An update regarding our initiative to improve the post-operative transtion of care for patients after surgery at Harborview Medical Center in Seattle, WA

1. Aalap Shah, MD
Clinical Fellow in Anesthesia,
Boston Children’s Hospital
Harvard Medical School
***April 2016 Update***

2. I have no relevant financial relationships to
disclose.

3. Evaluate systems-wide limitations to improving
current handover practice
Understand the major outcome measures
associated with handover research
Recognize common themes in handover
research in different settings
Familiarize with Institutional initiatives in
standardizing and optimizing handover
practices

4. 17th century origin
Meeting of Europeans and Chinese
Described as replete with “confusion” and “
incomprehensibility”
Created a sense of inability to understand China’s culture
and worldview
Metonymy seen in other cultures and indigent
expressions
"It's all Greek to me”
“It’s Double Dutch”
“That’s a Volapuk thing”
“It’s German to me”
“Boheman villages!”

5. Rosenberg 1979 – concluded that Chinese was
the “hardest language” to learn
Wikipedia: 22of 50 languages with expression
regarding difficulty learning the Chinese language
Telephone
Russian scandal, whisper down the lane, broken
telephone, operator, grapevine, gossip, don’t drink
the milk, the messenger game

6. Why isn’t there a single term?
Handoff, Handover, Dropoff, Transfer-of-Care,
Transitions
In Reality: Handoff ≠ Transition-of Care
Many Definitions!
JCAHO 2010
“The process of transferring primary authority and
responsibility for providing clinical care to a patient from
one departing caregiver to one oncoming caregiver.”
“Your patient is my patient”

7. Transfers of information represent high-risk,
error-prone patient care episodes that are
closely related to patient outcomes
Standardization with protocols or
checklists are recommended
Joint Commission 2006 WHO 2008
Institute of Medicine 2008 BMA 2004
BEME 2003
Literature Review
223 PubMed/MEDLINE CITATIONS as of March
2015

8. 205 / 554 errors due to nurse-physician
communication errors
44,000 to 98,000 preventable deaths each
year, with an associated cost of $17 to $29
billion.
Donchin 2003

9. CriCO (February 2016) –
- 1744 patient deaths / 5 years
- 1.7 billion in malpractice costs (30% of
cases)CriCO 2016

11. Gawande 2003 Gawande 2003
•Review of 100 incident reports from 45
surgeons
•60% of events in OR+PACU
•43% due to communication failure; of
which 2/3 were due to inadequate
handoffs.
Other landmark papers: Adamski 2007, Patterson 2010
Wakefield 1999, Donchin 1995, Hempel 2015

12. Formula1: Pit Stops (2004)

14. Beer 2015: ISBAR Patient Safety

15. Beer 2015: ISBAR Patient Safety

16. • Informal/Brief Roughton 1996, Bomba 2005), Kalkman 2010, Mazzocco 2009, Kitch 2008, Nagpal 2010,
Hom 2004, Cohen 2010, Bomba 2005, Alvarado 2006, McFertridge 2007
• Setting
 Cluttering
 Small patient pods, limited space
 Noise level in PACU
 Sidebars, adjacent pod conversations, monitors
 Cultural/setting differences Delrue 2013, Behara 2005), Wong 2007
• Lack of attendance
• Interruptions / Shift change (Staggers 2011, Donchin 2003)
 RN, Attendees, Other

17. To OR
- SCOAP
- Incision
- PACU orders
placed
intraop
PACU
ICU
IIa. Day before Surgery
Pt. arrives
on DOS
IIb. Day of Surgery
Providers
assigned
cases
I. Pre-operative
data collection
and plan
formation
- PAC Note
- Cerner
- OSH Records
- ?Epic
II. D/w attending
Need to see:
- Preop Nurse
- Surgeon
- Anesthesia
- OR Nurse Decide
Dispo**
DOS
cancellation?
Pre-Op
Issues?*
Cancel; off
pathway
Intraop
Handover?
MD-MD
handover
- PACU Orders
placed
- Surg Orders
placed
- Case finish,
emergence,
extubation
- Surg ICU Orders
placed
- Nurses call report
and for ICU bed
- RT brings bent to
ANES
- Techs bring monitors
+ O2 to anes
Reschedule
1. Anes
2. OR Nurse
3. +/- Surgery
1. Anes
2. OR Nurse
3. Surgery
Pre-Op 
IntraOp

18. Un-planned
ICU
1. Bay
Assigned
2 Arrive in
PACU,
Handover
- Attach O2
- Monitors
- Positioning
- MD: Verbal
handoff, +/-
anticipatory
guidance, +/-
surgical plan
- RN: SSHR
filled
Stable for
Dispo?
(Aldrete)***
Monitor in
PACU
CODE/still
unstable?
Home
Floor
Tx
or
Planned
ICUOrders in?
Bed avail?
Yes! To floor
Yes!
Go
home
Outpt Rx
ready?
No No
Limbo
Limbo
RN-RN
hand-
over
RN-RN
hand-
over
Post-Handover
- Providers leave
immediately
- RN checks post-op
orders afterwards,
pages if incomplete
- Pt. wakes up, +/-
pain, +/- PONV, +/-
cardio-respiratory
issues
- Call for additional
post-op orders or
dose changes
Additional
MED-SURG
Admission
Guidelines
****
PASS
Post-Op [PACU]

19. • Information Omission/”Overload”
Anwari 2002, Arora 2007, Lauterbach 2009, Welsh 2010, Horwitz 2008, Kitch 2008, McCloughen 2008, Thomas 2012, McCloughen
2008
• Multiple Intra-operative Handovers
•  Saager 2014 - N=138932
 Morbidity Incidence of 8.8, 11.6, 14.2, 17.0, and 21.2% for patients
with 0, 1, 2, 3, and ≥4 transitions; odds ratio 1.08
• Inadequate pre-operative preparation Kluger 2000
• Level of experience Van Eaton 2005, Van Eaton 2010, Chang 2010, Borowitz 2008, Lofgren 1990,
Gandhi 2005
• No anticipatory guidance Bump 2011, Horwitz 2008, Ilan 2012, Kitch 2008, Philibert
2009, Thomas 2012, Hinami 2009

20. • No accepted content structure/agreement on
content categories (Collins 2011)
• Content-related data standards (CCD)
 C48 Referral Summary
 Health Information Technology Standards Panel (HITSP)
• Clinical Care Classification System (3C)
 American Society for Testing and Materials International
(ASTM)
 Continuity of Care Record (CCR)
 Health Level 7 (HL7)
• SNOMED-CT
• Unified Medical Language System (UMLS)
• Integrating the Health Enterprise Cross-Enterprise Document
Sharing of Medical Summaries (IHE XDS-MS)
• International Classification of Nursing Practice (ICPN) Dykes 2009

21. • Intraoperative
 Agarwala 2015
• Post-Operative
 PACU Anwari 2002, Weinger 2015, van Rensen 2012
 ICU Agarwal 2012, Hom 2004, Nagpal 2010, Sabir 2006, Agarwala, Salzwedel 2013, Petrovic 2012, Joy 2011, Zavalkoff 2011,
Catchpole 2006,
• Anesthesia-based literature Hom 2004, Nagpal 2010, Sabir 2006, Agarwala 2015,
Salzwedel 2013, Smith 2008, Weinger 2015, van Rensen 2012, Segall 2012
STUDY SETTING
1 of 2

22. • Shift-to-Shift Bump 2011, Horwitz 2008, Ilan 2012, Kitch 2008, Philibert 2009, Thomas 2012,
Hinami 2009, Arora 2007, Lauterbach 2009, Welsh 2010, Horwitz 2008, Kitch 2008, McCloughen 2008, Thomas 2012,
McCloughen 2008, Chung 2011, Clark 2009, Wilson 2007, Christie 2009, Jukkala 2012, Raies 2007, Nelson 2010,
Roberts 2012, Baldwin 1994, Kalisch 2007, Wentworth 2012, Riesenberg 2010, Flanagan 2009, Ferran 2008, Stahl
2009, Cheah 2005, Wayne 2008, Anderson 2010, Frank 2005, Van Eaton 2005, Van Eaton 2010, Wohlaeur 2012,
Rabinovich 2009, Ryan 2011, Raptis 2009, Barnes 2011, Campion 2007, Campion 2010, Palma 2011), (Bigham 2014,,
Bittner 2012, Catchpole 2007, Ferran 2008, Ryan 2011, Salemo 2009, Jukkala 2012, Stahl 2009, Govier 2012), Ram
1992, Raptis 2009, Wayne 2008, Anderson 2010, Barnes 2011, Palma 2011, Wohlauer 2012, Singer 2006, Wolff
2004, Alvarado, Cohen 2010, Maxson 2012
• Age Group (Pediatrics) Chen 2011, Zavalkoff 2011, de Laval 2000, Catchpole
2006, Singer 2006
• Interdepartmental Handoffs Joy 2011, Christie 2009, Delrue 2013,
McFertridge, Beckmann 2004
• Inter-hospital/Post-hospital Wong 2008, Gandara 2010, Helloso
2005, Anderson 1993, Anderson 1993, Anderson 1995
STUDY SETTING
2 of 2

23. • RN-to-RN Chung 2011, Clark 2009, Wilson 2007, Christie 2009, Jukkala 2012, Raies 2007, Nelson 2010,
Roberts 2012, Baldwin 1994, Kalisch 2007, Wentworth 2012, Riesenberg 2010, O’Connell 2008, Patterson 1995,
Berkenstadt 2008, Miller 2009, Chaboyer 2010, Lamond 2000, McFetridge 2007, Welsh 2010, McLane 2009, Staggers 2009,
Currie 2002, Lally 1999, Sexton 2004, Nelson 2010, Fenton 2006, Block 2010, Sherlock 1995, Mascioli 2009
• MD-to-RN Rabinovich 2009, Ryan 2011, Raptis 2009, Barnes 2011, Campion 2007, Campion 2010, Palma
2011, Agarwal 2012
• MD-to-MD Flanagan 2009, Ferran 2008, Joy 2011, Stahl 2009, Cheah 2005, Wayne 2008, Anderson
2010, Frank 2005, Van Eaton 2005, Van Eaton 2010, Wohlaeur 2012, Solet 2005, Agarwala 2015
• Other members
 Respiratory Therapists, NP, Assisting RN
STUDY MEMBERS

24. • Prospective Observational Interventional
(Pre-/Post) Bigham 2014, Agarwala 2015, Agarwal 2012, Bittner 2012, Catchpole 2007, Chung 2011,
Ferran 2008, Joy 2011, Ryan 2011, Salemo 2009, Jukkala 2012, Stahl 2009, Govier 2012), Ram 1992, Raptis 2009, Wayne 2008,
Anderson 2010, Barnes 2011, Palma 2011, Wohlauer 2012, Kochendorfer, Salerno, Gakhar, Pickering, Van Eaton, Chu, Alem,
Nabors, Cheah, Delrue 2013, Edozien 2011, Maxson 2012, Bhabra 2007, Petrovic 2015, Starmer 2013, Starmer 2014
• Prospective Survey/Interviews Anwari 2002, Flanagan 2009, Rabinovich
2009, Clark 2009, Wilson 2007, Basu 2011, Christie 2009, Raines 2007, Stahl 2009, Cheah 2005, Nelson 2010, Roberts 2012,
Baldwin 1994, Kalisch 2007, Bernstein 2010, Campion 2007, Frank 2005, Wentworth 2012, Campion 2010, Sidlow 2006) Ye,
Horwitz, Solet, Apker, Smith 2008, Rayo 2014
• Prospective RCT Lee 1996, Van Eaton 2005, Van Eaton 2010, Salzwedel 2013
• Systematic Reviews Abraham 2014, Collins 2010, Arora 2009, Riesenberg 2009, Risenberg
2010, Flemming 2013, Cohen 2010, Nagpal 2010, Gordon 2011, Hesselink 2012, Moller 2013, Segall 2012, Li 2012
STUDY DESIGN

25. STUDY MEDIUM / INTERVENTIONS
• In-patient verbal handover Patterson 2004, Bhabra 2007
• EMR-based tools Flanagan 2009, Anderson 2010, Barnes 2011, Palma 2011, Van Eaton 2010,
Wentworth 2012, Wohlauer 2012, Sidlow 2006, Benham-Hutchin 2008, Blouin 2011, Collins 2011
• Third-party software Rabinovich 2009, Cheah 2005, Nelson 2010, Ram 1992, Wayne
2008, Baldwin 1994
• Paper Tools: Clark 2009, Joy 2011, Salermo 2009, Raines 2007,
 Checklists Berkenstadt , Alem, Ferran, Gakhar, Hart, Wolff
 Guides/cognitive aids Fenton, Block, Chaboyer, Nelson 2010, Lee 1996,
Edozien 2011
1 of 2

26. Agarwala 2012
Vanderbilt University
Petrovic 2015
Johns Hopkins Hospital
Reprinted with permission

27. • Structured handover order Simmons 2000, Chu, Catchpole 2007, Sower 2008
(Formula One), Edozien 2011, Talbot 2007, Maxson 2012, Joy 2011, Ferran 2008, Petrovic 2015
• Formula1 in ICU Catchpole 2007, Sower 2008
• Electronic handovers Ram, Nabors, Kochendorfer, Cheah, Van Eaton, Salerno, Ryan
2011, Rabinovitch 2009
• Direct Supervision Nabors
• Multidisciplinary Projects/ Simulation Delrue 2013, Shah
2016, Broehuis 2007, Klaber 2009, Edozien 2005, Chaboyer 2009), Delrue 2013, Jettcott 2009, Shah 2016, Katzenbach 1993,
Awad 2005, Lingard 2006, Millery 2011, IHI, Chang 2010, Van Eaton 2010), Weinger 2015, Petrovic 2015, Nadzam 2009, Mistry
2008. Berfeenstadt 2008, Weinger 2015, Clancy 2008
STUDY MEDIUM / INTERVENTIONS
2 of 2

28. • Surveys/Scoring Criteria/Thematic
Assessments
• Pt. Complications
 Agarwal 2012 – decrease in 24-hr major complication rate
[CPR, ECMO, severe metabolic acidosis])
• Successful extubation in PCICU within 24hrs: 50% vs 43.2%;
(p< .04).
• Completion of healthcare-related tasks,
 Missed medications, delay in subspecialist notification
STUDY OUTCOME CATEGORIES
1 of 2

29. • Item Reporting/Technical Errors Agarwala 2015, Catchpole 2007,
Flanagan 2009, Chung 2011, Govier 2012, Ferran 2008, Wilson 2007, Raptis 2009, Joy 2011*, Van Eaton 2010* Chen 2011,
Hughes 2008, Horwitz, Lamond, Staggers 2009, Cheah 2005,
• Missing Corrobrative Information in EMR Patterson
2010, Sexton 2004, Shah 2016, Lauterbach 2009
 Palma 2011: 5 extra minutes spent correcting handoff
information
• PACU LOS/Readmissions: Salzwedel 2013, Ryan 2011, Bittner 2012, Patterson
2010
 Bittner 2012 (Finding: Non-linear relationship
between Quality Score, Spearman rho=0.258)
• Interruptions/Handover Duration
Wentworth 2012, Chen 2011, Alvarez 2006, Van Eaton 2005, 2010, Pezzolesi 2010
STUDY OUTCOME CATEGORIES
2 of 2

30. • Shah 2016
• Targeted Obstacle: No structured post-
operative handover

31. 0% 20% 40% 60% 80%
Call parameters for vitals
Call parameters for labs
Dressing change instructions
PO status
Activity status
Discharge/inpatient medications
Discharge/inpatient orders
Other
If you had questions regarding patient care, what where they about?

32. Please rate 1-5 (1=strongly
disagree; 5=agree)

34. https://drive.google.com/file/d/0B2uK7WoIRn
Tyc2pTcWR3SDFjQjQ/view
• Required surgical
representative to give
report before anesthesia
report
• Laminated
Tabletop/Bedside
Checklist Cards
• Grand Rounds
Presentations/Weekly E-
mails
• Instructional Simulated
Video on Intranet

35. • Prospective interventional study
• Post-Operative Elective Procedures w/
Inpatient Stay (non-ICU)
• Information Omission, LOS, Handover
Length
• Observers (2) observe post-operative
handovers in PACU West using Audit Form
• Auditors (2) independently record
information items from EHR

36. Table 1a: Pre-vs Post-Implementation Data – “Matched Reporting”

37. Table 2a: Pre-vs Post-Implementation Data – “Reporting Errors”

38. Table 1b: Pre-vs Post-Implementation Data – “Matched Reporting”

39. • EHR/Clinical Pathway Integration Bernstein 2008, KalkMan 2010
• Templates Co 2010, Whipple 2007, Benham-Hutchins 2008, Blouin 2011, Collins 2011, Fielsten 2006,
Siebens 2001, Gardner 2013, Gandra 2010, Hayrinen 2008, Henry 1997, Shah 2016, Swinglehurst 2012, Vawdrey 2008
 Vawdrey 2008: Need to guarantee usability
• 793 / 1699 templates in use (Mt. Sinai)
• Most common: free text note called “Miscellaneous
Nursing Note
• Institutional Reporting Standards Bonney 2013, Bosmans 2012,
Gandara 2010
• Content Overlap Dykes 2009, Collins 2011

40. • EBL format (Resilience Theory/Convergence
Science) Delrue 2013, Jettcott 2009, Shah 2016, Katzenbach 1993, Awad 2005, Lingard 2006, Millery 2011, IHI
 Student/Junior Trainee Education Chang 2010, Van Eaton 2010
 High-Reliability Training: Wilson 2005
• Coordinate Institutional Initiatives (i.e. BCH I-
PASS)
 Decreasing # of handovers – Surgical Home
 I-PASS

41. • Starmer 2014 (NEJM)
 Medical errors dropped by 23 percent when nine
other pediatric hospitals implemented I-PASS

42. • Weinger 2015:
- standardized electronic handover report form,
- a didactic webinar, mandatory simulation training focused on improving
interprofessional communication
- post-training performance feedback

43. • Display Adoption Metrics (p-charts)
• Quality Improvement Projects
• Anticipate multiple revisions
• Get the stakeholder’s input
• Identify shift champions
• PDSA Cycles

44. • Improve intraoperative handovers Tscholl 2014, Saaeger 2014
• Delegate representative to attend the
handover
 shared mental model/teamwork
• Cognitive Aids (Videos, Handout cards)
 SBAR Haig 2006
• Situational awareness Simons 2000
 identify common overlap items first
• Interactive Questions, Receiver Summary Rayo
2014