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Patients boarding in a 14-bed postanesthesia care unit (PACU) impacted throughput in a large university hospital in West Virginia. The PACU and operating room (OR) boarder rate in 2019 was 12% (n = 1241) and 5% (n = 503), respectively. The purpose of this initiative was to improve PACU throughput by developing an efficient and evidence-based handoff communication process between the PACU and the medical-surgical floors.
Design
The design of the project was evidence-based quality improvement.
Methods
An interprofessional team created a nursing patient dashboard in the electronic medical record to be used during handoff communication between the PACU and medical-surgical floor nurses. The dashboard displayed real-time vital signs, patient history, medications, and laboratory results. When the patient met Aldrete score requirements for transfer, PACU nurses notified the floor that the patient was ready for transfer. After allowing 20 minutes for the floor nurse to view the dashboard, the PACU nurse and floor nurse spoke on the phone to discuss any outstanding questions. PACU and OR boarder rates were obtained from the electronic medical record 12 months before and after implementing the nursing patient dashboard. User feedback was gathered via plan-do-study-act cycles, posters, and interviews.
Findings
The electronic dashboard was a successful strategy to improve handoff communication between the PACU and receiving units. The dashboard was accepted by the staff with 70% (n = 24) of the comments being positive. A significant decrease in the number of PACU (χ2(1, n = 20,608) =122.63, P < .00001) and OR boarding (χ2 (1, n = 20,283) =14.55, P = .000136) of patients was found in the C-year compared to 2019. For patients who were boarded in the PACU, no significant difference in PACU delay duration was found (t(11) =1.49, P = .149) with the mean in 2019 of 166.96 (SD = 68.38) and the C-Year mean 132.84 (SD = 39.74). For patients who boarded in the OR, there was a significant difference (t(11) =15.590162, P <.00001) between groups for average duration of boarding with the mean in 2019 of 19.06 minutes (SD = 3.72) compared to 1.62 (SD = 1.1) in C-year. However, in July 2020 the PACU intermittently opened 2 flexible beds when the PACU was full, suggesting that OR boarding was not a reliable measure, but PACU boarding remained an accurate measure.
Conclusions
The findings of this evidence-based quality improvement project demonstrated the usefulness of an electronic dashboard tool combined with verbal report to improve patient throughput by decreasing the number of patients boarding in the PACU.
Healthcare organizations face a challenge to identify barriers to safe, efficient, and quality patient care while meeting the changing needs of consumers.
The quality and safety of patient care are jeopardized when there is a breakdown in communication between healthcare providers. As a result, The Joint Commission revised a 2006 National Patient Safety Goal addressing handoff and created a national standard concerning patient admission and handoff communication.
The standard required an opportunity for verbal discussion between the giver and receiver of information. In 2017, The Joint Commission released a sentinel event alert identifying the potential patient safety issues related to inadequate handoff communication and patient outcomes
Understanding the barriers to adequate and timely handoff communication provides the foundation for improving the quality and safety of patient care.
Nationally, organizations struggle to efficiently admit and discharge patients in a timely manner, commonly referred to as patient throughput. Throughput not only impacts the patient experience but can significantly impact the organization's financial bottom line.
To improve throughput, organizations must identify the barriers that lead to delays in admission, transfer, and discharge. Patient throughput does not impact 1 specific unit within a hospital; the problem is a system-wide issue that often results in boarding, which is the housing of patients in inappropriate units of the hospital.
Boarding in the postanesthesia care unit (PACU) usually begins as patients need to wait for the inpatient unit beds. When the PACU is full, patients are then boarded in the OR.
In 2021–2022, the American Society of Perianesthesia Nurses' Nursing Standards, Practice Recommendations, and Interpretative Statements offered guidance for the safe transfer of care during handoff. Recommendation 6 provided a structured guideline and process for using standardized tools and methods to communicate information from the sender to the receiver.
American Society of Perianesthesia Nurses Standards and Guidelines Committee. 2021-2022 Perianesthesia nursing standards, practice recommendations, and interpretative statements.
1st ed. American Society of PeriAnesthesia Nurses,
Cherry Hill, NJ2020
The recommendation included that the PACU give report to the receiving unit before or at the time of transfer using standardized tools and methods to communicate and that opportunity for questioning between caregivers be provided.
Background
A 690-bed, Magnet designated, Joint Commission certified, Level 1 Trauma Center was facing capacity management and patient throughput challenges. The OR averaged monthly case volume was 3,536 cases, with an average of 40% (n =1,410) of those patients requiring an inpatient transfer from the PACU. When the hospital was near capacity, full medical-surgical units hampered PACU transfers. During 2019, the PACU boarder rate was 12% (n =1241) and the OR boarder rate was 5% (n = 503).
After reviewing the reasons for boarding, the inability to give report to the floor nurse was identified by nursing staff and administration as a problem that could most easily impact patient flow. Additionally, the hospital was planning to eliminate a recorded report process and wanted to implement an efficient process and allow for direct communication between the PACU and floor nurses. In the outdated process, when the patient had met discharge criteria, the nurse recorded a verbal report via a phone message to the receiving unit. The nurse then notified the unit that the recorded report had been completed. The process used old technology and at times resulted in delays in the receiving unit listening to the recorded report. Since the organization was already experiencing capacity management issues, this was the perfect time to identify opportunities for improving the handoff communication process.
Literature Review
A literature search was conducted for the PICO question: In the transfer of PACU patients, does the use of the electronic medical record (EMR) and verbal report improve inpatient transfer time? The literature review resulted in three themes: standardization, use of technology, and creating buy-in.
Standardization
Continuity of care can be significantly impacted when the transfer of patient information is lost or delayed from provider to provider. Standardization is one way to decrease the loss of information and promote timely care. In a large academic hospital in the Southeastern United States, 50 inpatient nursing units and 3 observation units served as the population for a quality improvement project that used lean methodology to evaluate the emergency department (ED) handoff communication process. A standardized handoff guide and Situation, Background, Assessment, Recommendation (SBAR) communication tool were developed to standardize the handoff process resulting in decreased patient transfer times from 30.5 minutes to 21.5 minutes.
completed a performance improvement project to decrease the bed-assignment to bed-occupy time using the electronic SBAR handoff communication within their electronic medical record, thus eliminating verbal report. 1-year post-implementation, the assign-to-occupy time was decreased from 97 minutes to less than 60 minutes. Other studies
Usability assessment of an electronic handoff tool to facilitate and improve postoperative communication between anesthesia and intensive care unit staff.
also noted improvements in communication with the use of SBAR.
An alternative to SBAR handoffs is the Illness Severity, Patient Summary, Action List, Situation Awareness, and Synthesis of the Receiver (IPASS) standardization tool used to facilitate patient handoff communication and decrease communication errors. In an observational, experimental study (N = 524 patients) by Skaret et al
the percentage of risk reduction for written errors was evaluated before and after implementing an automated electronic IPASS tool. Errors were determined by assessing the handoff documents used for transitions of care compared to the correct information found in the electronic chart. Multiple plan-do-study-act (PDSA) cycles were completed, and the results revealed an aggregate absolute risk reduction for written errors of 46.6% post-implementation.
surveyed patients (n = 451), nurses (n = 236), and physicians (n = 168) in a 360-degree description of the patient-transfer experience focusing on intensive care unit (ICU) patients transferred to an inpatient unit. Results revealed that nurses, doctors, and patients had different needs and expectations regarding handoff communications. The sending physicians and nurses reported giving more elements of clinical information than their receiving counterparts reported, including significant differences in communicating the patient's diagnosis, current problems and treatment, allergies, mobility, plan of care, social issues, and family involvement. After receiving suggestions for improvement from participants, the authors recommended a multi-pronged communication process involving all stakeholders using standardized templates and verbal updates at the time of transfer to promote timely transfer and prevent information loss.
In multiple quality improvement projects, the use of technology or electronic medical record integration was used to augment the handoff communication process.
Usability assessment of an electronic handoff tool to facilitate and improve postoperative communication between anesthesia and intensive care unit staff.
Usability assessment of an electronic handoff tool to facilitate and improve postoperative communication between anesthesia and intensive care unit staff.
Usability assessment of an electronic handoff tool to facilitate and improve postoperative communication between anesthesia and intensive care unit staff.
Usability assessment of an electronic handoff tool to facilitate and improve postoperative communication between anesthesia and intensive care unit staff.
created an IPASS handoff tab within the existing EMR. The tool auto-populated from the EMR, and the end-user could add or remove tool components to meet their handoff needs. Senders and receivers of the handoff communication (n = 38 handoffs) evaluated the tool and found that the tool was easy to use (87.5%), satisfactory (75%), and user-friendly (75%). Potts et al
initiated an electronic SBAR nursing handoff tool at a 495-bed urban academic center to decrease delays from the ED. Use of the tool was associated with a decreased ready-to-move to occupied-time from 83.6 minutes to 47 minutes ten months after implementation. Similarly, Wolak et al
developed the standardized handoff guideline and SBAR communication tool that significantly decreased ED transfer times by 8.8 minutes (SD = 7.4) and decreased the time to give/receive report by 1 minute (SD = 1.2).
focused on information technology (IT) integration to augment their electronic infrastructure to create a handoff list for an orthopedic and trauma department. Before implementation, nurses, therapists, and physicians all created and maintained their own list daily. However, the list contained errors, mostly about the patient's location within the hospital, but also contained patients who had been discharged while others were erroneously missing from the list. The hospital IT department used the existing patient management software to create an electronic handoff list that was inclusive of all patients and updated in real-time as the patient's condition changed. After the electronic list was created, the location and patient discharge problems were eliminated, and the missed patient problem was improved. Modifying the existing software made this a cost-effective quality improvement that increased communication efficiency and decreased the workloads required to create the lists manually.
Creating Buy-In
Creating and promoting a change in the culture of safety, including how handoff communication is completed, requires the support and commitment of stakeholders at all levels. The end-user can help to identify gaps or potential pitfalls to the process. Sujan et al
examined caregiver and organizational priorities when transferring the care of patients across boundaries. They used process mapping of 270 clinical handovers in 3 emergency care pathways, two ambulance service, and 3 acute medicine units. Their findings suggested that leadership support and commitment were essential for sustainable improvements in the handover process across boundaries.
Similarly, process improvement leaders led a quality improvement project in a 664-bed urban medical center to determine options to improve patient throughput by decreasing bed assignment-to-occupy time. Buy-in was achieved by including end-user staff in the development of the electronic tool. After implementing a standardized workflow using an electronic tool, the assign-to-occupy time decreased from 95 minutes to 55 minutes.
The purpose of this project was to develop an efficient and evidence-based handoff communication process between the PACU and the receiving floors during the transition from a voice-recorded report system to an electronic and verbal handoff. The project's goals included decreasing the rate, number, and duration of PACU and OR boarders.
Design
Two theoretical models were used to plan and implement this evidence-based quality improvement project. The Johns Hopkins Evidence-Based Practice (JHNEBP) model was used to search the literature.
The model guided the development of the practice questions, gathering evidence, and translating research findings into practice recommendations. The Institute for Healthcare Improvement (IHI) Improvement model was used when implementing practice changes.
The model includes plan-do-study-act (PDSA) cycles, which guided the development and refinement of the Nursing Patient Dashboard (NPD) throughout the project to improve handoff communication.
Methods
Context
The setting of this project was a 14-bed PACU in a large university, level 1 trauma center in West Virginia, with an average monthly volume of over 1,000 surgical cases that required inpatient beds. Patients admitted to the PACU and requiring an inpatient bed between January 2019-May 2021 were included in this project. Patients admitted during the COVID pandemic months of March-May 2020 and November-December 2020 were excluded from data analysis. Also, patients who require ICU beds were directly admitted to the ICU and therefore were not included in this project.
The PACU nurses used the Modified Aldrete scoring system to document the patient's readiness for discharge in the electronic medical record. The modified Aldrete scoring system is a valid and reliable tool used in the PACU to determine PACU patients' discharge appropriateness
The Aldrete scoring system provides a numeric score of 0,1, or 2 on ten parameters: respiration, circulation, consciousness, oxygenation, dressing, pain, ambulation, intake, urine output, and activity level. Although generally used for ambulatory or outpatients, the hospital adopted this method to assess inpatient and outpatient readiness for discharge in the PACU. The hospital's policy states the patient is ready for transfer from the PACU when they have achieved a score one to two points from their baseline Aldrete score and can maintain their airway.
An interprofessional team consisting of hospital nursing leadership, perioperative leaders, inpatient nursing staff from the PACU, ad hoc nursing representatives from the medical-surgical floors, and information technology was formed to improve the handoff communication process and patient throughput. Following a review of the literature to determine best practices, a gap analysis was completed to determine areas for improvement opportunities. The team's findings suggested that a standardized communication tool embedded into the electronic medical record could provide an opportunity to improve the transition of care handoff process.
Develop the Dashboard
Bimonthly team meetings were held between August and December 2019 to review the possibilities for standardizing the patient handover process using the EMR. End-user nursing staff, a handoff communication steering committee, and clinical leadership representatives met to determine the needs of sending and receiving units for safe patient handoff. The lack of a consistent handoff process was noted. The tools within the EMR did not meet the organizational needs, and the concept of creating a nursing patient dashboard (NPD) to be used for nursing inpatient handoff communications emerged as a possible solution.
The team recommended the SBAR format as the foundation for developing a standardized handoff tool. Information from the NPD would provide background and assessment information, current patient status, links to progress notes, and vital signs, including graphic trends (Figure 1). The team used PDSA improvement cycles to modify the tool for use, testing the tool in an offline EMR playground. As part of the development, team members observed the transfer process in the PACU and on inpatient units to determine barriers to the NPD use for handoff communications. As part of the transfer process, PACU nurses called the floor to notify them the patient was ready for transfer once the patient achieved an acceptable modified Aldrete score. In the first PDSA cycle, the team identified the need for a standardized process for documenting the notification of the floor nurses that the report was ready, which was solved by creating an electronic signature for both the sending and receiving nurse. The second PDSA cycle identified the need for background information to be included in the NPD so that the receiving nurse could obtain all necessary patient information on one screen. The tool was tested in November-December 2019 and was ready for deployment in the live environment in January 2020.
Figure 1Excerpts from the nursing patient dashboard. This figure is available in color online at www.jopan.org.
Implement the Standardized Electronic Handoff Communication Tool
In November and December 2019, education about the NPD was shared with all nurses in the organization via the Nursing Education Council and a mass email. The education described the NPD tab of the EMR and gave step-by-step instructions for its use. The IT team member created a tip sheet within the EHR as an additional resource. An algorithm of the handoff communication process was created and shared with all staff members (Figure 2).
Figure 2Handoff communication algorithm. This figure is available in color online at www.jopan.org.
The NPD go-live date was January 2020. To determine the end-user acceptance of the NPD, posters with 3 standardized informational questions were placed on all 16 medical-surgical floors that receive PACU patients (Table 1) in February of 2021. Additionally, the project leader conducted face-to-face interviews with ten bedside staff nurses to get sender and receiver input on knowledge, use, and functionality of the handoff communication tool. The same three poster audit questions were asked in the face-to-face interview.
Table 1Audit Questions
Question 1
Are you aware of the NPD handoff communication policy and process when transferring a patient to another unit? Yes = 81.25% No =18.75%
Question 2
Does the NPD contain all the needed information for patient transfer communication? If not, what is missing? Yes = 70% No =20% no response =10%
Question 3
What are the barriers to using the NPD for patient transfer communication?
The organization's business analyst extracted transfer delay data related to handoff communication from the PACU's EMR case tracking and delay data. Other reasons for delays such as transfer delay or bed readiness were not included in the boarder time. The outcome measure for this project was the PACU and OR boarder rates per month. A boarder was defined as a patient staying more than 20 minutes after meeting a qualifying Aldrete score. Boarder rates were determined by dividing the number of patients who boarded by the total number of patients seen in the PACU. The secondary outcomes included the number and duration (minutes) of PACU and OR boarders. Process measures for the project included the percentage of staff educated about the NPD; Structural measures were the number of surgeries and the daily hospital census. The structural measures were important due to their impact on bed availability and resources, which can affect throughput regardless of any interventions. For example, one would expect throughput to be improved during times of low census compared to high.
Ethical Considerations
This project was approved by the hospital's nursing research council and the institutional review board as quality improvement.
Analysis
Descriptive statistics were used for the number and percentage of PACU patients who experienced delays in the PACU related to handoff communication. Chi-square test compared the number of PACU and OR boarder rates between the 2 time periods. An independent two-tailed t-test was used to evaluate the average daily census and OR case volume and boarder minutes. The alpha for both the t-test and the Chi-square was set at .05.
Findings
Soon after initiating the NPD, the global coronavirus disease 2019 (COVID-19) pandemic occurred. The hospital's OR was closed to elective surgeries from March through May 2020 and again in November and December of 2020. The hospital decided to exclude those months from its standard OR reporting. Those months were also removed from our analysis, and the resulting COVID-adjusted year (C-year) was defined as January-February 2020, June 2020- October 2020, and January 2021-May 2021.
No significant difference was found between the two years for average daily census (t(11) = 2.01, P = .0567) or the OR case volumes (t(11) = -0.540928, P = 0.594), indicating that the hospital and OR experienced a similar number of cases each year. The PACU boarder rate decreased from 12% in 2019 to 7.9% in the C-year. Operating room boarder rates decreased from 5.0% to 3.9% in the same period. A significant decrease in the number of PACU (χ2(1, n = 20,608) =122.63, P < .00001) and OR boarders (χ2 (1, n = 20,283) =14.55, P = .000136) was found in the C-year compared to 2019.
For patients who were boarded in the PACU, no significant difference in PACU delay duration was found (t(11)=1.49, P = .149) with the mean in 2019 of 166.96 (SD = 68.38) and the C-Year mean 132.84 (SD = 39.74). For patients who boarded in the OR, there was a significant difference (t(11)=15.590162, P <.00001) between groups for average duration of boarding with the mean in 2019 of 19.06 minutes (SD = 3.72) compared to 1.62 (SD = 1.1) in C-year.
Of the 16 medical-surgical units, 14 units (87.5%) provided qualitative feedback on posters. Ten nurses participated in interviews. At least one staff member completed an interview for the 2 units that did not complete poster feedback. Thirteen of the 16 units indicated they were aware of the NPD handoff communication policy and process. Barriers to using the NPD included that the NPD was missing information found on the electronic Kardex, such as floor status, and lacked detail for patient-specific needs. Other nurses reported that the font was too small, and the NPD had too much information or information overload.
Discussion
The NPD was a successful strategy to improve handoff communication between the PACU and receiving units. Consistent with other literature, we found that embedding SBAR into the comprehensive NPD resulted in significant decreases in PACU and OR boarding.
However, for those patients who were boarded in the PACU, the duration of boarding did not change significantly between 2019 and C-year, suggesting that factors other than handoff communication may have delayed patient transfer. Though the EMR had a robust drop-down menu for delay reasons, some nurses charted the delay reason in the comments section. Additionally, no standardized definitions guided the PACU nurse's selection, and it was not a mandatory field, making it difficult to determine why patients were boarded. In future work, deciding how to best document the reason for a delay and educating the staff on the process before implementation would garner more details about delays.
For patients who boarded in the OR, the duration of boarding was significantly decreased from 9,896 to 703 minutes in 2020. This finding is congruent with boarder data published in previous studies completed in the emergency department.
Usability assessment of an electronic handoff tool to facilitate and improve postoperative communication between anesthesia and intensive care unit staff.
However, in July 2020 (the fourth month of the C-year), two overflow beds intermittently opened in the PACU making comparison difficult for the year. Notably, in the first 3 months of C-year (January, February, and June 2020), the OR average boarding duration was 66 minutes compared to 824 in 2019. For our analysis, we were unable to determine when the overflow beds were used but assume that some of the improvement was related to the use of overflow beds.
The average PACU boarding time, though not statistically significant, was decreased by 34 minutes in the C-year compared to 2019, which could represent significant savings to the hospital. When patients are boarded in the PACU, they are charged at the floor rate rather than the PACU rate while blocking potential admissions to the PACU. The cost of this project, including the salaries for all who attended meetings and the development of the NPD was $15,755. Once patients are assigned boarder status, the PACU no longer accrues revenue for their stay. Using the hospital's cost of the PACU at $171 per 15-minute-stay to calculate money saved, the project's cost was recouped in the first month.
Limitations
This project had several limitations. It was conducted in one academic medical center using a quality improvement design. Outcomes cannot be generalized to other settings; however, the concepts and strategies may be transferrable to other settings or institutions. The COVID pandemic occurred in the middle of this project, and the hospital adjusted the reporting year to reflect that elective surgeries were canceled for five months in 2020. Though the OR was fully open in 2021, the volume of patients was low in January (n = 911) and February (n = 1175) compared to the other months, which may have influenced the number of delays. The hospital opened two additional PACU beds in July 2020, making direct comparison of the OR boarding times between years difficult. Due to COVID pandemic, organizational management of throughput was difficult. However, the PACU throughput was not affected and the PACU boarder rates remained reliable. Additionally, the COVID patients were assigned to medical units and did not overflow into surgical floor beds. Despite the pandemic, we believe the overall hospital operations on the surgical floors were not substantially affected since the COVID patients were assigned on the medical units. Therefore, we believe our throughput results remained accurate.
Conclusions
This evidence-based quality project demonstrated the usefulness of an electronic handoff communication tool that used an SBAR format combined with a verbal report in improving patient throughput from the PACU to the inpatient unit. The NPD provided floor nurses with a quick overview of the patient on one screen. The NPD and report process was well-received by nurses and quickly started to be used in other areas of the hospital for change of shift handoffs and in-house transfers. To sustain the project improvements, the team is now addressing comments from the nursing staff about the font size and large amount of information on the NPD. A recent upgrade to the EMR created a storyboard that included some of the information on the NPD on every page of the EMR. This upgrade will enable re-sizing and other improvements to the NPD.
Others could use processes from this project to implement a similar project in their organization. The key to creating an efficient NPD was determining the information required for handoff communication and building the NPD based on the needs of the end-users. Staff should be an integral part of the design as they ultimately know what is needed, and their buy-in to a practice change is imperative. Recommendations for practice for future PACU-related delay projects include that the PACU nurse document the reason for any delays. To achieve this goal, delay reasons from any dropdown menu should be clearly defined to allow for electronic tracking. Communication during handoffs is imperative for safe patient care. Time and attention to how and when the handoff occurs are invaluable for patients, nursing staff, and hospitals.
Usability assessment of an electronic handoff tool to facilitate and improve postoperative communication between anesthesia and intensive care unit staff.
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