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J Nurs Care Qual Vol. 30, No. 2, pp. 113–120 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Surgical Suite to Pediatric Intensive Care Unit Handover Protocol Implementation Process and Long-term Sustainability Tracie Northway, MSN, RN; Gordon Krahn, RRT; Kristine Thibault, BScN, RN; Lisa Yarske, BScN, RN, CNCCP(C); Nataliya Yuskiv, MD, MPH; Niranjan Kissoon, MD, FRCP(C), FAAP, FCCM, FACPE; Jean-Paul Collet, MD, PhD The article reports the long-term sustainability of a standardized transfer protocol from cardiac surgical suite to the pediatric intensive care unit. Using rapid process improvement technique, the original mean defect rate per handover decreased from 13.2 to 0 and 0.3, 12, and 24 months postimplementation, respectively. This study stresses the importance of long-term assessment to control for possible observation biases; it also illustrates a successful implementation strategy that used video recording to engage staff in identifying solutions to the observed defects. Key words: communication, handoff, pediatric intensive care, rapid process improvement, team-to-team handover, transfer, video recording
Author Affiliations: Critical Care Unit, BC Children’s Hospital and Sunny Hill Health Centre for Children, The University of British Columbia, British Columbia Canada (Mss Northway, Thibault, and Yarske, and Mr Krahn, and Drs Kissoon and Collet); Child & Family Research Institute, Vancouver, Canada (Drs Kissoon, Yuskiv, and Collet); and Department of Pediatrics, The University of British Columbia, British Columbia, Canada (Dr Kissoon and Collet). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Jean-Paul Collet, MD, PhD, BC Children’s Hospital, The University of British Columbia; and Department of Pediatrics The University of British Columbia, CFRI V3-320-948 West 28th Ave, Vancouver, BC V6H 3N1 ([email protected]). Accepted for publication: September 17, 2014 Published ahead of print: November 25, 2014 DOI: 10.1097/NCQ.0000000000000093
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OOR COMMUNICATION of complete and accurate information between teams, especially those caring for the critically ill, is a significant threat to patient’s safety.1-4 Indeed, suboptimal transfer of information and unclear professional responsibility between individuals and teams (clinical handover) accounts for more than 60% of adverse events reported to The Joint Commission.3,5 These events include inaccurate clinical assessment and diagnosis, delays in diagnosis and ordering tests, medication errors, duplications of tests, increased length of stay, increased in-hospital complications and decreased patient satisfaction,6-9 and even death.3 In 2012, a systematic review of 31 articles by Segall et al9 revealed an association between poor-quality handovers and adverse events and outlined several recommendations 113
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including standardizing the processes, completing urgent clinical tasks before the transfer, allowing only patient-specific discussions, requiring the presence of all relevant team members, and providing training in team skills and communication. Standardization of postoperative handover processes is especially important in the intensive care unit because of the presence of multiple specialists, the complexity of the tasks and interfaces, time pressure, and the need for accuracy;10,11 furthermore, frequent staff interruptions and distractions from monitor alarms, pagers, and telephone calls are common.9 Several methods have been proposed to achieve comprehensive handover,3,12-20 such as face-to-face communication,21-23 the use of a structured communication process and mnemonics tools,24 and the use of a tool kit to guide handover communications.25,26 While many methods may be suitable, most have evaluated short-term successes only.15,27 Long-term impact has been elusive because of unclear outcome indicators and little attention to sustainability17,28 although recent studies are reporting longterm sustainability of the intervention.29-31 In shift handovers, while the importance of nontechnical skills was highlighted,32 there are few reports on whether the initial efforts to standardize handover were sustained. In our unit, inconsistent or incomplete teams and poor communication of information between teams during handover of cardiothoracic surgery patients from the operating room (OR) to pediatric intensive care unit (PICU) led us to conceive and undertake this improvement project. Our goal was to identify the cardiacOR to PICU team-to-team handover defects and develop a new protocol to be implemented through a rapid process improvement strategy; long-term sustainability was part of our initial plan with assessment at 12 months and 2 years after the implementation.
MATERIALS AND METHODS Setting The study was conducted in 1 PICU of the British Columbia Children’s Hospital, a quaternary care facility of 22 beds that serves all children and their families in British Columbia. The British Columbia Children’s Hospital PICU admits approximately 1200 children annually. To address the challenges of adverse events, the British Columbia Children’s Hospital PICU has become a regional and national leader in developing, testing, and adopting quality improvement (QI) programs. Strategy The approach we chose complies with classic QI methods33,34 ; careful planning identified 4 stages. Stage 1 was observation phase to define the clinical context for handover and identify the process defects, using video recordings. In the second stage, the information from stage 1 along with the clinicians’ feedback was reviewed and used to develop a new handover protocol. Stage 3 was an 8-month implementation period that included multiple communication strategies to facilitate the process. Success at the end of stage 3 led to the development of a specific study (stage 4) to assess long-term sustainability and staff’s perception 2 years after the intervention. The first 3 stages were performed as QI project, and the long-term follow-up stage was a specific study submitted and approved by The University of British Columbia Research Ethics board. Methods for QI project Stage 1: observation Observations of cardiac surgical handovers (from March 2 to 20, 2009) were conducted by 2 PICU clinicians who had extensive experience in PICU nursing and QI. They observed and videotaped the handover of care process for 6 cardiac surgical patients from the time the OR team arrived with the patient at the designated bed in the PICU until the
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Surgical Suite to Pediatric Intensive Care Unit Handover Protocol anesthetist left the bedside, which indicated that the handover process was complete. The same clinicians reviewed the tapes of each transfer and constructed the process maps, using standard work sheets, time measurements, and spaghetti diagrams to highlight workflow and identify barriers to safe and effective handover of care. Before analyzing each tape, the 2 clinicians went through each step of the review to standardize the process and ensure high consistency between reviewers. After careful coding of the videotapes, the defects identified were grouped in categories (see Supplemental Digital Content, Table, available at: http:// links.lww.com/JNCQ/A139) that align with technical and information transfer errors as outlined by Catchpole et al.35 For each recording, the total number of defects identified in each category was counted and the mean de-
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fect rate for all handovers in the period was calculated (Table). Stage 2: Generating and testing of handover process protocol From the defects outlined in the observation stage, the effort focused on the creation of a new handover protocol by members of the cardiac surgical and PICU teams as well as LEAN improvement experts. During the 1week rapid process improvement workshop, the protocol underwent several iterations as a result of brainstorming and testing of ideas with frontline staff after reviewing the videotapes of 3 handovers. The final protocol contained pretransfer and transfer responsibilities for the PICU and cardiac surgical teams as outlined by Catchpole et al35 ; in particular, the specific position of the staff was arranged to optimize the view of
Table. Long-term Sustainment of Cardiac Operating Room to Pediatric Intensive Care Unit Handover Protocola Initial Phase
Defect Categories Role crossover Tangled equipment/lines Essential supplies are not easily accessible Staff with no clear roles, crowded space Waiting for essential team members Deviation from “norm” Multitasking during handover Total number of defects observed(defect rate)
Follow-Up Phases
Implementation 2-y Observation Improvement and 1-y Sustainment Sustainment Week (Nb = 6) Week (Nb = 3) (Nb = 17) (Nb = 19) c d c d c d n( ) n( ) nc (d ) n( ) 25 (4.2) 17 (2.8) 9 (1.5)
0 (0) 1 (0.3) 3 (1.0)
0 (0) 0 (0) 0 (0)
0 (0) 0 (0) 2 (0.1)
9 (1.5)
0 (0)
0 (0)
0 (0)
7 (1.2)
0 (0)
0 (0)
0 (0)
8 (1.3) 4 (0.7)
0 (0) 0 (0)
0 (0) 1 (0.1)
0 (0) 3 (0.2)
4 (1.3)
1 (0.06)
5 (0.3)
79 (13.2)
a Defects
observed during handover processes. of admissions (handovers). c Number of defects observed. d Average number of defects per handover observed during a given period (eg, improvement week). b Number
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the patient and monitors and to facilitate the duties assigned to each staff in accordance with his or her responsibilities. Supplemental Digital Content, Figure 1, available at: http://links.lww.com/JNCQ/A136, shows the main features of the transfer protocol and Supplemental Digital Content, Figure 2, available at http://links.lww.com/JNCQ/A137, illustrates the team positioning at bedside. Stage 3: New handover protocol implementation and sustainment The implementation of the revised protocol (March 2009 to March 2010) started with an ambitious goal: to reach zero defects in most (>80%) handovers. During this period, 17 cardiac OR to PICU handovers were videotaped (most of them during the first 2 months) and used for education. This stage was labor-intensive and entailed orientation and education of staff to the new processes. Clinician leaders including those from quality and safety, nursing, and respiratory therapy were required to be available on short notice to answer questions and update the protocol on the basis of feedback from frontline staff. Multiple modes of communication and support were used to educate and support physicians and staff involved with cardiac OR to PICU handover for a smooth transition to the new handover model. E-mails were sent to all PICU and OR staff of the practice change. The e-mail was linked to a practice change summary, an education presentation and contact information for further information. A visual public display of the project was posted in the PICU (area accessed by both OR and PICU staff,) describing the defects, the measurement process, the ideas tested, and the resulting practice changes observed. To keep the change “front and center,” announcements of the new protocol were made at shift changes and prior to each cardiac admission for a 2-week period. The quality and safety leader provided daily clinical assistance for the cardiac admission team for a period of 6 weeks and as needed. This assistance translated to supporting the PICU receiving nurse, respiratory therapist, and cardiac OR aide in
preparation of the bed and clinical space; it also included speaking with the PICU physician team of the day to update them on the practice change and answer any questions. Another aspect of the education approach, led by the quality and safety leader and frontline nursing leaders, focused on real-time feedback and posthandover debriefs to be responsive to specific needs. Anecdotal report indicated that staff felt informed and part of the change. The handover of care process was monitored by the quality and safety leader or designate who conducted weekly audits for a 4-week period, then monthly for 4 months and then quarterly up to the 1-year period. The audits involved direct observation of the admissions and tracking of the defects. Communication of adherence or deviation to the process was provided posthandover to participants. Methods for study of long-term sustainability Cognizant of a possible Hawthorne bias, long-term assessment was conducted 2 years after protocol implementation (July-August 2011). Informed consent was obtained from parents and their children who were involved in videotaping of the handover. The clinicians were not aware of the exact time when they were being videotaped, although, as per ethics requirements, they were briefed a priori that some handover events would be recorded. We also conducted an anonymous survey among PICU and cardiac OR staff involved in handovers to assess their experience and acceptance of the process (questionnaire available on request). A total of 20 handovers were videotaped by one of the QI leaders unobtrusively to avoid distracting the teams. Nineteen were of sufficient quality and were evaluated and scored independently by 2 QI experts using the 7 defects categories (see Supplemental Digital Content, Table, available at: http://links.lww .com/JNCQ/A139); one of whom had been involved in the 2009 observation stage. Evaluators’ coding were compared and discrepancies resolved by discussion or, if needed, the intervention of a third party. These
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Surgical Suite to Pediatric Intensive Care Unit Handover Protocol results were then compared with the previous ones gathered 2 years earlier using the MannWhitney U nonparametric rank sum test for statistical comparison. The survey of PICU and OR handover teams gathered demographic information and assessed knowledge of the handover process as well as handover protocol acceptance. To test the participants’ knowledge of the sequence of steps in the handover process, participants were presented with a list of handover elements in random order and asked to arrange the elements in the proper sequence in which they should occur. Opinions of the current handover process were assessed by a series of questions using a Likert-type response scale with 5 options from “poor” to “excellent,” with additional open-ended questions. Data were analyzed with descriptive statistics, and graphic representations (box-plot) were used to communicate results to the teams. RESULTS BY STUDY PHASES QI project During the observation period (stage 1), the total number of process defects observed for the 6 cardiac handovers was 79, with a mean defect rate of 13.2 defects per handover (Table). The time for handovers ranged between 4 and 17.2 minutes, with an average time of 10.6 minutes. By the end of the rapid process improvement week (stage 2), the protocol had been tested on 3 handovers and revised to achieve a 90% reduction in the initial defect rate: from a mean of 13.2 (79/6) during the observation stage to 1.3 (4/3) during the improvement week (see the Table and Supplemental Digital Content, Figure 3, available at: http:// links.lww.com/JNCQ/A138). Finally, during the protocol implementation period (stage 3), 17 handovers were videotaped and the run chart updated for discussion (see Supplemental Digital Content, Figure 3, available at: http: //links.lww.com/JNCQ/A138). Only 1 defect was detected during this period, which gives a mean defect rate of 0.06 (Table).
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Long term sustainability study During this period, a total of 5 defects were observed among 19 handovers observed, which gives a mean defect rate per handover of 0.3 (Table). Statistical comparison between the observation period is significant: Mann-Whitney U test (P < .001). The Table and the Supplemental Digital Content, Figure 3, available at: http://links.lww .com/JNCQ/A138, show the handover defects during the different periods. Furthermore, in 2011, 14 of 19 transfers (76%) were free of defects while none was defect-free in 2009. Eighty-five questionnaires were distributed among the team involved in transfers. In total, 51 (60%) completed questionnaires were returned. The majority of the responders were nurses (n = 39, 76%) and 18 (46%) had more than 16 years of working experience in either OR or PICU. Twenty-eight percent of the responders participated in the improvement week in 2009. There was no statistically significant difference between responses of those who did or did not participate in the improvement week; we, therefore, analyzed the results of all surveys together. Most of the staff indicated that they knew their role in the handover process “precisely” or “almost precisely” (88%, n = 45/51), and 69% (n = 35/51) could clearly identify their role during the handover. Most (n = 37, 73%) believed that the handover process worked but not in every situation whereas only 12% (n = 6/51) believed that the process always works. Ninety-eight percent (n = 50) of the responders like the current handover process, with 96% (n = 49) of respondents indicating that they would recommend it to other units and facilities. DISCUSSION Following the SQUIRE guideline,36 we present this report to outline the implementation of a standardized surgical suite to the PICU transfer protocol and the teams’ long-term adherence. Two years postprotocol implementation and 1 year after last
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observation, we found that defect rates in the handover process were lower than the initial preimplementation and improvement week rates; moreover, 76% of handovers were free of defects in 2011 (see Supplemental Digital Content, Figure 3, available at: http://links.lww.com/JNCQ/A138), and the Table shows the drastic reduction of defects. Other studies have reported similar changes at the end of the intervention period15,37 ; however, short-term assessments of behavioral changes in context of observation are prone to Hawthorne bias that can account for most of the observed effects.38-40 Sustainability of gains represents a significant challenge in QI interventions.36 Long-term sustainability requires staff engagement, charismatic champions and leaders, and a culture that sustains the change despite staff turnover and pressing competing needs. Indeed, longer-term success in our PICU has been elusive in that 1-year sustainment rates were achieved in only 9 of 23 other QI projects (about 40%). Our results are in alignment with other cardiac transfer improvement projects that have targeted improving handover effectiveness through process improvement and improving accuracy of information..12,15,27,35 However, to our knowledge, the evaluation of long-term sustainability of the surgical cardiac OR to PICU handover implementation has not yet been reported. We chose to concentrate on the processes of care rather than whether key clinical information was relayed. This study was not designed and sufficiently powered to evaluate clinical outcomes following the intervention; poor outcomes are infrequent and may be attributable to many factors beyond handovers. Regardless, studies focused on improving handover quality have reported effectiveness in reducing patient morbidity and mortality in other health care activities.10,41-43 Furthermore, it has been shown that nontechnical skills, including collaboration, teamwork, and communication, play an essential role in good practice and may have a substantial effect on safety and the risk of human error in health care.10,11
The success and long-term sustainability of this project can be attributed partly to the readiness of the transfer team. Both the PICU and cardiac OR teams had tried various strategies over the years to improve the handover process with limited success partly due to adoption of individual preferences versus a standardized process in all cases. Burdened by previous failures, the 2 groups were fully engaged in identifying the barriers and understanding how these could be overcome. In addition, the challenges were presented with a clear understanding of expected behaviors and the environmental context.44 The presence of a videographer and ongoing discussions 3 weeks prior to the improvement week allowed sufficient time to advertise the project and enabled the team leads to actively engage frontline staff. Frontline staff volunteered ideas or concerns enthusiastically. This highly visible dedicated observation time was essential for staff engagement. Another factor believed to contribute to the success of this project was the ongoing communication focused on sharing each day’s progress during the project. After each rapid process improvement workshop day, we communicated the progress to the day and night staff. In addition, staff engagement was sustained by soliciting their ideas at the end of their shifts. This also occurred in real time with all team members working together through the changes being tested. This responsiveness to both practice areas ideas was seen as valuable and inclusive. While lessons from our past contributed to our improvement process design and implementation, others’ successes informed our actual handover protocol design. In particular, Great Ormond Street Hospital’s handover design with a focus on Formula 1 pit crew and aviation crew procedures was fundamental in reshaping our handover process.35 This process was championed by the cardiac anesthetists, and their leadership was significant in leading the handover process. There are a number of limitations to this project. First, there is small number of observations during preimplementation period and during the rapid process improvement
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Surgical Suite to Pediatric Intensive Care Unit Handover Protocol workshop week, which results in larger uncertainty. Second, the number of defect categories in the video checklist is limited, which might result in ignoring other “noncategorized” defects during surgical cardiac handover process; this list, however, was developed iteratively with the participation of the whole handover team and was guided by the literature. Third, we cannot completely eliminate the possibility of a Hawthorne bias because of the videotaping. However, we feel that this was insignificant given our safeguards and unobtrusive recording. Finally, we did not measure patient-centered outcomes such as survival or duration of hospital stay. Such analyses would require considerably larger
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sample size, which was not the objective of this project. SUMMARY We report that the successful sustainability of a complex handover process can be achieved through interactive communication with staff to encourage active involvement in the change process. Our experience shows the importance to analyze the challenges in the local setting to ensure that solutions are customized to fit the specific context in which the handovers take place. Team readiness is another important factor for successful implementation and sustainability.
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J Nurs Care Qual Vol. 30, No. 2, pp. 113–120 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Surgical Suite to Pediatric Intensive Care Unit Handover Protocol Implementation Process and Long-term Sustainability Tracie Northway, MSN, RN; Gordon Krahn, RRT; Kristine Thibault, BScN, RN; Lisa Yarske, BScN, RN, CNCCP(C); Nataliya Yuskiv, MD, MPH; Niranjan Kissoon, MD, FRCP(C), FAAP, FCCM, FACPE; Jean-Paul Collet, MD, PhD The article reports the long-term sustainability of a standardized transfer protocol from cardiac surgical suite to the pediatric intensive care unit. Using rapid process improvement technique, the original mean defect rate per handover decreased from 13.2 to 0 and 0.3, 12, and 24 months postimplementation, respectively. This study stresses the importance of long-term assessment to control for possible observation biases; it also illustrates a successful implementation strategy that used video recording to engage staff in identifying solutions to the observed defects. Key words: communication, handoff, pediatric intensive care, rapid process improvement, team-to-team handover, transfer, video recording
Author Affiliations: Critical Care Unit, BC Children’s Hospital and Sunny Hill Health Centre for Children, The University of British Columbia, British Columbia Canada (Mss Northway, Thibault, and Yarske, and Mr Krahn, and Drs Kissoon and Collet); Child & Family Research Institute, Vancouver, Canada (Drs Kissoon, Yuskiv, and Collet); and Department of Pediatrics, The University of British Columbia, British Columbia, Canada (Dr Kissoon and Collet). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Jean-Paul Collet, MD, PhD, BC Children’s Hospital, The University of British Columbia; and Department of Pediatrics The University of British Columbia, CFRI V3-320-948 West 28th Ave, Vancouver, BC V6H 3N1 ([email protected]). Accepted for publication: September 17, 2014 Published ahead of print: November 25, 2014 DOI: 10.1097/NCQ.0000000000000093
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OOR COMMUNICATION of complete and accurate information between teams, especially those caring for the critically ill, is a significant threat to patient’s safety.1-4 Indeed, suboptimal transfer of information and unclear professional responsibility between individuals and teams (clinical handover) accounts for more than 60% of adverse events reported to The Joint Commission.3,5 These events include inaccurate clinical assessment and diagnosis, delays in diagnosis and ordering tests, medication errors, duplications of tests, increased length of stay, increased in-hospital complications and decreased patient satisfaction,6-9 and even death.3 In 2012, a systematic review of 31 articles by Segall et al9 revealed an association between poor-quality handovers and adverse events and outlined several recommendations 113
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including standardizing the processes, completing urgent clinical tasks before the transfer, allowing only patient-specific discussions, requiring the presence of all relevant team members, and providing training in team skills and communication. Standardization of postoperative handover processes is especially important in the intensive care unit because of the presence of multiple specialists, the complexity of the tasks and interfaces, time pressure, and the need for accuracy;10,11 furthermore, frequent staff interruptions and distractions from monitor alarms, pagers, and telephone calls are common.9 Several methods have been proposed to achieve comprehensive handover,3,12-20 such as face-to-face communication,21-23 the use of a structured communication process and mnemonics tools,24 and the use of a tool kit to guide handover communications.25,26 While many methods may be suitable, most have evaluated short-term successes only.15,27 Long-term impact has been elusive because of unclear outcome indicators and little attention to sustainability17,28 although recent studies are reporting longterm sustainability of the intervention.29-31 In shift handovers, while the importance of nontechnical skills was highlighted,32 there are few reports on whether the initial efforts to standardize handover were sustained. In our unit, inconsistent or incomplete teams and poor communication of information between teams during handover of cardiothoracic surgery patients from the operating room (OR) to pediatric intensive care unit (PICU) led us to conceive and undertake this improvement project. Our goal was to identify the cardiacOR to PICU team-to-team handover defects and develop a new protocol to be implemented through a rapid process improvement strategy; long-term sustainability was part of our initial plan with assessment at 12 months and 2 years after the implementation.
MATERIALS AND METHODS Setting The study was conducted in 1 PICU of the British Columbia Children’s Hospital, a quaternary care facility of 22 beds that serves all children and their families in British Columbia. The British Columbia Children’s Hospital PICU admits approximately 1200 children annually. To address the challenges of adverse events, the British Columbia Children’s Hospital PICU has become a regional and national leader in developing, testing, and adopting quality improvement (QI) programs. Strategy The approach we chose complies with classic QI methods33,34 ; careful planning identified 4 stages. Stage 1 was observation phase to define the clinical context for handover and identify the process defects, using video recordings. In the second stage, the information from stage 1 along with the clinicians’ feedback was reviewed and used to develop a new handover protocol. Stage 3 was an 8-month implementation period that included multiple communication strategies to facilitate the process. Success at the end of stage 3 led to the development of a specific study (stage 4) to assess long-term sustainability and staff’s perception 2 years after the intervention. The first 3 stages were performed as QI project, and the long-term follow-up stage was a specific study submitted and approved by The University of British Columbia Research Ethics board. Methods for QI project Stage 1: observation Observations of cardiac surgical handovers (from March 2 to 20, 2009) were conducted by 2 PICU clinicians who had extensive experience in PICU nursing and QI. They observed and videotaped the handover of care process for 6 cardiac surgical patients from the time the OR team arrived with the patient at the designated bed in the PICU until the
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Surgical Suite to Pediatric Intensive Care Unit Handover Protocol anesthetist left the bedside, which indicated that the handover process was complete. The same clinicians reviewed the tapes of each transfer and constructed the process maps, using standard work sheets, time measurements, and spaghetti diagrams to highlight workflow and identify barriers to safe and effective handover of care. Before analyzing each tape, the 2 clinicians went through each step of the review to standardize the process and ensure high consistency between reviewers. After careful coding of the videotapes, the defects identified were grouped in categories (see Supplemental Digital Content, Table, available at: http:// links.lww.com/JNCQ/A139) that align with technical and information transfer errors as outlined by Catchpole et al.35 For each recording, the total number of defects identified in each category was counted and the mean de-
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fect rate for all handovers in the period was calculated (Table). Stage 2: Generating and testing of handover process protocol From the defects outlined in the observation stage, the effort focused on the creation of a new handover protocol by members of the cardiac surgical and PICU teams as well as LEAN improvement experts. During the 1week rapid process improvement workshop, the protocol underwent several iterations as a result of brainstorming and testing of ideas with frontline staff after reviewing the videotapes of 3 handovers. The final protocol contained pretransfer and transfer responsibilities for the PICU and cardiac surgical teams as outlined by Catchpole et al35 ; in particular, the specific position of the staff was arranged to optimize the view of
Table. Long-term Sustainment of Cardiac Operating Room to Pediatric Intensive Care Unit Handover Protocola Initial Phase
Defect Categories Role crossover Tangled equipment/lines Essential supplies are not easily accessible Staff with no clear roles, crowded space Waiting for essential team members Deviation from “norm” Multitasking during handover Total number of defects observed(defect rate)
Follow-Up Phases
Implementation 2-y Observation Improvement and 1-y Sustainment Sustainment Week (Nb = 6) Week (Nb = 3) (Nb = 17) (Nb = 19) c d c d c d n( ) n( ) nc (d ) n( ) 25 (4.2) 17 (2.8) 9 (1.5)
0 (0) 1 (0.3) 3 (1.0)
0 (0) 0 (0) 0 (0)
0 (0) 0 (0) 2 (0.1)
9 (1.5)
0 (0)
0 (0)
0 (0)
7 (1.2)
0 (0)
0 (0)
0 (0)
8 (1.3) 4 (0.7)
0 (0) 0 (0)
0 (0) 1 (0.1)
0 (0) 3 (0.2)
4 (1.3)
1 (0.06)
5 (0.3)
79 (13.2)
a Defects
observed during handover processes. of admissions (handovers). c Number of defects observed. d Average number of defects per handover observed during a given period (eg, improvement week). b Number
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the patient and monitors and to facilitate the duties assigned to each staff in accordance with his or her responsibilities. Supplemental Digital Content, Figure 1, available at: http://links.lww.com/JNCQ/A136, shows the main features of the transfer protocol and Supplemental Digital Content, Figure 2, available at http://links.lww.com/JNCQ/A137, illustrates the team positioning at bedside. Stage 3: New handover protocol implementation and sustainment The implementation of the revised protocol (March 2009 to March 2010) started with an ambitious goal: to reach zero defects in most (>80%) handovers. During this period, 17 cardiac OR to PICU handovers were videotaped (most of them during the first 2 months) and used for education. This stage was labor-intensive and entailed orientation and education of staff to the new processes. Clinician leaders including those from quality and safety, nursing, and respiratory therapy were required to be available on short notice to answer questions and update the protocol on the basis of feedback from frontline staff. Multiple modes of communication and support were used to educate and support physicians and staff involved with cardiac OR to PICU handover for a smooth transition to the new handover model. E-mails were sent to all PICU and OR staff of the practice change. The e-mail was linked to a practice change summary, an education presentation and contact information for further information. A visual public display of the project was posted in the PICU (area accessed by both OR and PICU staff,) describing the defects, the measurement process, the ideas tested, and the resulting practice changes observed. To keep the change “front and center,” announcements of the new protocol were made at shift changes and prior to each cardiac admission for a 2-week period. The quality and safety leader provided daily clinical assistance for the cardiac admission team for a period of 6 weeks and as needed. This assistance translated to supporting the PICU receiving nurse, respiratory therapist, and cardiac OR aide in
preparation of the bed and clinical space; it also included speaking with the PICU physician team of the day to update them on the practice change and answer any questions. Another aspect of the education approach, led by the quality and safety leader and frontline nursing leaders, focused on real-time feedback and posthandover debriefs to be responsive to specific needs. Anecdotal report indicated that staff felt informed and part of the change. The handover of care process was monitored by the quality and safety leader or designate who conducted weekly audits for a 4-week period, then monthly for 4 months and then quarterly up to the 1-year period. The audits involved direct observation of the admissions and tracking of the defects. Communication of adherence or deviation to the process was provided posthandover to participants. Methods for study of long-term sustainability Cognizant of a possible Hawthorne bias, long-term assessment was conducted 2 years after protocol implementation (July-August 2011). Informed consent was obtained from parents and their children who were involved in videotaping of the handover. The clinicians were not aware of the exact time when they were being videotaped, although, as per ethics requirements, they were briefed a priori that some handover events would be recorded. We also conducted an anonymous survey among PICU and cardiac OR staff involved in handovers to assess their experience and acceptance of the process (questionnaire available on request). A total of 20 handovers were videotaped by one of the QI leaders unobtrusively to avoid distracting the teams. Nineteen were of sufficient quality and were evaluated and scored independently by 2 QI experts using the 7 defects categories (see Supplemental Digital Content, Table, available at: http://links.lww .com/JNCQ/A139); one of whom had been involved in the 2009 observation stage. Evaluators’ coding were compared and discrepancies resolved by discussion or, if needed, the intervention of a third party. These
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Surgical Suite to Pediatric Intensive Care Unit Handover Protocol results were then compared with the previous ones gathered 2 years earlier using the MannWhitney U nonparametric rank sum test for statistical comparison. The survey of PICU and OR handover teams gathered demographic information and assessed knowledge of the handover process as well as handover protocol acceptance. To test the participants’ knowledge of the sequence of steps in the handover process, participants were presented with a list of handover elements in random order and asked to arrange the elements in the proper sequence in which they should occur. Opinions of the current handover process were assessed by a series of questions using a Likert-type response scale with 5 options from “poor” to “excellent,” with additional open-ended questions. Data were analyzed with descriptive statistics, and graphic representations (box-plot) were used to communicate results to the teams. RESULTS BY STUDY PHASES QI project During the observation period (stage 1), the total number of process defects observed for the 6 cardiac handovers was 79, with a mean defect rate of 13.2 defects per handover (Table). The time for handovers ranged between 4 and 17.2 minutes, with an average time of 10.6 minutes. By the end of the rapid process improvement week (stage 2), the protocol had been tested on 3 handovers and revised to achieve a 90% reduction in the initial defect rate: from a mean of 13.2 (79/6) during the observation stage to 1.3 (4/3) during the improvement week (see the Table and Supplemental Digital Content, Figure 3, available at: http:// links.lww.com/JNCQ/A138). Finally, during the protocol implementation period (stage 3), 17 handovers were videotaped and the run chart updated for discussion (see Supplemental Digital Content, Figure 3, available at: http: //links.lww.com/JNCQ/A138). Only 1 defect was detected during this period, which gives a mean defect rate of 0.06 (Table).
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Long term sustainability study During this period, a total of 5 defects were observed among 19 handovers observed, which gives a mean defect rate per handover of 0.3 (Table). Statistical comparison between the observation period is significant: Mann-Whitney U test (P < .001). The Table and the Supplemental Digital Content, Figure 3, available at: http://links.lww .com/JNCQ/A138, show the handover defects during the different periods. Furthermore, in 2011, 14 of 19 transfers (76%) were free of defects while none was defect-free in 2009. Eighty-five questionnaires were distributed among the team involved in transfers. In total, 51 (60%) completed questionnaires were returned. The majority of the responders were nurses (n = 39, 76%) and 18 (46%) had more than 16 years of working experience in either OR or PICU. Twenty-eight percent of the responders participated in the improvement week in 2009. There was no statistically significant difference between responses of those who did or did not participate in the improvement week; we, therefore, analyzed the results of all surveys together. Most of the staff indicated that they knew their role in the handover process “precisely” or “almost precisely” (88%, n = 45/51), and 69% (n = 35/51) could clearly identify their role during the handover. Most (n = 37, 73%) believed that the handover process worked but not in every situation whereas only 12% (n = 6/51) believed that the process always works. Ninety-eight percent (n = 50) of the responders like the current handover process, with 96% (n = 49) of respondents indicating that they would recommend it to other units and facilities. DISCUSSION Following the SQUIRE guideline,36 we present this report to outline the implementation of a standardized surgical suite to the PICU transfer protocol and the teams’ long-term adherence. Two years postprotocol implementation and 1 year after last
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observation, we found that defect rates in the handover process were lower than the initial preimplementation and improvement week rates; moreover, 76% of handovers were free of defects in 2011 (see Supplemental Digital Content, Figure 3, available at: http://links.lww.com/JNCQ/A138), and the Table shows the drastic reduction of defects. Other studies have reported similar changes at the end of the intervention period15,37 ; however, short-term assessments of behavioral changes in context of observation are prone to Hawthorne bias that can account for most of the observed effects.38-40 Sustainability of gains represents a significant challenge in QI interventions.36 Long-term sustainability requires staff engagement, charismatic champions and leaders, and a culture that sustains the change despite staff turnover and pressing competing needs. Indeed, longer-term success in our PICU has been elusive in that 1-year sustainment rates were achieved in only 9 of 23 other QI projects (about 40%). Our results are in alignment with other cardiac transfer improvement projects that have targeted improving handover effectiveness through process improvement and improving accuracy of information..12,15,27,35 However, to our knowledge, the evaluation of long-term sustainability of the surgical cardiac OR to PICU handover implementation has not yet been reported. We chose to concentrate on the processes of care rather than whether key clinical information was relayed. This study was not designed and sufficiently powered to evaluate clinical outcomes following the intervention; poor outcomes are infrequent and may be attributable to many factors beyond handovers. Regardless, studies focused on improving handover quality have reported effectiveness in reducing patient morbidity and mortality in other health care activities.10,41-43 Furthermore, it has been shown that nontechnical skills, including collaboration, teamwork, and communication, play an essential role in good practice and may have a substantial effect on safety and the risk of human error in health care.10,11
The success and long-term sustainability of this project can be attributed partly to the readiness of the transfer team. Both the PICU and cardiac OR teams had tried various strategies over the years to improve the handover process with limited success partly due to adoption of individual preferences versus a standardized process in all cases. Burdened by previous failures, the 2 groups were fully engaged in identifying the barriers and understanding how these could be overcome. In addition, the challenges were presented with a clear understanding of expected behaviors and the environmental context.44 The presence of a videographer and ongoing discussions 3 weeks prior to the improvement week allowed sufficient time to advertise the project and enabled the team leads to actively engage frontline staff. Frontline staff volunteered ideas or concerns enthusiastically. This highly visible dedicated observation time was essential for staff engagement. Another factor believed to contribute to the success of this project was the ongoing communication focused on sharing each day’s progress during the project. After each rapid process improvement workshop day, we communicated the progress to the day and night staff. In addition, staff engagement was sustained by soliciting their ideas at the end of their shifts. This also occurred in real time with all team members working together through the changes being tested. This responsiveness to both practice areas ideas was seen as valuable and inclusive. While lessons from our past contributed to our improvement process design and implementation, others’ successes informed our actual handover protocol design. In particular, Great Ormond Street Hospital’s handover design with a focus on Formula 1 pit crew and aviation crew procedures was fundamental in reshaping our handover process.35 This process was championed by the cardiac anesthetists, and their leadership was significant in leading the handover process. There are a number of limitations to this project. First, there is small number of observations during preimplementation period and during the rapid process improvement
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Surgical Suite to Pediatric Intensive Care Unit Handover Protocol workshop week, which results in larger uncertainty. Second, the number of defect categories in the video checklist is limited, which might result in ignoring other “noncategorized” defects during surgical cardiac handover process; this list, however, was developed iteratively with the participation of the whole handover team and was guided by the literature. Third, we cannot completely eliminate the possibility of a Hawthorne bias because of the videotaping. However, we feel that this was insignificant given our safeguards and unobtrusive recording. Finally, we did not measure patient-centered outcomes such as survival or duration of hospital stay. Such analyses would require considerably larger
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sample size, which was not the objective of this project. SUMMARY We report that the successful sustainability of a complex handover process can be achieved through interactive communication with staff to encourage active involvement in the change process. Our experience shows the importance to analyze the challenges in the local setting to ensure that solutions are customized to fit the specific context in which the handovers take place. Team readiness is another important factor for successful implementation and sustainability.
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