Postoperative handoff communication in practice:

An observational study based on an SBAR

Abraraw Lehuluante RN, Spec. Primary Care Nursing; Msc, Nursing Science Spring 2013

Theatre Care, Thesis of 15 credits for a Degree of Master of Medical Science (60

credits), 15.0 Credits

Advisor: Inger Öster; RNT, Ph.D

Table of contents Abstract

Abstrakt

Background ................................................................................................................................................... 1

Patient safety and care- related adverse events: a birds-eye- view ............................................................ 1

The place of handoff communication in causing CRAE ........................................................................... 2

The quest for safer handoff methods ......................................................................................................... 4

SBAR: a synopsis of its development and use in handoff communication ............................................... 5

SBAR: its use in postoperative nursing handoff communication ............................................................. 6

Aim ................................................................................................................................................................ 7

Study design .................................................................................................................................................. 7

Method of data collection .......................................................................................................................... 7

Method of data analysis and interpretation ............................................................................................... 8

Ethical considerations ................................................................................................................................ 8

Results ........................................................................................................................................................... 9

Patient characteristics ................................................................................................................................ 9

Postoperative handoffs ............................................................................................................................. 9

Table 1: patient characteristics .............................................................................................................. 9

Table 2: patients with no SN- delivered postoperative handoffs ......................................................... 10

Table 3: observation checklist with contents of handoff communication .......................................... 12

Discussion ................................................................................................................................................... 14

Method discussion ....................................................................................................................................... 17

Conclusion and recommendation ................................................................................................................ 18

Reference ..................................................................................................................................................... 19

Appendix i

Abstract

Background: The health, psychosocial and economic costs of care- related adverse events

(CRAE) have been known for quite some time. One of the main causes of preventable CRAE has

been communication failures on the part of care- giving staff. It has been known that surgical

patients are more prone to CRAE and one of the efforts that have been made to reduce CRAE has

been the introduction of standardized handoff communication tools such as the situation,

background, assessment, and recommendation (SBAR) mnemonic. However, there is scantiness

in research regarding the extent and content of surgical nurses’ (SN) handoff communication

compared with SBAR. Aim: The aim of this study was to explore the extent to which SN made

postoperative handoff reports as well as to describe the agreement in structure and content

between SN handoff reports and the SBAR adapted for postoperative handoff communication.

Study design: A non- participant observation method was used to collect data as handoff

communications took place at a post- anesthesia intensive care unit (PAICU). Both SN and

PAICU nurses were acquainted with SBAR and recommended to use the SBAR version adapted

to use by their respective clinics. Data was collected by a checklist prepared from a SBAR

version adapted to use in postoperative settings. Collected data was analyzed quantitatively

complemented by field notes. Results: SN made postoperative handoffs in 9 (41%) of the 22

observations made at the PAICU. The amount of information delivered per patient ranged from

6.7 to 36.7 % making the average amount of information omitted per patient to 76%. The mean

handoff time was 60. 8s (Std ± 20.9s). Conclusion: The results of this study have shown that the

responsibility of delivering postoperative patient- related information was not discharged

adequately. The structures and contents of handoff communications were also found to be

inadequate. There is a need for further research to design adequate communication tool that either

specify the part of patient- related information that each member of the multi professional team

can handle adequately and deliver effectively and responsibly or make this information delivery a

collective responsibility and specify how best it can be transferred between clinics.

Key word: intensive care, postoperative handoff, SBAR, communication, adverse events

Abstrakt

Bakgrund: Hälsomässiga, psykosociala och ekonomiska kostnaderna av vårdrelaterade skador

(CRAE) har varit kända sedan länge. En av de viktigaste orsakerna till CRAE har varit bristfällig

kommunikation bland vårdpersonal. Det har varit känt att kirurgiska patienter är mer benägna att

drabbas av CRAE och en av de ansträngningarna som gjorts för att minska CRAE har varit

införandet av standardiserade kommunikationsverktyg så som situationen, bakgrund, utvärdering

och rekommendation (SBAR) mnemonik. Det finns emellertid brist på specifika studier som

fokuserade på i vilken utstreckning operationssköterskor (SN) sköter postoperativa rapporter

samt hur strukturerade och innehållsrika sådana rapporter kan vara. Syfte: Syftet med studien var

att undersöka i vilken utsträckning SN sköter postoperativa överrapporteringar samt att beskriva

hur pass överrapporteringarnas struktur och innehåll överensstämmer med en SBAR version som

tagits fram för postoperativ överraportering. Studiedesign: En icke - deltagande observation

metod användes för att samla in data då postoperativa rapporter lämnades över till sköterskor som

jobbade på intensivvårdsavdelning (PAICU). Både SN och PAICU sjuksköterskor var bekanta

med SBAR och använder en anpassad SBAR version som rekommenderades av respektive

kliniker. Data samlades in genom at utforma en checklista från en SBAR version som är anpassad

för användning i postoperativa överrapporteringar. Insamlade data analyserades kvantitativt och

kompletterades med fältanteckningar. Resultat: SN gjorde postoperativa överrapporteringar

under 9 (41 %) av de 22 observationer som gjordes på PAICU. Mängden information som

överrapporterades per patient varierade från 6,7 till 36,7 % vilket gjorde den genomsnittliga

mängden per patient till 76 %. Den genomsnittliga överrepporteringstiden per patient var 60. 8s

(Std ± 20.9s). Slutsats: Denna studie har visat att postoperativa patientrelaterad information ej

överrapporterades fullt ut. Strukturen samt innehållen i överrapporteringarna var ej adekvat. Det

finns ett behov av ytterligare forskning för att utforma lämpliga kommunikationsverktyg som

antingen specificerar den del av patientrelaterad information som varje medlem i det

multiprofessionella operationsteamet kan hantera och leverera på ett effektivt och ansvarsfullt sätt

eller göra överrapporteringen ett kollektivt ansvar och specificera hur bäst det kan överföras

mellan kliniker/vårdavdelningar.

Key word: intensivvård, postoperativ överrapportering, SBAR, kommunikation, vårdrelaterade skador

1

Background

Patient safety and care- related adverse events: a birds-eye- view

Ensuring the safety and wellbeing of the care- receiving patient is often deemed to be a clear priority of the care profession in general

and the nursing profession in particular (Richardson & Storr , 2010; Smeds et al. 2013). Patient safety has much to do with protecting

the patient from care- related physical and psychic injuries or sufferings (The Swedish Patient Safety Act (2010:659), [Online]).The

World Health Organization (WHO) defines patient safety as “ …the absence of preventable harm to a patient during the process of

health care” (WHO, [Online]). The Hippocratic “first, do no harm” has been well known within the medical profession for centuries.

However, care- related adverse events (CRAE) have continued to occur (Öhrn, 2012).

Although studies in patient safety and CRAE existed since the 1950s, it was during the past two decades that the problem started to

attract much attention (WHO, 2002; Öhrn, 2012; Toffoletto & Ruiz , 2013).The report entitled “To Err Is Human: Building a Safer

Health System” that was authored by the Institute of Medicine (IOM) has been often cited as the ground breaking work that brought

to light the seriousness of the problem of unsafe care (Öhrn, 2012; Toffoletto & Ruiz , 2013). The report revealed that 44,000 to

98,000 Americans died annually mainly due to care- related incidents that were largely preventable (Toffoletto & Ruiz, 2013). After

this report a number of international, regional and national investigations were conducted in CRAE and means of reducing them

(WHO, 2002; Farley et al., 2008; Perneger, 2008; Soop et al.; 2009). For example, a European study done by the year 2000 revealed

that every tenth patient in hospitals in Europe suffered from preventable harm and CRAE related to his or her care (WHO, 2002). In an

Australian study covering more than 14,000 admissions that led to 17% CRAE, 11% of those events were associated with

communication problems (Riesenberg, Leitzsch & Cunningham, 2010). Even though patient safety has been ensured by law in

Sweden, unsafe care affects about 100 000 patients every year (The National Board of Health and Welfare, [Online]; The Swedish

Patient Safety Act 2010:659, [Online])). A Swedish study that included 1967 patients in 28 hospitals revealed that 12.3 % of the

patients were affected by CRAE among which 70 % were preventable. Moreover, the report specified that 55% of the incidents of

2

these preventable events led to impairments or disabilities that were resolved during the time of admission or within a month from

discharge. Some other 33% of them were resolved within a year, 9% of the preventable events led to permanent disability, and 3% of

the CRAE contributed to deaths (Soop et al., 2009). Besides the tremendous effects of CRAE on the quality of life of individual

patients and their relatives, their enormous economic consequences did not pass unnoticed. The US 1.5 million CRAE occur annually

among which 26% are preventable. The cost of such preventable CRAE reaches 910 million dollar annually (Pham et al., 2012)

The place of handoff communication in causing CRAE

Although there are questions and controversies around its definition and connotation, (Cohen & Hilligoss, 2010) the term “handoff ”

often refers to a contemporaneous, interactive process of passing patient specific information from one caregiver to another for the

purpose of ensuring the continuity and safety of patient care (Wayne et al., 2008). It is not only a transfer of information but

professional responsibility, accountability and authority for some or all aspects of care for a patient or groups of patients, to another

person or professional group on a temporary or permanent basis (Abraham et al., 2011; Manser & Foster ; 2011). Handoff

communication is a natural part of patient care and as such a potential moment of risk that can lead to CRAE that compromise patient

safety (Manser & Foster; 2011).

The single most important outcome of reports of CRAE has been the urge to investigate the root causes of these failures. Such kind of

investigation triggered by reports like “To Err Is Human…” was the 2004 Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) investigation in root causes of near- miss and CRAE. In the JCAHO root cause analysis of infant deaths and

permanent disabilities, for example, faulty or delayed communication was found to cause 72% of the CRAE (Guise & Lowe, 2006).

JCAHO report further revealed that CRAE due to communication failures increased from 65% in 2004 to 70 % 2005, with 50% of

those events happening during the hand-off communication (Sandlin, 2007)

Vulnerability to CRAE is much higher in surgical patients since patients are more exposed to handoff errors than patients in other

clinical specialties (Amato-Vealey, Barba & Vealey 2008; Ong & Coiera, 2011). Surgical patients often pass a number of checkpoints

3

and transitions that occur throughout pre- intra - and postoperative care. It suffices to have in mind the number of caring staff that not

only exchange hands but also exchange information when a surgical patient goes through pre- intra- and postoperative care as well as a

number of clinics and intermediary units. Besides, care provided in all phases of the perioperative process is often characterized by

rapid turnover, the demand for increased speed and efficiency, and the need to accelerate throughput for the surgical patient (Amato-

Vealey, Barba & Vealey 2008). Such speedy transfers are often followed by speedy handoffs and thereby broader chances for

communication failure.

Lingard et al. (2004) found that communication failures in operation rooms (OR) occurred in approximately 30% of cases during team

exchanges and a third of these resulted in effects which jeopardized patient safety. The authors observed 421 communication events of

which 129 were categorized as being tainted with communication failures. Failure types included untimeliness in reporting, missing or

inaccurate information, and information exchange where key individuals were excluded. It is not difficult to discern that such

communication failures can lead to further errors and CRAE as patients transfer to post- anesthesia intensive care unit (PAICU) and

from there to clinics and/or outpatient care settings. Studies have indicated that information breakdown is frequent when patients

transfer from one to another clinic than within a clinic (Ong & Coiera, 2011)

A review of 38 articles that focused on communication failures showed that information transfer failures were common in surgical care

and were distributed across the continuum of care (Nagpal et al., 2010 a). Greenberg et al. (2007) found 81 communication

breakdowns in 60 surgical cases leading to reported CRAE. Of these errors 38% occurred during the preoperative phase, 30% during

the intraoperative and 32% during the postoperative period. The authors found that the majority of these breakdowns occurred during

verbal communications involving one transmitter and one receiver. Nagpal et al. (2010 b) followed 20 patients through the surgical

journey and found that preoperative and postoperative handoffs were poor, incurring an information loss of 61.7% and 52.4%

respectively. Preoperative verbal handoff from the ward to the OR was completed for only 45% of the patients. They found that only

66% of the patient-specific information, 67% of the anesthetic information, and 30% of the essential surgical information was

transferred.

4

The quest for safer handoff methods

After studies and reports in communication breakdowns unveiled subsequent CRAE the quest for better and safer communication

methods started to be heard louder. Problems associated with patient handoff have been an international concern for some time and

countries like Australia, the UK and Northern Ireland had reviewed this issue, and developed risk reduction recommendations (WHO,

2007). In the USA, following the JCAHO report, calls for standardized approach to handoff communications were made (Odom-

Forren, 2007; Mascioli et.al. 2009). Accreditation Council on Graduate Medical Education (a comparable counterpart to The Swedish

National Board of Health and Welfare) had formalized the requirement of proficiency in communication skills (Horwitz, Moin &

Green, 2007). WHO has joined the call for standardization in handoff communication (Wacogne & Diwakar; 2010).

The question of how, where and what a handoff communication should include has also been a matter of discussion. Research

literature shows that there are different ways and means of conducting handoff communication depending on location and the mode of

communication. Information can be delivered verbally (either in person or by using devices for voice messages), in a pre-typed

handover document etc. It can be delivered at a bedside, at the nurses’ station, or in a staff room (Kerr 2002; O’Connell & Penney

2001).Each type of handoff communication and communication setting can have its own advantages/disadvantages. However, written

handoff communication can by no means be a substitute to face to face communication since it gives no room to discussions and

opportunities to ask questions (Rothrock, 2011)

It has been suggested that the information communicated during handoff should be current, complete and concise and the receiving

caregiver should be given an opportunity to read back, repeat back, and ask questions as needed (Sandlin ,2007; Mascioli et.al. 2009;

(Rothrock , 2011). It has been further suggested that adequate time should be given for the handoff period and interruptions should be

limited. Minimal content requirements include current condition of the patient, recent changes in condition, pertinent history, test

results, current vital signs, diagnosis, planned treatment, response to treatment already given, and plans for future treatment (Sandlin

,2007; Rothrock , 2011) . Communication is said to be ineffective and potentially dangerous if it’s incomplete, confusing, unclear,

misunderstood, not standardized, misinterpreted, or nonexistent (Mascioli et.al. 2009).

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There were clear efforts made by healthcare systems to learn from other institutions and organizations that had standardized

communication tools for safety. The aviation industry and military institutions were mentioned in the research literature as potential

sources of experience in safety measures (Leonard, Graham & Bonacum; 2004; Guise & Lowe; 2006, Catchpole et al. 2007).As

mentioned below, these efforts yielded some results.

Efforts made to improve handoff communication have led to some innovative ways of organizing information. Several mnemonics

such as SBAR (Situation, Background, Assessment , Recommendation); I PASS the BATON (Introduction , Patient Assessment,

Situation, Safety, Background, Actions, Timing , Ownership, Next), SHARQ first version ( Situation, History , Assessment,

Recommendations, Questions), 5 Ps (Patient, Plan, Purpose of Plan, Problem, Precaution ), EIDET (Acknowledge the patient,

Introduce yourself, Duration of the procedure, Explanation of process and what happens next, Thank you for choosing our hospital

(note: handoff done at bedside), SIGNOUT (Sick or do not resuscitate/ do not intubate patient, Identifying data (name, age, gender,

diagnosis), General hospital course, New events of the day, Overall health status/clinical condition, Upcoming possibilities with plan,

rationale, Tasks to complete overnight with plan ) etc. have been some of them (Sandlin, 2007; Riesenberg, Leitzsch & Little 2009).

SBAR: a synopsis of its development and use in handoff communication

SBAR was adapted from the U.S. Nuclear Navy safety communication tools and developed by Michael Leonard to be used in care

settings (Haig, Sutton & Whtington, 2006; Frankel, Leonard, & Denham, 2006). Following reports that revealed the contribution of

communication breakdown on near- miss and CRAE efforts were made to reduce the risks. A small patient safety workgroup within

Kaiser Permanente (Colorado) was constituted and during a brainstorming session, Doug Bonacum (a captain and a former safety

officer in the US Navy nuclear submarine), described the SBAR version he developed and used in the Navy (Heinrichs, Bauman &

Dev, 2012). Michael Leonard and co-workers Doug Bonacum and Suzanne Graham, adapted a SBAR version that could be uses in

healthcare (Moorman, 2005; Haig, Sutton & Whtington, 2006 Heinrichs, Bauman & Dev; 2012).

6

Amato-Vealey, Barba, and Vealey (2008) wrote that the SBAR communication mnemonic was meant to specify four central

components of a handoff communication. According to them the person who hands –over should:

1) Situation- explains what was going on with the patient; identify oneself and the patient, and state the problem of the patient.

2) Background- explain the patient’s background; review the chart before speaking up if the situation allows; anticipate questions

the other care provider may have.

3) Assessment- provides one’s observations and evaluations of the patient’s current state.

4) Recommendation- makes an informed suggestion based on sound information for the continued care of the patient.

Following its application in care settings, SBAR has been recommended by various international and local institutions to be use in

health care. The WHO has recommended the use of it (WHO, 2007). SBAR has been recommended by The Swedish Association of

Local Authorities and Regions (SALAR), The Swedish National Board of Health and Welfare, and The Swedish Association of Health

Professionals (Socialstyrelsen [Online]; SKL [Online]; Vårdförbundet [Online]).

SBAR: its use in postoperative nursing handoff communication

The research literature offers little in relating postoperative nursing with the use of an adapted SBAR that was meant to suit the

delivery of information from a surgical nurse (SN) to a nurse working in a post- anesthesia intensive care unit (PAICU). While

research literature unanimously deemed postoperative handoff communication as a moment of communication failure that in turn can

jeopardize patient safety, little has so far been said about the share of SN in this regard or the way SN can avoid making

communication errors. Reports of postoperative communication errors did not specifically differentiate the role SN plaid while

mistakes were made, although, as a member of the surgical team, SN could not avoid accountabilities.

The only research literature that has been quoted by teaching literature for SN and that has related postoperative nursing handoff with

the use of SBAR in postoperative settings was authored by Amato-Vealey, Barba & Vealey (2008) (cited in Rothrock, 2011). The

authors asserted that the surgical nurse should be as specific as possible about the OR events that have occurred while reporting to

PAICU nurse. They considered the passing of patient’s past medical history as important. Components of this handoff communication,

7

according to the authors, should include presenting information on how the patient tolerated the procedure, whether the procedure went

as planned, whether the patient was hemodynamically stable, whether the patient experienced any intraoperative complications, any

medication the patient received and his/her therapeutic responses, and the patient’s current comfort level.

As mentioned above, handoff communication is not only a transfer of information but also a transfer of responsibility and the

concomitant authority that enable the nurse to shoulder that responsibility. Although communication failure has been reported to occur

in postoperative settings little has been done to focus on to what extent SN discharge their responsibilities. Besides there is scantiness

in the research literature concerning the extent to which contents of real time postoperative patient handoff communications tally with

the contents of the SBAR version that has been recommended for postoperative handoff communication.

Aim The aim of this study was to explore to what extent SN discharge their responsibilities by making postoperative handoff

communication as well as to describe the agreement (in structure and content) between the SBAR adapted to postoperative handoff

communication and SN actual postoperative handoff communications.

Study design

Method of data collection

Non- participant observation method was chosen as a method of data collection. This observation method is suitable to collect data

during verbal communications by using checklists and rating scales (Polit & Beck, 2006). The observation was chosen to be non-

participant since this believed to allow the observer to be detached from activities focus on the phenomena observed. The setting

chosen to make the observations was a PAICU in a teaching hospital situated in Northern Sweden where patients aged three months

and above underwent both elective and emergency surgery. Both SN that delivered patients to the PAICU postoperatively and critical

care nurses that received patients at PAICU were acquainted with SBAR by their respective clinics earlier on.

8

Data was mainly collected by using a checklist adapted from the postoperative SBAR version proposed to use by Amato-Vealey,

Barba & Vealey (2008). The first version of the checklist was tested in the selected setting for its feasibility and inclusiveness.

Following the tests adjustments were made to include items such as patient- related data and whether SN discharges their

responsibilities by making handoff communications.

The sampling method chosen was convenient sampling where every postoperative handoff communication that was expected to take

place while the observer was not preoccupied by another observation was considered as eligible. The study was conducted for seven

days (two days used to make clinical test of the checklist included) of different length between the end of October and the middle of

December 2013. Data was collected by using the checklist during and immediately after each handoff communication. The non-

participant observer also took short notes not to miss relevant information as handoff communications took place. Total handoff time

was measured by using digital stopwatch. Patient- related data such as age and type of operation were mainly retrieved during handoff

communications.

Method of data analysis and interpretation

Collected data was analyzed by using descriptive statistical methods. The use of statistical methods in analyzing data collected by

observations has been well known in the research literature (Polit & Beck, 2006nagpa; Ilan et al., 2012). Field notes were used to

compile and analyze data that had to do with, for example, the types of surgery the patients underwent, assessment of the handoff

environment and whether chances were given to PAICU nurses to ask questions during handoffs. A complete handoff communication

was considered to fulfilled 30 out of the 30 handoff items included in the checklist and omissions were calculated on the basis that.

Ethical considerations

Consent was sought and obtained from the leadership for both the involved surgical and acute care units. The integrity of nurses and

patients as well as data from the observations was treated according to the 1964 Helsinki declaration and its subsequent revised

versions that are meant to protect study participants (World Medical Association, 2013).

9

Results

Patient characteristics

A total of 22 observations involving 10 male and 12 female patients were made at the PAICU. The patients were aged from 8 months

to 79 years with a median age of 46 years. A total of 6 patients (27 %) were under 10 years (table 1).

Postoperative handoffs Among the 22 patients that were fetched to the PAICU, only 11(50%) of them were accompanied by both anesthetist nurses (AN) and

SN. Of those 11 patients, SN made postoperative hand- over reports only for 9 patients (41% of the total number of patients). During

two of these 11 occasions SN left the PAICU area without making hand- over reports.

Table 1: patient characteristics

Age (year/s) Sex Type of operation

0,67 F Reconstruction, pharyngeal flap (soft palate)

1 M adenotonsillectomy

7 F Reconstruction of the hard palate by bone transplantation from crista iliaca.

8 F Ultrasound-guided botulinum toxin injection in the Iliopsoas muscle (pat had spastic paraplegia).

8 M Aspiration of bone marrow biopsy (becken bone) under anesthesia

11 F Teeth extraction and extirpation of cysts in the upper jaw.

30 F Episcleral sealing and episcleral circlage (left eye) due to retinal detachment.

33 F Extirpation of benign tumor (cyst) from right lower jaw bone

39 F Functional endoscopic sinus surgery (FESS), Ethmoidal

39 F Replacement of earlier breast prothesis

44 M Fixation with plat, proximal humeral fractures (right )

48 F Laparoscopic re-operation for uterine bleeding

54 M Repositioning of an open fracture with osteosynthetic material (plates and screws), ankle (talocrural region)

59 M Excision of malignant tumors, (right ear), removal of three Affected neck lymph nodes and skin transplantation to the operatation site.

60 M Removal of plates and screws, right shoulder

60 F Insertion of intrathecal catheter for infusion due to pain from metastasis in cervical and thoracic spines

64 M Laparoscopic splenectomy

68 F Vitrectomy

71 F Extirpation of pathological bit of bone from caput humeri (right)

74 M Removal of earlier osteosyntesis (plates and screws) from earlier fixation, foot (left).

75 M Percutaneous transluminal embolization of an abdominal blood vessel (unspecified!)

79 M Wound revision (crown) and skin transplantation to the crown

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Handoffs were not made in a total of 13 (59 %) cases and these involved 9 female and 4 male patients. No handoff reports were made

for all of the pediatric patients (n= 6) (table 2). In other words, SN accompanied and delivered postoperative reports to PAICU nurses

during 9 (41 %) of the 22 occasions that involved a total of 6 male and 3 female patients (table 3).

Table 2: patients with no SN- delivered postoperative handoffs

Age Sex Type of operation Remarks

0,67 F Reconstruction, pharyngeal flap (soft palate) Parents/relatives were not available at the PAICU

7 F Reconstruction of the hard palate by bone transplantation from crista iliaca. Parents/relatives were not available at the PAICU

68

F

Vitrectomy

The SN forgot to bring patient document from the ophthalmological clinic

and went to fetch it. Never returned to the PAICU again

11 F Teeth extraction and extirpation of cysts in the upper jaw. Parents were not at the PAICU when the child arrived

8

F

Ultrasound-guided botulinum toxin injection in the Iliopsoas muscle (pat had

spastic paraplegia).

Parents waiting at the PAICU

8 M Aspiration of bone marrow biopsy (becken bone) under anesthesia Mother waiting at the PAICU

33 F Extirpation of benign tumor (cyst) from right lower jaw bone

30 F Episcleral sealing and episcleral circlage (left eye) due to retinal detachment.

1 M adenotonsilectomy Parents contacted by PAICU nurse

39 F Replacement of earlier breast prothesis

60 M Removal of plates and screws, right shoulder

60

F

Insertion of intrathecal catheter for infusion due to pain from metastasis in cervical

and thoracic spines

75

M

Percutaneous transluminal embolization of an abdominal blood vessel (Blood

vessel unspecified in postop. document )

The surgical nurse came, but left without making a handoff report

Handoff communications did neither follow SBAR nor were structured. In reports there identification of patients were made, reporting

used to start by the identification of patients. Then, SN would take up whatever point in SBAR (often information about dressing

material used) and continue the report to some length.

No SN started the handoff communication by introducing herself/himself. Patients were identified in 6 of the 9 occasions. Types of

invasive/ surgical procedures were mentioned in 67.8 % of the cases.

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When it comes to items that were included under ‘Background”, SN reported about local anesthetics used (often Carbocain or Marcain

with Adrenalin) in 77. 8% of cases and the kind of material used in wound dressing in 55.5% of cases. Of the items included under

“Situation” urine production during the intra operative period or the amount of urine taped immediately before the start of the surgical

procedures was mentioned at 3 occasions (33%). Information about surgical complications (rather the absence of any complication)

was mentioned ones only ones.

Among the items included under “Recommendation”, SN informed PAICU nurses about the need to make hemodynamic controls

(specifically control of blood pressure in a hypertonic patient) ones, continuation in specific medication (pain killer) ones, the needs

for continued wound dressing and types of dressing materials to be used in 6 of the 9 occasions. Types of suture material used were

mentioned in 4 of the occasions where wound dressing was mentioned. In none of these occasions mention was made when and how

non- absorbable suture materials could be removed. Patients’ needs for mobilization were mentioned and recommendations in patients’

nutrition were mentioned 3 and 4 times respectively.

The amount of information delivered per patient ranged from 6.7 to 36.7 % with the mean percentage of 24 %. The average amount of

information omitted was 76%. It is important to note that these calculations were based on frequencies and did not include qualities of

reports. It was not methodologically possible to investigate and report whether each delivered handoff information contained errors or

not.

but one occasion where there was time for questions and answers. The initiative however came from the PAICU nurse. All of the

handoff communications were ended without SN inviting/giving time for PAICU to ask questions. Often there were tendencies from

the side of SN (such as being in haste, being in the urge to leave the PAICU area) that could have discouraged PAICU nurses from

asking questions.

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Table 3: observation checklist with contents of handoff communication

Patient data

Age 44 39 54 74 79 64 71 59 48

Sex M F M M M M F M F

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Situation

1) The nurse has presented herself No No No No No No No No No

2) The nurse has identified the patient

2:1) By name only - - - No - No - No -

2:2)By age only - - - No - No - No -

2:3) By personal number only - - - No - No - No -

2:4) By name, age and personal number Yes Yes Yes No Yes No Yes No Yes

3) Type of operative/ invasive procedure, named Yes Yes Yes Yes No No No Yes Yes

Background

1) Type of anesthesia administered mentioned No Yes Yes Yes No Yes Yes Yes Yes

2) Intraoperative medication mentioned No No No No No No No No No

3) Surgical cite information (dressing material, drainage,

packing etc.)

No

Yes

No

Yes

No

No

Yes

Yes

Yes

4) The way the patient was positioned during surgery named. No No No No No No No No No

Assessment

1) Most recent vital signs reported

1:1) Blood pressure No No No No No No No No No

1:2)Pulse rate No No No No No No No No No

1:3)Blood oxygen level No No No No No No No No No

1:4) Breathing rate No No No No No No No No No

1:5) Body temperature No No No No No No No No No

1:6) Urine output No No No No Yes No Yes No Yes

2) Changes that occurred during and after the surgery reported

2:1) Hemodynamic changes (blood losses etc.) mentioned No No No No No No No No No

2:2) Changes in skin color No No No No No No No No No

13

* Each reported item was given one point and the sum of the items under each patient was divided by 30, i.e. the sum total point for a

complete SBAR report.

**Seconds

Patient data

Age 44 39 54 74 79 64 71 59 48

Sex M F M M M M F M F

Assessment contd.

2:3)Changes in neurological status No No No No No No No No No

2:4) Surgical complication/s is/are reported No Yes No No No No No No No

2:5) Level of pain/ pain management intervention/s named No No No No No No No No No

Recommendation

1)Recommended controls in vital /neurological/

hematological etc. signs/controls are mentioned

No

No

No

Yes

No

No

No

No

No

2) Recommendation/continuation in specific medications

mentioned No No No Yes No No No No No

3)Recommendation/continuation in wound dressing, suture

removal, drainage management/removal mentioned No No Yes No Yes Yes Yes Yes Yes

4) Recommendations in pat. mobilization mentioned Yes No No No No No No Yes Yes

5) Nutritional recommendation are mentioned Yes Yes No No No No No Yes Yes

6) Date/time of discharge mentioned No No No No No No No No No

7)Date and time for readmission/ x-ray control /next visit/

mentioned No No No No No No No No No

8)Contact information about parents/relatives mentioned No No No No No No No No No

Time was given for questions and answers No No No No No No No Yes No

Total information delivered in %* 23 30 23 16.7 20 6.7 26.7 33 36.7 Total hand-off time 47s** 85s 47s 60s 65s 30s 32s 125s 56s

The handoff environment

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ks

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per

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.

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om

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ICU

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.

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14

Total handoff time varied ranging from 30 to 125s with and means handoff time of 60. 8s (Std ± 20.9s). Total handoff time included

moments of quietness; time lapsed while nurses browsed through documents, and conversations (questions and answers). There was

The specific environmental situations that existed during the handoff communications are summarized in table 3. Even if all of the

handoff communications were conducted uninterrupted, the environmental situations were far from optimal for quite conversations.

Reports were made amidst other activities that were going on simultaneously.

Discussion

The aims of this study were to explore whether SN discharge their responsibilities by making postoperative handoff communication

and to describe to describe the comparability of SN postoperative handoff communications with the recommendations made in SBAR.

To the knowledge of this author, little has been done to study handoff communications between SN and PAICU nurses in

postoperative settings.

As indicated above SN made postoperative hand-overs in 9 (41%) of the 22 patients. That involved more male patients (n= 6) than

females (n=3) but no pediatric patients. Although it is difficult to say whether the gender of the patient affected handoff information

about the patient concerned, the female gender was more represented in those occasion where no handoff communication was made.”

The vice versa is true for male patients. Analysis of collected data has shown that on average 79% of relevant information was omitted

from handoff reports. Generally, there is no doubt that a handoff communication of such frequency, magnitude and content is

suboptimum. Given this fact it is hard to say if SN had discharged their responsibilities in handing over patient- related postoperative

information to PAICU staff.

Compared to most preoperative stats patients enter the PAICU in a vulnerable, semiconscious state where they cannot contribute

much in their care (Ross & Ranum, 2009). On the other hand, they have increased care needs that require closer monitoring that often

depend on what happened before and during the intraoperative period. As mentioned earlier, omissions and absence of or the transfer

15

of erroneous care- related information can lead not only to suboptimal patient care but also CRAE that otherwise could have been

minimized/avoided had proper hand-over communications were made. Patients but also patients’ relatives expect to be safe while

being cared for (Halm, 2013). To meet that expectation is impossible without the contribution of careful and complete handoff

communication.

In those 13 occasions (59%) where SN did not deliver postoperative information at the PAICU, patients were accompanied by AN

(often together with assistant nurses). Although AN can deliver useful postoperative handoff information that would not necessarily

cover all the information that otherwise could be delivered by SN and thereby make the handoff information more wholesome. SN are

well- situated and well- versed in, among others, information involving the surgical site, blood loss during the invasive procedure, type

of osteosynthesis material used, outcome of the surgical procedure etc. SN can give such necessary and detailed information not only

to PAICU nurses but also to parents/relatives who may anxiously be waiting to hear such information. To let AN take the

responsibility to deliver all relevant postoperative information can be neither realistic nor an expedite way of working in a team.

Besides, research has shown that even information delivered by AN was by no means free from errors (Anwari, 2002; Smith et al.,

2008; Nagpa et al. 2010 c).

As indicated above, handoff communications were not made for all of the pediatric cases. However, pediatric patients have no lesser

needs when it comes to the handing over of care- related information. Let alone with the absence of some relevant patient-related

information there is always a chance of omitting relevant information or giving erroneous information when every attempt is made to

transfer information. Handoff processes for critically ill children to PAICU may be prone to error. The contributing factors mentioned

in the literature include the fact that the handoff often takes place in a busy, distraction-rich environment; that PAICU staff may have

no prior knowledge of the patient’s medical history and thus depend on the handoff process for critical information; that patients are

often clinically unstable during the immediate admission period, which limits time for reviewing the medical record (Chen et al.,

2011). Communication errors in pediatric surgical handoffs occurred in 100% of events, with an average of 6.6 errors per handoff

16

(Chen et al., 2011). Minimizing the chance of omissions or errors in handoff communication may therefor include the making of

attempts by all involved in the care of the pediatric patient to transfer information.

The results of this study have indicated that SN did not identify themselves but also patients (in at least three occasions) during

handoffs. It is difficult to say whether SN were already known to PAICU staff given the fact that the SN meet and work with the

PAICU staff regularly. While there were more efforts made to mention the identity of patients, some patients were not identified to the

PAICU staff. There were no excuses for taking any risk/s/consequence/s that could follow with lack of proper identification of

patients no matter how minimum the risks deemed to be. Types of operative procedures were mentioned in the majority of cases even

if that were not always accompanied by reports of the outcome of the operative procedure, other assessments related to the operative

procedure, and relevant recommendations that have to do with the entire patient and go far beyond information about the surgical site

and wound dressing.

Generally, details in handoff information did not vary dramatically across the items summarized under S-B-A-R. However, the near

non- existence of detailed intraoperative information (summarized under “Assessment”) cannot be left unnoticed. The average handoff

time was about one minute. Although length of details can vary depending on the individual patient’s pre- intra- and postoperative

situation the shortness in the length of handoff time in the study reflected the general lack of details. Although not comparable with

this study in aim and study design, Chen et al. (2011) reported an average handoff time of 4 minutes while studying handoff

communication in pediatric patients.

The handoff communication was done in an environmental characterized by disturbing sound and commotion. However the

disturbance did not cause interruptions in the handoff process. The concerned patients but also other patients and their relatives in the

nearby beds were within hearing distance and could have listened to handoff reports had they had the attentions and interests to listen

to what were reported.

17

The results of this study has indicated a clear need in improving safety culture. Safety culture is but a product of individual and group

values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency

of health safety management. Improving safety culture involves, among others, improving staff perceptions of the quality of handoffs,

teamwork across units, and teamwork within units (Pham et al. 2012). Such improvements can serve the purpose of clinics and

clinicians, most importantly care- receiving patients.

Method discussion

Non- participant observation method is said to make study subjects become conscious of the presence of the observer and thereby

‘stimulate’ them to show the behavior the observer wants to witness. This author, although known to some of the SN and PAICU

nurses that seemed not to influence the observed behavior.

The adapted SBAR used as a checklist had a number of shortcomings. First, it did not have items that include patients’ background or

the reason why the surgical procedure was needed. Secondly, it has items that, despite genuine efforts, no SN can have full control or

knowledge. Items such as intravenous medications, results from hemodynamic and blood oxygen monitoring etc. would be easily

noticed and reported by AN. Thirdly, despite the fact that the contents of a handoff communication are results of the perioperative

period and as such involve team members, the SBAR adapted for postoperative use neither take this into account nor advise the need

for team members to discuss contents of handoff communication before delivery. Fourthly, the SBAR version does not take into

account whether certain items are applicable for the individual patient and/or the specific surgical procedure performed. For instance, a

tooth extraction done on an otherwise healthy girl under anesthesia (due to patient’s psychic state) may not necessarily include

information around needs of rehabilitation. Such items that otherwise could have been removed as inapplicable, might have

accentuated calculated results of omissions and thereby led to biases.

18

Conclusion and recommendation

The results of this study have shown that SN did not discharge their responsibility adequately by reporting patient- related information

postoperatively. The structures and contents of handoff communications were also found to be inadequate.

These and other results of this study are indicative of the fact that being acquainted with SBAR cannot guaranty the use of it. The

author of this study was surprised by the lack of demands for thorough reports on the side of PAIC staff. Nor did critical care nurses

made impressions of initiating discussions by asking questions, demanding detailed information in some areas etc. Even if more

research that can cover perioperative periods and settings can reach a comfortable conclusion, this study has implied the need for a

radical change in safety culture. There is also a need for further research to design adequate communication tools that either specify the

part of patient- related information that each and every member of the multi professional surgical team can handle and deliver

effectively and responsibly or make this information delivery a collective responsibility and specify how best it can be transferred

during handoffs.

19

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23

Appendix i

Patient information Age

Sex

Type of operation

Situation Yes No Remarks

1) The nurse has presented herself

2) The nurse has identified the patient

2:1) By name only

2:2)By age only

2:3) By personal number only

2:4) By name, age and personal number

3) Type of operative/ invasive procedure, named

Background

1) Type of anesthesia administered mentioned

2) Intraoperative medication mentioned

3) Surgical cite information (dressing material, drainage, packing etc.)

4) The way the patient was positioned during surgery is named.

Assessment

1) Most recent vital signs reported

1:1) Blood pressure

1:2)Pulse rate

1:3)Blood oxygen level

1:4) Breathing rate

1:5) Body temperature

1:6) Urine output

2) Changes that occurred during and after the surgery are reported

2:1) Hemodynamic changes (blood losses etc.) mentioned

2:2) Changes in skin color

2:3)Changes in neurological status

2:4) Surgical complication/s is/are reported

2:5) Level of pain and pain management intervention/s named

Recommendation

1)Recommended controls in vital /neurological/ hematological etc. signs/controls are mentioned

2) Recommendation/continuation in specific medications mentioned

3)Recommendation/continuation in wound dressing, suture removal, drainage management/removal mentioned

4) Recommendations in pat. mobilization mentioned

5) Nutritional recommendations are mentioned

6) Date/time of discharge mentioned

7)Date and time for reCRAEmission/ x-ray control /next visit/ mentioned

8)Contact information about parents/relatives mentioned

24

Time was given for questions and answers

Total information delivered in %

Total hand-off time

Environmental situation