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The purpose of this project was to develop and implement a pause and standardized perioperative handoff to improve the quality of the handoff and the satisfaction of the perioperative team in the postanesthesia care unit (PACU) setting.
Design
The Iowa Model for Evidence-Based Practice guided this evidence-based practice-quality improvement project.
Methods
A team was formed of key nurses and other perioperative members to execute the project. The outcome of the evidence review, appraisal, and synthesis supported the change to a pause and standardized perioperative handoff. The project team educated perioperative staff on the practice change and new process. Baseline, 3-month and 1-year data were collected for adherence to the PACU PAUSE and handoff critical elements, and baseline and 3-months for satisfaction.
Findings
PACU PAUSE adherence was 42.30% prepractice change, 92.3% postchange and 96.10% at 1-year. Adherence to the 17 critical elements in the standardized handoff was 40.16% prepractice change, 77.36% postchange and 71.78% at 1-year. Nurse satisfaction with the PACU PAUSE and handoff increased 59% and 50% respectively from pre to postpractice change. Operating room nurse and anesthesia provider satisfaction with PACU PAUSE and handoffs was greater than 85% at baseline and increased 14% and 8% respectively.
Conclusions
The PACU PAUSE allows for increased nurse concentration during the handoff and this can improve patient safety. Using a standardized handoff in situation, background, assessment, response format can decrease information loss and miscommunication, improve the quality of the handoff and the perioperative team members satisfaction with the handoff, and may mitigate patient safety events.
Joint Commission on Accreditation of Healthcare Organizations Joint commission center for transforming healthcare releases targeted solutions tool for hand-off communications.
The handoff from the anesthesia provider to the PACU nurse is often a verbal bedside report of the patient's medical history, interoperative events and postoperative plan.
This verbal communication is susceptible to information loss because the PACU environment is fast-paced and filled with distractions, interruptions, and multi-tasking that may divert the nurse's attention.
Standardized checklists that include the pertinent information that must be transferred from anesthesia provider to the PACU nurse have been shown to improve communication and transfer of pertinent information.
A pause or timeout by operating room (OR) and PACU team members before initiating the handoff allows the PACU nurse time to set up the patient monitoring devices and this pause has been associated with improved nurse concentration and satisfaction with the handoff.
Combining a pause and a standardized perioperative handoff process should improve the quality, safety and satisfaction with the handoffs.
Local Problem
Nurses in a 14-bed PACU at a Level II Trauma Center in the mid-Atlantic were receiving bedside report at the same time they were connecting the patient to monitoring devices. This resulted in suboptimal handoffs, disjointed communication and dissatisfied perioperative team members. A team of PACU nurses decided to look for evidence to answer the clinical question: In the PACU setting, does a standardized perioperative handoff with a pause affect the quality of the handoff and the satisfaction of the perioperative team? The goal of this project was to develop and implement a standardized perioperative handoff with a pause to improve the quality of the handoff and the satisfaction of the perioperative team in the PACU setting.
Methods
The Iowa Model for Evidence-Based Practice guided this evidence-based practice-quality improvement (EBP-QI) project. The Iowa model uses EBP and QI processes to promote excellence in health care.
Joint Commission on Accreditation of Healthcare Organizations Joint commission center for transforming healthcare releases targeted solutions tool for hand-off communications.
Steps in this model include identifying triggering issue described in local problem section, the project goal, form a team, assemble, appraise, and synthesize the evidence, design and pilot the practice change, integrate and sustain the practice change, and disseminate the results.
Form a Team
The project was led by a senior certified perianesthesia nurse (CPAN; project manager) and two experienced staff nurses (project champions) with one having critical care registered nurse (CCRN) certification. The project was endorsed by the OR/PACU Nurse Manager, Surgical Services Director and the hospital Nursing Research Council (includes research, EBP, QI). Key stakeholders were the anesthesia providers, surgeons, preoperative holding area staff, OR circulators and PACU nursing staff. Anesthesia and surgeon buy-in was obtained by sharing the baseline handoff data and PACU and OR staff satisfaction surveys. This sparked the interest of an anesthesiologist, who agreed to be a project champion and facilitated buy-in of other anesthesia providers, both anesthesiologists and certified registered nurse assistants (CRNAs) and surgeons. The anesthesia champion helped to create the situation, background, assessment, response (SBAR) handoff format, and a vascular surgeon and CRNA assisted with data interpretation.
Assemble, Appraise and Synthesize the Evidence
A review of the evidence supported the use of a standardized handoff to improve quality and content of information, safety and PACU team member satisfaction.
A pause or handoff timeout for the PACU nurse to set up the patient monitoring devices was supported by several evidence sources that found this timeout to be effective in OR to intensive care unit (ICU) handoffs
and evidence sources described in the previous paragraph were used to create the new handoff process. Figure 1 displays the new standardized perioperative handoff process with the PACU PAUSE. The process begins with the postsurgical debriefing before the surgeon leaves the OR. At this time the circulator asks the surgeon about any patient concerns to relay in handoff to the PACU staff. Prior to leaving the OR, the circulator calls the PACU to notify of the charge RN of impending arrival as well as any isolation or special needs required on arrival. The PACU charge nurse assigns a bay for the incoming patient. Upon arrival to the PACU bay, the anesthesia provider announces the patient's name, date of birth and procedure. Monitor-line set-up occurs followed by receiving PACU RN stating, “I am ready for report”. The anesthesia provider follows the SBAR template, stating any concerns and anticipatory guidance, followed by opportunity for questions. Next, the OR circulator follows the SBAR OR nurse template, followed by opportunity for questions. PACU RN ends report after any questions answered. A copy of the OR RN written report is left with the PACU RN.
Figure 1Standardized Handoff process. DOB, date of birth; EBL, estimated blood loss; IV, intravenous; OR, operating room; OSA, obstructive sleep apnea; PACU, postanesthesia care unit; SBAR, situation, background, assessment, response; UOP, urinary blood loss. This figure is available in color online at www.jopan.org.
This project was reviewed by the hospital's Nursing Research Council and determined to be an EBP-QI project that did not require Institutional Research Board approval.
The project was branded as the PACU PAUSE by the project manager and nurse champions because it highlighted the required pause for monitor line setup prior to the bedside handoff. OR and perioperative staff were educated about the PACU PAUSE and the standardized perioperative handoff process using multiple formats. To educate the anesthesia providers, the anesthesia champion introduced the new PACU PAUSE process in the anesthesia group's newsletter. The champion also shared a PowerPoint with the standardized handoff process and required pause at the anesthesia provider's monthly provider meeting, along with the rollout plan and start date. A hard copy of the PowerPoint was posted in the PACU and scrolled on the departmental monitor. The project manager met with each anesthesia provider to reinforce the new process. The OR nurses, preoperative holding room and PACU staff received education on the PACU PAUSE during staff meetings presented by the project manager and nurse champions. In addition, all OR/PACU and preoperative holding room staff were assigned an on-line learning activity with the same PowerPoint that was used to educate the anesthesia providers.
The project manager or nurse champions met individually with the staff that did not attend the live educational activity to review the PACU PAUSE PowerPoint and answer questions. Go-live reminders were delivered via huddles, flyers and emails. Surgeon notification of participation in the PACU PAUSE process, communicating concerns to the OR circulator that needed to be passed to the PACU nurse before the operative case ended, occurred via verbal and PACU PAUSE process handouts and flyers. Lastly, each surgical specialty OR nurse coordinator was asked to notify the surgeons in their specialty, of the PACU PAUSE process and roll out date. Sharing of practice-based evidence from Johns Hopkins where surgeons give bedside report improving handoff quality in the PACU was a motivating factor for the practice setting surgeons.
A month prior to project implementation a PACU PAUSE banner was hung in PACU to peak interest, to signal that the practice change was coming, and to encourage staff to ask questions. The week of PACU PAUSE implementation both anesthesia and OR nurse SBAR posters were affixed to the wall over each PACU bay for easy reference. Laminated perioperative handoff flowcharts were available at each PACU bay table. The project manager served as extra staff on go-live day with name tag on “PACU PAUSE Support Staff” and helped to guide the new handoff process as needed.
The project evaluation included the handoff audit tool and satisfaction survey adapted from Johns Hopkins Perioperative Toolkit.
The handoff audit tool was used to evaluate staff (PACU nurse, OR nurse, anesthesia provider) adherence to the new standardized perioperative handoff process. Table 1 lists the critical elements that were audited. Audits were done prepractice change (January to February 2016), after the July 2017 project roll out (November 2017 to February 2018) and at 1-year (July to August 2018). Table 2 lists the questions for the PACU nurse and OR nurse/anesthesia provider satisfaction survey. These data were collected before the practice change and after the project roll out at the same time as the audits.
Table 1PACU Nurse, OR Nurse, Anesthesia Provider Adherence to PACU PAUSE and Standardized Perioperative Handoff
Table 1 displays the results for staff adherence to the PACU PAUSE and standardized perioperative handoff for each of the critical elements at the time points of prepractice change, postpractice change and at 1-year. The PACU PAUSE for monitor line set-up started at 42.3% adherence prepractice change and increased to 92.3% postpractice change, and at 1-year increased to 96.1% adherence. Overall, there was a 37% increase from prepractice change to postpractice change (40.16% to 77.36%) in the total critical elements exchanged during handoff. This practice change was sustained at 1-year with 71.78% in total critical elements exchanged. There was an improvement in all of the individual critical elements pre to postpractice change and this improvement was sustained at 1-year for 88.2% (n = 15) of the critical elements.
Table 2 displays the PACU nurse and OR nurse/anesthesia provider satisfaction with the PACU PAUSE and standardized perioperative handoff. Overall, there was an improvement in satisfaction for PACU nurses, OR nurses and anesthesia providers. Specifically, nurse satisfaction with the PACU PAUSE and handoff increased 59% and 50%, respectively from pre to postpractice change. Despite OR nurses and anesthesia providers reporting high satisfaction rates prepractice change, improvements occurred in postpractice change satisfaction rates for PACU PAUSE and handoffs at 14% and 8% respectively.
There were several factors that contributed to the successful implementation of this project. There was a dedicated group of three PACU nurses who were committed to improving the perioperative handoff. There was organization support for the practice change. The EBP process was used to identify effective strategies for improving the perioperative handoff. The right team was formed that included an anesthesia champion and key stakeholders who effectively supported the project implementation and evaluation.
Improvement opportunities still exist for the PACU PAUSE and standardized perioperative handoff. The critical elements that decreased or did not reach greater than 70% adherence need to be evaluated for the ‘why’ and root cause. The PACU PAUSE and standardized perioperative handoff education materials and resources need to be added to the new employee onboarding process for both nurses and anesthesia providers.
Disseminate the Results
Project results were presented at the 2018 American Society of PeriAnesthesia Nursing National Conference
and at the Regional Research Symposium for the authors' health system. After hearing about the project success, nurses in the ICU (eg, neuro ICU) and other specialty areas (eg, interventional radiology, cardiac catheterization/electrophysiology lab, endoscopy) have expressed interest in piloting the process in their practice setting. The rationale is that nonoperating room anesthetizing locations where patients undergo invasive diagnostic and therapeutic procedures are steadily increasing and these procedures require anesthesia services with subsequent postanesthesia care in the PACU. A reference manual was created for the other PACUs and specialty areas in the health system that includes the PowerPoint education module, one-page SBAR handoff process (Figure 1), checklist of critical elements for audits, satisfaction tools, PACU PAUSE poster and authors contact information.
Conclusion
The handoff from the OR to the PACU is an especially susceptible time for information loss that can lead to patient safety events. Implementing a PACU PAUSE allows for increased nurse concentration during the handoff and this can improve patient safety. Using a standardized handoff in SBAR format can decrease information loss and miscommunication, improve the quality of the handoff and the perioperative team members satisfaction with the handoff, and may mitigate patient safety events.
References
Halterman RS
Gaber M
Janjua MST
Hogan GT
Cartwright SMI.
Use of a checklist for the postanesthesia care unit patient Handoff.
Defined as ± 5% from postintervention to 1-year audit.
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