Improving Communication During Patient Handoff: Anesthesia to the Intensive Care Unit

Abstract

Problem & Purpose: The omission of essential patient information during handoff report between health care providers is a cause of sentinel events, leading to medication errors and misdiagnoses. An acute care community hospital in Maryland lacked a systematic exchange of patient information from the operating room to the Intensive Care Unit, resulting in omission of patient information in 100% of handoffs. The inadequate communication jeopardized patient safety in the form of medication errors and delays in care. The purpose of this Doctor of Nursing Practice quality improvement project was to implement and evaluate the compliance of an evidence-based anesthesia to Intensive Care Unit handoff protocol, as well as to decrease information omissions during patient transfer. Methods: A site-specific assessment was performed to establish root causes and develop a feasible handoff protocol. A team of leadership and change champions were mobilized to identify barriers and facilitators before and during project implementation. Anesthesia and intensive care staff were educated on the protocol. Anesthesia providers gave bedside report using an evidence-based handoff tool. During handoff, a total of 25 items were communicated to the Intensive Care nurse. Surveys assessing the items communicated during handoff were collected and analyzed weekly for trends in both completion and number of information omissions. Results: Weeks one through four showed a 0% compliance in use of the handoff protocol, with an incline to a compliance rate of 90% in weeks four through 14. The average number of essential patient items communicated when the handoff tool was utilized was 98.5%. Conclusion: Preliminary findings suggest that incorporating the use of a handoff protocol is feasible at a small community hospital. Improving the exchange of essential patient information, such as past medical history, intraoperative course, and future plan of care, will encourage clarity and patient safety during the handoff process.