The Art of the Handoff:Are You Following Best Practices?

Jeffrey B. Cooper, PhDProfessor of AnaesthesiaHarvard Medical School

Department of Anesthesia, Critical Care and Pain Medicine

Massachusetts General Hospital

No Financial Disclosures

Objectives1. Know the different handoff types anesthesia professionals may be involved with

2. Recognize the evidence linking anesthesia handoffs to patient harm

3. Recognize some key principles in safe and effective handoffs (and commit to at least trying to use one or more new ones)

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Handoffs defined

“The process of transferring primary authority and responsibility for providing clinical care to a patient from departing caregivers to oncoming caregivers.”

• (Based on Patterson and Wears 2010)

• care transition

• bedside report

• turnover

• handoff• handover• sign-out• shift change

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Perioperative Handoffs

Courtesy: Amanda Lorinc, Vanderbilt

Pre-operative

Post-operative

Intra-operative

FLOOR HOLDINGROOM

EMERGENCYROOM ICU

PACU

OPERATINGROOM

INTERVENTRADIOLOGY

ICU

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Getting your input via ARS

Use your smart phone, pad or laptop• This URL:POLLEV.com/jeffreybcoop662

Or to do via text messagimg• Text 223339 just once • To: jeffreybcoop662

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1982

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MOREDANGEROUS

MORESAFE

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The Downside

• Pregnant patient; advanced labor • epidural wet tap• Spinal effective; delivery in 20 mins• Left catheter (evidence re:headache prevent)• Several handovers over several days• Catheter never pulled until discharge• Later admitted with suspected meningitis

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Jones, et al: JAMA, 2018, 319:143-53.

“On average, for every 15 patients exposed to a complete anesthesia handover, 1 additional patient would be expected to experience the primary outcome.”

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Ineffective handoffs can lead to: Wrong treatment Delay in diagnosis Severe adverse events Patient complaints Increased costs, length of stay

Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety Literature Review Report; March 2005. Available http://www.safetyandquality.org/clinhovrlitrev.pdf 14

Joint Commission National Patient Safety Goal-2E

• Implement a standardized approach to “hand-off” communications including an opportunity to ask and respond to questions– Both process and content

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Intraop exchanges?

Intraoperative Care Transitions Are Not Associated with Postoperative Adverse Outcomes

Terekhov et al: Anesthesiology, 2016 125(4):690-9.

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The upside

• TXA infused from 100mg/ml vial• No pump library entry for this dose• Used basic mode to set up; thought 1

mg/kg/hr but was x10• Shift change after ~ 5 hrs• Relief picked up dosing error

• (no patient harm)

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Why Are Good Handoffs Challenging?

• Transferring tacit knowledge• Production Pressure• Competing Priorities • Different Perspectives between professions• Lack of Evidence for what’s optimal• Lack of Training

• WE DON’T LISTEN VERY WELL!

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The of the Matter

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Part 3: Solutions

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Evidence for Improvement in outcomes with better handoffs

Changes in Medical Errorsafter Implementation of a Handoff Program

Starmer et al NEJM 2014; 371(19):1803-1811

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Is A Structured Handoff Helpful?

• Meta-Analyses of the Effects of Standardized Handoff Protocols on Patient, Provider, and Organizational Outcomes.

• Keebler et al. Human Factors. 2016

• Protocols improve information transfer and patient outcomes

• Bias toward positive results publications

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A right structure?

• Standardizing Handoff CommunicationContent Analysis of 27 Handoff Mnemonics

• Nasarwanji MF et al, J Nursing Care Quality

• SBAR, I-PASS popular names• No one standard for anesthesia nor data to

support what is optimal

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A standardized approach should identify:

• Situation• Who • What

• Diagnoses, current condition, recent changes • Anticipated changes – what to watch for in the next

interval• Opportunities for questions • Who to contact; how

Segall N, et al., Anesth Analg. 2012;115(1):102-115 and Patterson ES, et al. Int J Qual Health Care. 2004;16(2):125-132

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Cognitive Aids

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• Cooper JB. Do short breaks increase or decrease anesthetic risk? J Clin Anesth 1989;1:228-231 28

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MGH badge cards

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Key features of effective handoffs:

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Recommendations from the APSF Consensus Conference: selection

from 51 statements

• Minimize interruptions• Receptivity to questions• Structured process• Seek tacit knowledge• Receiver summarizes• Training for all

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High Quality Handover

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Practical Advice

• How to minimize disruptions– Get coverage– Have a script for what to say– Create accepance in the culture– Your tricks?

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Implementing a new Handoff process*

• Use quality improvement principles• Involve all stakeholders in the planning early• Engage subject matter experts• Iterate• Common and special elements by type of

handoff• Message often• Provide feedback

*From APSF Consensus Conference36

Being Metacognitive

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RISK BENEFIT

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DO YOUROWN THING

More information

• https://www.apsfhandoffs.info/• See References in your handout• Jcooper@mgh.harvard.edu

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