EXPERT REVIEW John G.T. Augoustides, MD, FASE, FAHA Section Editor

Transition of Care in the Cardiothoracic Intensive Care Unit: A Review of Handoffs in Perioperative Cardiothoracic and Vascular Practice Jesse M. Raiten, MD,* Meghan Lane-Fall, MD, MSHP,* Jacob T. Gutsche, MD,† Benjamin A. Kohl, MD,† Michael Fabbro, DO,† Aris Sophocles, MD,† Sy-Yeu S. Chern, MD,† Lourdes Al-Ghofaily, MD,† and John G. Augoustides, MD, FASE, FAHA†


HE FAILURE TO EFFECTIVELY COMMUNICATE critical patient information among healthcare providers is a potential source of patient morbidity and mortality.1–4 Breakdowns in communication commonly contribute to sentinel events in perioperative care.5 Problems with communication are very likely during handoffs, a particular type of communication that occurs upon patient transition between locations or when patient care responsibility is transferred among members of the healthcare team.1–5 The handoffs involving critically ill patients are particularly susceptible to fault as they involve complex patients on varying degrees of life support. As such, efforts to improve transitions in care in the intensive care unit have focused on increasing the reliability of information exchange about these complicated patients, largely through the creation of a standardized handoff process.6,7 Standardized handoff processes have been credited with improving communication among team members, reducing medical errors, and improving patient outcomes.8–10 In this expert review, the challenges to achieving safe and effective communication when cardiac surgical patients transition among healthcare providers are considered, as well as why a structured handoff is ideal, the impact of this practice, current trials that are underway in the field, and future areas of research. IDENTIFYING THE PROBLEM: UNDERSTANDING THE MANDATE FOR CHANGE

Patient handoffs are a multifaceted process involving the transfer of patient information, responsibility, and authority between healthcare providers, and typically have been characterized by systematic errors.11,12 The implementation of shift work and stringent work hour regulations for trainees in graduate medical education at all levels have contributed further to the complex medical environment, with constant flux among practitioners caring for any given patient, resulting in disruptions of the continuity of care.13,14 As such, the transfer of critical patient information among providers has significantly increased in volume and highlights the importance of high-quality handoffs for the maintenance in the continuity of patient care.10,15 High-quality and effective handoffs are the product of multiple steps in a dynamic process that typically

involve the interactions of a variety of healthcare providers from different services (Fig 1). The barriers to effective handoffs are numerous.15,16 They may originate from factors such as ineffective communication among providers (due to environmental, language, or cultural factors),16 a lack of standardization of the handoff process,6–10 a paucity of educational materials and methods for teaching best practices for transfer of patient care,17–20 or deficiencies in real-time knowledge about the patient’s clinical status.5,6 Taking a step back, ineffective handoffs may begin even earlier, in that there is little consensus on what material should even be conveyed among providers, let alone on how effectively it is conveyed. Collins et al analyzed the content of 22 resident physician and nursing handoffs in an urban cardiothoracic intensive care unit and identified variables that were present in physician handoffs, nursing handoffs, and both.21 Although there was significant overlap, there were also multiple variables that were inconsistently present during sign-out

From the *Cardiovascular Critical Care Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and †Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, PA. Supported by a grant to Meghan Lane-Fall from the Anesthesia Patient Safety Foundation to support research in perioperative handovers. Address reprint requests to John G. T. Augoustides, MD, FASE, FAHA, Cardiothoracic Section, Anesthesiology and Critical Care, Dulles 680, HUP, 3400 Spruce Street, Philadelphia, PA, 191044283. E-mail: [email protected] © 2015 Published by Elsevier Inc. 1053-0770/2601-0001$36.00/0 Key words: critical care, intensive care unit, admission, discharge, complexity, errors, safety, handoff process, communication, synchronous, asynchronous, standardization, curriculum, templates, SBAR, PACT, PDSA cycles, best practices, mortality, morbidity, cognitive aids, checklists, quality, reliability, validity, accuracy, hat-trick, HATRICC, pICUp trial, PKAT, continuous improvement, handoff metrics, best practices, costs, value

Journal of Cardiothoracic and Vascular Anesthesia, Vol ], No ] (Month), 2015: pp ]]]–]]]




Anesthetic technique Vital signs Ins/Outs Lab results Medication totals

Patient in OR

Pre-hando preparation (anesthesia provider)

Patient in ICU

Stabilization & monitor transfer (anesthesia & ICU teams)

Hando to ICU team

Information exchange discussion / questions

Fig 1. The phasic approach to the high-quality handoff. The initial preparation is completed in the operating room by the anesthesia team. The transition and transfer of care during the admission process in the intensive care unit are a joint process among the anesthesia, surgical, and critical care teams. Abbreviations: OR, operating room; ICU, intensive care unit.

among different types of providers.21 Fundamental patient information, such as main diagnosis and cardiopulmonary status, were among the critical data that were conveyed inconsistently among providers.21 There has been a call for content standardization of handoffs in different specialties, including emergency medicine, pediatrics, anesthesiology, and critical care.11–13,22–25 In the critical care setting, the high patient acuity and the large, multidisciplinary teams (with multiple providers at varying stages of training) mandate effective communication and information transfer to ensure continuity of care. The sicker patients in the intensive care unit tend to be at greater risk for handoff errors, due in part to their higher acuity and consequent higher complexity.6–9,26 This high patient complexity introduces another source for error in the handoff process—the tendency to focus on the details of patient care (eg, specific ventilator settings, medication infusions) and to omit a broad overview of the patient’s condition.27 This “big picture” overview is important to set the stage for the receiving provider to appreciate the subsequent details of the patient’s condition.27 In cardiac surgery, patients transition from the care of the perioperative team to that of the critical care team in the intensive care unit. These handoffs involve physical transport between hospital locations as well as transfer of staff, technology, and information.6,7,28 Furthermore, hemodynamic instability, medication infusions, mechanical ventilation, and bleeding all contribute to a dynamic, rapidly changing patient status that is being managed by the cardiac anesthesiology and cardiac surgical teams during the transport and admission process in the intensive care unit.6,7,29 Furthermore, patient handoff often takes place at the bedside in a noisy and crowded environment as the patient is admitted to the intensive care unit, with the transfer of hemodynamic monitoring and mechanical ventilation to the new care paradigm.28,29 In addition to physical and environmental challenges, the handoffs of care for the cardiac surgical patient arriving in the intensive care unit may be particularly susceptible to errors, because handoff involves providers of different disciplines (eg, anesthesia and surgery) and with different professional backgrounds (eg, physicians, nurses, advanced

practitioners).30,31 Most medical centers still lack a standardized sign-out process, and when this is combined with a rotating pool of providers caring for a high-acuity cardiac surgical patient population, the potential for miscommunications and errors is understandably high.29–35 THE VERBAL HANDOFF: PRINCIPLES AND PRACTICE

Given the multiple sources of errors in the handover process already outlined, a variety of templates have been developed and tested to standardize and reduce errors during the exchange of medical information among providers.32–35 The mnemonic SOAP (Subjective, Objective, Assessment, Plan) was established as a traditional template for daily progress notes and parallels the clinical encounter with patients, but this template has lacked widespread adoption in the verbal handoff process.36 The verbal communication template known as SBAR (Situation, Background, Assessment, Recommendations) was originally developed by the United States Navy to facilitate efficient information transfer in an accurate and predictable structure.37–39 Multiple handoff studies have shown that the SBAR template significantly improves communication quality among healthcare providers, including both within and between physicians and nurses in the care of acutely ill patients both within individual care units and between units in large health systems.38–41 Further adequately powered clinical trials are indicated to explore the performance of the SBAR communication template in reducing errors and improving clinical outcomes in the critical care setting, especially in the complex environment of pediatric and adult cardiac anesthesiology and critical care. These trials also could compare the perioperative performance of a mature communication template tool, such as SBAR, with the newly derived PACT (Priority, Admissions, Changes, Task) model.41,42 This area represents a major research opportunity for the clinical investigators around the world in the perioperative cardiothoracic and vascular community to advance the knowledge and practice of this specialty. PRINCIPLES OF HANDOFF COMMUNICATION: DEFINITION OF BEST PRACTICES

High-quality communication reduces medical errors, maintains continuity of care, and fosters a collaborative work environment.43,44 Handoff communication among providers may be synchronous (involving direct communication in person or via telephone), or asynchronous (involving written or recorded communication).45 Technology-assisted templates and related tools have been advocated strongly by multiple thought leaders, including the Institute of Medicine, as mechanisms to improve communication and reduce errors in healthcare teams.46–49 Multiple handoff electronic platforms ranging from an internet-based sign-out to smartphone-assisted techniques have been studied.50–54 As a rule, a structured electronic handoff template tends to improves the quality, consistency, and reliability of handoffs in perioperative practice, compared with traditional techniques.50–54 Physician-to-physician direct communication is easiest to facilitate when patients are transitioning among providers in the same geographic location (eg, within the intensive care unit) or



when they are escorted between point-of-care locations by a physician. In the cardiothoracic intensive care unit, patients arriving from the operating room environment typically are accompanied by an anesthesiologist and a surgeon, thereby enabling face-to-face synchronous verbal handoff interactions.29,32 These handoffs in this environment, however, need not rely exclusively on synchronous communications, but may be augmented with a written or electronically-assisted component, as illustrated by the following practice possibilities from other specialties. In an extreme example of an electronically facilitated handoff, Gonzalo et al described the application of the “eSignout”, an electronic handoff tool characterized by the following triad: Firstly, an internet-based dashboard visible by both the sending and receiving teams; secondly, an automatic paging system; and thirdly, the ability for the receiving team to electronically complete the handoff process.30 In their study, which trialed this eSignout tool in the setting of handoffs between the emergency room and the medical ward, the rates of adverse events and near-misses were similar compared with the traditional verbal handoff, although the eSignout was perceived as more efficient and was preferred by the receiving care providers.30 In a second handoff model characterized by a lack of direct person-to-person interaction, Horwitz et al evaluated the asynchronous voice-mail–assisted handoff for patients transitioning from the emergency room to the medical ward.45 The asynchronous telephone-assisted tool resulted in equivalent outcomes, as judged by rates of adverse events and early transfers to the intensive care unit.45 Handoff techniques that use a combination of electronic and verbal interface may be more common because communication and information retention are significantly enhanced by their synergistic interactions. In an observational study of 12 simulated patients over 5 consecutive handoff cycles, 2.5% of information was retained with verbal handoff alone, compared with 99% when patient information was communicated on a printed handout.55 How do these studies translate to the handoff practice in the cardiothoracic intensive care unit? Transitions in care from the operating room to this complex environment may be particularly error-prone because success depends on transfer of a large amount of critical patient information and equipment among multiple providers. Handoffs of this kind have been analogized to the pit-stop in Formula 1 motor car racing, where a group of professionals work under considerable time pressure to safely perform a complex series of actions.29 Based on these concepts, Catchpole et al developed a handoff protocol for a structured admission process to the intensive care unit after pediatric complex congenital heart surgery.29 This admission protocol was developed in collaboration with a Formula 1 racing team, as well as aviation captains, for identification of safety themes that could be incorporated into the complex healthcare environment under study.29 In this collaborative professional care model, patient handoff was conducted in a series of phases as follows: Phase 0: Prehandover; phase 1: Equipment and technology handover; phase 2: Information handover; and phase 3: Discussion and plan.29 The implementation of the new handoff protocol significantly reduced technical errors, omissions of important information, with no

increase in handoff time.29 Although this landmark trial was underpowered to assess patient outcomes, it strongly endorses handoff standardization for improving information transfer and patient outcomes in the complex environment of the cardiothoracic intensive care unit, a concept supported by multiple subsequent clinical trials.6,7,29,32–34,56,57 THE STANDARDIZED HANDOFF: THE WAY FORWARD

The standardizing of the handoff process has been an area of intensive research because errors in handoffs are common and clinically important.1–4 Multiple clinical trials have sought to establish whether using a standard structure during the handoff process reduces errors, morbidity, and mortality.4–6,8–10,12–14,22,23,26,27,29–35,38–45,50–54 These trials have targeted dynamic and complex environments with multiple providers such as the emergency room, the operating room, and intensive care units and their related interfaces of care. Different models have been studied to standardize the patient handoff process both in critical care and within the hospital in general.58–61 The interventions to improve the handoff process commonly have focused on enhancing the quality of communication among healthcare providers, frequently with assistance from electronic handoff adjuncts, and/or improving the accuracy of patient information flow among providers.60 To these ends, varying degrees of electronic and technologic interventions, handoff templates and checklists, communication techniques, and simulation studies have been investigated.51–54,60 A prospective, interventional study of a handoff protocol was conducted by Joy et al in 79 pediatric cardiac surgical patients during their transition-of-care from the operating room to the intensive care unit.32 The protocol was developed by a multidisciplinary team and then subsequently dynamically modified based on real-time PDSA cyclic feedback (“PlanDo-Study-Act Cycles”) before being enacted.32 After implementation of this polished handoff protocol, the mean number of technical errors per handover was significantly reduced from 6.24 to 1.52 (p o 0.0001), and the mean number of information omissions decreased from 6.33 to 2.38 (p o 0.0001) per handoff encounter.32 Trial surveys also suggested that the handoff protocol improved teamwork, without any significant increase in the duration of handover.32 In one of the few studies of perioperative handoffs from the operating room to the intensive care unit in adult cardiac surgical patients, Petrovic et al conducted a prospective study of a standardized handoff protocol and checklist in 60 patients. The protocol was developed in consultation with multiple care providers from different medical services, surveys, and focus groups.6 The protocol was detailed in that it specified who would be present at handoff, the order in which information was communicated, required a period for questions and clarifications, and included a clear way to conclude the handoff.6 This protocol significantly improved the attendance of team members at the bedside during the handoff period and the sharing of information, adding minimal time to the handover process. The authors described the protocol as successfully changing the handoff environment from “one that was noisy with multiple parallel conversations to an orderly exchange of information”.6 Further handoff studies are required to define best practices in the


complex perioperative cardiothoracic environment that seems particularly well-suited to this type of clinical investigation. DIRECTIONS OF FUTURE RESEARCH: OPPORTUNITIES FOR CLINICAL INVESTIGATORS

Given the recent focus on medical errors and that handoffs represent a major remediable source of these errors, it is no surprise that in the past decade there has been a swell in research activity to understand and improve the handoff process in multiple clinical settings and between different categories of medical professionals.62–71 Given its importance in optimizing patient safety, considerable research currently is underway to improve the handoff process. One such clinical trial is currently in progress at the University of Pennsylvania.3,28 The Handoffs and Transitions in Critical Care (HATRICC) study is a trial of handoff standardization that aims to determine whether handoff standardization is effective in improving handoff communication for mixed (cardiac and noncardiac) surgical populations by studying the process of implementing standardized handoffs.28 Its goals are tripartite: To understand current critical care handoff practices, to develop a best practice, and to implement handoff improvement interventions. This study was launched in 2014 and will include handoff observations, focus groups and interviews of practitioners, and a simulation component of a standardized handoff.28 Clinical trials such as HATRICC will contribute to the understanding of best practices for safe and effective transfer of care for complex surgical patients from the operating room to the intensive care unit.3,28 The handoff of care takes place not only during the admission process but also during the discharge process from the intensive care unit.28,72 The Dutch pICUp clinical trial aims to investigate the safety and efficiency of current discharge practices from intensive care units across the Netherlands.72 Furthermore, this clinical trial aims to identify barriers and facilitators for development of an implementation strategy to enhance the quality of the handoff process during discharge from the intensive care unit.72 The clinical trial will have 5 phases.72 Phase A will be an analysis of the Dutch National Intensive Care Evaluation Registry to identify variations in hospital mortality and readmissions after discharge from the intensive care unit. Phase B will entail a systematic review of effective interventions for improvements in safety and efficiency of the discharge process from the intensive care unit. Phase C will be the administration of a nationwide questionnaire to assess adherence to these intervention practices among Dutch intensivists. Phase D will involve the assessment of barriers and facilitators to the implementation of these interventions based on inputs from a questionnaire, focus groups, and clinician interviews. Phase E will entail the systematic development of an implementation strategy to enhance the transfer of care during discharge from the intensive care unit based on the sampled data from phases A through D.72 Innovative trials such as the Dutch pICUp clinical trial will help ensure that best practices for handoffs are identified and implemented for all cardiothoracic and vascular surgical patients, not only during the entry phase but also during the exit phase from the critical care process in the intensive care unit. In addition to research to improve the transmission of information among providers, trials still are indicated to develop


and validate tools for assessing how effectively patient data actually are being communicated. As Bates et al described it, an “instrument to measure shared clinical understanding as a marker of handoff quality” is needed.71 To this end, Bates et al studied the Patient Knowledge Assessment Tool (PKAT) in a pediatric cardiac intensive care unit.71 This tool, consisting of a questionnaire that focused on data related to individual patients, was developed from information from prior studies, internal survey data, expert opinion, and pilot testing.71 In the clinical trial, the PKAT was validated as a reliable assessment tool in real-time clinical environments to measure a provider’s understanding of a patient’s clinical status and treatment plan.71 As such, the PKAT represents a measurement tool to document the impact of interventions to improve the handoff process in inpatient settings.71 The Bates study is an important step into an important area of patient handoff research; namely, the assessment of a communal understanding of the patient’s status and direction of care. The developed and validated measurement tool, the PKAT, adds a trial outcome for handoff trials beyond the commonly measured variables of “improved satisfaction” among healthcare providers and a perception that a standardized signout improves handoff efficiency and quality. Further research in this area of handoff metrics is essential to develop a comprehensive toolbox of handoff measures for endpoints such as quality, efficiency, accuracy, and reliability.73–75 There is also a dearth of research about best practices for the incorporation of patients and their families into the handoff and transfer process, and into the patient safety movement in general.76,77 Indeed, a lack of understanding and knowledge by patients and their families about the discharge process from the intensive care unit contributes significantly to dissatisfaction about this handoff process.72,77 Because this lack of quality may stem from poor communication among healthcare teams, the patient and the patient’s family, the improvement of communication quality among all stakeholders likely will enhance safety and satisfaction during the discharge process from the intensive care unit.72,77,78 Engaging the patient and family in the healthcare process remains essential for a high-quality “patientcentered care” model of health care. Further clinical investigation such as the Dutch pICUp trial set will advance the frontiers of knowledge in this area so that the exit and handoff process from the intensive care unit will become safer, more efficient and more patient-centered.72,76,78 The titration of this process of communication remains important to achieve the right balance depending on the clinical circumstances and the preferences of the patient and/or family.79–80 FINANCIAL CONSIDERATIONS

Preventable medical errors take a large financial toll on the healthcare system that cost billions of dollars every year.81–83 Although it makes sense that improving handoff communication would save money, there remains insufficient data to support this claim.84 The successful widespread implementation of quality improvement initiatives is challenging, without evidence of increased revenue or cost savings.84,85 In fact, most studies of quality improvement interventions do not include an analysis of potential financial impact.84–86 Quantifying the financial gain from improved communication and reduced errors directly related



to handoffs and transitions in care would carry considerable weight to persuade hospital administration and policy makers to adopt and implement these interventions as institutional priorities.87 CONCLUSIONS

Most patients admitted to a hospital, and practically every patient in the ICU, will be at the center of a handoff at some point during their hospitalization. For many patients undergoing cardiac surgery, their first transition in care will be the interface between the operating room and the intensive care

unit. Multiple studies clearly have shown the importance of an effective and accurate handoff in ensuring quality and continuity of patient care to the extent that high quality in this process has become a recent focus in this specialty.88,89 Considerable research is underway around the world to identify ways to improve this handoff process, with an array of electronic and verbal communication tools being investigated. Funding for further research will improve as quantifiable outcome and financial benefit are linked to an effective and efficiently conducted handoff process.

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Transition of Care in the Cardiothoracic Intensive Care Unit: A Review of Handoffs in Perioperative Cardiothoracic and Vascular Practice.

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