Care transitions, handovers and continuity of peri-operative medical care: recent developments and how to train residents and staff (Østergaard)
Patient handovers are ‘situations where the professional responsibility for some or all aspects of a patient’s diagnosis, treatment or care is transferred (hand over, hand off) from one healthcare professional to another on a temporary or permanent basis’.299,300 Peri-operative anaesthesia care transitions (Fig. 5) involve changes in the level of monitoring or staff attendance, and changes in environment. According to the WHO, care transition is a high-priority patient safety issue because it can, for example, result in delayed treatment and increased morbidity if done improperly.301,302 Several countries have implemented WHO recommendations and incorporated them in national care transitions strategies. They also are part of the Helsinki Declaration on Patient Safety in Anaesthesiology.303
Handover used to be seen as a simple information and communication issue. Numerous detailed communication tools have been studied and developed, but many remained difficult to implement because they went into too much detail.304 User-friendlier tools have been developed, such as the SBAR tool (situation, background, assessment and recommendation) used by nurses when calling a doctor.305 But even though intended to support written and verbal communication, they failed to sufficiently mitigate the risk of misinterpretation and fixation errors. Actually, even an ‘ideal’ handover tool might not be able to improve handover quality and prevent incidents because they are context and culture dependent.306 Care transitions are complex activities that involve multiple professionals, each of which has their own way of working (culture). Co-ordination of individual processes and activities therefore is important.307
The current chapter reviews the factors that affect peri-operative handover; highlights the anaesthesiologists’ role in patients’ peri-operative transition and shifts; provides an example of a context-specific design process to analyse handover processes and implement changes; describes how to train anaesthesiologists; and provides recommendations for future studies.
Factors of importance for a safe handover
Poor handover has been related to problems with communication, information, organisation, infrastructure, professionalism, responsibility, team awareness and culture,299 for which the following solutions have been offered: information transfer, shared understanding, working atmosphere and teamwork.299,308,309 These are reviewed in more detail.
A handover protocol in-and-by-itself does not solve the challenges of a handover, but it could be one element in a bundle of measures to improve patient safety.310,311 Poor design, inadequate training, poor integration and cultural barriers may cause ‘checklist fatigue’, which may be avoided by tailoring checklists to the specific needs of the users and the environment in which they will be used.312 Even though information transfer may have been deemed sufficient during the initial transfer, it may later turn out to have been incomplete if the missing information only becomes clinically relevant later. This limits the significance of studies that only evaluate the quality of the handover immediately after the handover process.309,313 Because electronic patient records already provide up to date patient information, only that information relevant to the patients’ actual care has to be verbalised during handover. Still, it is important to understand handovers are a combination of written and verbal communication.
A shared perception of the handover situation (shared mental model) by the different health professionals that are involved is important for patient safety.314 Nurses have a specific interest in vital parameters, laboratory data and treatment, whereas doctors focus on patients’ disease trajectories and try to anticipate problems.314,315
These differences between different professions’ interests and behaviour need to be taken into account during handover. In addition, the receiving team has more information-seeking behaviours, for example, requesting explanations and asking for predictions or anticipated problems, especially if the assessments were not volunteered by the transferring team.316 The time of the handover is the time to pause, to ask questions, to detect errors, and to confirm critical information. A handover has an educational function for the team members – a possibility to share information about concerns and possible patient trajectories. Studies in other domains have addressed the importance of such a ‘question and answer period’ to detect errors in assessments and plans.317
Working atmosphere and teamwork
Care transition involves health professionals from different professions and specialties, which brings individual knowledge, skills and attitude into the team. The organisational culture will be a mix of the individual culture of these professions and specialties. A mature patient safety culture entails participation of all parties in decision-making and giving all involved a chance to speak up. Such culture has been associated with a wide range of positive patient outcomes such as reduced mortality, falls and hospital-acquired infections, as well as improved patient satisfaction.318
The question ‘what makes a good handover’ overlaps with the question ‘what makes teamwork effective’.302 Communication, collaboration and leadership are important aspects of teamwork. The team members must be able to adapt to changes in the situation – from a routine noncritical to a critical situation. A shared understanding of team tasks and roles as well as mutual respect and trust is essential for good teamwork.307 Task-related, situational and organisational factors can influence safe performance of teams in high-risk domains such as health care.307,308 Resources, like space and staffing level and competence, as well as patient volume and flow can differ, and time pressure, interruptions and distractions have a significant influence on task management within teams.
The anaesthesiologists’ role in peri-operative patient handovers
Anaesthesiologists are part of different care transitions during the patient’s journey (Fig. 5): transitions take place in various institutions involving different procedures, context (acute vs. elective) and organisation of work (number of team members, direct or phone contact).
Handover in the emergency department
The risk of miscommunication when transferring care for the acutely ill patient from the ambulance crew to the receiving emergency department (ED) team is high. Both teams do not necessarily have a shared mental model or understanding of different tasks. Cultural and organisational aspects might contribute to gaps. Ambulance crew and the ED nurses work in different contexts and might have different perspectives on how and what information needs to be transferred. Some information might not be useful for the immediate treatment but may become valuable for other professions later.319 The anaesthesiologist can be part of the emergency medical services (EMS) that bring the patient to the ED or may be taking over the patient as a member of the trauma and medical emergency team in the ED. The anaesthesiologist will often be involved in the immediate care of the patient, while simultaneously providing or receiving important information. This might result in a conflict and it is recommended that essential information is delivered immediately, and supplementary information later, after the initial treatment.320 Distraction and lack of training in handover and non-technical skills (NTS) can contribute to poor handovers. Organisational factors may also affect the quality of handover in the emergency care pathway.321 The health professionals’ experience, competing organisational demands and priorities such as patient flows and time-related performance targets might also affect the quality of the handover. For example, the EMS anaesthesiologist might have to trade off delaying patient departure from the ED against providing patient important information to another health professional.
Handover from the surgical ward or ICU to the operation room
In the operating room, the WHO surgical checklist is widely used. Handover from the ward to the operating room is less structured.19 Challenges have been identified in several of the steps prior to entering the operating room.322 Most communication failures (62%) occur in the pre-operative phase.323 Three types of failures are described: source, transmission and receiver-failures, all of which had an impact on patients, healthcare team or organisation.324 A generic checklist developed to facilitate this care transition resulted in only minor improvements 12 months after its introduction, maybe because it was too comprehensive.325 Handover from the ICU to the operating room remains poorly studied.
Handover during surgery
It is safe to have an anaesthesiologist give a short break to a colleague during surgery.326 In some cases, the relieving anaesthesiologist detected an error, resulting in better care. In contrast, complete handover of anaesthesia care during major surgery was associated with a higher risk for adverse postoperative outcomes compared with no handover.327
From the operating room to the postoperative care unit (PACU)
Postoperative handover in the PACU is a complex and dynamic process because it involves multitasking: simultaneously providing information to the PACU nurse, moving equipment and taking care of the patient. It also represents a ‘step down’ from an anaesthetist taking care for only one patient to a ward with a nurse taking care of several patients.328 The pressure to maintain short turnover times in the operating room may be one of the main reasons for this difference: the anaesthesiologist is making a trade-off between taking the time to handover a patient and going back to the operating room to prepare the next patient. A systematic review recommended analysing the challenges in the local setting and customising solutions to fit the specific context. NTS of all staff members play a significant role.322
From the operating room to the ICU
During operating room to ICU handovers, the patient may be critically ill or may have just undergone major surgery and may be receiving circulatory or ventilatory support while being extensively monitored.313 The risk of technical problems is increased. The handover team may consist of different professions and specialities. A structured handover has been shown to decrease communication and task errors, specifically information omission.313,329,330
From the PACU or the ICU to the ward
When the patient is transferred from the PACU to the ward, the sender (anaesthesiologist) and receiver (ward nurse, ward physician) my not meet in person – it may be done by phone before the patient is transferred. Expectations about the content of this communication have been frequently reported to be inconsistent. The sender primarily provides information about vital signs, eager to demonstrate that the patient is in a stable condition. The receiving nurse is more interested in pain control and whether the patient is allowed to get out of bed.331 The most vital information should be presented first, and the remaining information should be brief and relevant.
The transfer of a patient from a highly staffed, technology-intensive ICU to a general ward that does not have the same observational level poses several patient risks. Whether a handover tool improves patient safety remains poorly documented because of study heterogeneity.332 Providing the patient and the relatives with a written summary before transfer might improve safety.332 A liaison nurse may improve communication between and participation of all members of the care team of the two departments. An electronic ‘attend-to’ follow-up list rather than a ‘check’ list has been proposed to mitigate the risk patient transfer from the ICU to the ward.333
A context-specific handover design process
Healthcare professionals may not understand their individual roles and responsibilities and often blame others for problems experienced during handover (Table 16).331 This suggests a shared understanding of the role and the needs of each professional is critical. The sender needs to understand what information the receiver needs before taking responsibility for the patient, and the receiver needs to understand the context in which the sender works. It is important that one views oneself as part of a larger team while working in different settings.334
How to train residents and staff
There is no consensus among anaesthesia residents on how to conduct a handover. They found the impact of lectures and written material to be limited and preferred directions by their supervisors.335 They felt most comfortable doing a handover in a one-to-one situation (e.g. to a nurse in the PACU) rather than to a group of health professionals.
The Accreditation Council for Graduate Medical Education requires that residents be competent in handover communication,336 and guidelines have been published.337 To evaluate and entrust residents to perform handover, in-training assessment of a handover situation might be useful.338 Such training reduced medical errors by paediatric residents from 33.8 to 18.3%.339 A tailored e-learning programme to improve handover is available, but the programme did not improve the adherence to a guideline.340 Simulation-based training (locally in the department or in simulation centres) is increasingly used to train both the sender and the receiver.
Team training of staff
Training of staff is needed to get a shared understanding of the handover situation, of the different needs of the sender and receiver, and of the challenges in care transitions, where a team member often is distracted or interrupted. Training has to address the vulnerability of the handover situation and involve learning objectives related to a specific handover.341 The debriefing after the simulation-based session is particularly useful.
The essence of the existing literature and the way forward
Because most research on handovers has been limited to one speciality,342 there is a need for a broader view: we need to distil common problems and separate them from speciality specific ones. There is a need for a patient-centred approach.342 We have to listen to valuable information from patients and relatives and involve them in our research.
An analytical framework for investigating the contextual, organisational and sociocultural aspects of care transition is needed. At the conceptual level, many studies have focused on protocols and guidelines, both of which are characteristic of what is known as Safety-I thinking: if we all follow the rules, the system will be safe-behaviour also referred as ‘work-as-imagined’.181 But peri-operative care is characterised by changing demands and finite resources, which implies that healthcare professionals have to prioritise tasks,343 and make many trade-offs that involve risk assessments based on their experience and their understanding of the situation. In other words, ‘work-as-done’ is often different from ‘work-as-imagined’.181 It is, therefore, important to understand how everyday work functions and why there is variability. Changes in procedures should not be based on how we ‘imagine’ the work is or should be done, but on understanding of ‘work-as-done’.
To improve our understanding of the different handover situations, we need to look at the individual, team and organisational level. Study methods have to evolve: besides handover observations and interviews, video recordings, in situ simulations in the clinical setting, and scripted scenarios in a simulation centre might be useful to better analyse the causes of poor and good handovers. Finally, we need to study how changes can be successfully implemented in an organisation.
While a structured peri-operative handover is useful and can improve communication, its content alone does not suffice to ensure a safe handover. A proper understanding of context and organisational factors is equally important. Care transitions are complex activities and it is crucial to understand how everyday work functions (‘work-as-done’ vs. ‘work-as-imagined’). Organisational factors may force healthcare professionals to make trade-offs when handing over a patient. For safe peri-operative handover, the individual and the team must be able to adjust when work conditions change. We must recognise that team members have different roles and have different information needs and goals, and therefore will have different perspectives during a handover situation.
For a safe handover, the transfer of accountability and responsibility, teamwork is essential. Therefore, any training has to involve the whole healthcare team with the goal of obtaining a shared mental model of peri-operative handover. This includes gaining an understanding of the social and cultural aspects of teamwork. Simulation-based training followed by debriefings can be particularly useful. But one should not forget that every clinical handover situation is a training opportunity in and of itself. Future research should be based on theoretical frameworks from the social and cognitive sciences, should focus on the patient journey and involve the patient in the team.
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