Making Handover Safer for Trauma Patients Admitted to the Neuro-Trauma ICU

US Manickavasagam1 A Pronovost2,3 N Ahmed4,5 D MacKinnon6,7 A Young8

1Department of Critical Care Medicine, St. Michael’s Hospital2Department of Anesthesia, St. Michael’s Hospital 3Department of Anesthesia, University of Toronto4Trauma Program, Department of Surgery, St. Michael’s Hospital5Department of Surgery, University of Toronto6Emergency Medicine, St. Michael’s Hospital 7Department of Family and Community Medicine, University of Toronto

4 Quality & Risk Management, St. Michael’s Hospital

Funding for this project has been provided through the St. Michael’s Hospital Quality Improvement Fund.

Context

ED-TTL-TNICU Handover Checklist

• Urban, academic, level-1 trauma centre (~650 trauma team activations 2012)• A collaborative Emergency Medicine-Trauma-Critical Care model of care

encourages comprehensive handover among all members of the team

Problem and Issue• The potential for errors in communication is high• 50% information loss between Trauma Team Leader (TTL) and TNICU MD was

identified through a 1-year retrospective review• Will a handover checklist standardize practice and reduce the omission of important

information during handover of trauma patients to the TNICU?

Lead Process Indicators• By April 30, 2013 100% of trauma patients transferred to the TNICU will be audited to

assess the adoption of the new TTL handover checklistMetrics:

• Number of patients transferred to TNICU/ Number of times the checklist used• Feedback from audits will be communicated to TTL, TNICU MD, ED RN and

TNICU RN via e-mail bi-weekly until April 30, 2013 starting March 1, 2013

ED-TTL-TNICU Handover Checklist

MeasurementFeedback from Users

•“I think its value will be greatest when it's used by those in more junior stages of their careers as they often haven't developed the systematic means to sign off patients to others” (TTL)

•“Sometimes patients were not accompanied by the TTLs” (TNICU MD)

•“One time handover involving all the 4 team member saves lots of time” (ED RN)

Lag Process Indicators

• Zero suggestions made to content of checklist• Communication to the team is ongoing

Lag Process Indicators• By April 30 2013, the number of suggestions to the TTL handover checklist will be

reduced to zero Metrics:

i. Number of suggestions provided by TTL, TNICU MD, ED RN and TNICU RN ii. Suggestions will be communicated to the team working on this project to further

revise the current process

ED-TTL-TNICU Handover Checklist

Contribution to Patient Safety & Quality Improvement

Trauma Team Leader Checklist for TNICU Handover

Co

nfi

rm

All MD and RN team members have introduced themselves by name and role

Patient Name

Details of the Trauma

Details of the Transfer

Allergies, Medications and known PMH

Cu

rren

t S

tatu

s

Airway/Breathing Circulation Neurological

Intubation details

Difficult airway: Y/N

Pneumo / Hemothorax

A/V Blood Gas

Temperature

Tubes and Lines

Hypotensive episodes?

Need for transfusion?

Massive Transfusion Protocol: Y/N

Tranexamic Acid: Y/N

C/T/L spine status

GCS Score

Pupils

Pre

-TN

ICU

Diagnostics and Labs Medications

Chest x-ray

Pelvis x-ray

FAST results

Preliminary CT results

Blood work: Hb / base deficit / tox screen / other

Pain meds: Y/N

Anxiolytics: Y/N

Paralytics: Y/N

Tetanus: Y/N

Antibiotics: Y/N

Su

mm

ary

of

Inju

ries

&

Pla

n C-Spine

T&L Spine

Head

Neck

Thorax

Abdomen

Pelvis

Extremities

Ongoing metabolic resuscitation

Next steps

Family notification: Are they en-route and how can they be reached? Are police involved?

Ask group: Are there any concerns?

Ask TNICU MD and RN: Need for Major Torso Trauma Resuscitation Protocol?

• Standardizing handover will reduce mortality and information loss that will impact patient care and missed injuries

• Plans are underway to permanently incorporate handover checklist into TTL charting notes and TINCU MD admission note

• TTL compliance with the checklist has been added as a reportable metric to the SMH trauma score card