Background

Effective communication during transitions of care between orthopaedic provider coverage teams is a key element for safe, quality patient care. The process of transferring responsibility of care to another clinical team member is known as a handoff (Alert, 2017). For elective orthopaedic surgical patients, proper handoff is a critical phase as these patients often present with not only their index pathology requiring surgery but also multiple comorbidities that, if not optimized, can cause adverse medical postoperative complications (Partridge et al., 2018).

The process of optimization requires that the primary care provider and/or specialist evaluate the patient and their current medications, determine whether they are stable to proceed with surgery, and at times give specific preoperative, intraoperative, and postoperative recommendations to control their comorbidities. Ineffective communication of this optimization across all phases of the perioperative pathway could present critical issues with patient safety and quality of care. The Joint Commission emphasizes that handoffs should be a priority for organizations, and that resources should be allocated for quality improvement (QI) initiatives regarding handoffs as it continues to be an area that contributes to adverse and sentinel events. In its 2017 report, The Joint Commission noted that 1,744 deaths and $1.7 billion in malpractice over 5 years were due to medication errors that could have been avoided with standardization of handoffs (Alert, 2017).

Within the total joint arthroplasty microsystem of the orthopaedic service, there are multiple providers reviewing and acting upon optimization notes through all phases of the perioperative process but there is no designated place to document or handoff this information. At times, the information is not relayed or delayed, and optimal patient care may be compromised. Caruso et al. (2015) in their prospective cohort study used a structured handoff process for information transfer from the operating room to the postanesthesia care unit (PACU) and found that overall transfer of information increased significantly from a mean score of 49%-83% (p < .001) in a specific defined area of a patient's surgical journey (Caruso et al., 2015). There is no available research that has specifically discussed the impact of a standardized handoff process incorporating medical clearance postoperative recommendations (POR) and orthopaedic-specific context elements on information transfer and provider knowledge of patient comorbidities from preadmission to hospital discharge.

Therefore, the purpose of this QI initiative is to address how medical clearance recommendations can be handed off by providers such as residents and nurse practitioners (NPs) by using the best evidence-based practices during all phases of care. We aimed to improve the transfer of POR provided by the patient's primary care provider and/or specialists from a baseline of 42%-52%, ensure that medical clearance POR were included in the EPIC "handoff tab" with appropriate orders placed within the electronic medical record (EMR), and improve the transfer of orthopaedic context elements such as mobility precautions, wound closure, and postoperative voiding. For context, specifically evaluating the impact of adding wound closure to improve specificity of staple and/or suture removal kits provided at discharge. The Evidenced-Based Practice Improvement model informed that the project was the Plan-Do-Study-Act (PDSA) cycles to appropriately adapt the intervention and ensure sustained improvement. The PDSA cycles allow for action-oriented learning because of their frequent adaptation and allow for shaping of the intervention for success in its local environment (Berman et al., 2018).

Methods

A structured method was used to systematically evaluate the quality and rigor of the studies in the systematic review of the evidence (Critical Appraisal Skills Programme [CASP], 2018; Grade Working Group, 2019; LoBiondo-Wood et al., 2019). Literature review found that, for elective surgical patients, the first phase of care starts at the preoperative assessment with evaluation and medical recommendations given. Handoffs for these patients should have a consistent structure to transfer information and should incorporate medical clearance recommendations when given. The details of the handoff should be tailored to the type of patients cared for such as orthopaedic surgical patients, OBGYN, or Oncology, as certain specifics may be appropriate only for the population served. Best practice integrates a standardized handoff into the electronic health record and would enable healthcare professionals to ask questions when needed. When a change in handoff structure is implemented, it should be evaluated through an appropriate clinical outcome such as information transfer because the information is critical in the care of orthopaedic surgical patients with multiple comorbidities.

Handoffs occur throughout the day with several types of providers and are at times integrated between services. Surgical patients have more handoff touchpoints due to the nature of their pathways that can lead to more communication mishaps if an appropriate handoff structure is not developed (Malfait et al., 2018; Nanchal et al., 2017; Pucher et al., 2015; Randmaa et al., 2016; Robertson et al., 2014). Recommendations include implementation of a structured handoff in the EMR created with input from key stakeholders regarding appropriate content for orthopaedic patients with inclusion of medical clearance recommendations. Changing the handoff process needs to be planned as it is a complex process (Reine et al., 2019).

Standardized Handoff Intervention

To improve the handoff, a standardized handoff intervention (SHI) communicating the POR provided in the medical clearance notes was developed including orthopaedic-specific context determined by the key stakeholders. The specific aim of the SHI was to improve information transfer about POR from the medical clearance notes and orthopaedic-specific context between the orthopaedic residents and NPs from the PACU to the postoperative orthopaedic unit. Goals included ensuring that the POR were included in the EMR "handoff tab" and the appropriate orders were placed within the EMR. In addition, wound closure details were captured in the handoff information to facilitate specificity in the distribution of either the staple and/or suture removal kit at discharge. After creation of the smart phrase, it was a reviewed with a physician informaticist to ensure that all appropriate smart lists could be added within the smart phrase to increase functionality and ease of use in clinical practice.

Evaluation Methods

The improvement initiative outcomes were evaluated against preimplementation baseline data to see whether the intended effect occurred. The preintervention assessment was conducted through chart audits and postintervention consisted of both chart audits and equipment data review (Kowalczyk, 2018). The QI project consists of a total of three PDSA cycles that enabled clinical adaptation of the project based on incorporation into the daily workflow by all providers.

Data Collection and Analysis

Data collected at the education session consisted of the attendance sheet to record how many providers attended each session. The evaluative questionnaire (see Supplemental Digital Content Appendix A, available at: http://links.lww.com/ONJ/A21) was broken down and each response was recorded using a 5-point Likert scale. The data were reviewed and exported to a separate file to calculate descriptive statistics that were used to report the information to project participants. The evaluative questionnaire had one free-text question that was used to assist the subsequent PDSA cycle for additional inclusion parameters for the handoff "smart phrase" (see Supplemental Digital Content Appendix B, available at: http://links.lww.com/ONJ/A21). The data regarding the number of providers who had the new "smart phrase" in were collected by manual audit from the EMR. Each resident was assigned a unique identifier number and their documentation was evaluated to determine whether their smart phrase list contained the new handoff smart phrase, whether they have multiple handoff smart phrases, or whether they had the old smart phrase.

Chart audits were completed to determine the number of times appropriate information was entered in the "handoff tab" using the new smart phrase and the number of times the appropriate information regarding POR was entered in the EMR by the providers (see Supplemental Digital Content Appendix C, available at: http://links.lww.com/ONJ/A21). Each PDSA performed completed a minimum of 30 chart audits. If the information was not captured on the first handoff, the second handoff was evaluated within the chart to see whether the information was captured. Data regarding the staple and suture kits provided at discharge to the patient by the bedside nurse were obtained at the completion of the QI initiative. A comparison of preimplementation distribution of staple and suture kits from the acute units where the project was implemented was done with the postimplementation data and was reported in a comparative whole numbers.

A descriptive qualitative approach was used to summarize the data. Considering research evidence and the feedback about current state handoff processes from key stakeholder within the orthopaedic service line, a "flexible standardization" approach was established so that the "smart phrase" can be modified for other institutions or services in the future (Davis et al., 2017). The tools used for the QI intervention as mentioned previously include education sessions, evaluative questionnaire, checklists, chart audits, feedback, and multiple interviews during PDSA cycles. For reporting of the data, descriptive statistics were used in the form of percentages and bar graphs.

Ethical Considerations

This was a QI study following Squire Guidelines and was exempt from institutional review board approval (Ogrinc et al., 2016).

Data used for the project did not include staff names or specific identifiers to ensure confidentiality.

Results

Sixty-one out of 70 (87%) residents/interns participated in the education session offered via video conference. Twelve out of 13 (92.3%) NPs participated in the NP education session (see Supplemental Digital Content Appendix D, available at: http://links.lww.com/ONJ/A21), which was offered via a combination of video conference and in-person meetings. For PDSA number 1, 30 out 30 chart audits were completed for a full handoff review. Adjustments for PDSA Cycle 2 included a compressed look, the ability to pick multiple dressing-type options, dual plan for home, trochanteric precautions, suture details, and the addition of the perioperative antibiotic to the smart phrase. For PDSA Cycle number 2 and number 3, 60% of handoffs were reviewed providing an in-depth review of provider handoffs. The plan for PDSA Cycle number 3 was primarily a corrective action, which included reminders and notifying staff when items were missed so that they were aware of the follow-up that was needed on the basis of the missed details within the smart phrase.

Smart phrase utilization increased with every PDSA Cycle. For the first handoff, smart phrase utilization after the first cycle was 83% increasing to 86% with the second and 97% with the third PDSA. For the second handoff, smart phrase utilization after the first cycle was 80%, increasing to 86% and then 100%, respectively.

During the first cycle, there were seven out of eight transferred postoperative medical clearance recommendations reaching 88%. The second cycle had four out of five reaching 80%, and the last cycle had five out six reaching 83%. In all three cycles, one postoperative medical clearance recommendation was not handed off and did not have the appropriate orders within the EMR. For the first two cycles, the missed POR were provided by cardiology recommending postoperative telemetry, serial troponins, and electrocardiograms for a high-risk cardiac patient. For PDSA number 3, the missed postoperative medical clearance recommendation was from vascular surgery for a patient with a history of a thromboembolic disease requesting a postoperative evaluation on post operative day 0 or post operative day 1 with a lower extremity venous duplex. The NP and/or provider managing the patient was notified of the missed opportunities found through chart audits for further follow-up and order placement as indicated by the surgical attending.

For specific orthopaedic context, there was 100% information transfer when the smart phrases were used at completion of the cycles for wound closure, mobility precautions, and postoperative voiding. Only in cycle number 2 did wound closure technique report decrease to 96% because it was skipped over in one handoff (see Supplemental Digital Content Appendix E, available at: http://links.lww.com/ONJ/A21). For wound closure equipment results, there was only 1 month of data to review. In June 2020, there were 244 surgeries with 295 suture removal kits and 224 staple removal kits used. When evaluating cost of equipment per surgery, each case spent $3.24.

To evaluate the difference in wound closure equipment distribution, a comparative month (March 2020) was used. In March, there were 226 surgeries. During that time period, 354 suture removal kits and 226 staple removal kits were used. Comparatively, June 2020 had more surgeries (244 vs. 226) with fewer suture removal kits (295 vs. 354) and fewer staple removal kits used (224 vs. 226). A follow-up month, July 2020, was used, which also had more surgeries (231 vs. 226) with fewer distribution of both staple and suture removal kits. When comparing with the cost of wound closure equipment prior to the project, there was a decrease in expense after project implementation resulting in a net savings of 0.69 cents per case. In addition, it was discovered that nurses were opening suture removal kits to use the scissors to remove the primary ace bandage dressing, incurring unintended expenses that impacted overall savings (see Supplemental Digital Content Appendix F, available at: http://links.lww.com/ONJ/A21).

Summary

There are no previous studies that have specifically discussed the impact of a standardized handoff process incorporating medical clearance POR and orthopaedic-specific context on information transfer and provider knowledge of patient comorbidity from preadmission to the inpatient orthopaedic units. By specifically looking at the transfer of information from the medical clearance recommendations and the provider handoffs across multiple transfers, the patient's journey throughout the surgical pathway was closely evaluated for information transfer. In addition, the impact of information transfer regarding wound closure technique at discharge could decrease costs by providing specific supplies at discharge.

Interpretation

Our initial goal was to have 75% attendance for the video conference education session for residents/interns and 100% for the NP session, for which we had 87% (61/70) and 92.3% (12/13), respectively. Total attendance was higher due to the attendance of 20 additional participants who were orthopaedic surgeons.

Prior to project implementation, the expectation was to complete 30 chart audits to establish baseline data that reflected 90 surgeries, which constituted 34% evaluation of all handoffs. When weekly surgical volumes decreased after the Covid-19 pandemic started, the percentage of chart audited for handoff evaluation improved substantially as 100% of the cases were reviewed. Furthermore, the implementation goal to have a minimum of 75% uptake of the new smart phrase for both the first and second handoff was easily reached as we observed more than 80% utilization for all three PDSA cycles in both handoffs. The transfer of postoperative medical clearance recommendations prior to implementation was 46%. The goal was to increase 10%-15% by the completion of the quality initiative. However, we observed 80% or greater in transfers for all three cycles. The new smart phrase is believed to alert the providers in both the first and second handoffs to review medical clearance recommendations and to hand them off immediately.

Using a standardized handoff initiative incorporating postoperative medical clearance recommendations provided by the patient's primary care provider and/or specialists and incorporating orthopaedic-specific context such as wound closure technique, mobility precautions, and postoperative voiding instructions improved information transfer. Transfer of information for medical clearance POR went from 46% to 83% at the conclusion of the three PDSA cycles. All of the orthopaedic-specific context reached 100% at the conclusion. When the smart phrase was not used, information was not as consistently transferred (see Supplemental Digital Content Appendix G, available at: http://links.lww.com/ONJ/A22).

Limitations

This study had several limitations. Conducting a QI initiative during a national pandemic impacted the initiative due to the hospital environment at the time. There were less surgical cases and the patients who decided to proceed with their surgery could have been different with respect to age and general comorbidities because those attributes were associated with a higher likelihood of morbidity and mortality if contracting COVID-19. With regard to data, the inability to monitor for equipment distribution such as staple and suture kits at discharge for a longer period of time limited the ability to understand the economic gain of adding it to the handoff aside to increasing specificity when providing discharge education by the nurse and the provider. This QI project was initiated at an orthopaedic specialty hospital with orthopaedic-specific context that may not be easily translated to a general hospital or different service.

Conclusion

Utilizing QI methods and standardizing the handoff to incorporate medical clearance POR and orthopaedic context improve information transfer. This may also have financial implications such as decreasing the need to provide inappropriate suture and/or staple removal kits, which is projected to have a cost saving of at least $1937.52 annually. Spread of the handoff smart phrase occurred during the implementation phase at one of our other hospital sites but due to their provider workflow, they were able to utilize the smart phrase in a different handoff section. To ensure sustainability, patient handoff was discussed at annual intern/resident workflow meeting so that the incoming class was aware of the expectations. Annually, handoff will be reviewed to understand whether workflow changes or specialty-specific context changes have occurred to update the existing handoff. Additional research should be conducted to further understand how many patients require specific tests, examinations, or instructions for a surgical intervention.

Acknowledgment

The authors offer special thanks to the Orthopedic Nurse Practitioners and residents who assisted with this quality improvement initiative.

References