Abstract
Purpose
The purpose of this study was to investigate interaction in the handovers between anesthesia and the recovery room and to examine the effect of using the Identification, Situation, Background, Analysis, and Recommendation (ISBAR) instrument as a structured dialogue tool during hand over.
Design
A prospective quality improvement project with pre/post assessment.
Methods
Fifty handovers in the postanaesthesia care unit were observed. Data were collected regarding parameters associated with ISBAR. Both certified registered nurse anesthetists and registered nurses (RNs) from postanaesthesia care unit were subsequently asked about their satisfaction with the handover via an electronic questionnaire survey. After 6 months, the questionnaire survey was repeated, and 50 observations were conducted identical to the baseline observations.
Findings
Results showed that from baseline to follow-up, RNs were more prepared to receive the patient (from 84% to 95%), read the patient records more frequently (from 18% to 54%), and were assigned to patients from the start of the day (from 86% to 100%). The content of the oral handover was more structured using the ISBAR, and handovers became more concentrated and undisturbed (from 12% to 86%). At baseline, certified registered nurse anesthetists were more satisfied with the handover than RNs (38% difference). At the follow-up, there was no discrepancy between the two groups.
Conclusions
Knowledge and focus on the verbal handover influence communication, team effectiveness, and quality of handovers. The ISBAR structured approach reduced disturbances to handover because everybody involved had a clear expectation of the different items to be reviewed and were less likely to interrupt to question or clarify. Using ISBAR as a structured tool along with organizational changes can improve the quality of patient handover and thereby improve patient safety.
Keywords
In a hospital with several specialities, handover of patients between health care professionals occurs multiple times daily as patients often require diagnostic tests and treatments in different units. The handover can take place using verbal or written communication between different health care professionals or by combining both modalities. It is vital to be alert to prevent mistakes and critical incidents and maintain a high level of safety for the patient, even when the specific task is quite common and well known to the health care professionals involved.
1
,2
In an anesthetic unit, the context of the patient course is well-known to most of the nurses. The patient undergoes surgery with general or spinal anesthesia and completes the treatment course in the postanaesthesia care unit (PACU). The patient has contact with more than 1 health professional and therefore handovers play a key role in ensuring patient continuity, quality, and safety. The different ways of structuring the handover can unfortunately entail loss of relevant information about the patient, the surgery, and the perioperative period.
3
, 4
, 5
After completion of surgery, the patient is woken in the operating theater. Certified registered nurse anesthetists (CRNAs) are responsible for the patient's condition until the patient has been handed over to the PACU registered nurse (RN). The PACU RN is responsible for more than 1 patient at the same time. We experienced that this patient assignment sometimes was a source of interruption or shortened the handover conversation between the CRNA and the PACU RN.
Previous research has found that an increased risk of incomplete and ineffective information transfer commonly occurs between anesthesia providers and the PACU. Randmaa et al
6
found that lack of structure and long duration of verbal handover decreases how much the receiver will remember. Li et al's7
systematic review suggested that interruption interferes with prospective memory and should be minimized in workplaces with high working memory demands.An analysis of 750 handovers in a PACU determined that many handovers had inadequate and missing information,
3
and a systematic review concluded that postoperative patient handovers were incomplete, imprecise, informal, filled with intrusions, and inconsistencies.4
These problems concerning lack of information are widespread and constitute a significant clinical problem. One way to improve communication is to use a structured tool such as Identification, Situation, Background, Analysis, and Recommendation (ISBAR).8
, 9
, 10
ISBAR stands for Identification, Situation, Background, Analysis, and Recommendation. During identification (I), the persons initiating the handoff introduce themselves and identify the patient by full name and identification number. You describe the current patient situation in relation to treatment and care (S), then the patient's background is elaborated (B), and at the end of the handover, an analysis of the situation will be given (A) and advice on problems recommended (R). The purpose of the tool is to make communication at the sector transitions more efficient and complete. ISBAR is a standardized way of communicating, especially during care transitions.
6
ISBAR can be used anywhere in the health care system when responsibility is transferred to another person and from one section to another.The aim of this project was to investigate interaction in the handovers between anesthesia and the recovery room, and to examine the effect of using the ISBAR as a dialogue tool in the handovers.
Methods
Design
A quality improvement design was implemented with assessments before and after the intervention.
Setting
The project took place at a Danish Hospital with cancer surgeries and elective surgeries of five surgical specialties. The Anesthesiology Department has a PACU and an anesthesia unit, each with its own manager.
In the anesthesia unit, anesthesiologists and CRNAs administer anesthesia collaboratively. The CRNAs maintain the anesthesia until the operation is over, after which the patient is extubated. The CRNAs accompany the patient to the PACU together with the porter. The RNs in the PACU then take over care of the patient until the patient is ready to be transferred to the parent ward. The PACU employs 25 RNs and the anesthesia unit has 40 CRNAs. The day-to-day collaboration between the two sections is centered on the handover of surgical patients and the perianesthetic period.
Pre-Assessment Workshop
To identify the issues experienced at handover, a workshop was held between PACU RNs and CRNAs. They were mixed in small groups and asked to bring up the two most important barriers for further collaboration. Different challenges in regard to communication, time available, and the amount of tasks were mentioned. Lack of knowledge and understanding of each other's task objectives and work procedures were expressed as important barriers in relation to the handover situation. Subsequently, the PACU RN and the CRNAs were asked to propose solutions. Among several proposals, the managers chose the communication tool ISBAR and a proposal to reorganize the daily workflow in the PACU to further enhance efforts.
Questionnaire Survey
Based on the workshop results, a questionnaire to assess the PACU RNs and the CRNAs opinions about patient handovers and possible improvements was developed and pilot tested. The questionnaire included questions about the following:
- 1The experience of how handover of patients between PACU RNs and CRNAs functioned
- 2How the content of the handover was experienced in relation to expectations
- 3Experiences of concentration and distraction during the verbal handover
The questionnaire was sent via e-mail to the PACU RNs and CRNAs in the Department of Anaesthesiology.
Observation
After the baseline questionnaire survey was administered, observations of 50 handovers of surgical patients between the CRNA and the PACU RN were conducted. The method of performing the observation and data registration was pilot tested, and two nurses (1 from the PACU and 1 from the anesthesia unit) conducted all the observations together during each handover. The first parameters registered on patient arrival at the PACU were as follows:
- 1The type of surgery
- 2Was the PACU RN ready for the reception of the patient?
- 3Had a place been designated for the patient beforehand?
- 4Had the PACU RN read the electronic medical record beforehand?
- 5Was the patient appropriately dressed?
- 6Did the patient have a warm blanket around the body?
- 7Was the patient was receiving oxygen at 2 to 3 l/min?
- 8Did the patient's condition require a nursing action from the very start of the patients' arrival at the PACU?
During the verbal handover, information about the following data were registered:
- 1Identification of the patient by name and ID number
- 2American Society of Anesthesiologists Classification (ASA)
- 3Comorbidity or comorbid disorders
- 4Type of anesthesia
- 5Course of anesthesia including complications
- 6Perioperative analgesic
- 7Postoperative pain assessment
- 8Number of interruptions to handover processes
In addition to these parameters, it was noted if the CRNA left the patient in stable condition, and whether the CRNAs followed up on the patient afterward.The PACU RN and the CRNA were both asked how satisfied they were with the handover. Finally, the duration of the handover was recorded.
Interventions
The interventions consisted of two parts: the communication tool ISBAR and organizational initiatives. The interventions were presented in both units several times during meetings and by e-mail, so that all staff members were aware of the changes. The intervention period lasted 6 months.
ISBAR
The communication tool, ISBAR, was defined, introduced, and implemented in a new and more specific way for use in the patient handover from CRNA to the PACU RN. The explanation of ISBAR was related to the anesthesiological context, so that the handover started with (I) identification of the patients full name, ID number, age, allergy; (S) Type of anesthesia, airway management, cardiovascular perioperative status, reversal/risk of residual reaction, fluid treatment, temperature, and the patient's mental state; (B) ASA, premedication, comorbidity (A) status; and overall assessment of the surgical and anesthetic course. Finally, (R) included recommendations regarding assessment of the patient's pain, medical orders, and areas that required follow-up.
The ISBAR material was designed in the form of pocket cards and paper pads and distributed in the PACU and the anesthesia unit. Every PACU RN and CRNA were encouraged to use the ISBAR material.
Organizational Initiative
Patients were assigned PACU rooms ahead of time via a whiteboard in the corridor and visual screens in the operation theater and in all corridors. The PACU rooms were individually assigned to PACU RNs, and the PACU RNs were encouraged to read the electronic medical records on delegated patients before their arrival.
Follow-Up
After 6 months, the questionnaire survey was repeated, and 50 observations were conducted identical to the baseline observations.
Data Analyses
Descriptive statistics were used to describe the questionnaire survey, and the observation (baseline and follow-up); frequencies and percentages were used. Fisher exact tests were used for comparative analyses. A value of P < .05 was considered to be significant.
Ethical Considerations
All employees had the opportunity to participate in the questionnaire survey and were informed that all data would be processed confidentially and results would be presented anonymously. Filling in the questionnaire was considered as consent. Likewise, employees were informed about the observations and ensured that all data would be processed confidentially and results would be presented anonymously. All the participants received written information about the study aim and procedures, were told that participation was voluntary, and participation could be discontinued at any time without explanation. As per Danish law, the study did not need approval from regional ethics committees.
Results
Questionnaire
A total of 64 PACU RNs and CRNAs were invited to participate in the baseline part of the study, and 56 in the follow-up. The response rate was 92% (n = 59) at baseline and 91% (n = 51) at follow-up.
The percentage of participants finding the handover of patients between CRNAs and PACU RNs very satisfactory increased from a baseline of 8% to 33% at follow-up. At baseline, the CRNAs were more satisfied with the traditional handover than the PACU RNs, but at the follow-up, there was no discrepancy between the two groups. At the follow-up, 25% found that the content of the handover very satisfactory met expectations compared with 10% at baseline (Table 1).
Table 1Anesthesia and Recovery Nurses' Opinions About Handovers
| Questionnaire | Baseline | Follow-Up | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Recovery Nurse | Anesthesia Nurse | Total | Recovery Nurse | Anesthesia Nurse | Total | |||||||
| Parametre | n | % | n | % | n | (%) | n | % | n | % | n | (%) |
| How do you experience the handover of patients between anesthesia nurse and the recovery nurse? | ||||||||||||
| Very satisfying | 1 | (5) | 4 | (10) | 5 | (8) | 1 | (7) | 16 | (44) | 17 | (33) |
| Satisfying | 14 | (74) | 31 | (78) | 45 | (76) | 14 | (93) | 20 | (56) | 34 | (67) |
| Neither-or | 4 | (21) | 4 | (10) | 8 | (14) | 0 | (0) | 0 | (0) | 0 | (0) |
| Unsatisfactory | 0 | (0) | 1 | (3) | 1 | (2) | 0 | (0) | 0 | (0) | 0 | (0) |
| Very unsatisfactory | 0 | (0) | 0 | (0) | 0 | (0) | 0 | (0) | 0 | (0) | 0 | (0) |
| How do you think the content of the handover is in relation to your expectations? | ||||||||||||
| Very satisfying | 1 | (5) | 5 | (13) | 6 | (10) | 1 | (7) | 11 | (31) | 12 | (24) |
| Satisfying | 13 | (68) | 27 | (68) | 40 | (68) | 14 | (93) | 23 | (64) | 37 | (73) |
| Neither-or | 4 | (21) | 7 | (18) | 11 | (19) | 0 | (0) | 2 | (6) | 2 | (4) |
| Unsatisfactory | 1 | (5) | 1 | (3) | 2 | (3) | 0 | (0) | 0 | (0) | 0 | (0) |
| Very unsatisfactory | 0 | (0) | 0 | (0) | 0 | (0) | 0 | (0) | 0 | (0) | 0 | (0) |
| How do you experience the concentration during the handover? | ||||||||||||
| Very satisfying | 1 | (5) | 5 | (13) | 6 | (10) | 2 | (13) | 11 | (31) | 13 | (25) |
| Satisfying | 14 | (74) | 27 | (68) | 41 | (70) | 13 | (87) | 24 | (67) | 37 | (73) |
| Neither-or | 3 | (16) | 6 | (15) | 9 | (15) | 0 | (0) | 0 | (0) | 0 | (0) |
| Unsatisfactory | 1 | (5) | 2 | (5) | 3 | (5) | 0 | (0) | 1 | (3) | 1 | (2) |
| Very unsatisfactory | 0 | (0) | 0 | (0) | 0 | (0) | 0 | (0) | 0 | (0) | 0 | (0) |
| Participants | 19 | 40 | 59 | (100) | 15 | 36 | 51 | (100) | ||||
Organizational Initiatives
The reorganization initiatives were visible in the patient flow and the arrival at the PACU. Patients were no longer waiting in line for the distribution of recovery patients among the nurses.
It was agreed to start the handover when the patient was placed and monitored in the room and when the PACU RN was ready. The agreement about starting time of the handover was a major change and a new workflow to implement for the CRNAs.
Every morning, the PACU RNs assigned the patients to different PACU rooms, so that each nurse knew which patients he/she was supposed to take care of. Therefore, the PACU RNs were more prepared for receiving the patient.
The communication tool ISBAR was visible as a pocket card during each handover, and the CRNA followed the relevant items. The CRNA gave time for questioning afterward.
The PACU RNs had read about the patient before the patient arrived and wrote notes while they read the electronic medical record so that the concentration was more on the specific perioperative data and the content of the handover.The CRNAs did not make any notes except completion of the standard record documentation.
Observations of Handovers on Arrival at the PACU
Fifty observations of patient handover were completed twice between CRNAs (n = 28) and PACU RNs (n = 16) in December 2017 and between CRNAs (n = 26) and from the PACU RNs (n = 15) in June 2018. All the patients had either had an orthopedic, otological, organ or day surgery operation. The median duration of verbal handover was 3 minutes both at the baseline (minimum 2 minutes to maximum 11 minutes) and at follow-up (minimum 1 minute to maximum 5 minutes) (P = .006).
All parameters observed on arrival of the patient to the PACU were improved from the baseline to follow-up. The parameter “to plan a bed space for the patient on arrival from the operating room” was significantly improved from 86% to 100%. The parameter “the recovery nurse had read the electronic medical record” was also significantly improved from 18% to 54% (Table 2).
Table 2Observations of Handovers on Arrival to the Recovery Room
| Observations | Baseline | Follow-Up | P | ||
|---|---|---|---|---|---|
| Parameters | n | % | n | % | |
| Operation section (n = 50/50) | |||||
| Orthopedic surgical operation section | 17 | (34) | 10 | (20) | .13 |
| Otological operation section | 12 | (24) | 9 | (18) | |
| Organ surgical operation section | 17 | (34) | 23 | (46) | |
| Day surgery section | 4 | (8) | 8 | (16) | |
| The recovery nurse was ready for reception of the patient (n = 50/50) | 42 | (84) | 47 | (95) | .11 |
| There was an allocated bed place for the patient (n = 50/50) | 43 | (86) | 50 | (100) | .006 |
| The recovery nurses had read the electronic medical journal (n = 49/50) | 9 | (18) | 27 | (54) | <.001 |
| The patients are appropriately positioned in the bed (n = 49/50) | 48 | (98) | 50 | (100) | .31 |
| The patients are properly dressed(n = 49/50) | 49 | (100) | 50 | (100) | |
| The patients had a warm blanket round the body (n = 49/50) | 47 | (96) | 50 | (100) | .15 |
| The patients was offered oxygen (n = 49/50) | 36 | (73) | 32 | (64) | .31 |
| The patient's condition needs intervention when arriving at the recovery room (n = 49/50) | 9 | (18) | 4 | (8) | .13 |
Fisher exact tests were used for comparative analyzes A value of P < .05 was considered to be significant.
Use of the ISBAR checklist yielded a more reliable percentage of patients undergoing identification by full name, by birth date, surgery type, ASA classification, competing disorders, type of anesthesia, anesthesia including complications type, perioperative analgesic and postoperative pain assessment as compared with the standard verbal report used in the baseline observations. Most of the parameters in regard to the content of the handover showed tendencies of improvement (Table 3). The parameter “undisturbed handovers” was significantly improved from 12% to 84% at the follow-up (Table 3).
Table 3Content of the Verbal Handover by Anesthesia Nurse
| Observations | Baseline | Follow-Up | P | ||
|---|---|---|---|---|---|
| Parameters | n | % | n | % | |
| Patient identification by full name (n = 49/50) | 42 | (86) | 47 | (94) | .17 |
| Patient identification by birth date (n = 49/50) | 16 | (33) | 23 | (46) | .17 |
| Surgery type (n = 49/50) | 45 | (92) | 50 | (100) | .04 |
| American Society of Anesthesiologists Classification (n = 49/50) | 30 | (61) | 38 | (76) | .11 |
| Competing disorders (n = 48/50) | 37 | (77) | 39 | (78) | .91 |
| Type of anesthesia (n = 48/50) | 38 | (79) | 44 | (88) | .24 |
| Anesthesia including complications type (n = 49/50) | 44 | (90) | 47 | (94) | .44 |
| Perioperative analgesic (n = 49/50) | 42 | (86) | 46 | (92) | .32 |
| Postoperative pain assessment (n = 49/50) | 27 | (55) | 35 | (70) | .13 |
| Undisturbed handover (n = 49/50) | 6 | (12) | 42 | (84) | <.001 |
Fisher exact tests were used for comparative analyzes A value of P < .05 was considered to be significant.
Discussion
The questionnaire survey, the observational study with interventions, and the organizational changes achieved revealed improvements in the overall handover, as well as the concentration on, and the content of the handover from the CRNA to the PACU RN. At baseline, the PACU RNs were not as satisfied concerning the general handovers as the CRNAs, but at the follow-up, there was no discrepancy between the two groups. A study looking at quality of handover showed that instruction about patient management was clear to the PACU RN in 80% of the cases. The PACU RN judged the handover as good, satisfactory, and bad in 48, 28, and 24% of cases, respectively.
11
Another study showed that professional perceptions of the postoperative handover differed with regard to temporal foci and transfer of responsibility. All professional groups were insecure about having all the information needed to ensure the quality of care. They strived to ensure quality of the handover by focusing on matters that deviated from the normal course of events, aiding memory through structure and written information, and cooperating within and between teams.12
In the present study, the explanation for the initial low level of satisfaction at baseline might be that the PACU RNs were not prepared for the specific patient and that they had several tasks at the same time. It may also have been stressful for the PACU to constantly organize RNs and places for each patient coming to the PACU room from the operation theater. Before the reorganization of the PACU systems, the CRNA was required to wait for a dedicated place to monitor the patient and start the handover, often resulting in time management problems for the anesthetic staff and delays in the day operations program. This could explain why anesthetic staff sometimes started handover before the PACU RNs were ready.The organizational change in which each patient had been assigned a place in the PACU ahead of time was a significant improvement. The fact that the PACU RN read the electronic medical record of the assigned patients and was more prepared for the task they faced when the CRNA came with the patients also seemed to support the improvement of the general experience of the handover. The improvement in staff members’ perception of between-group communication accuracy after implementation of the communication tool ISBAR noted in this present study is similar to findings from a study by Randmaa et al
11
where communication also improved.The median duration of verbal handover was 3 minutes at both the baseline and follow-up, which is 1 minute and 22 seconds longer than the verbal handover in a study at a daytime surgery center
12
and even longer than handovers in another study.3
In the study by Milby et al,3
handovers were in most cases incomplete, whereas in the present study, the duration of the handover had the same length, but the content was more complete after the handovers were structured using the ISBAR tool. Another explanation for the longer duration of the handover in the present study, compared with the study in a daytime surgery unit,12
could be that in the present study more complex data were verbally handed over.In the present study, the parameter “undisturbed handover” increased significantly from 12% to 42% after interventions. One explanation for this might be that ISBAR was used as a structured way to conduct the handover and that both the PACU RN and the CRNA were introduced to the specific items in the ISBAR. The expectation of the ISBAR structured approach might have reduced disturbances to handover because everybody involved had a clear expectation of the different items to be reviewed and were less likely to interrupt to question or clarify.
Another study found that 77% of the handovers were interrupted and the senders expressed unclear information at 70% of the handovers. Staff concentration on the handover was higher when handover was given without interruption. The study concluded that lack of structure decreased how much the RN will remember.
12
A study by Li et al7
also supports that interruptions interfere with memory and should be minimized in workplaces with working memory demands. The present study did not examine these connections.Studies about ISBAR support that structured information is easier to remember.
1
,13
, 14
, 15
In the present study, the parameter “notes written by the PACU RN” decreased slightly at the follow-up, as the RNs already had read and written notes about each patient from the start of the shift and therefore had less need to make notes during the handover.Strength and Limitations of the Project
Strengths of the project include the mixed method with observation and survey data, the pilot tested and joint observation model, and the high survey response rate. Further strengths were a robust participation from nurses on both units as well as organizational/managerial support for the change. The joint workshop in the planning phase was of great importance for the involvement and commitment of the participants in the project.
Limitations include it being a single-center study and that the RNs and CRNAs were aware of the observers’ presence, and therefore may have acted differently than normal. However, as this was the case at both the baseline and follow-up, it probably did not influence the differences between the two observation periods.
Conclusion
Knowledge and focus on the verbal handover influence the communication, the team effectiveness and the quality of handovers. ISBAR was used as a structured way to conduct the handover. The ISBAR structured approach reduced disturbances to handover because everybody involved had a clear expectation of the different items to be reviewed and were therefore less likely to interrupt to question or clarify. The parameter “undisturbed handover” increased significantly. Using ISBAR as a structured tool along with organizational changes can improve the quality of patient handover and thereby indirectly increase patient safety.
Acknowledgments
The authors thank all participating nurses.
References
- Impact of the Communication and Patient Hand-Off Tool SBAR on Patient Safety: A Systematic Review.BMJ Open. 2018; 23: 1-10
- Postoperative Handover: Characteristic and Considerations on Improvement: a systematic review.Eur J Anaesthesiol Actions. 2013; 30: 229-242
- Quality of Post-Operative Patient Handover in the Post-Anaesthesia Care Unit: A Prospective Analysis.Acta Anaesthesiol Scand. 2014; 58: 192-197
- Durham VA Patient Safety Center of Inquiry, et al. Can we make postoperative patient handovers safer? A systematic review of the literature.Anesth Analg. 2012; 115: 102-115
- A quantitative study on personnel’s experiences with patient handovers between the operating room and the postoperative anesthesia care unit before and after the implementation of a structured communication tool.Nurs Rep. 2019; 9: 1-6
- SBAR Improves Communication and Safety Climate and Decreases Incident Reports Due to Communication Errors in an Anaesthetic Clinic.BMJ Open. 2014; 21: 4
- Systematic Review of the Psychological Literature on Interruption and Its Patient Safety Implications.J Am Med Inform Assoc. 2012; 19: 6-12
- SBAR Improves Nurse-Physician Communication and Reduces Unexpected Death: A Pre and Post Intervention Study.Resuscitation. 2013; 84: 1192-1196
- Situation, Background, Assessment, and Recommendation-Guided Huddles Improve Communication and Teamwork in the Emergency Department.J Emerg Nurs. 2015; 41: 484-488
- Increasing Patient Safety in Hemodialysis Units by Improving Handoff Communication.Nephrol Nurs J. 2020; 47: 439-446
- The postoperative handover: a focus group interview study with nurse anesthetists, anesthesiologists and PACU nurses.BMJ Open. 2017; 4: 7
- An Observational Study of Postoperative Handover in Anesthetic Clinics; The Content of Verbal Information and Factors Influencing Receiver Memory.J Perianesth Nurs Actions. 2015; 30: 105-115
- Patient Care Handoff in the Postanesthesia Care Unit: A Quality Improvement Project.J Perianesth Nurs. 2017; 32: 125-133
- SBAR Tool Implementation to Advance Communication, Teamwork, and the Perception of Patient Safety Culture.Creat Nurs. 2018 1; 24: 116-123
- Interprofessional Handover and Patient Safety in Anesthesia: Observational Study of Handovers in the Recovery Room.Br J. 2008; 101: 332-337
Article info
Publication history
Published online: November 18, 2021
Footnotes
Conflict of interest: None to report.
Funding: The study received no funding.
Identification
Copyright
© 2021 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
