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Improved patient ‘handover’ process bolsters outcomes

Oct. 18, 2012, 10:18 AM

Patient handovers matter. A lot.

That’s the conclusion from Vanderbilt researchers who reviewed three years of patient data and found that major complications occurring within 24 hours after cardiac surgery were cut in half following the adoption of an improved handover process.

“Patient handover” refers to the transfer of vital information about a patient from one team or one provider to the next. The new study from the Monroe Carell Jr. Children’s Hospital at Vanderbilt examines handovers from the operating room (OR) to the Pediatric Cardiac Intensive Care Unit (PCICU). Patient handover discussions with no fixed, definitive form were jettisoned in favor of more structured and thorough discussions with broader participation from both teams.

Use of OR safety checklists and timeouts have been shown to reduce surgical errors, but they leave patient complication rates unaffected. This study is among the first to examine patient complications and clinical outcomes following handover improvements. The study, led by Hemant Agarwal, MBBS, appears in a recent issue of Critical Care Medicine.

Investigators learned that:

  • Children undergoing cardiopulmonary resuscitation within 24 hours post handover dropped from 5.4 percent to 2.6 percent.
  • Twenty-four hour rates of surgical reexploration (generally triggered by suspected internal bleeding) dropped from 9 percent to 5.5 percent.
  • Patients placed on extracorporeal membrane oxygenation within 24 hours dropped from 2.8 percent to 1.3 percent.
  • Twenty-four hour rates of severe metabolic acidosis dropped from 6.7 percent to 2.6 percent.
  • Fifty percent of patients were able to come off their ventilators within 24 hours, up from the previous rate of 43 percent.

During the period of the study there were no initiatives aimed specifically at lowering these complications for this patient group. The observation period for each patient was limited to 24 hours in an effort to screen out other influences and bring the impact of the changed process into greater relief.

“I think the reason this type of study has been absent from the literature has to do with the difficulty of instituting a structured handover process and sustaining it over the long haul,” Agarwal said.

In July 2009 Agarwal led the PCICU in implementing its new handover process, introducing participation from surgeons and cardiologists, 30-minute advance notice from the OR about the status of each arriving patient and a question period for the benefit of the full receiving team. As before, the attending cardiac anesthesiologist from the OR leads the handover discussion.

Intensive care medicine fellows use a checklist to document which topics are covered in each handover discussion, and Agarwal uses these records to guide improvements.

PCICU team members were surveyed before and after adoption of the structured handover, and in the latter survey they judged handover information to be adequate for 84 percent of the survey items, up from 57 percent in the prior survey. The new process also received high scores for improved depth, consistency and thoroughness.

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