OR to ICU Patient Handoff: A Matter of Communication
Chapter
First Online:
Abstract
Breakdown in communication during transition of care may result in adverse events. The Joint Commission listed the implementation of a standardized approach to “handoff” communication, including an opportunity to ask and respond to questions, as a requirement for hospitals. This chapter discusses why we have handoff checklists, will present data that handoffs make a difference and give guidance as to how to implement checklists.
Keywords
Critical care Patient safety Handoff checklistsReferences
- 1.Kohn L. To err is human: an interview with the Institute of Medicine’s Linda Kohn. Jt Comm J Qual Improv. 2000;26:227–34.PubMedGoogle Scholar
- 2.https://psnet.ahrq.gov/perspectives/perspective/170/handoffs-and-transitions. Accessed 2 Jul 2018.
- 3.Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–9.CrossRefGoogle Scholar
- 4.Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32.CrossRefGoogle Scholar
- 5.Williams M, Hevelone N, Alban RF, Hardy JP, Oxman DA, Thorsen C, et al. Measuring communication in the surgical ICU: better communication equals better care. J Am Coll Surg. 2010;210:17–22.CrossRefGoogle Scholar
- 6.Vidyarthu AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1:257–66.CrossRefGoogle Scholar
- 7.Wilson JL, Whyte RI, Gangadharan SP, Kent MS. Teamwork and communication skills in cardiothoracic surgery. Ann Thorac Surg. 2017;103:1049–54.CrossRefGoogle Scholar
- 8.Evanina EY, Monceaux NL. Anesthesia handoff: a root cause analysis based on a near-miss scenario. Clin Sch Rev. 2012;5:132–6.CrossRefGoogle Scholar
- 9.Volpp KGM, Grande D. Residents’ suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003;348:851–5.CrossRefGoogle Scholar
- 10.Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure; lessons for health care operations. Int J Qual Health Care. 2004;16(2):125–32.CrossRefGoogle Scholar
- 11.Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204:533–40.CrossRefGoogle Scholar
- 12.Catchpole KR, De Leval MR, McEwan A, Pigott N, Elliott MJ, McQuillan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17(5):470–8.CrossRefGoogle Scholar
- 13.Hall M, Robertson J, Merket M, Aziz M, Hutchens MA. Structured transfer of care process reduces perioperative complications in cardiac surgery patients. Anesth Analg. 2017;125(2):477–82.CrossRefGoogle Scholar
- 14.Segall N, Bonifacio AS, Schroeder RA, Barbeito A, Rogers D, Thornlow DK, et al. Can we make postoperative handovers safer? A systematic review of the literature. Anesth Analg. 2012;115(1):102–15.CrossRefGoogle Scholar
- 15.Human Factors Report on the Tenerife Accident. Air Line Pilots Association of the United States. 1977. https://www.webcitation.org/5zRT8z0Rm?url=http://www.project-tenerife.com/engels/PDF/alpa.pdf. Accessed 2 Sept 2018.
- 16.Wick KE. The vulnerable system: an analysis of the Tenerife air disaster. J Manag. 1990;16:571–93.Google Scholar
- 17.Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol. 1999;9:19–32.CrossRefGoogle Scholar
- 18.Gordon S, Mendenhall P, O’Connor BB. Beyond the checklist: what else health care can learn from aviation teamwork and safety. Ithaca: Cornell University Press; 2013.Google Scholar
- 19.Wahr JA, Prager RL, Abernathy JH, Martinez EA, Sala E, Seifert PC, et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation. 2013;128(10):1139–69.CrossRefGoogle Scholar
- 20.Petrovic MA, Aboumatar H, Baumgartner WA, Ulatowski JA, Moyer J, et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac Vasc Anesth. 2012;26(1):11–6.CrossRefGoogle Scholar
- 21.Joy BF, Elliott E, Hardy C, Sullivan C, Becker CL, Kane JM. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med. 2011;12(3):304–8.CrossRefGoogle Scholar
- 22.Agarwal HS, Saville BR, Slayton JM, Donahue BS, Daves S, Christian KG, et al. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance. Crit Care Med. 2012;40(7):2109–15.CrossRefGoogle Scholar
- 23.Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, Pronovost PJ. Clinical review: checklists-translating evidence into practice. Crit Care. 2009;13(6):210. https://doi.org/10.1186/cc7792.CrossRefPubMedPubMedCentralGoogle Scholar
- 24.Dixon JL, Stagg HW, Wehbe-Janek H, Jo C, Culp WC, Shake JG. A standard handoff improves cardiac surgical patient transfer: operating room to intensive care unit. J Healthc Qual. 2015;37(1):22–32.CrossRefGoogle Scholar
- 25.Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803–12.CrossRefGoogle Scholar
- 26.Logio LS, Djuricich AM. Handoffs in teaching hospitals: situation, background, assessment, and recommendation. Am J Med. 2010;123(6):563–7.CrossRefGoogle Scholar
- 27.Lane-Fall MB, Speck RM, Ibrahim RM, Shea SA, McCunn M, Bosk CL. Are attendings different? Intensivists explain their handoff ideals, perceptions, and practices. Ann Am Thorac Soc. 2014;11(3):360–6.CrossRefGoogle Scholar
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