A Standardized Electronic Handover Report for Anesthesia Providers

Background: Numerous studies and agencies have recommended the standardization of handovers to improve the quality and safety of patient care. Intraoperative anesthesia handovers remain unstandardized at many institutions. Objectives: The purposes of this study were to 1) develop a preliminary Anesthesia Handover Report (AHR) and evaluate its accessibility, layout, and content using feedback from an Expert Sampling Group; 2) create a finalized AHR and evaluate the impact it had on the perceived quality of handover among anesthesia providers; and 3) to assess the uptake of the finalized AHR. Methods: This study was implemented at NorthShore University Health System (NSUHS), Evanston, Highland Park and Glenbrook locations. The study utilized a post-test design. In Phase 1, an Expert Sampling Group evaluated a preliminary AHR for its accessibility, layout and content. Study investigators used the feedback gained during Phase 1 to develop the finalized AHR. In Phase 2, all anesthesia providers at the three study locations were invited to utilize and evaluate the finalized AHR when giving intraoperative anesthesia handovers. In Phase 3, use of the finalized AHR was queried twice a week for the duration of Phase 2 to assess uptake. Results: Five anesthesia providers completed the Expert Sampling Group Questionnaire in Phase 1. Changes made to the preliminary AHR in response to feedback from the Expert Sampling Group included the removal of redundant information, more appropriate layout of information in the sidebar, the addition of total drug dose given in the medications panel, an additional hyperlink to anesthesia nerve block reports, and corrections to wrong information being pulled into the AHR. 21 anesthesia providers used the AHR and completed the Anesthesia Handover Survey in Phase 2, which evaluated the perceived handover conduct, teamwork, and A STANDARDIZED ELECTRONIC HANDOVER 4 quality. The overall mean Likert score for handover conduct was 3.72 with a SD of . 475 (minimum 2, maximum 4), this indicated that overall the majority of the respondents perceived that the AHR improved the conduct component of handover. The overall mean Likert score for teamwork was 3.76, with a SD of . 432 (minimum 3, maximum 4), indicating that respondents felt the AHR improved teamwork during handover. Lastly, the mean Likert score for the handover quality was 3.64 with a SD of . 611 (minimum 1, maximum 4), indicating respondents felt the AHR improved overall handover quality. Results of Phase 3 indicated the uptake did not increase as expected over the six-week monitoring window but rather peaked during week four and quickly dropped off thereafter. The mean number of times the “Anesthesia Handoff” button was clicked each week was 3.17. Conclusions: The use of the AHR improved the perceived conduct, teamwork, and quality of anesthesia handovers. The use of the AHR did not improve over time. Overall, use of the AHR improved the perceived quality of anesthesia handovers. Future studies should be done to determine if use of the AHR would result in the standardization of anesthesia handovers. A STANDARDIZED ELECTRONIC HANDOVER 5 Introduction Background and Significance of the Problem The American Association of Nurse Anesthetists (AANA) recommends all nurse anesthetists follow the standards of practice published by AANA (2013). According to Standard VII, the nurse anesthetist is required to provide a handover that accurately reports the “patient’s condition, including all essential information, and transfer the responsibility of care to another qualified healthcare provider in a manner that assures continuity of care and patient safety” (AANA, 2013, p. 2). The Joint Commission Center for Transforming Healthcare (2014) defines handover as: A transfer and acceptance of patient care responsibility achieved through effective communication. It’s a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care (para 1). Despite the AANA standard of practice, ineffective communication between health care professionals has been recognized as one of the leading causes of errors and handovers, and are no longer seen as “care-neutral events” (Hyder et al., 2016, p.141). Handover of patient care is a time when critical details may be lost resulting in delays, inefficiencies, adverse events, increased length of stay, increased costs or even patient harm (Joint Commission Center for Transforming Healthcare, 2014). In its groundbreaking report, Crossing the Quality Chasm, the Institute of Medicine (2001) stated that one of the first breakdowns in patient safety occurs during handovers. In 2006, as part of its National Patient Safety Goals, the Joint Commission (2007) published recommendations for patient safety that included the standardized handover of care. Despite this A STANDARDIZED ELECTRONIC HANDOVER 6 recommendation, in 2012 the Joint Commission (2015) continued to cite breakdown in communication to be responsible for up to 80% of hospital sentinel events and 91% of anesthesia-related sentinel events. The preoperative, intraoperative, and postoperative periods are complex environments that involve multiple providers who interact with the patient. Typically, one surgical team provides care to the patient during all aspects of the operative period. However, the anesthesia profession utilizes a care team model that allows for several anesthesia providers to participate in a single patient’s surgery. The care team often consists of different types of anesthesia providers, namely anesthesiologists, certified registered nurse anesthetists (CRNAs), resident anesthesiologists, and student registered nurse anesthetists (SRNAs). Owing to breaks, meals and the end of shifts, multiple anesthesia providers may provide care to a single patient in this period; consequently, multiple anesthesia handovers may occur during a single operative case. A recent study by Hyder et al. (2016) has shown a positive correlation between the number of anesthesia providers and postoperative complications. Hart and Owen (2005) found that the breakdown in communication during patient handover is due to the lack of standardization of the handover. Additionally, Wright (2013) states that when “information and processes are standardized, variation, and all of its unknown consequences, is minimized” (p. 231). Currently, no universally accepted standardized handover exists among anesthesia providers. To address this issue, The Joint Commission Center for Transforming Healthcare (2014) identified root causes for breakdown in communication during handover, which included ineffective communication methods and inaccurate or incomplete information provided. The Targeted Solutions Tool for Hand-off Communication was developed and identified solutions to target these root causes, which included development of a standardized tool, method, or form to A STANDARDIZED ELECTRONIC HANDOVER 7 be used every time a handover occurs and to identify new and existing technologies to assist in making handover efficient and complete. Despite this recommendation, many anesthesia providers have yet to adopt a standardized handover. The Problem Statement Gibney, Lee, Feczko, and Florez (2016) conducted a needs assessment among anesthesia providers at NorthShore University HealthSystem (NSUHS), Evanston Hospital for the development of an anesthesia handover tool. The results of this survey indicated that 64.6% of respondents did not currently have a standardized process for anesthesia handover and that 73.2% of the time they felt that sometimes, most of the time, or always were given inadequate information (Gibney et al., 2016). The study investigators concluded that most respondents perceived anesthesia handovers as inadequate. Despite hospitals investing in electronic health records (EHRs) with the goal of improving safety, quality, efficiency, and cost-savings, handovers have remained a major source of breakdown in communication, leading to adverse outcomes (Patterson, 2012). Wright (2013) stated that: The use of an effective communication tool or checklist by anesthesia providers actively engaged in the transfer of care could enable the incoming anesthetist to adapt more readily to the new environment through a purposeful orientation directed at the salient components of the anesthetic and patient condition (p. 225). To improve the quality of anesthesia care, the primary goal in the development of a Anesthesia Handover Report (AHR) was to determine if the use of the standardized report would improve the perceived quality of anesthesia handovers. A STANDARDIZED ELECTRONIC HANDOVER 8 Purpose of the Study The purposes of this study were to 1) develop a preliminary AHR based on data collected by Gibney and colleagues in 2016, and evaluate its accessibility, layout, and content using feedback from an Expert Sampling Group, 2) create a finalized AHR and evaluate the impact it had on the perceived quality of handover among anesthesia providers and 3) to assess the uptake of the finalized AHR. Findings of this project identified if the use of the AHR improved the perceived quality of anesthesia handover and if use of the AHR increased over time. Clinical Questions The following clinical questions were addressed through this research: • What is the usability and acceptability rate of the AHR during transfer of care in the intraoperative period among anesthesia providers? • Does a standardized AHR in the EHR improve anesthesia provider perceptions of conduct, teamwork, and quality of handover communication? • What is the rate of uptake for the AHR post implementation? Literature Review Prior to designing this study, a comprehensive review of existing literature was performed. The academic search engines used were CINAHL and PubMed.