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Periop nurses strive to make handoffs safer, more efficient

Monday July 22, 2013
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Well-executed handoffs are especially critical before, during and after surgery, when nurses and healthcare providers make patient care decisions quickly and move patients to different care units throughout the hospital.

When handoffs are completed safely, efficiently and accurately, patients benefit from admission to postop care and members of the care team have the most accurate, current patient information every step of the way.

Input from nurses has been critical in shaping and refining the perioperative handoff over the years, said Linda Groah, RN, MSN, CNOR, NEA-BC, FAAN, executive director and CEO of the Association of periOperative Registered Nurses.

"The focus on the culture of safety has put a lot of emphasis on the handoff," Groah said.

She pointed to a recent study by Boston researchers on whether a surgical crisis checklist helped OR teams complete lifesaving steps when a crisis such as cardiac arrest or massive hemorrhage occurred.

A total of 17 OR teams took part in 106 simulated surgical crises. Researchers found that when checklists were available, adherence by the surgical team to lifesaving steps was much greater. According to the study, which was published in January in the New England Journal of Medicine, 6% of steps were missed when checklists were available compared with 23% when they were unavailable.

"I think youíll start to hear more about this [study]," Groah said.

Handoffs after surgery are particularly important.

The OR nurse essentially hands over the patient to the PACU nurse and frequently does not have another interaction with that patient.

Complete information about the surgery is essential. The PACU nurse should be informed about the surgical procedure as well as patientís vital signs, medications and fluids administered, estimated blood loss, adverse reactions to anesthesia, catheters, drains and incisions, just to name a few.

Ineffective, incomplete handoffs can result in everything from delays in care to patient care and medication errors to wrong-site surgery.

Tool kit basics

Groah noted that The Joint Commission determined that poor communication is the top reason for medical errors. Handoffs are a big part of that communication, so AORN developed a regularly-updated handoff tool kit in 2007 to help standardize best practices.

The tool kit was derived, according to the AORN website, from the U.S. Department of Defenseís Team Strategies and Tools to Enhance Performance and Patient Safety program, known as TeamSTEPPS. With permission from the Department of Defense, AORN adjusted the model to focus specifically on perioperative settings.

The tool kit offers sample handoff tools and recommendations for nurses during handoffs from preop to the OR, within the OR and from the OR team to the PACU.

Information overload

Nurses know it is not always easy to transfer information, given the rapid patient turnover in the periop setting.

"Thereís a push to be efficient timewise, as well as a push to be efficient with the actual clinical care," said Lee Clark, RN, BSN, MBA, director of perioperative services at Long Islandís Nassau University Medical Center, East Meadow, N.Y.

Caregivers involved in handoffs at NUMC use a combination of written and verbal checklists. Among the most important information conveyed between nurses and healthcare professionals is documenting any allergies or previous adverse reactions to anesthesia, and verifying that patients have remained NPO for the proper amount of time and that they donít have any skin breakdown or rashes, the flu or communicable conditions that put everyone in the OR at increased risk during surgery. Nurses also convey such information as whether a patient has consented to surgery or, for example, whether a patient with a cardiac condition has received medical clearance from cardiology.

Clear communication is essential, Clark said.

"If you say a patient is 'a little unstableí is that because her blood pressure is fluctuating?" Clark said. "Is she unstable because [of mental health issues]? It can have a lot of interpretations."

Handoffs can cover more than just a wide range of important patient care issues, said Charlene Yousey, RN, director of the respiratory care unit at Vassar Brothers Medical Center, Poughkeepsie, N.Y.

As nurses prepare patients for surgery, little things can be a big deal, she said. Another important element in the handoff is making sure the nurse who admits the patient knows the location of personal effects, such as hearing aids and dentures.

Team training

At New York-Presbyterian Hospital in Manhattan, all perioperative care providers use the Situation, Background, Assessment, Recommendation, or SBAR, system for handoffs.

Kara Gasiorowski, RN, MSN, CNOR, ONC, perioperative patient safety specialist for NYP, said that thanks to a year-old training program, all members of the care team use the SBAR guide for all verbal and written handoffs.

"Our goal was to train 80% of general surgery, and we achieved that goal," Gasiorowski said. As staff is added, members are trained on handoffs in small groups.

One of the most challenging aspects can be conducting a handoff over the phone, Gasiorowski said. It may be difficult to hear, and because you canít read facial expressions, it is harder to tell whether the receiver is understanding what is being communicated.

Handoffs in disaster situations

The best handoffs, of course, happen when information about the patient is comprehensive. When a disaster with mass casualties occurs, handoffs are every bit as important, but the information available may be very different.

"In a disaster situation, you could potentially be taking someone to the OR where you have little, if any, information on them other than their obvious injuries," said Kathe M. Conlon, RN, BSN, CEM, MSHS, burn emergency preparedness education coordinator at Barnabas Health, West Orange, N.J.

In those instances, keen observation will be important information when one nurse is handing off to another, and even the smallest details become important.

In a mass disaster, such as a plane crash or the Boston Marathon bombings, many patients might have similar injuries. Identifying patients who are unable to communicate, and handing off patient identification information such as piercings, hair color or tattoos, is crucial in keeping track as patients are triaged and moved from holding areas to the periop settings or to treatment areas.

"We had a family one time where the three children were close in age and the father identified them by the barrettes in their hair," Conlon said. •

Marcia Frellick is a freelance writer.

READ RESEARCH about handoffs at NCBI.nlm.nih.gov/pubmed/23323901.

REVIEW AORNíS TOOLKIT online at AORN.org/Secondary.aspx?id=20849.

To comment, email editorNY@nurse.com.
What makes a good handoff?

Perioperative nurses say the following factors
increase the odds of a successful handoff:

Find a quiet location. Ideally, this would happen in a calm area with few distractions and interruptions.

Confirm that information is understood. People receiving the information should repeat what they understand. Handoffs should include time for questions.

Offer the most up-to-date information. Making sure a patient has an empty stomach, no rashes or breaks in skin integrity, no recent illnesses and no previous adverse reactions to anesthesia just before surgery, for instance, is important information for the OR nurse to confirm.

State the most basic information. Repeating name of patient, surgery or procedure being performed and which body part is involved are a final checkpoint to avoid disasters such as wrong-site surgery.

Identify yourself and your title for over-the-phone handoffs. You canít assume people will immediately know your role in a particular patientís care, especially in a large medical center.

Filter information. Too many details may mean more important information gets lost.
Avoid jargon or acronyms. The receiver may not have the same understanding of these short-cut words as the speaker does.

Source: Nurse interviews