1
Background Improving Patient Handoffs in OR-ICU and OR-OR Settings Thomas Lowrey, Jim Sheng, Eleanor Phelps, BSN, MA, RN, Philip Greilich, MD, Multi-disciplinary team: Gary Reed, MD, Fallon Ngo, MD, Trent Bryson, MD, Isaac Lynch, MD, Kenni Landgraf, RN, Mandy McBroom MPH Aim Defined project with stakeholders involved in TOC process. Literature review on TOC research. Shadowed to construct detailed process maps of OR-ICU and OR-OR TOCs. Next Steps • Complete observer training (CRNA’s and resident physicians) • Begin baseline data collection on Nov. 1 • Pilot program implementation and measurement (Dec – Feb) Project Design Through stakeholder survey, constructed detailed evaluation tool for measuring completion of essential elements in TOC (% critical elements completed per TOC). Simulation videos created to train observers and ensure reliability. Baseline measures to begin Nov. 1 Analyzed prelim data to create Critical-to Quality (CTQ) list and evaluation tool. Will analyze baseline data, construct histogram and pareto chart. Root cause analysis to be performed with key stakeholder From analysis, brainstorm a list of possible solutions. Will rank ideas according to prioritization matrix, incorporating failure modes effect analysis (FMEA) . Potential solutions include 1) ICU cognitive aid (OR- ICU) and 2) EMR cognitive aid (OR- OR). Lessons Learned • Medical students can apply QI methodology to design implementations for improvement • 3 months of a summer is enough time for full-time medical students to progress to the implementation phase of DMAIC • Multi-disciplinary team and cooperation are essential for project success •Poor handovers, or transfer-of-care (TOC), are a common cause of preventable harm. Clinical handovers in high-paced, high-stakes environments, such as operating rooms (ORs) and intensive care units (ICUs), are especially risky and error prone. •Previous studies indicate that the standardization of the handoff process, to include communication-enhancing devices such as cognitive aids, have the potential to decrease medical- error rates by nearly a quarter (23%) and the occurrence of preventable adverse events by nearly a third (30%). Opportunity A more reliable OR-ICU and OR-OR TOC process will optimize care provision and reduce time spent on treating complications due to failure in communication. Scope The 2 nd and 3 rd floor operating rooms and 9 th floor CVICU at UT Southwestern Clements University Hospital. The primary aim of this project is to improve the reliability of OR-ICU and OR-OR patient handoffs at Clements University Hospital by 50% by April 2016. Surgeon Anesthesiologist Intensivist ICU Nurse After the first round of modified Delphi survey, elements passed if >80% of responders believed them as essential (red) (i.e. Patient dx and greatest concerns). Elements that did not pass went through one more round of survey to determine the final CTQ list. (A) A. Process map (L) and fishbone diagram (R) of the OR-to-ICU /OR-OR TOC ; Allowed us to identify the problem step (red on left) to be the verbal transfer of patient information, and determine various causes of unreliable TOC. B. Previous studies indicated that the use of a handoff checklist can significantly improve the quality of TOCs. A survey was sent to the UT Southwestern Department of Anesthesiology: Blue: Do you feel like the Handover Checklist will increase the quality of information received in handoffs? Green: Do you think the Handoff checklist will increase patient safety? Results indicated that most anesthesiologists believe a handoff checklist would improve the quality of TOCs in the OR and would use it if provided. A Measurement and Training Simulation videos were created to train observers on how to collect data with measurement tool. In order to ensure intra- and inter- rater reliability, 4 simulation videos were established with varying degrees of “quality” and observers must receive kappa = 80%. Measures Used Observations data % critical elements completed per OR-ICU/OR- OR handoff Trained Observers CRNA’s and Resident physicians Baseline Measurement Period November – December Measurement tool was created to objectively measure quality of TOCs. Elements were derived from best-in-class literature review, expert interviews and Critical-to-Quality (CTQ) surveys Yes 86% No 14% B We surveyed stakeholders from varied backgrounds (B) for elements they believe as critical to verbal TOC’s. A B D efine M easure A nalyze Pending Implementation Applied DMAIC methodology to improve the hospital’s processes: 1 Yes 85% No 15% 1 TOC Evaluation Tool 1 1 TOC Critical to Quality Survey D M M A QI Tools used: • Project Charter • Direct observations • Stakeholder analysis/interviews • Process map/Fishbone QI Tools used: • Root cause analysis • Fishbone diagram • Control chart • Process map review QI Tools used: • FMEA N = 122
