Transcript Communication

Communication: Critical to
Preventing Errors in Pediatric
Peri-Operative Care
Jennifer Schoonover CPNP-AC, PC
Pediatric Anesthesia Associates
Objectives
• List, describe, and understand the key
elements of the perioperative handoff.
• Identify barriers to communicating important
details.
• Make a plan to integrate changes in handoffs
for your personal or institutional practices.
com·mu·ni·ca·tion
͞
kəˌmyoonəˈkāSHən/
noun
1. the imparting or exchanging of information
or news.
• The goal of the peri-operative handoff is to
exchange information about the surgical
patient to the team that will be taking care of
them.
• The hand off definition:
– “the transfer of information in care across the
continuum for the purpose of ensuring the
continuity and safety of the patient’s care” AORN
Key Elements of the Handoff
• Specific information about the patient: name, age, weight,
allergies.
• Procedure performed
• Preoperative conditions: developmental delays, medical
history, pertinent chronic medications
• Intra operative review: airway management, IV access and
fluids given, intraoperative medications given
• Intra operative complications
• Postoperative concerns: pain management, nausea
prevention, any further follow up with labs or any other
procedures
• Surgical site issues, dressings
Who reports what?
Anesthesia provider may report:
• Patient name, gender, age, procedure, physician
• History of present illness
• History of chronic illness
• Relevant pre-op lab tests
• Type of anesthesia administered
• Patient response to anesthesia agents
• Duration of anesthesia
• Reversal agents
• Narcotics
• Antibiotics
• Fluid replacement and type (I & O)
• Invasive monitoring line
• Vital signs
• Allergies
• Other conditions
• Medications given
• Complications related to the procedure
• Orders
Surgeon may report:
• Immediate orders
• Diagnostic tests for PACU
• Interventions needed in PACU
Perioperative nurse may report:
• Baseline patient assessment
• Positioning during procedure
• Skin prep
• ESU pad placement and removal assessment
• Use of special equipment (laser, endoscope)
• Intraoperative irrigation fluids
• Administration of medications or dyes from
surgical field
• Implants, transplants, explants
• Dressing
• Drains, stents, catheters
• Sensory or motor limitations
• Prosthesis presence
• Pressure ulcer risk assessment
• Other pertinent patient information
• Information about the family or others waiting
for the patient
Cooper, A. Applying Evidence-Based Information to Improve Hand-Off
Communication in Perioperative Services, Back to the Basics, OR Connection
file:///C:/Users/NHB2LIBU07/Downloads/Hand-OffCommunication.PDF
What makes relaying this information
difficult?
• Stabilizing the patient after transfer in the PACU and
preparing the patient in preoperative
• Lack of time: hurried report, rushing to the next case,
computerized charting, patient needing pain medicine,
etc.
• Multiple people giving the handoff: circulating RN,
anesthesia, surgeon
• Making assumptions (this was an ear tube case, no
airway or line was placed)
• Failure of mode of communication
(speaking softly, non verbal cues)
• Resistance of change among all
team members
Example of Poor Communication
Why does it matter?
• Sentinel Events can occur…death, dismemberment,
infections, chronic health issues, etc.
• “A Sentinel Event is defined by The Joint Commission (TJC)
as any unanticipated event in a healthcare setting resulting
in death or serious physical or psychological injury to a
patient or patients, not related to the natural course of the
patient's illness.”
• “The reporting of most sentinel events to The Joint
Commission is voluntary and represents only a small
proportion of actual events. Therefore, these root cause
data are not an epidemiologic data set and no conclusions
should be drawn about the actual relative frequency of root
causes or trends in root causes over time.”
One Nurses Experience
Sentinel Event Data Root Causes by
Event Type 2004 –2Q 2014
• Joint Commission reviews all reported sentinel
events and their root cause analysis to
determine what causes are more likely.
• They make goals and recommendations for
hospitals and institutions to focus on based on
this information.
Joint Commission
• Joint Commission ranks communication as one
of the highest contributors to sentinel events.
• They define communication as “oral, written,
electronic, among staff, with/among
physicians, with administration, with patient
or family”
• The majority of sentinel events have multiple
root causes, communication is often in the top
3.
Communication Rankings in Root
Cause Analysis
• Transfer related events: # 2 20/27 (74%)
• Wrong site, wrong procedure events: #2
726/1071 (71%)
• Unintended retention of foreign objects: # 3
584/932 (63%)
• Op/Postop complications: # 2 434/823 (53%)
• Anesthesia related events: # 4 55/104 (53%)
We want to do what we can to
prevent these events
In 2006, a national patient safety goal
was added regarding communication
“The organization implements a standardized
approach to hand off communications, including
an opportunity to ask and respond to
questions.”
Joint Commission looks for these
attributes in hand offs:
•
•
•
•
•
Interactive communication
Up to date information exchange
A method to verify (repeat back)
A review of the chart by the receiver
Uninterrupted report (or minimized)
a standardized process is recommended
Current Standardized Processes
•
•
•
•
I PASS the Baton
I SBAR
PACE
Five “P”s
It doesn’t matter which one you use, or if you
make one of your own up as an institution
SBAR Example
Effective Handoff Tips
• Two way communication, both participants
taking joint responsibility for ensuring
accurate relay of information.
• Face to face handoffs are best
• Uninterrupted time, as much as needed
• Use verbal and written means of
communication
Cincinnati’s review of their
perioperative handoff system (2013)
• They did not have a standardized reporting
system.
• They evaluated two handoffs: intraoperative
anesthesia handoffs and the anesthesia handoff
to PACU
• Then they instituted a standardized system and
reevaluated.
• The reliability of intraoperative handoffs
increased from 20%-100%
• The reliability of the PACU handoff increased
from 59%-90%
KCH Recovery Room Data
• We are currently looking at key components of
our handoffs
– Stabilizing airway/vital signs, name, age, weight,
allergies, procedure, relevant medical history
including developmental delay, type of airway
management, IV access/fluids, medications given,
intraoperative complications, postoperative concerns
– Also asking: Is the nurse ready for report? Any
questions? Did the nurse feel they received all the
information needed to care for the patient?
KCH Recovery Room Data
• Our recovery room is fast paced with the number
of surgeries recovered daily averaging 30 to 50.
• A strict schedule is adhered to as best as possible.
• Patient care is our number one concern.
• The PACU nurse is bombarded with stabilizing the
patient and getting the handoff from both the
anesthesia provider and the
perioperative/circulating RN at the same time.
KCH Recovery Room Data
• Observed 57 handoffs
• Handoffs are given as a team approach including
a circulating RN and an anesthesia provider
– The circulating RN is a part of the handoff team 100%
of the time
– Attending anesthesiologists participate in the handoff
29.8% of the time
– CRNA 54.4% of the time
– SRNA 31.6% of the time
– Resident 5.3% of the time
– 29.8 % of the time the handoff is given by multiple
anesthesia providers (2)
KCH Recovery Room Data
• Our average for meeting all of the key
components for handoffs was 59%
• We found we were really good at: stabilizing the
airway/VS (100%), reporting procedure (95%),
medications given (98%), relevant medical history
(91%), and developmental delays (93%)
• We found that we were not so good at: reporting
the patients’ age (23%), weight (28%), and asking
the PACU RN if they had any questions (35%)
KCH Recovery Room Data continued
• PACU RN’s are utilizing our computerized
charting system to get the information they
need prior to the patients’ arrival in the PACU
• Of all observations,
RN's felt they got
all the information
they needed from
their OR handoff
team 90% of the
time.
KCH Recovery Room Handoff
Evaluation Plans
• Data collection (observing handoffs).
• Discussion of findings with the entire team (PACU
RN’s, circulating RN’s, anesthesia providers).
• Implementation of an agreed upon standardized
tool for handoffs-institutional specific (February
2015).
• Reevaluation of tool approximately 8 weeks after
implementation.
• Evaluation of intraoperative handoffs (this is
more difficult because they do not happen at an
appointed time).
How does this relate to your
institution?
• The same process can be repeated in your
institution (if you go through the process you will
have buy in from all team members).
• Your team will feel empowered.
• Your team will be encouraged to be accountable
for reporting all pertinent information.
• Your patients’ will transfer through your area with
a higher level of safety.
• Your institution will meet JCAHO standards
How does this relate to your personal
practice?
• The process of change begins with ourselves.
• We can not control others, but we do have
power over how we communicate.
• You can be sure that you are giving the best
possible handoff you can
• You can ask questions to the person giving you
the handoff to clarify the information you are
gathering.
• Attend a communication seminar/conference
References
• Boat AC & Spaeth JP. Handoff checklists improve reliability of
patient handoffs in the operating room and postanesthesia care
unit. Pediatric Anesthesia 23 (2013)647-654
• The Joint Commission: Advancing Effective Communication, Cultural
Competence, and Patient- and Family-Centered Care: A Roadmap
for Hospitals. Oakbrook Terrace, IL: The Joint Commission, 2010.
• Joint Commission on Accreditation of Health-care Organizations.
Sentinel Event Data; root causes by event type. The Joint
Commission, 2013 retrieved from
http://www.jointcommission.org/sentinel_event.aspx and
http://www.jointcommission.org/assets/1/18/Root_Causes_by_Eve
nt_Type_2004-2Q_2014.pdf
• file:///C:/Users/NHB2LIBU07/Downloads/HandOffCommunication.PDF