclinics.com . perspectives. Explicit support in writing. Through interviews. an accurate assessment of existing practices can be made. Getting early support from front-line workers who possess influence over resources and staff will also increase the likelihood of effective change. and ideally active involvement. surveys.

ICU. pulse oximeter oxygen saturation. nasogastric tube. SBARQ. intensive care unit. central venous pressure. blood pressure. HIV . Background.58 ’ Bonifacio et al improve information transfer and limit interruptions was achieved 3 years after implementation. RN. registered nurse.anesthesiaclinics. methicillin-resistant Staphylococcus aureus. and Questions. MD. ECG. Implementation begins by educating all involved staff in the new handover Figure 6. HEP . MRSA. thermodilution cardiac output. NGT. pulmonary arterial pressure. Handover sustainment poster. Example of educational poster developed for display in high traffic areas of OR and ICU. OR. electrocardiogram. Assessment. CVP . estimated time of arrival. past medical history. BP . PMHX.35 Adequate preparation for implementation is a key to success. Anes indicates anesthesiology provider. human immunodeficiency virus. NIBP . hepatitis. ETA. www. medical doctor. SPO2. PAP . endotracheal tube. operating room. TDCO.com . Recommendations. Situation. noninvasive blood pressure. ETT.

37 However. flyers. including scalability. and brief presentations during OR and ICU staff meetings are useful methods of publicizing the new process. Codifying the new handover into policy will establish it as a clear expectation. versions of the instruments used to initially examine the process can be reapplied to compare results. These materials should be widely available in break rooms. some forms of simulation such as high-fidelity mannequin-based simulation. Recent evidence has shown that other. Once the handover is being performed regularly. and other common areas.com . Implementation of the new handover process. www. newsletter articles. convenience. In health care. Training must be schedule-friendly. It is important to immerse the target units with resources to facilitate the transition. This level of support can be scaled down as the process gains traction. Current handover training initiatives such as 3Di Teams developed at Duke University employ this concept by first allowing learners to master concepts in games-based learning before moving to high-fidelity simulation to begin interprofessional learning and to focus on nuances of care. informal support by front-line champions. less costly forms of simulation can be equally effective in the learning process and in the transfer of skills to patient care. distributability. Introductions by formal leaders. Further refinements can then be made using these data. accessibility. Active coaching in the new handover by process owners or frontline leaders is key to success. impactful. 6). can be prohibitively expensive. posters. The authors have no conflicts of interest to disclose .38 Alternative forms of simulation such as games-based learning offer several advantages over mannequin-based simulation.anesthesiaclinics. which blend these and other learning solutions such as active coaching. and built-in assessment. and fun. Easy-to-understand checklists and protocols serve to explain the redesigned handover process and to facilitate the transition (Fig.39 Multimodal training platforms. and a genuine demonstration of enthusiasm by process owners will help in generating excitement and buy-in. may maximize efficacy and efficiency. should be a celebrated event. standardization. The active endorsement or even mere presence of both formal and informal leaders will demonstrate their commitment to improvement and convey the project’s importance. address unplanned issues that may arise. or “Go live” day. education classrooms.Handovers From the OR to the ICU ’ 59 strategies. and support the staff. simulation is an effective educational strategy36 and is increasingly associated with improved patient care. nursing stations. Informative emails.

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