Intraoperative Handoff Research Articles

Surgical Intraoperative Handoff Initiative: Standardizing Operating Room Communication Using SHRIMPS.

Operating room (OR) handoffs are not universally standardized, although standardized sign outs have been proven to provide effective communication in other aspects of healthcare. We hypothesize that creating a standardized handoff will improve communication between OR staff. A frontline stakeholder approached our quality improvement team with concern regarding inadequate quality surgical technician handoffs during staff changes. An audit tool was created for a pilot cohort of 23 cases to evaluate surgical technician handoffs from May 2022 to November 2022. Handoffs occurred in 82.6% of cases. Elements of handoff varied significantly, with an average of 34.4% completion of critical handoff elements. Audits were reviewed with stakeholders to develop a standardized communication checklist, including domains regarding sponges, sharps, hidden items, replaced items, instruments, implants, medications, procedure overview, and specimens. An acronym of these domains, SHRIMPS, was affixed to each OR wall. In the initial Plan-Do-Study-Act cycle, piloted in urology, general surgery, and neurosurgery, 100% of the 15 observed cases included handoff, averaging 76 seconds per handoff. Additionally, 100% of cases announced a handoff to the surgeon, and all elements were addressed 99.6% of the time. Plan-Do-Study-Act cycle 2 involved implementation to all service lines. Of the 68 cases observed, 100% included handoff, averaging 69.4 seconds per handoff, with 98.2% of elements addressed, though only 97.1% of handoffs were announced. Little communication standardization exists within the OR, especially regarding intraoperative staff changes. Implementation of a standardized handoff between surgical technicians resulted in substantial improvement in critical communication during staff changes.

MP48-10 SURGICAL INTRAOPERATIVE HANDOFF INITIATIVE: STANDARDIZING OPERATING ROOM COMMUNICATION USING A VISUAL COGNITIVE AID

You have accessJournal of UrologyCME1 Apr 2023MP48-10 SURGICAL INTRAOPERATIVE HANDOFF INITIATIVE: STANDARDIZING OPERATING ROOM COMMUNICATION USING A VISUAL COGNITIVE AID Wesley Wilt, Brittany Levy, Sherry Lantz, and Andrew Harris Wesley WiltWesley Wilt More articles by this author , Brittany LevyBrittany Levy More articles by this author , Sherry LantzSherry Lantz More articles by this author , and Andrew HarrisAndrew Harris More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Operating room (OR) staff changes can potentiate communication failures, potentially leading to adverse events and disruption of OR flow. OR handoffs are not universally standardized, though standardized sign outs have been proven to provide effective communication in other aspects of healthcare. We hypothesize creating a standardized handoff, with persistent auditing, will result in highly reliable, standardized communication between OR staff members. METHODS: An engaged frontline stakeholder approached our OR quality improvement (QI) team, led by a QI experienced urology faculty member, with concern regarding lack of information discussed during surgical technician handoffs during staff changes. Following, the Surgical Intraoperative Handoff Initiative commenced from 5/2022 through 9/2022. The OR QI team created an audit tool for preliminary data collection, and current handoffs were audited. The pilot cohort of audits was discussed with stakeholders, including intraoperative staff and OR leadership, to develop a standardized communication protocol. A finalized communication tool was created with domains regarding sponges, sharps, hidden items, replaced items, instruments, implants, medications, procedure overview, and specimens. As a memory aid, an acronym of these domains, SHRIMPS, was affixed to each OR wall. RESULTS: 23 cases were observed both pre- and post-implementation. Handoffs occurred in 83% of cases pre-intervention, of which only 42% included communication with the surgeon, and the elements of the handoff varied. Sharps were discussed in 78%, instrument needs in 61%, medications in 65%, specimens requiring collection in 39%, and hidden items in 30% of handoff communications. In the initial Plan-Do-Study-Act (PDSA) cycle, piloted and audited in urology, general surgery, and neurosurgery after implementation of the standardized handoff, 100% of the 15 observed cases had a handoff performed, averaging 65 seconds per handoff. Additionally, 100% of cases announced a handoff to the surgeon, and all elements were addressed 99.6% of the time. PDSA cycle 2 involved implementation to all service lines, and of the 9 cases observed, 100% had a handoff performed at an average of 86 seconds per handoff, with 100% of elements addressed. CONCLUSIONS: Little standardization of communication exists within the OR, especially regarding intraoperative staff changes. Implementation of a standardized handoff resulted in substantial improvement in critical communication during staff changes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e658 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wesley Wilt More articles by this author Brittany Levy More articles by this author Sherry Lantz More articles by this author Andrew Harris More articles by this author Expand All Advertisement PDF downloadLoading ...

Perioperative Handoffs

Safety Tip of the Month| April 2023 Perioperative Handoffs ASA Monitor April 2023, Vol. 87, 9. https://doi.org/10.1097/01.ASM.0000924940.04175.39 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Perioperative Handoffs. ASA Monitor 2023; 87:9 doi: https://doi.org/10.1097/01.ASM.0000924940.04175.39 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: perioperative care, transition of care There is growing literature studying the role of perioperative handoffs. This has included efforts to understand the extent to which the occurrence of an intraoperative handoff itself is helpful or harmful, interventions to improve handoffs when they occur, and protocols for the transition of a patient to a different care setting (e.g., PACU or ICU) (Anesth Analg 2021;132:1559-62; Crit Care Med 2018;46:1863-4; Br J Anaesth 2021;127:830-3; BMJ Qual Saf 2021;30:513-24). The conversation on this topic has persisted for decades, and it likely would not take long to find a perioperative clinician with an opinion on the matter. It is valuable that work on handoffs continues to be done and adds valuable insight. As the concept of perioperative handoffs represents a broad range of care areas and practices, the literature varies based on the specific question asked. In a systematic review of intraoperative anesthesia handoffs and... You do not currently have access to this content.

Beyond the Surgical Safety Checklist: Using Intraoperative Handoff to Facilitate Team Situation Awareness in the OR.

The surgical safety checklist (SSC) has been credited with improving team situation awareness (SA) in the operating room. Although the SSC may support team SA at the outset of the operative case, intraoperative handoff provides an opportunity for either SA breakdown or, more preferably, SA reinforcement. High-functioning surgical teams demonstrate a high level of continued SA, whereas teams deficient in SA are more likely to be affected by surgical errors and adverse events. To date, no interprofessional intraoperative tools exist to support team SA beyond the SSC. This study was divided into 2 phases. The first used qualitative methods to (1) characterize intraoperative handoff processes across surgery, nursing, anesthesia, and perfusion, and (2) identify cultural factors that shaped handoff practices. Data for phase one were collected over 38 observation days and 41 brief interviews. Phase 2, informed by phase 1, used a modified Delphi process to create a tool for use during intraoperative handoff. Data were analyzed iteratively. Handoff practices were not standardized and rarely involved the entire team. In addition we uncovered cultural factors-specifically assumptions held by participants-that hindered team communication during handoff. Assumptions included: (1) team members are interchangeable, (2) trained individuals are able to determine when it is appropriate to handoff without consulting the OR team. Despite claims of improved teamwork resulting from the SSC, many participants held a fragmented view of the OR team, resulting in communication challenges during handoff. Findings from both phases of our study informed the development of multidisciplinary intraoperative handoff tools to facilitate shared team situation awareness and a shared mental model. Intraoperative handoff occurs frequently, and offers the opportunity for either renewed or fractured team SA beyond the SSC.

A Collaborative Partnership between the Multicenter Handoff Collaborative and an Electronic Health Record Vendor.

Objectives The operating room is a specialized, complex environment with many factors that can impede effective communication during transitions of care between anesthesia clinicians. We postulated that an efficient, accessible, standardized tool for intraoperative handoffs built into standard workflow would improve communication and handoff safety. Most institutions now use an electronic health record (EHR) system for patient care and have independently designed intraoperative handoff tools, but these home-grown tools are not scalable to other organizations and lack vendor-supported features. The goal of this project was to create a standardized, intraoperative handoff tool supported by EHR functionality. Methods The Multicenter Handoff Collaborative, with support from the Anesthesia Patient Safety Foundation, created a working group of frontline anesthesia experts to collaborate with a development team from the EHR vendor (Epic Systems) to design a standardized intraoperative handoff tool. Over 2 years, the working group identified the critical elements for the tool and software usability, and the EHR team designed a standardized intraoperative handoff tool that is accessible to any institution using this EHR. Results The first iteration of the intraoperative handoff tool was released in August 2019, with a second version in February 2020. The tool is standardized but customizable by individual institutions. Conclusion We demonstrate that work on complex health care processes critical to patient safety, such as handoffs, can be performed on a national scale through cross-industry collaboration. Frontline experts can partner with health care industry vendors to design, build, and release a product on an accelerated timeline.

Systematic Review of Intraoperative Anesthesia Handoffs and Handoff Tools.

Intraoperative handoffs between anesthesia clinicians are critical for care continuity. However, such handoffs pose a significant threat to patient safety. This systematic review synthesizes the empirical evidence on the (a) effect of intraoperative handoffs on outcomes and (b) effect of intraoperative handoff tools on outcomes. All studies on intraoperative handoffs and handoff tools published until September 2019, in any study setting and population, and with no prespecified criteria on the type of comparison and outcome were included. Data extracted from the included studies were aggregated to identify common patterns related to the type of surgery, clinician(s) involved, patient population, handoff tool, the tool design approach (where relevant), tool implementation strategies, and finally, all reported clinical and process outcomes. Quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Fourteen studies met the inclusion criteria. All included studies used adult patients. Eight studies were retrospective cohort studies that used administrative or electronic health record (EHR)-based databases to investigate the effects of intraoperative handoffs on morbidity and mortality. These studies included a total of 680,855 surgeries, with 139,426 of these surgeries having at least 1 handoff (20.47%). Seven of the studies found a positive association between intraoperative handoffs and considered outcomes. However, a pooled meta-analysis across these studies was not feasible across the retrospective studies due to differing surgical populations and varying definitions of the considered outcomes. Six studies used a nonrandomized prospective design to evaluate the effects of handoff tools on process-based outcomes such as clinician satisfaction, information transfer, handoff duration, and adherence. Five of the 6 handoff tools were checklist based. All prospective tool-based studies relied on small samples and reported a significant improvement on the considered process-based outcomes. The median quality score among retrospective (median [interquartile range {IQR}] = 9 [1]) was significantly higher than that of prospective (median [IQR] = 5 [1.5]) studies (U = 21, P = .0017). This systematic review provides a unique appraisal of the current state of intraoperative handoff research. To improve the quality and outcomes of handoffs, future efforts should focus on design and implementation of standardized handoff tools integrated within EHR systems, consider the use of similar metrics for evaluating handoff process and clinical outcomes, and improve the execution and reporting of studies using standard protocols and guidelines.

Evaluation of Intraoperative Hand-Off Frequency, Duration, and Context: A Mixed Methods Analysis

BackgroundHand-offs in the operating room contribute to poor communication, reduced team function, and may be poorly coordinated with other activities. Conversely, they may represent a missed opportunity for improved communication. We sought to better understand the coordination and impact of intraoperative hand-offs. MethodsWe prospectively audio-video (AV) recorded 10 operations and evaluated intraoperative hand-offs. Data collected included percentage of time team members were absent due to breaks, relationships between hand-offs and intraoperative events (incision, surgical counts), and occurrences of simultaneous hand-offs. We also identified announcement that a hand-off had occurred and anchoring, in which team members not involved in the hand-off participated and provided information. ResultsSpanning 2919 min of audio-video data, there were 74 hand-offs (range, 4-14 per case) totaling 225.2 min, representing 7.7% of time recorded. Thirty-two (45.1%) hand-offs were interrupted or delayed because of competing activities; eight hand-offs occurred during an instrument or laparotomy pad count. Six cases had simultaneous hand-offs; two cases had two episodes of simultaneous hand-offs. Eight hand-offs included an announcement. Seven included anchoring. Evaluating both temporary and permanent hand-offs, one or more original team members was absent for 40.7% of time recorded and >one team member was absent for 20.5% of time recorded. ConclusionsIntraoperative hand-offs are frequent and not well coordinated with intraoperative events including counts and other hand-offs. Anchoring and announced hand-offs occurred in a small proportion of cases. Future work must focus on optimizing timing, content, and participation in intraoperative hand-offs.

Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study

BackgroundThe significance of intraoperative anesthesia handoffs on patient outcomes are unclear. One aspect differentiating the disparate results is the treatment of confounding factors, such as patient comorbidities and surgery time of day. We performed this study to quantify the significance of confounding variables on composite adverse events during intraoperative anesthesia handoffs.MethodsIn this retrospective study, we analyzed data from the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP). We examined the effects of intraoperative handoffs between anesthesia personnel. A total of 12,111 cases performed examined at two hospitals operated by a single healthcare system that were that included in the ACS NSQIP database performed. The presence of attending and anesthetist or resident handoffs, patient age, sex, body mass index, American Society of Anesthesiologists Physical Status (ASA-PS) classification, case length, surgical case complexity, and evening/weekend start time were measured.ResultsA total of 2586 of all cases in the NSQIP dataset experienced a handoff during the case. When analyzed as a single variable, attending handoffs were associated with higher rates of adverse outcomes. However, once confounding variables were added into the analysis, attending handoffs and complete care transitions were no longer statistically significant.ConclusionsInclusion of significant covariates is essential to fully understanding the impact provider handoffs have on patient outcomes. Case timing and lengthy case duration are more likely to result in both a handoff and an adverse event. The impact of handoffs on patient outcomes seen in the literature are likely due, in part, to how covariates were addressed.

Consensus Recommendations for the Conduct, Training, Implementation, and Research of Perioperative Handoffs.

Consensus Recommendations for the Conduct, Training, Implementation, and Research of Perioperative Handoffs.

Status of Operating Room Nurses’ Intraoperative Hand-off

Status of Operating Room Nurses’ Intraoperative Hand-off

Intraoperative Handoffs Among Anesthesia Providers Increase the Incidence of Documentation Errors for Controlled Drugs

When electronic anesthesia records are compared to pharmacy transactions, discrepancies in total doses of controlled drugs are commonly found (≈16% of cases), potentially affecting patient safety and placing hospitals at risk for regulatory action. Errors (≈5%) persisted even with near real-time drug reconciliation feedback to providers. A study was conducted to test the hypothesis of greater risks of discrepancy for longer-duration cases and for intraoperative handoff involving a permanent handoff of care. Anesthesia drug documentation and pharmacy transaction data were examined for all anesthetics between May 2014 and September 2015 at an academic medical center, and discrepancies between the two systems were determined. Nine logistic regression models were constructed to evaluate the influence of covariates (for example, case duration, general anesthesia vs. sedation, and handoff involving a permanent transfer of patient care) on the presence of a discrepancy. Linear regression was also performed between case duration decile and the logit (discrepancy rate), stratified by anesthesia type and handoff. For all models, handoffs were associated with higher discrepancy rates (p <10-6; odds ≥ 1.38). There was a progressive increase in discrepancy rates as a function of the case duration. Handoffs involving a permanent transfer of patient care during cases increase the risk of controlled drug discrepancies. Staff scheduling and assignment decisions to decrease the chance of a handoff occurring should help mitigate this. In addition, future studies should examine ways to improve the handoff process related to controlled drugs (for example, a formal, structured processes in the anesthesia information management system).

Assessing SBAR during intraoperative handoff

BackgroundThe purpose of the current study was to explore the use of SBAR (Situation, Background, Assessment, Recommendation) for handoffs between surgical team members six years after implementation in a large academic tertiary care center. MethodsResearchers observed 23 operative procedures for the presence of SBAR components (“S”,“B”,“A”,“R”) and the duration of handoffs by role type (circulating registered nurses (RN), certified surgical technicians (CST), certified surgical assistants/first assistants (CSA), and anesthesia team members(ANES)). Handoffs by role were further investigated between the giver and receiver of information defined as “personnel-change”. Inter-rater reliability, descriptive statistics, ANOVA, Kruskal-Wallis tests and appropriate post hoc tests were employed. ResultsOverall, of 119 handoffs observed, each on average addressed 67% of the four possible components. Specifically, 90% included component “S”, 58% included “B”, 64% included “A” and 55% included “R”. The frequency of SBAR components used differed by role type, (ANES included components “B”, “A” and more factors in total than CSA), as well as the duration of each handoff (ANES handoffs were longer than CST and CSA). Frequency of components used also differed significantly by personnel-change type (handoffs from original members to relief included significantly more SBAR components). ConclusionFindings suggest that while handoffs included most of the four SBAR factors, each varied by role type as well as personnel-change type involved. While SBAR has been implemented in several healthcare organizations, it may not be a “one-size fits all” model for all involved in the transfer of information and responsibility of care intraoperatively.

Dual Console Technology Robotic Platform Intraoperative Handoffs: “Near Miss” Prevention and Patient Safety Enhancement

BACKGROUND: Dual Console Robotic training has been used in resident training and assessment as well as faculty development. A trans cockpit authority gradient coupled with poor communication skills during robotic arm handoffs contributed in several “near misses” over 6 years of dual console instruction and curriculum development and assessment. These events prompted development of an intraoperative handoff with verbal declaration followed by verbal confirmation. This mirrors current aviation cockpit safety models. Pre and post study Lickert questionnaires utilizing Lickert scale evaluated factors such as comfort levels of teacher and learner, arm assignment confusion, and apprehension. Near misses were tracked. Percentage of complete handoffs were tracked. This study outlines a safe, easily adopted communication and teaching skill that enhances patient safety and reduces near misses. METHODS: Analytic Observational Cohort Study. Lickert Pre and Post intervention. Setting: University Teaching Hospital. Patient Population: All from faculty practice associated with Medical School. All agreed to resident participation in their care. RESULTS: No interventions were required. No near misses in the study. No adverse events occurred during intraoperative handoffs. No confusion over control of robotic arms. There were incomplete surgical handoffs identified. DISCUSSION: Dual console robotic technology provides an unique teaching opportunity for surgical education. Aviation cockpit verbal handoffs are well documented to enhance aviation safety. The robotic intraoperative handoff can mimic this and is an easily adopted and useful teaching method to minimize confusion in co surgeons and minimize risks to patients in dual console robotic surgical procedures.

An Electronic Checklist Improves Transfer and Retention of Critical Information at Intraoperative Handoff of Care

An Electronic Checklist Improves Transfer and Retention of Critical Information at Intraoperative Handoff of Care

An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care.

Communication failures are a significant cause of preventable medical errors, and poor-quality handoffs are associated with adverse events. We developed and implemented a simple checklist to improve communication during intraoperative transfer of patient care. A prospective observational assessment was performed to compare relay and retention of critical patient information between the outgoing and incoming anesthesiologist before and after introduction of an electronic handoff checklist. Secondary measurements included checklist usage and clinician satisfaction. Sixty-nine handoffs were observed (39 with and 30 without the checklist). Significant improvements in the frequency of information relay occurred with checklist use, most notably related to administration of vasopressors and antiemetics (85% vs 44%, P = 0.008; 46% vs 15%, P = 0.015, respectively); estimated blood loss and urine output (85% vs 57%, P = 0.014; 85% vs 52%, P = 0.006, respectively); communication about potential areas of concern (92% vs 57%, P = 0.001), postoperative planning (92% vs 43%, P < 0.001), and introduction of the relieving anesthesiologist to the operating team (51% vs 3%, P < 0.001). When queried after the handoff, relieving anesthesiologists more frequently knew the antibiotic (97% vs 75%, P = 0.020), muscle relaxant (97% vs 63%, P = 0.003), and amount of fluid administered (97% vs 72%, P = 0.008) when the checklist was used. Voluntary use of the checklist occurred in 60% of the handoffs by the end of the observation period (99% control limits: 58%-75%.). Clinicians who reported using the checklist in at least two-thirds of their handoffs reported higher satisfaction with quality of communication at handoff (P = 0.003). An electronic checklist improved relay and retention of critical patient information and clinician communication at intraoperative handoff of care.

Simulation-based education with deliberate practice may improve intraoperative handoff skills: a pilot study

Study ObjectiveTo examine the results of simulation-based education with deliberate practice on the acquisition of handoff skills by studying resident intraoperative handoff communication performances. DesignPreinvention and postintervention pilot study. SettingSimulated operating room of a university-affiliated hospital. MeasurementsResident handoff performances during 27 encounters simulating elective surgery were studied. Ten residents (CA-1, CA-2, and CA-3) participated in a one-day simulation-based handoff course. Each resident repeated simulated handoffs to deliberately practice with an intraoperative handoff checklist. One year later, 7 of the 10 residents participated in simulated intraoperative handoffs. All handoffs were videotaped and later scored for accuracy by trained raters. A handoff assessment tool was used to characterize the type and frequency of communication failures. The percentage of handoff errors and omissions were compared before simulation and postsimulation-based education with deliberate practice and at one year following the course. Main ResultsInitially, the overall communication failure rate, defined as the percentage of handoff omissions plus errors, was 29.7%. After deliberate practice with the intraoperative handoff checklist, the communication failure rate decreased to 16.8%, and decreased further to 13.2% one year after the course. ConclusionsSimulation-based education using deliberate practice may result in improved intraoperative handoff communication and retention of skills at one year.

Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit

Ineffective communications among healthcare providers are common and increases the risk of medical errors. During the perioperative period, multiple handoffs occur within a short period of time, and failure to convey important patient information can compromise safety. We used quality improvement methodology to improve the reliability of our handoffs in the operating room and postanesthesia care unit (PACU). Two quality improvement teams were developed to focus on the intraoperative and postanesthesia handoff processes. Key driver diagrams and 'smart aims' were developed for each process based on feedback from anesthesia and nursing staff, and handoff checklists were developed and revised using multiple plan-do-study-act cycles. Data on the reliability of the handoff processes were obtained prior to initiation of the projects and throughout the 6-month project period. The reliability of intraoperative anesthesia handoffs improved from 20% to 100% with use of the intraoperative handoff checklist. Similarly, with the introduction of a standardized PACU checklist, the reliability of PACU handoffs improved from 59% to greater than 90%. We utilized quality improvement methodology to develop and implement standardized checklists for handoffs of care in the operating room and PACU. Acceptance of and adherence to the standardized handoff protocols dramatically increased the quality and reliability of our handoff process.