Eur J Anaesthesiol 2013; 30:764–769
ORIGINAL ARTICLE
Implementation of a structured information transfer checklist improves postoperative data transfer after congenital cardiac surgery Arif Karakaya, Annelies T. Moerman, Harlinde Peperstraete, Katrien Franc¸ois, Patrick F. Wouters and Stefan G. de Hert BACKGROUND During one hospital stay, a patient can be cared for by five different units. With patient transfer from one unit to another, it is of prime importance to convey a complete picture of the patient’s situation to minimise the risk of medical errors and to provide optimal patient care. OBJECTIVE(S) This study was designed to test the hypothesis that the implementation of a standardised checklist used during verbal patient handover could improve postoperative data transfer after congenital cardiac surgery. DESIGN Prospective, pre/postinterventional clinical study. SETTING Cardiac centre of a university hospital. PATIENTS Forty-eight patients younger than 16 years undergoing heart surgery. INTERVENTIONS A standardised checklist was developed containing all data that, according to the investigators, should be communicated during the handover of a paediatric cardiac surgery patient from the operating room to the ICU.
MAIN OUTCOME MEASURES Data transfer during the postoperative handover before and after implementation of the checklist was evaluated. Duration of handover, number of interruptions, number of irrelevant data and number of confusing pieces of information were noted. Assessment of the handover process by ICU medical and nursing staff was quantified. RESULTS After implementation of the information transfer checklist, the overall data transfer increased from 48 to 73% (P < 0.001). The duration of data transfer decreased from a median (range) of 6 (2 to 16) to 4 min (2 to 19) (P ¼ 0.04). The overall handover assessment by the intensive care nursing staff improved significantly after implementation of the checklist. CONCLUSION Implementation of an information transfer checklist in postoperative paediatric cardiac surgery patients resulted in a more complete transfer of information, with a decrease in the handover duration. Published online 1 June 2013
Introduction During one hospital stay, a patient can be cared for by five different units: the operating room; postanaesthesia care unit (PACU); ICU; stepdown unit; and medical/surgical unit. With patient transfer from one unit to another, it is of prime importance to convey a complete picture of the patient’s clinical condition to minimise the risk of medical errors and to provide optimal patient care.1 A clinical handover refers to the transfer of information and professional responsibility and accountability between individuals and teams, within the overall care
system.2 Handovers are a ‘high-risk’ process that might influence patient safety by causing gaps in the continuity of care.3,4 Increasing attention has focused on the process of data transfer since The Joint Commission added to its National Patient Safety Goals Requirements 2E to ‘Implement a standardised approach to ‘hand off’ communications, including an opportunity to ask and respond to questions’.1 This initiative directly affected the vast majority of hospitals and at the same time signalled the importance of research investigating how handovers are accomplished and how they could be improved.5 In light
From the Department of Anaesthesiology (AKA, ATM, PEW, SGDH), Department of Intensive Care (HP), Department of Cardiac Surgery (KF), Ghent University Hospital, Gent, Belgium Correspondence to Dr Annelies T. Moerman, Department of Anaesthesiology, Ghent University Hospital, De Pintelaan 185, 9000 Gent, Belgium Tel: +32 9 332 32 81; fax: +32 9 332 49 87; e-mail:
[email protected] 0265-0215 ß 2013 Copyright European Society of Anaesthesiology
DOI:10.1097/EJA.0b013e328361d3bb
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Use of a standardised checklist during postoperative handover 765
of this interest, we analysed the current practices in postoperative transfer of our paediatric cardiac surgery patients and we identified methods to optimise the handover process. Postoperative paediatric cardiac surgery patients may be unstable and within this population, good communication skills and a quick but efficient handover are absolutely vital. Several studies have investigated handover and care transitions in this particular discipline.6–10 Suggested areas for improvement of handover practice included protocols to structure tasks and processes,6,7 information transfer checklists to optimise communication6–10 and training in team skills and communication.6–8 To improve the postoperative handover in our paediatric cardiac surgery unit, we decided to implement a structured information transfer checklist. All previously reported studies 6–10 have evaluated the introduction of the structured handover tool after a learning period for the involved team members. Some of the success achieved from the handover protocol might therefore be attributable to the development process and participation from the concerned parties. Furthermore, to be universally applicable and sustainable, it is important that any change in practice is easy to accomplish, without the requirement for additional training. The objective of the present study, therefore, was to evaluate the clinical handover of paediatric cardiac surgery patients from the operating room to ICU before and after the implementation of a structured communication tool, when no team training was provided, and with the involved care teams blinded to the objective of the observations. Our hypothesis was that the implementation of a structured handover tool would improve knowledge transfer.
severity of illness was scored using the RACHS-1 (Risk adjustment for congenital heart surgery) method, which classes risk levels from 1 (low risk) to 6 (highest risk).11 Development of the checklist
We developed a checklist containing all essential elements that, according to the investigators, should be communicated during the handover of a paediatric cardiac surgery patient from the operating room to ICU. The checklist provided patient-specific information, including preoperative history, details of anaesthesia and surgery, and information about the postoperative status (Table 1). The structure of the checklist was derived from a review of the literature,6–10,12,13 adapted by the investigators (A.K., A.M., S.D.H.) to create a specialtyspecific version that met the particular requirements of our own department. In order to reduce potential bias, the aim of the study was not revealed, no other parties were involved in development of the information transfer checklist and the study was not discussed with colleagues. Data collection
All individuals involved in the patient’s care were informed that an observer would attend the postoperative handover, without revealing the purpose of his presence, nor the specific data being collected. In both the pre and Table 1 Information transfer checklist used by the observer during the pre and postintervention arm Name Age Weight Preoperative data
Materials and methods Patients and procedures
Ethical approval for this study (Ethical Committee Number 2012/426) was provided by the Ethical Committee of the Ghent University Hospital, Gent, Belgium on 14 August 2012. This prospective interventional study was conducted in the ICU of a tertiary hospital where approximately 150 paediatric congenital cardiac patients undergo surgery each year. All children (age less than 16 years) undergoing cardiac surgery were considered eligible. Written informed consent was obtained from the parents or legal guardian of the child. Every member of the medical and nursing staff was briefed that an observer (A.K.) would attend the postoperative handover, without revealing the objectives of the observation to minimise the risk of bias. Patients were transferred from the operating room to the ICU whilst sedated. All patients had remained intubated and ventilated with one or more sites of venous access, invasive monitoring and one or more intercostal drains in situ. The
Ventilation
Catheters Surgery
Pacemaker
Medication
Medical history Allergies Medication use Disease Preop results Tube size Tube depth Ventilation mode Complications Details Complications Procedure Cross-clamp time Bypass time Complications Mode Heart rhythm Antibiotics Tranexamic acid Sedation Inotropy concentration and inotropy dose
Diuresis Blood products Coagulation parameters Postop TEE pH analysis Postop care plan TEE, transoesophageal echocardiography.
Eur J Anaesthesiol 2013; 30:764–769 Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
766 Karakaya et al.
postintervention phase, the handover was communicated by the operating room anaesthetist. A single observer (A.K.) was responsible for data collection during all preintervention and postintervention handovers. In the preintervention phase, the data transfer during the postoperative handover was evaluated by noting whether each information item on the checklist had been communicated or not. In the postintervention phase, the operating room anaesthetist was asked to fill in the information transfer checklist and to use it as a guide for information transfer. The objectives of the study and the evaluation criteria were still not revealed. For each information item on the checklist (Table 1), the observer noted whether it was verbally communicated or not. The two intervention arms were undertaken consecutively with no learning or training period in between. In both pre and postintervention phases, the observer also recorded the number of interruptions, the number of irrelevant data and the number of confusing pieces of information that had occurred during the handover process. Interruptions were noted whenever the anaesthetist’s handover of information was interrupted. This was a broad definition and included everything occurring prior to finishing the verbal update, from asking questions (even if related to the patient), to conversations between other members of the care team, patient related or not. Irrelevant was defined as ‘extraneous conversations or commentaries not pertaining to the subject under consideration’. Confusing was defined as ‘lacking clarity of meaning’, for example ‘the patient was really in trouble’. The duration of data transfer was calculated from the moment all urgent tasks were completed and the patient was transferred safely to the ICU monitoring and ventilation, to the moment handover communication was completed and no further information was required. In both arms, the key ICU doctor and key ICU nurse were asked four questions, 1 h after admission of the patient to the ICU to evaluate their assessment of the handover. The questions addressed how ready they were to receive the patient, how well organised the handover was, whether sufficient information was provided and how accurate the handover was. The answers were rated by scoring on a 100 mm visual analogue scale (VAS). Table 2
Statistical analysis
Sample size calculation was based on an aimed difference in the information points handed over of 20% between the pre and postintervention group.7 Accepting a twotailed a error of 0.05 and a b error of 0.8, a total of 40 patients were required. Statistical analysis was performed using the statistical software SPSS Statistics 20 (SPSS Inc., Chicago, Illinois, USA). Distribution of the data was tested for normality using the Shapiro–Wilk test. For all data, normality had been rejected. Therefore, data are presented as median (range). Comparison between the pre and postintervention arms was performed with Mann–Whitney U test for continuous data and with the Chi-square test for categorical data. P values of less than 0.05 were considered significant.
Results Twenty-three patients were included in the preintervention arm and 25 patients in the postintervention arm. Patient characteristics are summarised in Table 2. There were no differences between the two arms in the listed variables. The checklist consisted of 31 items, which the authors considered essential to be communicated (Table 1). After implementation of the information transfer checklist, the overall data transfer increased from 48 to 73% (P < 0.001). Data transfer (percentage) for each information item is presented in Table 3. After implementation of the information transfer checklist, information about the patient details (name, age, weight) increased from 77 to 96% (P ¼ 0.001), and data transfer about the preoperative status (medical history, allergies, medication use, disease, preoperative results) increased from 48 to 69% (P ¼ 0.001). Information about anaesthesia details (ventilation and vascular lines) and surgical details (procedure, cross-clamp time, bypass time, complications) were given in 56 and 35% of the preintervention handovers, respectively. These data increased to 85 (P < 0.001) and 63% (P < 0.001) for anaesthesia and surgical details, respectively. Data transfer about medication use increased from 43 to 74% (P < 0.001). Information about the postcardiopulmonary bypass status (pacemaker mode, heart rhythm, diuresis, blood products given, postoperative bleeding and coagulation, transoesophageal echocardiography details, laboratory values, postoperative care plan) was provided in 41% of the preintervention handovers, and in 63% of the postintervention handovers (P < 0.001).
General data of patients in the preintervention and postintervention arms
Number of patients (n) Age (month) Weight (kg) Sex (male/female) RACHS score
Preintervention arm
Postintervention arm
P
23 16 (0.03–148) 9.7 (2.9–42.0) 13/10 3 (1–6)
25 44 (0.01–198) 15.4 (2.8–68.0) 18/7 2 (1–6)
0.27 0.36 0.37 0.24
Data are expressed as n, or median (range). RACHS, Risk adjustment for congenital heart surgery.
Eur J Anaesthesiol 2013; 30:764–769 Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Use of a standardised checklist during postoperative handover 767
Table 3 Percentage data transfer in the preintervention (n U 23) and postintervention (n U 25) arms
Demographics Name Age Weight Preoperative data Medical history Allergies Medication use Disease Preop results Ventilation Tube size Tube depth Mode Complications Catheters Details Complications Surgery Procedure Cross-clamp time Bypass time Complications Pacemaker Mode Heart rhythm Medication Antibiotics Tranexamic acid Sedation Inotropy conc Inotropy dose Diuresis Blood products Coagulation Postop TEE pH analysis Postop care plan
Preintervention
Postintervention
P
70 74 87
96 96 96
0.02 0.04 0.34
74 17 30 91 26
100 52 72 84 36
