Improving the quality of the operating room to intensive care unit handover at an urban teaching hospital through a bundled intervention

Journal of Clinical Anesthesia

Volumn 31, Issue , 2016, Pages 5-12

  Moon, Tiffany S ^a   Gonzales, Michael X ^a   Woods, Amy P ^a   Fox, Pamela E ^a  

^a UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER   (United States)

Author keywords

Handoff; Handover; Intensive care unit; Operating room; Quality improvement; Transfer of care

Indexed keywords

ARTICLE; CLINICAL HANDOVER; HOSPITAL ADMISSION; HUMAN; INTENSIVE CARE UNIT; INTERVENTION STUDY; JOB SATISFACTION; MEDICAL DOCUMENTATION; NURSING STAFF; OPERATING ROOM; POSTOPERATIVE PERIOD; PRIORITY JOURNAL; PROSPECTIVE STUDY; PUBLIC HOSPITAL; TEACHING HOSPITAL; TELEPHONE; URBAN AREA; ANESTHESIOLOGY; EVALUATION STUDY; HEALTH PERSONNEL ATTITUDE; HEALTH SERVICES RESEARCH; HOSPITAL; INTERPERSONAL COMMUNICATION; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PATIENT TRANSPORT; POSTOPERATIVE CARE; PROCEDURES; PSYCHOLOGY; STANDARDS; TEXAS; TOTAL QUALITY MANAGEMENT; TREATMENT OUTCOME;

ANESTHESIOLOGY; ATTITUDE OF HEALTH PERSONNEL; COMMUNICATION; HEALTH SERVICES RESEARCH; HOSPITALS, TEACHING; HOSPITALS, URBAN; HUMANS; INTENSIVE CARE UNITS; NURSING STAFF, HOSPITAL; OPERATING ROOMS; OUTCOME AND PROCESS ASSESSMENT (HEALTH CARE); PATIENT CARE TEAM; PATIENT HANDOFF; PATIENT TRANSFER; POSTOPERATIVE CARE; PROSPECTIVE STUDIES; QUALITY IMPROVEMENT; TEXAS;

EID: 84961217852     PISSN: 09528180     EISSN: 18734529     Source Type: Journal    
DOI: 10.1016/j.jclinane.2016.01.001     Document Type: Article

References (30)

1. Society of Critical Care Medicine Critical care statistics; c2001-2015 [Internet, cited 2015 June 19]. Available from: http://www.sccm.org/Communications/Pages/CriticalCareStats.aspx
2. E. Parmentier-Decrucq, J. Poissy, R. Favory, S. Nseir, T. Onimus, M.-J. Guerry, and et al. Adverse events during intrahospital transport of critically ill patients: incidence and risk factors Ann Intensive Care 3 2013 10
3. S.A. Jeffcott, S.M. Evans, P.A. Cameron, G.S.M. Chin, and J.E. Ibrahim Improving measurement in clinical handover Qual Saf Health Care 18 2009 272 277
4. R.P. Lofgren, D. Gottlieb, R.A. Williams, and E.C. Rich Post-call transfer of resident responsibility: its effect on patient care J Gen Intern Med 5 1990 501 505
5. M.N. Lyons, T.D. Standley, and A.K. Gupta Quality improvement of doctors' shift-change handover in neuro-critical care Qual Saf Health Care 19 2010 e62
6. V. Arora, J. Johnson, D. Lovinger, H.J. Humphrey, and D.O. Meltzer Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis Qual Saf Health Care 14 2005 401 407
7. P.J. Pronovost, D.A. Thompson, C.G. Holzmueller, L.H. Lubomski, T. Dorman, F. Dickman, and et al. Toward learning from patient safety reporting systems J Crit Care 21 2006 305 315
8. B.T. Kitch, J.B. Cooper, W.M. Zapol, J.E. Marder, A. Karson, M. Hutter, and et al. Handoffs causing patient harm: a survey of medical and surgical house staff Jt Comm J Qual Patient Saf 34 2008 563 570
9. L. Saager, B.D. Hesler, J. You, A. Turan, E.J. Mascha, D.I. Sessler, and et al. Intraoperative transitions of anesthesia care and postoperative adverse outcomes Anesthesiology 121 2014 695 706
10. K. Nagpal, M. Abboudi, L. Fischler, T. Schmidt, A. Vats, C. Manchanda, and et al. Evaluation of postoperative handover using a tool to assess information transfer and teamwork Ann Surg 253 2011 831 837
11. H.S. Agarwal, B.R. Saville, J.M. Slayton, B.S. Donahue, S. Daves, K.G. Christian, and 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 40 2012 2109 2115
12. V. Chang, V. Arora, S. Lev-Ari, M. D'Arcy, and B. Keysar Interns overestimate the effectiveness of their handoff communication Pediatrics 125 2010 491 496
13. A.S. Bonifacio, N. Segall, A. Barbeito, J. Taekman, R. Schroeder, and J.B. Mark Handovers from the OR to the ICU Int Anesthesiol Clin 51 2013 43 61
14. D.J. Solet, J.M. Norvell, G.H. Rutan, and R.M. Frankel Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs Acad Med 80 2005 1094 1099
15. The Joint Commission Sentinel event data - root causes by event type; c2015 [Internet, cited 2015 June 19]. Available from: http://www.jointcommission.org/Sentinel-Event-Statistics/
16. D.J. Solet, J.M. Norvell, G.H. Rutan, and R.M. Frankel Physician-to-physician communication: methods, practice and misgivings with patient handoffs J Gen Intern Med 19 2004 108
17. Accreditation Council for Graduate Medical Education Common program requirements: section VI.B. Transitions of care 2013
18. Association of American Medical Colleges Core entrustable professional activities for entering residency: entrustable professional activity (EPA) 2014 8
19. The Joint Commission Transitions of Care (ToC) Portal; c2015 [Internet, cited 2015 Oct 16]. Available from: http://www.jointcommission.org/toc.aspx
20. T.S. Moon, M.X. Gonzales, and A.P. Woods A mnemonic to facilitate the handover from the operating room to intensive care unit: "I PUT PATIENTS FIRST" J Anesth Clin Res 6 2015 545
21. M.A. Petrovic, H. Aboumatar, A.T. Scholl, R.S. Gill, D.A. Krenzischek, M.S. Camp, and et al. The perioperative handoff protocol: evaluating impacts on handoff defects and provider satisfaction in adult perianesthesia care units J Clin Anesth 27 2015 111 119
22. L.I. Horwitz, T. Moin, H.M. Krumholz, L. Wang, and E.H. Bradley What are covering doctors told about their patients analysis of sign-out among internal medicine house staff Qual Saf Health Care 18 4 2009 248 255
23. P. Pronovost, D. Needham, S. Berenholtz, D. Sinopoli, H. Chu, S. Cosgrove, and et al. An intervention to decrease catheter-related bloodstream infections in the ICU N Engl J Med 355 2006 2725 2732
24. A.J. Starmer, N.D. Spector, R. Srivastava, A.D. Allen, C.P. Landrigan, T.C. Sectish, and et al. I-pass, a mnemonic to standardize verbal handoffs Pediatrics 129 2012 201 204
25. R. Resar, P. Pronovost, C. Haraden, T. Simmonds, T. Rainey, and T. Nolan Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia Jt Comm J Qual Patient Saf 31 2005 243 248
26. A.B. Haynes, T.G. Weiser, W.R. Berry, S.R. Lipsitz, A.-H.S. Breizat, E.P. Dellinger, and et al. A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 360 2009 491 499
27. B.F. Joy, E. Elliott, C. Hardy, C. Sullivan, C.L. Backer, and J.M. Kane Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit Pediatr Crit Care Med 12 2011 304 308
28. K.R. Catchpole, M.R. de Leval, A. McEwan, N. Pigott, M.J. Elliott, A. McQuillan, and et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality Paediatr Anaesth 17 2007 470 478
29. J.G. Chen, M.C. Wright, P.B. Smith, J. Jaggers, and K.P. Mistry Adaptation of a postoperative handoff communication process for children with heart disease: a quantitative study Am J Med Qual 26 2011 380 386
30. A.J. Starmer, N.D. Spector, R. Srivastava, D.C. West, G. Rosenbluth, A.D. Allen, and et al. Changes in medical errors after implementation of a handoff program N Engl J Med 371 2014 1803 1812