International Journal of Health Care Quality Assurance

Standardized ICU to OR handoff increases communication without delaying surgery

Juan Luis Sandin Marquez, Melanie S. Gipp, Stephen P. Kelleher, Paul J. Sharek, Thomas J. Caruso,
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To cite this document:
Juan Luis Sandin Marquez, Melanie S. Gipp, Stephen P. Kelleher, Paul J. Sharek, Thomas J. Caruso, (2017) "Standardized
ICU to OR handoff increases communication without delaying surgery", International Journal of Health Care Quality
Assurance, Vol. 30 Issue: 4,pp. -, doi: 10.1108/IJHCQA-02-2016-0015
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 1

Standardized ICU to OR Handoff Increases Communication without Delaying Surgery

Introduction

Ineffective handoffs may lead to an increased risk of patient harm (Saager et al., 2014).

The Joint Commission has reported that communication errors contribute to two-thirds of all

reported sentinel events, with more than half of these related to handoffs (Joint Commission

Perspectives on Patient Safety, 2007). The Joint Commission requires providers to implement
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standardized handoff communications that include an opportunity to ask and respond to

questions as stated in National Patient Safety Goal 2E. The Agency for Healthcare Research and

Quality and the Institute of Medicine have also recommended standardized handoffs to improve

patient safety (Institute of Medicine, 2001, Agency for Healthcare Research and Quality, 2012).

As previously reported by other industries that have high emphases on safety such as aviation

and Formula 1 racing, standardized protocols create models of efficiency that maximize

information transfer while minimizing process duration (Catchpole et al., 2007). Similar to these

industries, standardized patient handoffs have been shown to increase the transfer of information,

decrease adverse events, and increase provider satisfaction without affecting the duration of

handoff (Agarwala et al., 2015, Bigham et al., 2014, Petrovic et al., 2012, Starmer et al., 2012,

Starmer et al., 2014).

Previous studies that have investigated handoffs in the perioperative setting have focused

on postoperative handoffs to the post anesthetic care unit (PACU) or intensive care unit (ICU)

(Agarwal et al., 2012, Petrovic et al., 2012, Petrovic et al., 2012, Boat and Spaeth, 2013, Caruso

et al., 2015, McElroy et al., 2015, Dixon et al., 2015). No studies have examined preoperative

handoffs from the ICU to OR (Evans et al., 2014). Up to 70% of transports involving ICU

patients experience an adverse event and over 30% of these occur during patient transport to the
 2

OR (Ong and Coiera, 2011, Waydhas, 1999, Beckmann et al., 2004). Poor communication has

been attributed to 10% percent of the critical incidents occurring during the transport of ICU

patients (Beckmann et al., 2004).

Given the risk of patient harm during ICU to OR transitions of care, we developed a

standardized ICU to OR handoff using components derived from a recent handoff study that

demonstrated a 69% decrease in handoff-related care failures across 23 children’s hospitals

(Bigham et al., 2014). Specifically, we incorporated the following components into the
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standardized handoff: defined intent, defined content, standardized tools and methods,

standardized format, clear and timely transition of responsibility, and maximized team

effectiveness (Bigham et al., 2014). The standardized format of the handoff is based on the I-

PASS mnemonic (illness severity, patient summary, action list, situation awareness, and

synthesis by receiver) because it has been to shown to significantly reduce medical errors

(Starmer et al., 2014).

The primary aims of the study were to determine whether this standardized ICU to OR

handoff process would increase the number of face-to-face multi-disciplinary team handoffs and

improve patient readiness for transport. Secondary aims were to determine if the process would

improve anesthesiologists’ satisfaction with the handoff without delaying surgery timeliness as

defined by on-time surgical starts and turnover time between surgeries.

Methods

Study Design and Setting

We conducted a prospective cohort study at a 311-bed, freestanding, academic, pediatric

hospital in Northern California containing 19 anesthetizing locations (defined below), 40-bed

neonatal intensive care unit (NICU), 24-bed pediatric intensive care unit (PICU), and 20-bed
 3

cardiovascular intensive care unit (CVICU). In this study, we define anesthetizing locations to

include the operating rooms, ambulatory procedure rooms, interventional radiology suites, and

cardiac catheterization rooms, and the ICU to include the NICU, PICU and CVICU.

The Institutional Review Board reviewed and approved a waiver of consent for this

study. The study took place between October 2013 and June 2014 and consisted of the following

phases:

1. Development of the handoff process (October 1, 2013 through October 31, 2013)
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2. Pre-intervention handoff audits (November 1, 2013 to Jan 31, 2014)

3. Intervention (February 1, 2014 to February 28, 2014)

4. Post-intervention handoff audits (March 1, 2014- May 31, 2014)

Sample size for the primary outcome was determined a priori. To show an increase in

frequency of a standard handoff from 25% to 80% with a significance at the 5% level and power

of 80%, a sample size of 13 pre and post- intervention (26 total) was required. Additional audits

above sample size requirements were completed to increase power.

Study Population

Patients were included if they were transferred from the CVICU, PICU, and NICU to the

OR. Surgical procedures performed in the ICU and emergent cases which occurred overnight or

during the weekend were excluded from the study.

Intervention

Our institution has adopted the I-PASS mnemonic as a hospital-wide guide for effective

handoff communication (Starmer et al., 2012, Starmer et al., 2014). Although the I-PASS

mnemonic provides an outline for handoff delivery, it does not dictate which providers should
 4

participate in the handoff. Prior to intervention, provider presence at handoffs between ICU and

OR was highly variable.

The first goal of the new handoff process was to require a face-to-face multi-disciplinary

handoff including participation by the ICU physician, ICU nurse, and respiratory technician as

the ‘senders’ and the anesthesiologist and OR nurse as the ‘receivers.’ The ‘Patient Summary’

aspect of the I-PASS mnemonic was reported in a traditional organ system-based approach

common to ICUs.
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The second goal of the new handoff process was to routinize communication between the

OR and ICU prior to patient transport. As part of the structured handoff process, anticipatory

phone calls were implemented to provide appropriate time for patient preparation and gathering

of ICU team members at the patient’s bedside for the handoff. These phone calls consisted of

the following: a) 45 minutes prior to surgery, the OR nurse notified the ICU nurse to allow

sufficient time to begin standard transport set up; b) 5 minutes prior to transport by the

anesthesiologist, the OR nurse notified the ICU nurse who would then gather appropriate ICU

personnel at the patient bedside for face-to-face handoff.

Education efforts targeted anesthesiologists, ICU physicians, OR nurses, ICU nurses, and

ICU respiratory technicians, and included presentations at ICU staff meetings, ICU nursing

leadership committee meetings, pediatric anesthesia staff meetings, and OR nursing staff

meetings. In addition to formal presentations, the study team sent educational information via

email and met informally with vested parties to address questions and to clarify the new process

as needed. A visual cognitive aid was designed for ICU nurses to aid the preparation of patient

readiness. A member of the study team was made available throughout the intervention phase to

help with on-site training and to answer questions and provide reminders.
 5

A member of the study team interviewed the anesthesiologist involved in each ICU to OR

patient transport to determine: 1) presence of a standardized, multi-disciplinary face-to-face

handoff and 2) patient readiness for transport. After the pre-intervention and intervention phases

were completed, a written satisfaction survey (Table I) regarding ICU to OR handoffs were

distributed to the anesthesiologists both electronically and in paper form. Turnover times

between cases and scheduled versus actual start times of first cases were also collected via

review of electronic medical records (EMR).

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Outcomes

Primary Outcomes

The primary outcome measures for this study were: 1) Frequency of formal handoff

occurrence and 2) Transport readiness. Frequency of formal handoff occurrence was defined as

the percentage of audited handoffs in which the anesthesiologist stated a face-to-face transition

using the I-PASS format occurred between ICU team and the physician anesthesiologist and OR.

Transport readiness was defined as the percentage of all audited handoffs in which the

anesthesiologist stated the patient was ready for transport at the time the anesthesiologist arrived

at bedside.

Secondary Outcomes

The secondary outcome measures were: 1) frequency of on-time first case surgery starts,

2) average duration of first case delays, 3) turnover times for non-first case surgeries, and 4)

anesthesiologist satisfaction with the ICU to OR handoff process. Frequency of on-time first

case surgery starts were defined as the percentage of surgeries scheduled as the first case of the

day whose actual start time matched the scheduled start times. Average duration of first case

surgery delays was defined as the mean time (minutes) between start time and scheduled start
 6

time of the first surgical case of the day. Turnover times for non-first case surgeries was defined

as the elapsed time (minutes) between the prior patient having exited the OR until the following

ICU patient arrived into the OR. Anesthesiologists’ satisfaction with the handoffs was assessed

immediately after the pre-intervention period, and then immediately after the post-intervention

periods using an anonymous satisfaction survey. Providers were asked to rate 9 questions using

a 5-point Likert scale (1= “Strongly Disagree” to 5= “Strongly Agree”) (Table I). Likert scores

for individual questions were summed to provide a total overall satisfaction score for each
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provider. Pre- and post-intervention surveys were paired using uniquely coded surveys.

Data Collection and Statistical Analysis

Observers collected data using paper instruments. Study data were managed using the

REDCap (Research Electronic Data Capture) tool v6.4.3 (Harris et al., 2009). REDCap is a

secure, Web-based application designed to support data capture for research studies, providing

(1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation

and export procedures, (3) automated export procedures for seamless data downloads to common

statistical packages, and 4) procedures for importing data from external sources.

Study data were analyzed using SAS 9.4 (SAS Institute, Cary, North Carolina). To test

for statistical significance, Fisher’s Exact Test was conducted to compare frequency of patient

handoffs and patient readiness pre- and post-intervention as well as frequency of on-time starts

for the first surgical cases of the day pre- and post-intervention. The Mann-Whitney U Test was

conducted to compare delay (minutes) in the first surgical cases of the day pre- and post-

intervention. A two-sample t-test was conducted to compare turnover time between surgeries

pre- and post-intervention. The Wilcoxon signed rank sum test was conducted to determine

changes in anesthesiologists’ satisfaction scores pre- and post- intervention. Values consisting of
 7

mean values are presented as mean +/- standard deviation while values consisting of median

values are presented as median (Interquartile Range ‘IQR’). Results were considered to be

statistically significant if p values were <0.05.

Results

Handoff and Patient Readiness

Twenty-eight audits were completed during the pre-intervention phase and 29 were

completed during the post-intervention phase. The frequency of standardized handoffs increased
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significantly from 25% (7 of 28) to 86% (25 of 29) (p<.0001) and the frequency of patient

readiness increased from 61% (17 of 28) to 97% (28 of 29) (p=.001) (Figure 1).

Timeliness and Turnover Time

Of the 28 pre- and 29 post-intervention audits, 14 pre- and 12 post- audits, involved

surgeries that were scheduled as the first case of the day. There were no changes in timeliness of

these cases as 50% (7 of 14) versus 58% (7 of 12) (p=.72) started on time. Of those cases that

were late, there was no change in duration of delay (11.7 min +/- 7.6 vs. 11.9 min +/- 6.6)

(p=.96). Turnover times between surgeries, not scheduled as first cases, were recorded for 10 of

14 pre-intervention and 17 of 17 post-intervention audits. Of these 4 pre-intervention audits

without turnover times, 3 did not have a case scheduled immediately prior to the audited case

and data collection for the remaining audit was unable to be completed due to technical errors

with the EMR. There was no significant change in these turnover times (58.4 min +/-17.9 versus

53.8 min +/- 16 min) (p=.51).

Anesthesiologists’ Satisfaction

Twenty-four anesthesiologists’ satisfaction surveys were completed pre-intervention and

21 surveys were completed post-intervention. Nine of these were paired based on the unique
 8

identification codes. The unpaired surveys reflect variability within the anesthesia personnel

between the two time periods. Paired median satisfaction scores increased significantly from 23

(IQR 19-28) to 32 (IQR 28-36) (p=.002) (Figure 2).

Discussion

This is the first study we are aware of describing the effects of implementing a

standardized ICU to OR handoff process. In this study, we have shown that implementation of a

reliable process for preoperative ICU to OR transfers increased the frequency of face-to-face,
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standardized handoffs, improved patient readiness for ICU to OR transport, and increased

anesthesia provider satisfaction without delaying surgery timeliness. This study adds critical

information to enhance safety during the high-risk perioperative timeframe, augmenting the

multiple OR to postoperative setting handoff studies that have shown improved information

transfer and provider satisfaction and decreased technical errors and omissions of information in

the OR to ICU and OR to PACU settings (Petrovic et al., 2012, Catchpole et al., 2007).

The ICU to OR transition contains significant risk to patient safety. Factors that place

these patients at higher risk include labile vital signs, complex medical problems, inability to

self-report information due to age, intubation or altered mental status and the increased number

of within-ICU handoffs resulting from increased ICU shiftwork (Evans et al., 2014, Saager et al.,

2014). Previous studies with similar handoff components have shown significant reductions in

handoff related care failures and decreases in medical errors (Bigham et al., 2014, Starmer et al.,

2014). Since effective provider communication has been shown to reduce harm, we believe that

the increased number of standardized handoffs shown in this study likely mitigates the risk of

harm during the high risk ICU to OR transition of care (Bigham et al., 2014).
 9

There were several limitations to our study. First, we used face-to-face handoffs as a

surrogate to indicate decreased risk of harm based on previous studies that have determined

miscommunication to be a factor affecting patient safety. Second, although over 20 anesthesia

satisfaction surveys were completed both pre- and post-intervention, only a subset were paired.

However, no significant differences were noted between unpaired and paired surveys for either

pre- or post-intervention satisfaction scores so it is unlikely that this affected the results. Third,

although the Hawthorne effect may potentially cause the improvements seen in handoffs and
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patient readiness, it is unlikely a major driver of these changes as it would have affected both

pre- and post-intervention behaviors similarly. Fourth, as with many substantial improvement

efforts, obstacles to process sustainment occurred, namely employment shifts in the ICU and OR.

Using the local quality improvement teams in these areas, we incorporated handoff education

into employee orientation. We also leveraged the local improvement teams to facilitate

communication of short term wins and barriers being encountered during the implementation and

maintenance phase of the process.

Conclusion

Transitions of care pose a high risk to patients especially when handoffs involve

complex, critically ill patients in the perioperative setting. This risk can be mitigated by

standardized handoffs between providers. Implementation of a face-to-face handoff process

between the ICU and anesthesia providers prior to transfer from the ICU to the OR provides

standard handoff information and improves patient readiness for transport. This shifts the focus

from basic, preparatory tasks to higher-level thinking necessary for quality patient care, and

improves satisfaction with patient handoffs. Additional research is needed to optimize the

effectiveness and efficiency of these handoffs.

 10

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 Table 1. Anesthesiologists’ Satisfaction Survey

Strongly Strongly
Disagree Neutral Agree
Disagree Agree
Overall, I am satisfied with ICU to
Anesthesia transition of care ☐ ☐ ☐ ☐ ☐

In the current state, the ICU care

team consistently provides a handoff
☐ ☐ ☐ ☐ ☐
with pertinent information

The hand-off period is free from

distractions ☐ ☐ ☐ ☐ ☐
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The ICU nurse has the patient

prepared for the OR when the
☐ ☐ ☐ ☐ ☐
anesthesia team arrives in the room

I am provided scheduled medications

in prefilled syringes at the time of
☐ ☐ ☐ ☐ ☐
handoff

I receive anticipatory guidance about

potential problems that may arise
during the transition of care from the ☐ ☐ ☐ ☐ ☐
ICU to anesthesia care

The ICU to anesthesia transition of

care is timely ☐ ☐ ☐ ☐ ☐

The ICU to anesthesia transition of

care is safe ☐ ☐ ☐ ☐ ☐

An ICU to anesthesia handoff

contributes to improved patient care ☐ ☐ ☐ ☐ ☐
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Figure 1: Patient Handoffs and Patient Readiness Pre- and Post-Intervention

Figure 1
152x114mm (220 x 220 DPI)
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Figure 2: Paired Pre- and Post-Intervention Anesthesiologists’ Satisfaction Scores

Figure 2
244x183mm (67 x 67 DPI)