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QUALITY OR SAFETY PROBLEM

Handoffs in our operating rooms (ORs) during staff changes are not standardized, and information transferred is variable. This leads to poor communication between the operative team and potential patient safety events.

BACKGROUND

A frontline stakeholder approached our OR quality improvement (QI) team with concern over inconsistencies within handoffs at the surgical technician (ST) level. Direct observation of ST handoffs for lunches and call shifts revealed drastic variation in communication with the operating surgeon as well as information exchange.

Literature has established the importance of standardized communication in healthcare settings. This is most often utilized during patient handoffs. Standardized handoffs have been established for nursing between shifts as well as for trainees.^1-4  Further, this has been demonstrated to be beneficial amongst anesthesia providers in the preoperative, intraoperative, and postoperative settings.^5-7 The benefit of a standardized communication tool in these settings revealed improved communication of critical information, decreased patient safety events, and even improved efficiency in patient transfers.^1,3,6-8

Preliminary data was assessed and condensed after evaluation of 23 handoffs to reveal dramatic variation in information shared during current handoffs, including the occurrence of ST handoffs in only 82% of observed cases, and only 61% of these handoffs being announced to the entire room. Using lean methodology, all frontline stakeholders were engaged with the OR QI team to determine a specific aim for the project, which involved standardizing ST communication at staff changes. Stakeholders then agreed upon information they felt was critical to share with the incoming ST, and a visual cognitive aid was created to facilitate the standardized handoffs.

PROJECT OBJECTIVES

The objective of the Surgical Intraoperative Handoff Initiative was to improve the exchange of critical information during handoffs between STs at staff changes to prevent potential patient safety events.

The aims of this project are as follows:

• Identify the current state of ST handoffs
• Determine what information classifies as critical knowledge during ST handoffs
• Collaborate with frontline stakeholders and the OR QI team to develop a standardized communication tool
• Create a reliable auditing system to assess for improved transfer of information

INTERVENTION

We evaluated 23 handoffs, identifying significant variation in ST handoffs depending on procedure, staff member, and service line involved, including failure of handoff between technicians nearly 1 out of 6 times. After engaging all STs in the operating rooms, a list of critical details was created to facilitate information transfer during handoff with domains regarding sponges, sharps, hidden items, replaced items, instruments, implants, medications, procedure overview, and specimens. These were used to create an acronym, SHRIMPS, which was made into a visual cognitive aid and posted in all ORs (Figure 1).

The first Plan-Do-Study-Act (PDSA) cycle involved using this tool amongst STs during handoffs in general surgery, urology, and neurosurgery cases. While there was a 100% accuracy and completion rate in handoff of information during this initial PDSA cycle, we did discover that in some of the rooms, there was difficulty seeing the visual cognitive aid posted.

A second PDSA cycle was initiated after adjustment of location of the tool, and the Surgical Intraoperative Handoff Initiative was rolled out to all service lines.

Figure 1: SHRIMPS visual cognitive aid.

MEASURES OF SUCCESS

Metrics of success included engagement with and use of the standardized handoff tool. Each ST handoff was audited by the room circulator, assessing success rates of addressing each piece of information within SHRIMPS agreed upon by STs during handoffs.

OUTCOMES

Following the implementation of SHRIMPS as the standardized handoff tool, a total of 43 ST handoffs were evaluated over both PDSA cycles. 100% of staff changes between surgical technicians involved a handoff, which was a 17% increase from prior. These handoffs were announced to the room 98% of the time, up from 61% prior to implementation. All components of SHRIMPS were discussed in each handoff, as applicable, 98-100% of the time post-implementation (Figure 2).

Figure 2: Compliance rate for each component of SHRIMPS handoff

POTENTIAL IMPACT AND SCALABILITY

1. Standardized handoffs take an average of 77 seconds with transfer of important pieces of information to facilitate the flow of a case and potentially avoid detrimental complications.
2. The entire operating room is aware when a handoff occurs, ensuring improved communication between both technicians and the entire operating room team.
3. Currently, we are discussing implementing a standardized handoff tool for circulators. Standardized handoffs could be implemented in ORs nationwide to facilitate communication and avoid patient safety events.

SUSTAINING THE CHANGES

The transition to standardized ST handoffs is sustained by regular auditing. Initially, ST handoff was audited by the QI team and trained circulators in each case. Results were reviewed weekly to ensure no changes and further PDSA cycles were required with ongoing success for 3 months. This is being transitioned to spot auditing to ensure continued compliance.

ADDITIONAL RESOURCES

Engaging frontline and topline stakeholders has been key in the success of this project. Frontline stakeholders were both heard and consulted in the creation of the standard for this handoff, and as a result, they became invested in positive outcomes.

KEY SUMMARY

1. Standardized communication in the operating room is key for staff comfortability
2. Post-implementation, there was a 17% increase in handoffs completed, and 98-100% of critical information was communicated during each of the 43 observed handoffs
3. There is minimal change in operating room flow during standardized handoffs

REFERENCES

1. Chladek MS, Doughty C, Patel B, Alade K, Rus M, Shook J, LIttle-Weinert K. The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. BMJ Open Qual. 2021 Jul;10(3):e001254. doi: 10.1136/bmjoq-2020-001254. PMID: 34244172; PMCID: PMC8273485.
2. Fryman C, Hamo C, Raghavan S, Goolsarran N. A Quality Improvement Approach to Standardization and Sustainability of the Hand-off Process. BMJ Qual Improv Rep. 2017 Apr 6;6(1):u222156.w8291. doi: 10.1136/bmjquality.u222156.w8291. PMID: 28469889; PMCID: PMC5387931.
3. Clarke CN, Patel SH, Day RW, George S, Sweeney C, Monetes De Oca GA, Aiss MA, Grubbs EG, Bednarski BK, Lee JE, Bodurka DC, Skibber JM, Aloia TA. Implementation of a standardized electronic tool improves compliance, accuracy, and efficiency of trainee-to-trainee patient care handoffs after complex general surgical oncology procedures. Surgery. 2017 Mar;161(3):869-875. doi: 10.1016/j.surg.2016.09.004. Epub 2016 Nov 5. PMID: 27825699.
4. Müller M, Jürgens J, Redaèlli M, Klingberg K, Hautz WE, Stock S. Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open. 2018 Aug 23;8(8):e022202. doi: 10.1136/bmjopen-2018-022202. PMID: 30139905; PMCID: PMC6112409.
5. Caruso TJ, Marquez JLS, Gipp MS, Kelleher SP, Sharek PJ. Standardized ICU to OR handoff increases communication without delaying surgery. Int J Health Care Qual Assur. 2017 May 8;30(4):304-311. doi: 10.1108/IJHCQA-02-2016-0015. PMID: 28470134. 
6. Agarwala AV, Firth PG, Albrecht MA, Warren L, Musch G. An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care. Anesth Analg. 2015 Jan;120(1):96-104. doi: 10.1213/ANE.0000000000000506. PMID: 25625256.
7. Schmidt RF, Vibbert MD, Vernick CA, Mendelson AM, Harley C, Labella G, Houser J, Becher P, Simko E, Jabbour PM, Tjoumakaris SI, Gooch MR, Sharan AD, Farrell CJ, Harrop JS, Rosenwasser RH, Jaffe RC, Jallo J. Standardizing postoperative handoffs using the evidence-based IPASS framework through a multidisciplinary initiative improves handoff communication for neurosurgical patients in the neuro-intensive care unit. J Clin Neurosci. 2021 Oct;92:67-74. doi: 10.1016/j.jocn.2021.07.039. Epub 2021 Aug 5. PMID: 34509265.
8. Shahian DM, McEachern K, Rossi L, Chisari RG, Mort E. Large-scale implementation of the I-PASS handover system at an academic medical centre. BMJ Qual Saf. 2017 Sep;26(9):760-770. doi: 10.1136/bmjqs-2016-006195. Epub 2017 Mar 9. PMID: 28280

PROJECT LEAD CONTACT INFORMATION

Wesley Wilt, MD
University of Kentucky Medical Center, Lexington Veterans Affairs Medical Center
wesley.stephens@uky.edu