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Patient Hand-Offs
Sheri S. Crow, MD, MSAssistant Professor of Pediatrics
Critical Care MedicineMayo Clinic
Rochester, MN
Intensive-care medicine has become the art of managing
extreme-complexity
……and a test of whether such complexity can, in fact, be
humanly mastered.
NewYorker 2007
Hand-Off Statistics
• During 24 ICU hours the average patient experiences:
• 178 individual actions per day• Nurse/doctor errors in 1% of these actions• 2 errors/day/patient
• Handover failures account for:• 20% of U.S. malpractice claims• Half of sentinel events involving communication
breakdowns (Joint Commission Report)
• Post-operative handovers: common area for communication breakdown.
Requirement for Success
“hold the odds of doing harm low enough for the odds of doing good to prevail”
http://www.youtube.com/watch?v=YS_llfT2kQc
http://www.youtube.com/watch?v=xQ4SVzxbp7Y&feature=related
Formula One Pit Stops
• A multi-professional team comes together as a single unit to effectively perform a complex task.
Overcoming the Odds
Do Checklists Really Work????
An ICU Fairy An ICU Fairy TaleTale
Checklist intervention
• Peter Pronovost: Johns Hopkins
• Goal: Reduce central line infections
• Central line checklist: • Wash hands with soap• Clean the patients skin with chlorhexadine
antiseptic• Use sterile drapes• Wear sterile mask, gown, gloves• Place sterile dressing over catheter site.
Checklist Implementation
• Month 1: Observation• Nurses document checklist compliance• At least 1 missed step > 1/3 of procedures
• Month 2: Intervention• Nurses authorized to stop doctors violating
protocol steps• Nurses asked each day if lines could be
removed
Results
• Significant decline in line infections:• After 1 year: 11% to 0.• After 2 years: 1 line infection/year• Prevention of 43 infections and 8 deaths
• Savings of 2 million dollars
• Next project: Ventilator associated pneumonia (VAP)
• Non-compliance with VAP prevention protocols decreased from 70% to 4%
• Pneumonia dropped by 25%• 21 fewer patients died than previous year• ICU length of stay dropped by half
Keystone Initiative
• Within 3 months: • Infection rate decreased by 60%• Michigan ICU infection rates: Worst
national rates to top 10%.
• Within 18 months saved:• 175 million dollars• 1500 lives
• Success persists almost 4 years later
Why they work?
• Assist with memory recall
• Specify the minimum expected steps in a complex process.
Intra-operative Checklist
Haynes AB et al. N Engl J Med 2009;360:491-499
Operative Theatre to ICUHand-Offs
Three Parts to a Successful Handover
1. Equipment and Technology Handover
2. Information Handover
3. Discussion and Plan
Catchpole et al Pediatric Anesthesia 2007
Sample Checklists: Post-op Handover
• Patient information:Patient detailsMedical historyAllergy statusName of procedureCurrent status of patient
• Anesthetic informationType of anesthesiaIntraop anesthetic courseAnticipated post-op problemsMonitoring and range for physiological parametersAnalgesia planPlan for IV fluidsAnesthesia contact number
• Surgical informationIntra-operative surgical course Blood lossAntibiotic planMedication plan-drugs to be restartedDVT prophylaxisPlan for tubes and drainsNG tube and feeding planPost-operative investigationsSurgical contact number
Clinical Applications for Checklists
• Central Line Placement
• Compliance with Clinical Practice Guidelines: Ventilator associate pneumonia
• Operative Theatre to ICU handovers
• Change of Shift handovers
• Hospital to hospital transfer
Questions/Discussion