Handoffs and Transitions of Care: Lessons from Lens Elizabeth A. Martinez, MD, MHS Associate Professor Anesthesia, Critical Care and Pain Medicine Massachusetts

Handoffs and Transitions of Care: Lessons from Lens Elizabeth A. Martinez, MD, MHS Associate Professor Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Harvard Medical School Cardiovascular Surgical Translational Study Armstrong Institute for Patient Safety and Quality Content Call: April 18, 2013 1

Objectives Define transitions of care and handoffs To recognize effective vs. ineffective handoffs To identify the components of an effective handoff To understand the importance of communication during transitions of care Understand ASA quality metric for transitions of care 2

Communication Breakdowns are frequently the root cause of undesirable outcomes 3

Analysis of errors reported by surgeons Gawande AA, et al. Surgery 2003; 133(6):614 4

The Joint Commission: The Importance of Communication National Patient Safety Goals Improve the communication among caregivers Read-back Handoff Accurately and completely reconcile medications and other treatments across the continuum of care Address specifically during handoff Encourage the active involvement of patients and their families in the patients care, as a patient safety strategy 5

Sign-offs: Transitions of Care Joint Commission Patient Safety Goal #2 vulnerable time in the care of patients since communication failures and environmental barriers often characterize such handoffs Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions. 6

Communication Process 7

Standards of Effective Communication Complete Communicate all relevant information Clear Convey information that is plainly understood Brief Communicate the information in a concise manner Timely Offer and request information in an appropriate timeframe Verify authenticity Validate or acknowledge information (closing the loop) 8

Why does communication break down? Cognitive workload Complexity increasing Implicit assumptions Authority gradients/Hierarchy Diffusion of responsibility Environmental factors Production pressures Competing priorities/Interruptions 9

Characteristics of High-reliability Communication Tactics Are easy to understand and follow Offer consistency & predictability: Standardization Feature redundancy Incorporate forcing functions Ensure that people cannot work around the system Minimize reliance on human memory 10

Lessons from LENS Locating Errors Through Networked Surveillance Methods: Observations, Contextual inquiry, Interviews, Surveys, Observations included the transition of care from the OR to ICU as a key time point In addition to intraop transitions and preop discussions that might have taken place Hazards were coded 11

LENS Domains Human Factors Engineering Organizational Sociology Industrial Psychology Cardiovascular Clinical Care Health Services Research

Taxonomy Potential Failure Mode Gurses et al;BMJ Qual Saf 2012;21(10):810-8.

Lessons from LENS Locating Errors Through Networked Surveillance Methods: Observations, Contextual inquiry, Interviews, Surveys, Observations included the transition of care from the OR to ICU as a key time point In addition to intraop transitions and preop discussions that might have taken place Hazards were coded **While some of the observations identify a specific provider type, we know these are not unique to that provider type. The goal of the next few slides are to share real-life examples of hazards and to have us begin to think about how these are related to our individual provider types and teams and how we can eliminate them.** 14

Lesson from LENS*: Organization NO standardization Variability within and between sites on how information and technology were transferred between team members No evidence of standard handoffs intraop or postop Purchasing decisions In multiple settings either the OR or ICU team needed to change over the pumps during critical times for patients while vasoactive agents were being infused In OR, they use only pump A. In PACU, they use both pump A and pump B. In ICU they use only pump B. they swicth the infusion pumps over before leaving the OR to the pumps that will be used in the OR (Can be done by a single practitioner including junior resident) Policies When the patient is transported to the PACU the drips are all changed over; this is especially true for drips that are made up peri- and intraoperatively by the anesthesiologist. RNs in the PACU will only use drips that come from the pharmacy. gtts are different concentration than ICU uses. Nurse wont use our drips either dif concentration, not from pharmacy or poorly labeled. Staffing patterns Little to no assistance during transfer: Anesthesia single team member preparing the patient to leave the OR. Focusing on equipment, etc. While monitoring the patient. *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you. 15

Lesson from LENS*: Patient characteristics We did not collect patient level data However.. These patients are obviously complex and this impacts the transitions of care and the information shared (or not shared) Multiple medical problems Can be on multiple drips and have received multiple intraop meds Have multiple lines, drains and tubes May be paced with/without intraop issues Mechanical support Hemodynamic lability needing to be addressed prior to complete transfer of information *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you. 16

Lesson from LENS*: Physical Environment Layout Distances needing to be traveled to post op setting Waiting for elevators Anesthesia resident, perfusionist and nurse transported the patient up 5 floors to the ICU. There was a long wait as no one has a key to divert the elevator for fresh post-op cases regardless of acuity Ease of traveling down a hallway Construction at one site [The postop setting] is down a long corridor that includes turns, doors, and carts lining the hallway. There appear to be many opportunities for trouble when pushing the stretcher, monitor, pole, etc. from the OR to the CVPACU. *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you. 17

Lesson from LENS*: Provider Professionalism Fellow to nurse. Thats all you get to know! The attending in the PACU did not get up from the desk for report. The anesthesiologist reported to the PACU attending while nurses changed lines, etc. they were not near the anesthesiologist and could not over hear the handoff report. Knowledge/Experience The anesthesia residents leave at 2pm. If a case is on-going at 2pm a CRNA comes in and covers for the anesthesia resident. The anesthesia attending perceive that this practices causes issues with handoff, professional responsibility, and role. Performance [Mid level] gave a short handoff report (medium level structure): No allergies. Heart rate was between 50s and 60s.,, You probably know history. Smoker. Do you have any questions? *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you. 18

Lesson from LENS*: Tasks Standardization Lack of PR team member to ICU: I would keep pressure close to 100. She got a dose of Insulin on the pump. 1 PRBC unit post pump. 1 unit PRBC on the pump. She had 1 gram of vanco after case. I turned the pacer down to 82 from 90. Phenylephrine is hanging. No Standard/Systematic approach to sharing information with new team Not much information shared about intraop course or guidance for post op care. Competing priorities Simultaneous transfer of information and technology Preparation Respiratory therapy had to be paged. Didn't have temp probe connection ready. Had to go find one. *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you. 19

Lesson from LENS*: Team Communication Incomplete report Not all team members present/give report The surgeon stopped by asked the BP, look at chest tube and left. NO surgical report given There was no sign out [information shared verbally] between nurses when the nurse was relieved for lunch Report is shared with some team members The handoff was not very in depth and [was in]complete. AR made handoff to the nurses and the ICU resident. The surgery fellow was present but gave handoff to the surgical resident out in the hall. The [postop] attending did not get up from the desk for report. The anesthesiologist [and surgeon] reported to the attending while nurses changed lines, etc. they were not near the anesthesiologist and could not over hear the handoff report. Notification/Preparation Circulator did not notify ICU team that the patient was coming Nurse who was giving break did not know the last name of the nurse for whom she was giving a break which resulted in delay and increased tension since it took longer to page her when she was needed to operate a piece of equipment. Knowledge Intensivist asked about hematoma. No explanation by anyone that was by the bedside. Distractions Unrelated personal conversations rather than a formal sign out . Another nurse called into the room about another patient ICU wasnt prepared for second A-line. This was not the routine and they were not notified Debriefings did not occur in the OR *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you. 20

Lesson from LENS*: Tools and Technology Man-machine interface (Heuristics) At each of the institutions, following at least one case, the transport monitor was not functioning and it was difficult for the providers to troubleshoot. Communication Brief report consisted of: Procedure, products, H/O AVR, Ventricle is good, info about peripherals. Problem with report is that the anesthesia team didn't have a record to read off the history since it was electronic. Lines/tubes/drains Brought bed in room (nursing) and got tangled in suction tubing. Couldnt get the foley temp connector undone, was knotted Frequently we know that it is a challenge to transfer central lines/PA catheter *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you. 21

Teamwork Across Units and Handoffs We do this Poorly* Site 5 All Sites Site 4 Site 3 Site 2 Site 1 Percent reporting a positive response Data from Hospital Survey of Patient Safety (HSOPS) *Unpublished data; Data and presentation to be used for educational purposes within your institution only. Thank you. 22

Potential Failure Mode Organization did not Purchase smart pump technology for all OR pumps Need to switch to Smart pump in the ICU Patient receives inadvertent bolus of nitroglycerin Patient becomes extremely hypotensive Patient arrests and dies 23

Potential Failure Mode Anesthesiologists make up their own drips and use their own concentrations Need to switch to New drips in the ICU Patient receives inadvertent bolus of nitroglycerin Patient becomes extremely hypotensive Patient arrests and dies 24

Adverse Consequences Antiplatelets not restarted appropriately Patient had an MI ICD not turned on and patient discharged to floor/home Diabetic patient had glucose checked on PACU admission per routine Hyperglycemia treated by nurse Patient had received insulin in the or and not given in report **Not LENS data 25

Adverse Consequences Patient with difficult intubation was extubated with only junior house officer available Required immediate, emergent reintubation Difficult airway not noted in report. Patient required am emergent cric Off-service patient had a complication Nobody took responsibility No clearly defined primary service **Not LENS data 26

Implementation of Periop Handoff Protocol Focus groups and survey of practitioners: what is wrong with our process? SENDERS: Surgery, anesthesia, nursing RECEIVERS: ICU, PACU Protocol elements: Require all practitioners be at the bedside Standardized the process Single person speaking at a time Technology transfer Information transfer Checklists for sender and receivers Clearly state when the handover is complete with opportunity for questions Education of all practitioners on handover process Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012 Petrovic MA, et al. Joint Commission Journal 2012. 27

Objectives Define transitions of care and handoffs To recognize effective vs. ineffective handoffs To identify the components of an effective handoff To understand the importance of communication during transitions of care Understand ASA quality metric for transitions of care 28

OR Debriefing: Step #1 29

Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012 Petrovic MA, et al. Joint Commission Journal 2012. 30

Surgery Checklist Actual procedure performed Surgical findings (anticipated and unanticipated) Surgical complications Drains/tubes (location, number, type) Special instructions (NGT, chest tubes, extubation) Patient disposition Responsible primary service Who to page Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012 Petrovic MA, et al. Joint Commission Journal 2012. 31

Anesthesia Checklist Preop Intraop Postop guidance PMH and PSH Allergies and Code status Medications what was taken prior to surgery Baseline vitals, exam, labs Airway Lines Fluid totals (ins and outs) Paralytic status Labs and Meds (Antibiotics) Key events Drips Respiratory: vent settings, etc Other Conclusion: The thing that I am most concerned about in the periop setting is Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012 Petrovic MA, et al. Joint Commission Journal 2012. 32

Nursing Checklist Actual surgery performed Isolation type Lines Drains Skin Inspection Packing Special equipment/Others Family information Belongings and valuables Events/Concerns Petrovic MA, et al. J Cardiothorac Vasc Anesth 2012 Petrovic MA, et al. Joint Commission Journal 2012. 33

Impact of Standardized Handoff in CSICU Pre- intervention Post intervention Presence of core team0%68%P

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Handoffs and Transitions of Care: Lessons from Lens Elizabeth A. Martinez, MD, MHS Associate Professor Anesthesia, Critical Care and Pain Medicine Massachusetts