Transitions of care in the pediatric cardiac intensive care unit*.

2245 Transitions of responsibility occur throughout many disciplines and professions. They have been recognized to be a fundamental activity outside of medicine that demands a detailed analysis to achieve the goals of efficiency and cost reduction. In 2002, Champy described “X-engineering” as a way for businesses to utilize current digital advancements in communication to achieve improvement in efficiency and quality of delivery to customers. He states, “a certain level of standardization is required to achieve the level of connection necessary for smooth, full flow of information, product, and money” (1). Similarly in 2008, Dunn and Murphy (2) describe racing car pit crews and air traffic control controllers as models of expert handovers with an extrapolation to the medical community. Within a hospital, handovers occur frequently without standardization. They occur between and within disciplines, locations, and between outpatient and inpatient providers. In addition, handovers occur at all levels of caretakers, including nurses, pharmacists, respiratory therapists, interns, residents, fellows, and attending physicians. As one may imagine, with this many levels of communication, there is bound to be communication failure. Dunn and Murphy describe that with the trend towards limited duty hour scheduling to minimize medical errors as a result of fatigue, the number and frequency of handovers has increased. In a study by Arora et al (3) in 2005, a group of interns on a general medicine rotation were queried on 25 incidents attributed to communication failure within the existing resident signout. The failures were concluded to be a result of two main problems. First was omission of pertinent patient information such as medications, active problems, and tests to follow-up. The second was a lack of communication including face-to-face discussion. These same failures are found amongst the pediatric population. McSweeney et al (4) surveyed pediatric housestaff with similar findings regarding the adequacy of verbal and written signout amongst the residents. The pediatric population being vulnerable at baseline, such gaps in communication could assumingly be deleterious in populations at higher acuity in the intensive care setting. One population at increased risk and morbidity includes the postoperative cardiac surgery population. The first major transition of care within this population is typically between the operating room team and the intensive care unit team. Identifying this as a potential for communication errors, there have been investigations striving to find an ideal handoff procedure or tool for this process. Mistry et al (5) recognized that the pediatric cardiac population was at increased vulnerability due the complexity of their disease and surgical intervention with high potential of postoperative complications. With this as the background, they utilized Six Sigma to study the problem and applied simulation training with resulting improved efficiency as noted by staff opinion via surveys. In 2011, Zavalkoff et al (6) conducted a prospective study involving postoperative cardiac handoffs in a pediatric intensive care unit. A one-page tool was developed for information from the cardiothoracic surgeon and anesthesiologist to transmit to the intensive care unit team during handoff with results suggestive of improvement in information transmission with no detriment to handoff timing. With this as the background, Agarwal et al (7) conducted similar work in this issue of Critical Care Medicine. The group sought to demonstrate that a standardized tool for handoff during the transfer of pediatric cardiac surgery patients from the operating room to the pediatric cardiac intensive care unit would result in a reduction in the loss of information and improvement in the quality of the handoff process. They also hypothesized that this process would be associated with a reduction in immediate postoperative complications and 24-hr patient outcomes in the pediatric cardiac intensive care unit. The study was conducted over 3 yrs as a prospective observational clinical study. Two surveys were administered to evaluate for information loss during these transfers before phases 1 and 2 in this 3-phase study. Both surveys were conducted before and after introduction of a structured handover tool. Patient complications and outcomes were compared between phases 1 and 2. Within the first 24 hrs in their pediatric cardiac intensive care unit, they included the need for cardiopulmonary resuscitation, mediastinal re-exploration, placement on extracorporeal membrane oxygenation, development of severe metabolic acidosis, and early extubations. The authors reported that they were able to demonstrate a significant reduction in loss of information while fostering an excellent overall general opinion of the handover tool. As well as these results, the handover tool is credited with an overall reduction in three of their four major complications that were studied as well as increase in the number of early extubations. This is one of the first studies to note that the intervention with a handoff tool led to better patient outcomes. One of the results reported in the study by Agarwal et al is that the handoff tool led to an increase in the number of early extubations. However, the practice and push for early extubation in the postoperative adult and pediatric cardiac has been a recognized goal in the field (8). Noting that this experience was limited in the pediatric population as of 2010, Alghamdi et al (8) performed a meta-analysis of existing literature and found that better outcomes came to those patients that were extubated earlier. In an earlier work, Manrique et al (9) demonstrated that the practice of early extubations of the postoperative pediatric cardiac patient within the first 24 hrs could safely be performed. The question to ask then is whether the practice of extubating a postoperative pediatric cardiac patient earlier in the study by Agarwalet al simply came from the national practice paradigm shift or completely from implementation of a structured handoff tool. The handoff tool by Agarwal et al was also correlated with a reduction in cardiopulmonary resuscitation, mediastinal reexploration, placement on extracorporeal Copyright © 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins