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When there is a cacophony of activity happening all at once, it is difficult to find the time for proper hand-offs and the communication that accompanies the hand-off. The patient is very often hustled from one department to another and from one healthcare professional to another-this in spite of everyone's best efforts to keep the patient's "transitions smooth" without any interruptions, catastrophes, or other unbidden woe. This article will focus on the need for hand-off communications that are methodical yet flexible and that promote patient safety.
Let us begin with the definition of a hand-off. A hand-off is defined as "the transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm" (King, Hohenhaus, & Salisbury, 2007). The hand-off communication then is the verbal and/or written exchange of pertinent information occurring during this transfer of responsibility and caregiving activities. This definition takes into account all areas and situations in which patient hand-offs occur such as at the time when the physician transfers on-call responsibility, at the change of shift, when the patient is transferred from one level of care to another, and when the physician transfers complete responsibility for a patient.
In the perioperative area, hand-offs begin with the information exchanged between the patient and the surgeon and/or surgeon's staff. Then there is another hand-off between the surgeon's office and the operating-room scheduler or other scheduling department at the facility. And the information exchanges move on from there. These hand-offs will be reviewed in the body of this article.
Just to illustrate the importance of hand-offs and the communication that accompanies them, here are some examples of how The Joint Commission (TJC), the Agency for Healthcare Research and Quality, and the World Health Organization (WHO) view and address the issue of hand-offs. Note, this is only a snap shot; the amount of literature is overwhelming on this topic.
The Joint Commission (2006) raised the awareness of the importance of hand-offs and hand-off communication in 2006 when it introduced National Patient Safety Goal (NPSG) 2E that required healthcare organizations to "implement a standardized approach to 'hand off' communications, including an opportunity to ask and respond to questions" (2006 Critical Access Hospital and Hospital National Patient Safety Goals, 2006). The overarching theme of NPSG 2, ever since its inception in 2003, has been and continues to be "to improve the effectiveness of communication among caregivers" (Accreditation Program, 2009a).
The Agency for Healthcare Research and Quality conducted a "Hospital Survey on Patient Safety Culture: 2008 Comparative Database Report." (Hospital Survey on Patient Safety Culture, 2008) A total of 160,176 hospital-staff members, 77% of which indicated they had direct patient interaction, responded to the survey from 519 hospitals across the United States. According to the survey results, the four types of hand-offs and transitions that posed problems were as follows: "Things 'fall between the cracks' when transferring patients from one unit to another"-(41%); "Important patient-care information is often lost during shift changes"-(49%); "Problems often occur in the exchange of information across hospital units"-(42%); and "Shift changes are problematic for patients in this hospital"-(46%) (Hospital Survey on Patient Safety Culture, 2008).
In 2007, the WHO published "Communication During Patient Hand-Overs" (Communication During Patient Hand-Overs, 2007) in which it was noted that hand-offs/"hand-overs" are an international dilemma. In this publication, it was conjectured that hand-off/"hand-over" problems may well relate back to three things: (1) the way in which healthcare providers are educated with regard to team training and communication, (2) lack of good role models, and (3) the promotion and reward, by healthcare systems, of those that are autonomous and excel through individual performance.
And, not to be forgotten, in its report, "Crossing the Quality Chasm," (2001) the Institute of Medicine (IOM) mentioned that hand-offs provide an opportunity for error and that "in a safe system, information is not lost, inaccessible, or forgotten in transitions" (Committee on the Quality of Health Care in America, Institute of Medicine, 2001).
As noted previously, numerous hand-offs occur during the care of a patient. There are many as well in the perioperative area, all of which, if not well executed, could result in an untoward event. Here is a list of some of the hand-offs that may occur during the patient's journey to, from, and through the perioperative area(s):
* between the surgeon and the person scheduling surgeries on behalf of the surgeon;
* between the person scheduling surgeries on behalf of the surgeon and the facility (operating room or facility scheduler);
* between the admitting office and the nursing unit/same-day-surgery unit;
* between the nursing unit/same-day-surgery unit and the transport team;
* between the transport team and the preoperative area;
* between the preoperative and intraoperative areas;
* between the surgeon and other team members while performing the different aspects of the Universal Protocol and World Health Organization's surgical safety checklist;
* between the intraoperative area and the postanesthesia care unit (PACU);
* between PACU and the unit/department to which the patient will be transferred/discharged;
* between the staff discharging the patient and the patient.
Following the guidelines set down by TJC in their NPSG on hand-offs is an excellent beginning. The standard, "to implement a standardized approach to 'hand off' communications, including an opportunity to ask and respond to questions" (Accreditation Program, 2009b) expresses "what" is to be done and the Elements of Performance (EPs) tell "how" to accomplish the standard. The five 2009 EPs for this standard are worth mentioning so they will be stated in their entirety below:
1. The hospital's process for effective hand-off communication includes the following: Interactive communication that allows for the opportunity for questioning between the giver and receiver of patient information.
2. The hospital's process for effective hand-off communication includes the following: Up-to-date information regarding the patient's condition, care, treatment, medications, services, and any recent or anticipated changes.
3. The hospital's process for effective hand-off communication includes the following: A method to verify the received information, including repeat-back or read-back techniques.
4. The hospital's process for effective hand-off communication includes the following: An opportunity for the receiver of the hand-off information to review relevant patient's historical data, which may include precious care, treatment, and services.
5. Interruptions during hand-offs are limited to minimize the possibility that information fails to be conveyed or is forgotten. (NPSG, 2008)
It is of significance that TJC regards all five of these EPs as "direct impact requirements." (A standard or EP is considered to have a "direct impact" if noncompliance is likely to create an immediate risk to patient safety or quality of care.) Thus, these EPs are earmarked for even more scrutiny because of their immediate risk potential.
These EPs can and should be followed for each hand-off communication that takes place regardless where it occurs. Are there interruptions? Are there, what seem like, insurmountable obstacles during a hand-off? Yes, there are and it is unlikely this will change. The crux of the matter and true aim of the hand-off communication is for all of the parties involved to deem that the information exchanged and received has been understood correctly by everyone. (It is this author's opinion that this NPSG takes into account, and in essence summarizes, many of the suggested activities to combat hand-off problems that have been proposed by organizations such as the Institute of Medicine, Agency for Healthcare Research and Quality, and WHO.)
Regardless when a hand-off takes place, it is paramount that the requisite information pertinent for that particular patient is exchanged. Otherwise, there is an increased risk of an untoward event.
Information included in any hand-off must be up-to-date and take into account the patient's condition, care, treatment, medications, services, and any recent or anticipated changes to the patient's condition.
Regardless where a hand-off takes place, there must be a method in which received information is verified. The techniques used for this include "repeat-back" or "read-back." This practice may be received with a bit of angst because there are those who don't want to repeat what they have already said and find it to be a "waste of time" and/or there are others who are incredulous that anyone would find what they said or wrote to be unclear. This "repeat-back" or "read-back" technique opens up more communication and lends itself to true interactive communication in which there is an opportunity for the caregivers involved to ask and answer questions that arise during the exchange. One caveat is here: language must be clear and concise and the caregiver must be specific in his or her report. Statements must be far more descriptive than "patient stable" or "patient not responding appropriately."
The Joint Commission recommends that a process be in place that allows the caregiver receiving information to review relevant patient's historical data as well. This makes perfect sense. Every patient is different and sometimes just a "wisp" of past treatment history can change the course of a patient's healthcare journey.
The Joint Commission recommends in its Frequently Asked Questions (National Patient Safety Goal 02.05.01, 2008) that a "standardized" approach to hand-off communication be used. According to TJC, the organization must define, communicate to staff, and implement a process in which information about the patient's care is communicated in a consistent manner. This standardization is also to encompass the education of staff about the process and is meant to support consistent implementation of the process throughout the organization. Some standardized communication approaches include SBAR (i.e., situation, background, assessment, and recommendation) and PACE (i.e., patient/problem, assessment/actions, continuing changes, and evaluation).
One additional comment is here: regardless what approach to hand-off communication is chosen, the education and training of all concerned is essential. The best strategies for hand-off communications will never be incorporated into daily routine without ample reinforcement of the organization's chosen "plan" for these communications. And, what better way to assure that the "plan" has been shared than through education and training that is consistent, reinforced, and its effectiveness measured?
While the first communication will likely be between the surgeon and the patient about the procedure to be performed; the first hand-off communication will be between the surgeon and his or her scheduler and the second will be between the scheduler and the facility. There may be a third hand-off if the facility has a primary scheduler who must in turn contact the perioperative scheduler. That just adds an additional chance for miscommunication. Even though the healthcare professionals at both ends of the information exchanges are practiced in their roles as schedulers and communicators, misinformation must be guarded against as it could lead to disastrous results later.
In the hand-off between the surgeon, scheduler(s) and facility/operating room scheduler (aside from the information to be included noted above under effective communication) the procedure(s), the side or site and any other information that could impact the procedure itself and/or subsequent care of the patient must be added during the information exchange. The date and time are to be conveyed as well.
Next the patient arrives at the facility and the conversation with the admitting office ensues. Then the hand-offs continue. There are the hand-off communications between the admitting office and the nursing unit/same-day-surgery unit; the nursing unit/same-day-surgery unit and the transport team; and the transport team and the preoperative area. Although the exchanges that occur at these hand-offs may seem more perfunctory in nature; they are important nonetheless for continuity of care and all of these are hand-offs, which require the correct exchange of information and should include the reason the patient is being admitted, the procedure to be performed, the site or side where the procedure is to be performed, and any other relevant information.
A few questions that might come into play here are as follows: Is the informed consent signed and available? Does it match the surgery schedule? If there is a discrepancy, is it addressed immediately? Is the History & Physical on the chart? If necessary, has an update been made to the History & Physical by the surgeon? Has the patient been NPO? Does the patient have any allergies? Has the patient received any medications? Are all required diagnostic tests present in the chart?
At this point in time, the hand-offs are directed at the perioperative area and include those between the preoperative and intraoperative areas; the surgeon and other team members while they perform the various aspects of the Universal Protocol (World Health Organization Surgical Safety Checklist, 2009) and World Health Organization's surgical safety checklist (World Health Organization, 2009); and the intraoperative area and PACU.
During the preoperative/intraoperative hand-off, the focus continues to be (as it should throughout the patient's progression through the perioperative area) whether the patient is the right patient and whether the procedure and site/side are correct. The preoperative nurse will relay to the intraoperative nurse the patient's history, reason for the procedure, procedure to be performed, site/side (if applicable), and information about the History & Physical and informed consent. Ideally, marking of the surgical site will be done in the preoperative "holding" area as well while the patient is still awake and can participate.
Intraoperatively, the surgeon and other team members continue with the elements of the Universal Protocol and World Health Organization's Surgical Safety Checklist (sign in, time-out, and sign out). Verification is again done-right patient, procedure, and site/side. The "time-out" is performed and while all other activities are suspended, confirmation is again made that it is the correct patient, procedure, and site/side, and that the necessary equipment and documentation, including radiological studies, are available and standing by. Also, the questions regarding the five "Anticipated Critical Events" (World Health Organization, 2009) are answered. Those five questions are as follows:
1. Surgeon review: What are the critical or unexpected steps, operative duration, and anticipated blood loss?
2. Anesthesia team reviews: Are there any patient-specific concerns?
3. Nursing team reviews: Has sterility (including indicator results) been confirmed? Are there equipment issues or concerns?
4. Has antibiotic prophylaxis been given with the last 60 min: Yes/not applicable.
5. Is essential imaging displayed? Yes/not applicable.
The hand-off communication between the intraoperative area and PACU is the point at which information regarding how well the patient tolerated the procedure and any intraoperative complications or abnormalities is discussed. Also, the type of anesthesia administered, estimated blood loss, medications administered intraoperatively, and the patient's hemodynamic status are conveyed.
And finally, there is the hand-off between PACU and the nursing unit/same-day-surgery unit. It is of utmost importance that the patient's background information and history be relayed as well as the procedure, type of anesthesia, names of surgeon and anesthesia provider, any significant event occurring in PACU, physiological assessment, surgical complications of lack thereof, pain level, and discharge instructions.
One may be asking whether the lack of adequate hand-off communication has led to any litigation. The answer is yes. However, the "lack of hand-off communication" verbiage is stated "per se" in the pleadings. Instead, when the facts of the case are laid out, there is invariably a reference to a situation in which certain crucial data about a patient was not exchanged and the result was the untoward event that led to the lawsuit.
As has been stated again and again, miscommunication at any of the junctures (hand-offs) discussed can be devastating for the patient and the staff involved in the patient's care. The safeguards proffered by TJC, WHO, and Agency for Healthcare Research and Quality, and so forth, are a way in which, these, if applied in earnest, can promote patient safety and the quality of care.
Accreditation Program. (2009a). Hospital, chapter: National patient safety goals (p. 4). Retrieved August 4, 2009, from http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8[Context Link]
Accreditation Program. (2009b). Hospital, chapter: National patient safety goals (p. 7). Retrieved August 10, 2009, from http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8[Context Link]
2006 Critical Access Hospital and Hospital National Patient Safety Goals (2006). Retrieved August 4, 2009 from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsg_[Context Link]
Communication During Patient Hand-Overs. (2007, May 3). WHO collaborating centre for patient safety solutions. Patient Safety Solutions: Vol. 1. Solution. Retrieved August 6, 2009, from http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf[Context Link]
Committee on the Quality of Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National Academies Press. [Context Link]
Hospital Survey on Patient Safety Culture. (2008, March 20). Comparative database report. AHRQ Publication No. 08-0039. Retrieved August 5, 2009, from http://www.ahrq.gov/qual/hospsurvey08/hospsurveydb1.pdf[Context Link]
King, H., Hohenhaus, S., & Salisbury, M., (2007, May 21-22). TeamSTEPPS(TM) strategies and tools to enhance performance and patient safety (Slide number 26). Slide presentation given at the New York State Department of Public Health Patient Safety Conference. Retrieved October 29, 2009, from, http://www.healh.state.ny.us/professionals/patients/patient_safety/conference/20. [Context Link]
National Patient Safety Goal 02.05.01. (2008, December 9). What is meant by "standardizing" an approach to hand-off communication? Retrieved August 12, 2009, from http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards/09_FAQs[Context Link]
Survey on Patient Safety Culture. (2008, March 20). Comparative database report (p. 34). AHRQ Publication No. 08-0039. Retrieved August 5, 2009, from http://www.ahrq.gov/qual/hospsurvey08/hospsurveydb1.pdf
The Joint Commission. (2006). 2006 critical access hospital and hospital national patient safety goals. Retrieved August 4, 2009, from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsg_[Context Link]
World Health Organization. (2009). Surgical safety checklist (1st ed). Retrieved August 13, 2009, from http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_fina[Context Link]
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