Informatics Tools and Patient Handovers
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The patient handoff is a contemporaneous, interactive process of passing patient-specific information from one caregiver to another to ensure the continuity and safety of patient care. It is well recognized that the handoff is a point of vulnerability where valuable patient information can be distorted and omitted [1, 2]. A plethora of studies in the nursing literature have identified a variety of problems, including incomplete or inaccurate information [3-6], uneven quality [7], repeated interruptions and lack of anticipatory guidance [8]. Many reports have focused on characterizing the weaknesses with non-operative patient handovers, the use of handoff checklists and aviation safety models for specific groups of patients [1,5,9], and the pre- and post-implementation comparisons. [10-12] However, few studies have focused on prospective cohort studies validating and testing patient information management systems such as smart-templates in the setting of handover quality. [10] Electronic templates containing patient information help to standardize the type of information conveyed during interactions, discourages ambiguous findings,[13] improves provider satisfaction and improves continuity of care.[14] Within the department, we developed the transfer template (T2) to address the issues in provider workflow and efficiency. With the press of a button, the T2 template automatically extracts live information from the anesthetic record, pertinent fields from the PAC note and laboratory values from IView, and provides a concise output of these relevant details.
![Table of Contents
• IT/Handoffs Overview [s3-21]
• Patient Handoffs [s3-6]
• UW PACU Handoff [s7-13]
• UW ICU Handoff (eff. 2/2014) [s14]
• EHRs/Meaningful Use [s15-21]
• PAST Template [s22-32]
• Case Example [s28-32]
• T2 Template [s33]
• Handover IT: Objectives [s34]
• Handover IT as a QI Project [s35-50]
• Handover IT as a Research Project [s51-62]
• Future Directions [s63-64]](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Informatics Tools and Patient Handovers
- 1. Smart-Templates and Post-Operative Patient Handovers A QI + Research Project Aalap Shah, MD Surgical Services Chair, Housestaff Quality and Safety Committee R4, Department of Anesthesiology and Pain Medicine University of Washington Medical Center
- 2. Table of Contents • IT/Handoffs Overview [s3-21] • Patient Handoffs [s3-6] • UW PACU Handoff [s7-13] • UW ICU Handoff (eff. 2/2014) [s14] • EHRs/Meaningful Use [s15-21] • PAST Template [s22-32] • Case Example [s28-32] • T2 Template [s33] • Handover IT: Objectives [s34] • Handover IT as a QI Project [s35-50] • Handover IT as a Research Project [s51-62] • Future Directions [s63-64]
- 3. Patient Handoffs • “Transfer of information, responsibility, and authority from one health care provider to another.” • ACGME 2003 – • Duty hour restrictions Increased # of handoffs • Gawande 2003 • Review of 100 incident reports from 45 surgeons • 60% of events in OR+PACU • 43% due to communication failure; of which 2/3 were due to inadequate handoffs.
- 4. Patient Handoffs • Joint Commission 2006 – • Requirement for standardized handoff approach at accredited institutions • Joint Commission + WHO 2008 – • Highlighted role for standardized processes to identify and reduce handoff-related errors • Institute of Medicine 2008 – • Increased focus on handoff processes to improve patient safety
- 5. Patient Handoffs Obstacles Different media (Nagpal 2010, Mistry 2005) Taped/written reports verbal bedside reports EMR/PHR Integration Lack of institutional standardization (Mistry 2008, Nagpal 2010) Descriptive reports structured templates Specialty and location-specific handoff tools, physician vs. nurse Information Omission (Nagpal 2011, Catchpole 2007, Zavalkoff 2011) Poor Setting (Smith 2008, 2010, Chen 2011) Interruptions/Misunderstandings Room Delays/”Rushed” Inaccurate clinical assessment Unclear task assignments and “anticipatory guidance” (Joy 2011)
- 6. Patient Handoffs Research and Data Collection Methods Pre-/Post- Implementation Studies (Catchpole 2007, Joy 2011, Jukkala 2012, Mistry 2008) Six Sigma, Model for Improvement Focus group (Bosmans 2013) Observational/Cross-Sectional (Chen 2011) RCT (Van Eaton 2005, 2010) Surveys (Flanagan 2009, Bernstein 2010)
- 8. Case Example 58yo F presents to clinic for laparoscopic cholecystectomy on xx/2014, 3weeks prior to DOS Postprandial symptoms ED visit last week Gallstones/GBW thickening PMHx: – A-fib – DM2 – HTN – GERD – Morbid Obesity (BMI 35.4) – Chronic LBP – Hypothyroidism – Hearing Loss PSHx: – h/o Breast Ca s/p R. lumpectomy, chemorx – Lipoma removal 2002 PONV – Tonsillectomy/Adenoidectomy Rx: – Coumadin 5mg Daily – HCTZ 25mg Daily – Ranitidine 150mg Daily – Vicodin 5/325 1 tab q4-6 hours – Lisinopril 5mg Daily – Metoprolol 25 mg Daily – Metformin 500mg BID – Levothyroxine 125 mcg Daily SocHx: – Tobacco use (1ppd x 20 years) – Alcohol use (3-5 glasses wine/day) ROS: - +palpitations w/exercise, +myopia, +heartburn, +tingling in b/l 1st/2nd digits, recent URI (2 days) PE: – VS: HR 79, BP 145/89, RR 16 shallow, Temp 36.7, Sp2 98% on RA – Wt: 96.4kg, Ht: 165cm – Airway: Mallamapati II, , TMD < 6, Loose #11, NC 15.5in – Respiratory: UATS – CV: IRIR, no gallops – Abd: +Murphy’s sign. Hypoactive BT – Ext: Varicose veins, no edema – Neuro: +numbness in b/l feet, + carotid bruit – Skin: Lumpectomy incision healed. – FS: >4 (3 flights of stairs back pain) Labs: – Na 139, K 3.3, Cl 109, HCO3 29, BUN 12, Cr 1.1 – WBC 8.3, Hct 35, Hgb 12, Plt 171 – PT 13.5 , PTT 35, INR 2.1 • Studies – Referred for sleep study – EKG: IRIR HR 67-98 – TTE: nl chamber size, wall motion,valves, and EF
- 9. UW PACU Handoff I. Pre-Anesthesia/Clinic Visit Surgery Clinic Visit Phone interview Need PAC Visit? Add’l studies? Chart review Pre-op phone call Pre-op phone call Pt. arrives on DOS Yes Referral visits
- 10. UW PACU Handoff PAC Note 6-8 sheets of paper, only 60% vital to patient care
- 11. UW PACU Handoff PACU ICU IIa. Day before Surgery Pt. arrives on DOS IIb. Day of Surgery Providers assigned cases I. Pre-operative data collection and plan formation - PAC Note - Cerner - OSH Records - ?Epic II. D/w attending Need to see: - Preop Nurse - Surgeon - Anesthesia - OR Nurse OR Case Dispo
- 12. UW PACU Handoff III. PACU Floor Tx Un-planned ICU Arrive in PACU, Bay Assigned Handover - Attach O2 - Monitors - Positioning - MD: Verbal handoff - RN: SSHR filled Stable for Dispo? (Aldrete) Monitor in PACU CODE/still unstable? Home Orders in? Bed avail? Yes! To floor,,. Yes! Go home,,. RN-RN handover Outpt Rx ready? No Oh helll no Limbo Limbo RN-RN handover
- 13. UW PACU Handoff Information Omissions (March 27, 2014) (n=63) Name -- Airway management 3% Status/Code 68% Induction Meds 16% PMHx 36% Lines 24% Home Rx 24% Resident name/pager 100% Allergies 10% Anticipatory Guidance 82% Pre-study nurse surveys: Multiple disturbances/interruption Providers almost always “rushed” Inconsistency with PACU arrival tasks (monitors, O2, patient positioning) prior to handoff Data re: PACU and 24hr events pending
- 14. UW ICU Handoff John Lang, MD Alan Artru, MD
- 15. EHRs: Meaningful Use Electronic Health Records Today: The Positives Standardized Accessibility (Dykes 2007) Funding and Support (Steinbrook 2009) The Perceived Positives Workflow facilitation Efficiency Accuracy (Steinbrook 2009) Patient Care
- 16. EHRs: Meaningful Use Medscape. July 16, 2014
- 17. EHRs: Meaningful Use • National Alliance of HIT – • Office of National Coordinator – 2004 • “Majority of Americans to have EHRs by 2014” • ARRA 2009 – • $19.2B (of $>170B) stimulus package allocated to Healthcare IT
- 18. EHRs: Meaningful Use • Center for Medicare/Medicaid Services (CMS) • 2010 – standards for “certified “EHR • 2011 – incentive payments for EHR “meaningful use” attestation • 2015 – Medicare payment deductions for providers not showing meaningful use • National Committee for Quality Assurance (NCQA) • Health Effectiveness Data and Information Set (HEDIS) – 2012 • 35 quality measures to facilitate reporting of accountable care organization (ACO) benchmark data
- 19. EHRs: Meaningful Use Medscape. July 16, 2014
- 20. EHRs: Meaningful Use Medscape. July 16, 2014
- 21. EHR Templates Improvement in physician note quality scores (Fielstein 2006) Facilitation for secondary data use (Bonney 2013) Automatized process of information transfer and extraction by domain (Siebens 2001) Discourages ambiguous findings in notes (Bosmans 2012) Highlights important findings Improved patient rapport and continuity of care (Co 2010, Millery 2011)
- 22. PAST Template Automatic and timely consolidation of data from disparate systems Anesthesia Information Management Systems (Merge/AIMS) Cerner Powerchart MINDScape Data access/processing from Cerner EHR via AMALGA Stand-alone web-based program (SQL Serve Reporting Services) Access granted with Cerner/ORCA User ID/Password (HIPAA-compliant) *It is NOT a replacement for: - your own patient assessments - other clinician’s evaluations in the EHR - any perioperative communication (i.e. day-before phone call)
- 23. PAST Template Key: Gray highlighted fields [ ]: extracted from PAC note Yellow highlighted fields [ ] : labs/studies electronically extracted from Cerner/PowerChart. Green highlighted fields [ ]: extracted from DOCUSYS server Text in blue direct links to the Cerner PowerChart/Mindscape where studies can be retrieved (XML format) Text in red fields which will require revision of the PAC note template in order to accurately extract information.
- 24. I. Quantitative Information - Numeric data, studies, vitals, etc. all represented in one section - CPT/ICD already present Facilitates rapid input into DOCUSYS - Improves information reporting (Surgeons, PACU) DEVELOPMENT PAST Template
- 25. II. Medical/Surgical History - Diagnosis-linked fields pull in medications and problems by organ system - Airway management and complication information extracted from previous DOCUSYS anesthetic record DEVELOPMENT PAST Template
- 26. All coded fields from the PAC note categorized by issue. Only positive findings will “light up” in the final template DOS Checklist for provider and Pre-Op Nursing Staff PAST Template III. Anesthetic Issue “Dashboard” - PAC note components (ROS, PE, Labs) directly transferred from PAC note i- Issue and timeframe-based organization assist with prioritization and contribute to thorough and rapid patient assessments DEVELOPMENT
- 27. PAST Template 1-7days prior to DOS DEVELOPMENT Information automatically extracted from sources to populate template
- 28. Case Example 58yo F presents to clinic for laparoscopic cholecystectomy on xx/2014, 3weeks prior to DOS Postprandial symptoms ED visit last week Gallstones/GBW thickening PMHx: – A-fib – DM2 – HTN – GERD – Morbid Obesity (BMI 35.4) – Chronic LBP – Hypothyroidism – Hearing Loss PSHx: – h/o Breast Ca s/p R. lumpectomy, chemorx – Lipoma removal 2002 PONV – Tonsillectomy/Adenoidectomy Rx: – Coumadin 5mg Daily – HCTZ 25mg Daily – Ranitidine 150mg Daily – Vicodin 5/325 1 tab q4-6 hours – Lisinopril 5mg Daily – Metoprolol 25 mg Daily – Metformin 500mg BID – Levothyroxine 125 mcg Daily SocHx: – Tobacco use (1ppd x 20 years) – Alcohol use (3-5 glasses wine/day) ROS: - +palpitations w/exercise, +myopia, +heartburn, +tingling in b/l 1st/2nd digits, recent URI (2 days) PE: – VS: HR 79, BP 145/89, RR 16 shallow, Temp 36.7, Sp2 98% on RA – Wt: 96.4kg, Ht: 165cm – Airway: Mallamapati II, , TMD < 6, Loose #11, NC 15.5in – Respiratory: UATS – CV: IRIR, no gallops – Abd: +Murphy’s sign. Hypoactive BT – Ext: Varicose veins, no edema – Neuro: +numbness in b/l feet, + carotid bruit – Skin: Lumpectomy incision healed. – FS: >4 (3 flights of stairs back pain) Labs: – Na 139, K 3.3, Cl 109, HCO3 29, BUN 12, Cr 1.1 – WBC 8.3, Hct 35, Hgb 12, Plt 171 – PT 13.5 , PTT 35, INR 2.1 • Studies – Referred for sleep study – EKG: IRIR HR 67-98 – TTE: nl chamber size, wall motion,valves, and EF
- 29. Case Example I. Quantitative Information DEVELOPMENT
- 30. Case Example II. Medical/Surgical History DEVELOPMENT
- 31. Case Example III. Anesthetic Issue “Dashboard” DEVELOPMENT
- 32. DEVELOPMENT
- 33. Transfer Template (T2) DEVELOPMENT Push F7 on OR Anesthesia computers to display T2
- 34. Handover IT: Objectives Engagement of nurses and providers in the development of web-based informatics application to improve the handover process. Decreased information omissions related to the patient’s relevant medical history on the Surgical Services Handoff Report (SSHR) (purple sheet), prior to patient discharge or ward transfer. Improvement in the quality of the provider-nurse handover process as gauged by third-party (nurse educator) evaluators and tested handover evaluation tools in the recovery room. Decreased incidence of minor complications in the immediate post-operative period, as well as within the first 24 hours of floor transfer. Improved intraoperative evidence-based anesthetic plans based on identifying at-risk patients (ex: multiple agent therapy for PONV prophylaxis, decreased volatile gas administration for patients with lower MAC requirements) “Provider” = any person administering an anesthetic (attendings, CRNA, residents) QI, RESEARCH
- 35. Handover IT: QI Approach: IHI Model For Improvement QI
- 36. Handover IT: QI Patient Task Factors Staff Factors Team Factors Organization Environment 1.) Omission of Information (OI) 2.) Poor handover quality 3.) PACU adverse events Cause/Effect Chart - OSH records not available - Language barriers - Complex pt/multiple medical issues -Incorrect/incomplete info presented at clinic visit - Incorrect info in EHR - Chart review instead of [needed] clinic visit -Multiple intraop handovers (anesthesia) -PACU nurse task burden/”shift change” -Provider/nurse - Burden of PAC documentation - Time-consuming EHR review - Case to follow, pressure to be efficient - Lack of or miscommunication between resident and attending re: anesthetic plans -Multiple sources of info in EHR -No standardized -Printouts/jotting down illegible notes -Noisy/clustered -Staff or pt. interruptions -Chart/SSHR not available
- 37. Handover IT: QI Accuracy of Post-Operative Handovers QI
- 38. Handover IT: QI AIMS Statement: Specific Stretch Measurable Achievable Realistic Timely Our team aims to decrease the rate of post-operative verbal handover OI in all checklist fields to ≤ 15% within 6 months of study start (e.g. June 30, 2015) in ASA3+ patients being admitted to UWMC after elective surgery. QI
- 39. Handover IT: QI Assemble A Team Research: G. Alec Rooke, MD PhD, Gail Van Norman, MD PAC Clinic coordinators: G. Alec Rooke, MD PhD IT: Dr. Bala Nair, Shu-Fang Newman (Programmer) CQI Coordinator: Karen McElhinney Nurse educator (CNE) team: TBA QI
- 40. Outcome Measures Primary Outcomes • OI (%), Run Chart • Quality (via Handoff CEX) • # of minutes until patient is transferred from PACU to inpatient floor QI Pre-Anesthesia Intraoperative Post-Anesthesia Demographics Airway Access Condition Antibiotics Disposition Allergies Induction Rx Sign-Out Medications BP Rx Anticipatory Plans PMHx Pain/PONV Rx Fluids
- 41. Outcome Measures Primary Outcomes • 1) OI Run chart QI
- 42. Outcome Measures Primary Outcomes • 2) Handoff CEX QI
- 43. Outcome Measures Secondary Outcomes (PACU) • 3) PACU adverse events PONV • Incidence of PONV in Group 1 and Group 2 • # of medications administered • # of emesis episodes Pain • # of separate pain medication administrations • Maximum pain score recorded by patients • Total opioid consumption (in milligrams) QI
- 44. Outcome Measures • PACU adverse events (cont’d) Sedation scores (Aldrete score) • 15 minutes, 1 hour, and 2 hours Hypotension (SBP < 90 and/or MAP <60) • # of patients with hypotensive episodes • # of individual pressor (blood pressure-elevating) medication administrations • Total pressor consumption (in milligrams) QI
- 45. Outcome Measures • PACU adverse events (cont’d) Respiratory compromise • # of patients with respiratory depression (RR < 8) • # of narcan administration events • # of desaturations QI
- 46. Process Measures • % attendance/participation at training sessions • % of PACU nurses using template for signout at 3 months • % provider (resident/CRNA/attending for signout at 3 months QI
- 47. Balance Measures • Administrative time expense • Whiteboard involvement • Provider time expense • Handover time, OR turnover time • Developmental/Programming Costs • Nursing/Provider satisfaction • Evaluation of PHI integrity (to be determined after 2nd PDSA cycle) QI
- 48. Handover IT: QI Problem/ Processes Improvements/ Interventions Omission of Information (OI) PAST, T2 Handover Quality PAST, T2 PACU adverse events PAST QI
- 49. Handover IT: QI • Pre-Implementation • IRB, etc. • PACU Nursing Survey • Online training module/instructional video • Provider Recruitment • Departmental, Class, or Group E-mail QI
- 50. Handover IT: QI • Implementation • Focus Groups (x4), 1.5 hr sessions • Focus on Qualitative Input • Foster provider-nurse partnership and ownership • Identify hospital-wide barriers and ways to facilitate implementation • Revise product • Pizza • Departmental announcements • Online modules/LMS Gateway • Model for Improvement – PDSA Cycles QI
- 51. Handover IT: Research • Study Design: • Prospective RCT • Single-blinded (PACU nurse/provider aware) • IRB needed: access to patient PACU data, intent to publish QI data outside UWMC • Study Population: N=64 dyads (provider-PACU nurse interactions + patient); 32 dyads/group • “Provider” = CA2 or CA3 resident or CRNA (>2yrs) • “PACU Nurse” = 1:1 nurse who is routinely in PACU • “Patient” = ASA 3+ with planned post-op admission RESEARCH
- 52. Handover IT: Research • Intervention: • Control Group: Provider preference in patient pre-op preparation and handover • Intervention Group: PAST for patient pre-op preparation, PAST + T2 for handover • Will receive additional instructional video (15 minutes) • Templates visible by both PACU nurse and provider • Recruitment: • E-mails, GR announcements • Consent: • Written consent from providers • Nursing staff to receive educational session during pre-implementation phase, RESEARCH
- 53. Handover IT: Research • Workflow • 1 day prior to DOS: Coordinate with Whiteboard/AIC • Providers notified 1 day prior to surgery re: control vs intervention group • DOS: Provider brings pt. to PACU • Audio recorders (numbered) distributed to each nurse prior to provider/patient coming from OR • Monitors, positioning, O2 after arrival, etc. • If provider is in intervention group, provider instructs PACU nurse to open PAST template • Verbal handoff, recording with pt. name and ID. RESEARCH
- 54. Workflow RESEARCH 15-min video tutorial
- 55. Handover IT: Research PACU ICU RESEARCH Ia. Day before Surgery Pt. arrives on DOS Ib. Day of Surgery Providers assigned cases I. Pre-operative data collection and plan formation - PAC Note - Cerner - OSH Records - ?Epic III. D/w attending Need to see: - Preop Nurse - Surgeon - Anesthesia - OR Nurse OR Case Dispo I. Access/download PAST II. Additional chart review T2 used for intraop handoffs T2 printed before arrival
- 56. Handover IT: Research Floor Tx RESEARCH PACU Arrive in PACU, Bay Assigned Handoff - Attach O2 - Monitors - Positioning - PAST Handoff at PACU computer - Anticipatory planning - PACU orders revised, if needed Un-planned ICU Stable for Dispo? (Aldrete) Monitor in PACU CODE/still unstable? Home Orders in? Bed avail? Yes! To floor,,. Yes! Go home,,. RN-RN handover Outpt Rx ready? No Oh helll no Limbo Limbo RN-RN handover
- 57. Handover IT: Research RESEARCH
- 58. Handover IT: Research Data Storage/Access Audio recorders (containing PHI) stored in locked desk in Anesthesia QI office Handover audio evaluations: OI: Recordings compared against PAC note and ORCA medication list Quality: Recordings graded via Likert Scale in Handover CEX (previously validated evaluation tool) PACU events: Recordings compared against completed PACU charting in CERNER IView.
- 59. Handover IT: Research Pre-Anesthesia Intraoperative Post-Anesthesia Demographics Airway Access Condition Antibiotics Disposition Allergies Induction Rx Sign-Out Medications BP Rx Anticipatory Plans PMHx Pain/PONV Rx Fluids Primary Outcomes • OI (%) • Quality (via Handoff CEX) • # of minutes until patient is transferred from PACU to inpatient floor
- 60. Handover IT: Research Secondary Outcomes PACU adverse events PONV Pain Scores Sedation scores Hypotension Respiratory depression RESEARCH
- 61. Handover IT: Research • Data Collection: • Audio recordings: End of OR Day • PACU data: Weekly review of patient charts • Analyses • Power analysis for study sample • Handoff CEX scores nonparametric tests of mean • Handover and PACU times Mann-Whitney U test • PACU outcomes Fisher-Exact Test RESEARCH
- 62. Timeline September 2014 – Submit IRB PAST/T2 rollout October-December 2014 – Provider Recruitment Focus Groups Template revisions/feedback Create 15-minute instructional video January-May 2015 (Resident Research Track)– Data collection and analyses June 2015 – Manuscript preparation
- 63. Research/QI: Long-Term Objectives Widespread implementation of PAST template at UW as well as affiliated hospitals. Institute a web-based handover report/checklist form to replace the paper-based Surgical Services Handoff Report (SSHR) Integrate surgical handoff/anticipatory guidance into electronic handoff tools (i.e. the T2) Decrease post-operative major + minor complications related to provider communication error Research/QI
- 64. HSQC Integration High Value Theme – Empowering PACU nurses to standardize handoffs Surgical subspecialty education about anesthetic workflow Non-handover-related aims to improve efficiency of patient disposition (avoid “limbo”) Documentation standardization modules HMC PACU QI Champions
- 65. References email me: Aalap Shah shaha3@uw.edu Aalap.c.shah@gmail.com
Editor's Notes
- Different templates