Patient Hand-Offs

Sheri S. Crow, MD, MSAssistant Professor of Pediatrics

Critical Care MedicineMayo Clinic

Rochester, MN

Intensive-care medicine has become the art of managing

extreme-complexity

……and a test of whether such complexity can, in fact, be

humanly mastered.

NewYorker 2007

Hand-Off Statistics

• During 24 ICU hours the average patient experiences:

• 178 individual actions per day• Nurse/doctor errors in 1% of these actions• 2 errors/day/patient

• Handover failures account for:• 20% of U.S. malpractice claims• Half of sentinel events involving communication

breakdowns (Joint Commission Report)

• Post-operative handovers: common area for communication breakdown.

Requirement for Success

“hold the odds of doing harm low enough for the odds of doing good to prevail”

http://www.youtube.com/watch?v=YS_llfT2kQc

http://www.youtube.com/watch?v=xQ4SVzxbp7Y&feature=related

Formula One Pit Stops

• A multi-professional team comes together as a single unit to effectively perform a complex task.

Overcoming the Odds

Do Checklists Really Work????

An ICU Fairy An ICU Fairy TaleTale

Checklist intervention

• Peter Pronovost: Johns Hopkins

• Goal: Reduce central line infections

• Central line checklist: • Wash hands with soap• Clean the patients skin with chlorhexadine

antiseptic• Use sterile drapes• Wear sterile mask, gown, gloves• Place sterile dressing over catheter site.

Checklist Implementation

• Month 1: Observation• Nurses document checklist compliance• At least 1 missed step > 1/3 of procedures

• Month 2: Intervention• Nurses authorized to stop doctors violating

protocol steps• Nurses asked each day if lines could be

removed

Results

• Significant decline in line infections:• After 1 year: 11% to 0.• After 2 years: 1 line infection/year• Prevention of 43 infections and 8 deaths

• Savings of 2 million dollars

• Next project: Ventilator associated pneumonia (VAP)

• Non-compliance with VAP prevention protocols decreased from 70% to 4%

• Pneumonia dropped by 25%• 21 fewer patients died than previous year• ICU length of stay dropped by half

Keystone Initiative

• Within 3 months: • Infection rate decreased by 60%• Michigan ICU infection rates: Worst

national rates to top 10%.

• Within 18 months saved:• 175 million dollars• 1500 lives

• Success persists almost 4 years later

Why they work?

• Assist with memory recall

• Specify the minimum expected steps in a complex process.

Intra-operative Checklist

Haynes AB et al. N Engl J Med 2009;360:491-499

Operative Theatre to ICUHand-Offs

Three Parts to a Successful Handover

1. Equipment and Technology Handover

2. Information Handover

3. Discussion and Plan

Catchpole et al Pediatric Anesthesia 2007

Sample Checklists: Post-op Handover

• Patient information:Patient detailsMedical historyAllergy statusName of procedureCurrent status of patient

• Anesthetic informationType of anesthesiaIntraop anesthetic courseAnticipated post-op problemsMonitoring and range for physiological parametersAnalgesia planPlan for IV fluidsAnesthesia contact number

• Surgical informationIntra-operative surgical course Blood lossAntibiotic planMedication plan-drugs to be restartedDVT prophylaxisPlan for tubes and drainsNG tube and feeding planPost-operative investigationsSurgical contact number

Clinical Applications for Checklists

• Central Line Placement

• Compliance with Clinical Practice Guidelines: Ventilator associate pneumonia

• Operative Theatre to ICU handovers

• Change of Shift handovers

• Hospital to hospital transfer

Questions/Discussion