Background: Omission of patient information in perioperative communication is closely linked to adverse events. Use of checklists to standardize the handoff in the post anesthesia care unit (PACU) has been shown to effectively reduce medical errors. Objective: Our study investigates the use of a checklist to improve quantity of data transfer during handoffs in the PACU. Design: A cross-sectional observational study. Setting: PACU at Memorial Sloan Kettering Cancer Center (MSKCC); June 13, 2016 through July 15, 2016. Patients, other participants: We observed the handoff reports between the nurses, PACU midlevel providers, anesthesia staff, and surgical staff. Intervention: A physical checklist was provided to all anesthesia staff and recommended to adhere to the list at all observed PACU handoffs. Main outcome measure: Quantity of reported handoff items during 60 pre- and 60 post-implementation of a checklist. Results: Composite value from both surgical and anesthesia reports showed an increase in the mean report of 8.7 items from pre-implementation period to 10.9 post-implementation. Given that surgical staff reported the mean of 5.9 items pre-implementation and 5.5 items post-implementation without intervention, improvements in anesthesia staff report with intervention improved the overall handoff data transfer. Conclusions: Using a physical 12-item checklist for PACU handoff increased overall data transfer.
Miscommunication is a major patient safety concern. In 2016, The Joint Commission reported communication error as the number one cause of all anesthesia related sentinel events for the period 2004 to 2015 [
From review of surgical malpractice claims, the highest percentage of perioperative mistakes, including 43% of all communication failures, occurs postoperatively as a result of poor handoffs [
Inadequate communication in PACU has been shown to increase morbidity and mortality [
To avoid adverse events caused by miscommunication, The Joint Commission mandated “a standardized approach to handoffs” as a patient safety goal in 2006 [
Overall, a checklist accomplishes two goals for both intraoperative and postoperative care providers. First, it provides a guideline that defines a standard for a handoff. Second, a physical checklist is used as a reminder of items to prevent omission of information [
The goal is to establish measures to decrease perioperative miscommunication and improve patient safety through standardized PACU handoff protocol. We hypothesize that a physical checklist will increase data transfer and efficiency at our PACU, and prevent omission of pertinent patient information in handoff.
IRB exemption was approved by MSKCC under the criteria of observation of public behavior and collection of unidentifiable information of clinician interactions. IRB exemption was approved on May 16, 2016.
According to a systemic review of 31 studies on PACU handoff, a handoff should include at minimum: patient information, anesthesia information, surgical information, current status, and care plan [
Every item was deemed equally important, and given a score of 1. Although surgical and anesthesia staff received separate grades, the primary endpoint was the total number of checklist items addressed by either department during the PACU handoff. This value ranged from the minimum of 0 to the maximum of 12. For the composite score, if an item is addressed by either a surgical or anes-
thesia staff, the item is considered to be addressed, and a score of 1 is allocated to the item. For department based scores, the surgical and anesthesia staff reports received separate score of 1 per item accordingly. The start and end time of the handoff was recorded for assessing the duration of handoff rounded to a whole minute. Lastly, every handoff was assigned an unidentifiable number to match the data between two observers.
Total duration of the study included 5 weeks of observation in the main PACU. The first week preceded the study to make adjustments to the checklist as a pilot period. All handovers were observed in real time by two observers. This pilot study yielded 100% consensus on “item qualified” between attending anesthesiologists and the observers. The observers were physically present at all observed handoffs between June 13, 2016 and July 15, 2016 from 10AM to 5PM. Immediately after each handoff, two observers resolved any differences in assessment and arrived at 100% consensus.
Second and third weeks served as the control period. Observers gathered data before the checklist was implemented to gauge the current quality of PACU handoff. Both anesthesia and surgical staff being observed were not informed of the reason for the presence of observers in PACU to avoid isolated improvements in handoff behavior.
After pre-implementation period and prior to the official implementation of the checklist, all anesthesia staff?including attending anesthesiologist, Certified Registered Nurse Anesthetists (CRNAs), resident physicians, and CRNA students? were made aware of the study. They were provided an electronic and physical copy of the checklist. An A4-sized laminated checklist was available by every patient bed. Additionally, ID badge-sized checklists were distributed to every provider (
A traditional randomized study would randomize each handoff 1:1 to the group with or without a checklist. However, this approach would require some staff to unlearn the checklist hints after being exposed to it. Because of these logistical and feasibility issues, our study is based on convenience sampling in that the first two weeks of the study was pre-implementation of the checklist, while the second two weeks was post-implementation. This approach assumes that the case mix (patient and surgical characteristics) is similar between the two phases of the study, which is reasonable in this high volume cancer center. Power calculation was performed prior to the study to determine the minimal detectable difference (MDD) necessary to achieve 80% and 90% power for a two-sided t-test, given 50 patients in each arm and type I error rate of 0.05. The MDD refers to the smallest treatment effect that can be identified assuming a known sample size. We assume mean of 5 items completed in the pre-implementation phase, with a conservative standard deviation (SD) of 5. The MDD are 2.85 and 3.25 for 80% and 90% power. This translates to an assumed mean of 7.85 and 8.25 checklist items completed in the post-implementation phase. If instead SD is 2, the MDD changes to 1.14 and 1.30 for 80% and 90% power.
We examined each item individually to identify the proportion of handoffs addressed for the specific item between the two groups using Fisher’s exact test. The secondary outcome of duration of PACU handoff is compared between the two groups using Wilcoxon rank sum test. As exploratory analyses, we compare the total number of items addressed in the post-implementation phase by consistency status to assess whether consistency impacts the quality of handoff. All analyses were repeated with the component scores which included the items addressed by the anesthesia provider only. All statistical tests were two-sided at alpha level of 0.05, performed using Stata 13 (Stata Corp, College Station, TX).
We observed a total of 120 PACU handoffs. 60 handoffs were each observed pre- implementation and post-implementation of the checklist. Composite values analyzed items as addressed by either surgical or anesthesia staff. Department based values analyzed items addressed by surgical and anesthesia staff separately. Pre-implementation of a checklist, the composite value showed a mean of 8.7 (SD = 1.5) items reported out of a total of 12 items on the checklist, and post- implementation the median report increased to 10.9 items (
From the composite values, most improvements were seen with the following items: Allergies, Anesthesia Technique, and Airway (
Composite Value | Anesthesia Reports Only | Surgery Reports Only | |||||||
---|---|---|---|---|---|---|---|---|---|
Preb | Post | P Value | Pre | Post | P Value | Pre | Post | P Value | |
Mean (SD) | 8.7 (1.5) | 10.9 (1.1) | <0.0001 | 4.8 (1.6) | 8.9 (2.0) | <0.0001 | 5.9 (1.6) | 5.5 (1.7) | 0.2 |
25th, 75th percentiles | 8.0, 10.0 | 10.0, 12.0 | 4.0, 6.0 | 7.5, 10.0 | 5.0, 7.0 | 4.0, 7.0 | |||
Median | 9.0 | 11.0 | <0.0001 | 5.0 | 9.0 | <0.0001 | 6.0 | 6.0 | 0.4 |
<12 items | 59 (98%) | 39 (65%) | <0.0001 | 60 (100%) | 51 (85%) | 0.003 | 60 (100%) | 60 (100%) | NA |
12 items | 1 (1.7%) | 21 (35%) | 0 (0%) | 9 (15%) | |||||
<11 items | 53 (88%) | 20 (33%) | <0.0001 | 60 (100%) | 47 (78%) | 0.0001 | 60 (100%) | 60 (100%) | NA |
11 items or < | 7 (12%) | 40 (67%) | 0 (0%) | 13 (22%) | |||||
<10 items | 43 (72%) | 6 (10%) | <0.0001 | 59 (98%) | 38 (63%) | <0.0001 | 60 (100%) | 60 (100%) | NA |
10 items or < | 17 (28%) | 54 (90%) | 1 (1.7%) | 22 (37%) |
The reported items of composite value increased from a mean of 8.7 items to 10.9 items post-implementation of the checklist. Minimum number of reported items increased in the composite value and anesthesia reports post-implementation of the checklist. Pre: pre-implementation; Post: post-implementation. aN = 12 items; bN = 60 handoffs in every pre and post categories.
Composite Value | Anesthesia Reports Only | Surgery Reports Only | |||||||
---|---|---|---|---|---|---|---|---|---|
Items | Pre | Post | P Value | Pre | Post | P Value | Pre | Post | P Value |
1. Patient Name | 33 (55%) | 53 (88%) | <0.0001 | 14 (23%) | 51 (85%) | <0.0001 | 29 (48%) | 23 (38%) | 0.4 |
2. Underlying diagnosis for the procedure | 53 (88%) | 56 (93%) | 0.5 | 14 (23%) | 35 (58%) | 0.0002 | 51 (85%) | 47 (78%) | 0.5 |
3. Significant past medical/surgical history | 51 (85%) | 59 (98%) | 0.017 | 41 (68%) | 55 (92%) | 0.002 | 38 (63%) | 34 (57%) | 0.6 |
4. Allergies | 38 (63%) | 56 (93%) | 0.0001 | 38 (63%) | 56 (93%) | 0.0001 | 2 (3.3%) | 6 (10%) | 0.3 |
5. Procedure done | 60 (100%) | 59 (98%) | 1 | 11 (18%) | 42 (70%) | <0.0001 | 60 (100%) | 57 (95%) | 0.2 |
6. Anesthesia technique | 35 (58%) | 56 (93%) | <0.0001 | 34 (57%) | 56 (93%) | <0.0001 | 8 (13%) | 2 (3.3%) | 0.095 |
7. Airway | 34 (57%) | 56 (93%) | <0.0001 | 33 (55%) | 56 (93%) | <0.0001 | 1 (1.7%) | 0 (0%) | 1 |
8. Intraoperative uneventful or events | 44 (73%) | 54 (90%) | 0.032 | 30 (50%) | 49 (82%) | 0.0005 | 31 (52%) | 34 (57%) | 0.7 |
9. Fluids/EBL | 59 (98%) | 60 (100%) | 1 | 59 (98%) | 60 (100%) | 1 | 22 (37%) | 20 (33%) | 0.8 |
10. Stability in next 30 mins | 12 (20%) | 41 (68%) | <0.0001 | 5 (8.3%) | 36 (60%) | <0.0001 | 9 (15%) | 6 (10%) | 0.6 |
11. PACU plans | 54 (90%) | 57 (95%) | 0.5 | 10 (17%) | 17 (28%) | 0.2 | 53 (88%) | 56 (93%) | 0.5 |
12. Disposition-Expected duration in PACU | 48 (80%) | 46 (77%) | 0.8 | 1 (1.7%) | 18 (30%) | <0.0001 | 48 (80%) | 44 (73%) | 0.5 |
Most improved reported items in composite value were items related to anesthesia, such as: patient name, allergies, anesthesia technique, and airway. Pre: pre-implementation; Post: post-implementation.
tation composite values, Allergies, Anesthesia Technique, and Airway were reported during 63% (38, N = 60), 58% (35, N = 60), and 57% (34, N = 60) of the handoffs respectively. Post-implementation of a checklist, reports about Allergies, Anesthesia Technique, and Airway all increased to 93% (56, N = 60, p < 0.0001). In contrast, the least improvements in composite value were noted with Patient Name and Stability in 30 Minutes. Pre-implementation of a checklist, Patient Name and Stability in 30 Minutes were mentioned 55% (33, N = 60) and 20% (12, N = 60) of the handoffs, respectively. Post-implementation of a checklist, Patient Name and Stability in 30 Minutes increased to 88% (53, N = 60, p < 0.0001) and 68% (41, N = 60, p < 0.0001) respectively (
Duration of each handoff is the total time of both surgical and anesthesia staff reports rounded to a minute. Post-implementation, the median duration of handoff, is increased by one minute (
Our results demonstrate that, in the setting studied, the use of a checklist improved the overall quantity of data transfer during PACU handoff. A checklist was introduced and implemented for two weeks. During the post-implementa- tion period, more items were reported in all intervals of “handoff duration” in comparison to pre-implementation period. Using a checklist to prevent omission of patient information during handoff is important because miscommunication from multiple care transfer has been shown to increase patient harm [
N | Mean | SD | Median | Min | Max | |
---|---|---|---|---|---|---|
Pre | 60 | 2.9 | 1.3 | 3 | 1 | 7 |
Post | 60 | 3.9 | 1.8 | 4 | 1 | 9 |
Overall duration of a handoff increased during the post-implementation period of the checklist. Pre: pre-implementation; Post: post-implementation; SD: standard deviation; Min: minimum; Max: maximum. aDuration included both surgical and anesthesia reports.
Duration | Pre | Post | ||||
---|---|---|---|---|---|---|
Median | 25th, 75th percentile | Percentage | Median | 25th, 75th percentile | Percentage | |
1 min | 6.5 | 6.0, 9.0 | (N = 8; 73%) | 11.0 | 10.0, 12.0 | (N = 3; 27%) |
2 min | 8.5 | 7.5, 9.0 | (N = 16; 62%) | 12.0 | 10.0, 12.0 | (N = 10; 38%) |
3 min | 9.0 | 8.0, 10.0 | (N = 21; 58%) | 11.0 | 10.0, 11.0 | (N = 15; 42%) |
4 min | 9.5 | 9.0, 10.0 | (N = 8; 36%) | 11.0 | 11.0, 12.0 | (N = 14; 64%) |
5 min | 8.0 | 8.0, 9.0 | (N = 5; 45%) | 11.0 | 10.0, 12.0 | (N = 6; 55%) |
6 min | 10.0 | 10.0, 10.0 | (N = 1; 13%) | 11.0 | 10.0, 12.0 | (N = 7; 88%) |
7 min | 11.0 | 11.0, 11.0 | (N = 1; 25%) | 11.0 | 10.0, 11.0 | (N = 3; 75%) |
8 min | - | - | ||||
9 min | - | 11.5 | 11.0, 12.0 | (N = 2; 100%) |
Improvements in handoff during the post-implementation period were independent of the duration. Pre: pre-implementation; Post: post-implementation. aDuration included both surgical and anesthesia reports; bN = 12.
a decrease in medical errors [
There are two important reasons for analyzing the data as composite values and department based values. First, PACU handoff is provided by both the surgical and anesthesia team at our institution. The median number of items reported by surgical staff stayed the same at a median of 6 items out of the total 12 during post-implementation period. This data indicates that the increase in overall improvement in handoff during post-implementation can be attributed to improvements in anesthesia reports without unintended observational influence on the quality of surgical staff reports. Quality of anesthesia reports as a standalone report is also important because collaborative report may not be a standard of practice at all institutions. In many institutions, only anesthesia gives report during PACU handoff. As an ideal standard, anesthesia staff should be able to adequately report surgical information in case anesthesia staff is the only informant of intraoperative events.
Second, comparing composite and department based values helped us to identify items pertinent to either surgical or anesthesia staff during handoffs. Items related to surgical procedure improved the least in the anesthesia staff reports (i.e. PACU plans, Disposition-Expected Duration in PACU, Underlying diagnosis, and Procedure done) (
Contradictory to our hypothesis that a checklist would reduce the duration of a handoff, we observed an overall increase in median time spent during a handoff. Previous studies have shown conflicting reports on the effect of handoff duration after implementing a checklist [
The lack of training in using the checklist led to providers stumbling or pausing during the report. Majority of the informal feedback from the anesthesia staff were disturbances to their original “flow” with a different order of items and some unfamiliar items on the checklist. Despite the foreseen improvements in handoff with a physical checklist [
improve incorporating a new checklist to practice [
Hawthorne effect is the influence of the presence of an observer on observed behavior. During pre-implementation phase, anesthesia staff was given limited details on what we were observing. We cannot overlook the influence of the presence of the two observers during all observed handoffs. It is likely that data transfer improved for our control group simply because of Hawthorne effect. For instance, we can assume that the observed handoffs were more comprehensive than the baseline handoffs before our study. It follows then, that the actual improvement in handoff is indeed better than we reported. We expect to find more pronounced improvement if our results were subject to the Hawthorne effect.
Although prior studies have correlated adverse events with poor handoff [
In conclusion, implementation of a physical checklist for PACU handoff increased overall data transfer and prevented omission of patient information. Report duration did not have an impact on overall data transfer. For future directions, we recommend incorporating staff feedback into Plan-Do-Study-Act cycles for an improved checklist to ensure compliance and familiarize the staff with the use of a checklist through multimodal training modules.
1) The authors would like to thank the anesthesia staff at Memorial Sloan Kettering Cancer Center for complying with the intervention during the study period.
2) Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R25CA020449. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
3) This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA00874.
4) Authors do not have conflicts of interest.
5) Preliminary data of this study was presented at the 14th Annual American Medical Association Research Symposium on November 11, 2016.
Park, L.S., Yang, G., Tan, K.S., Wong, C.H., Oskar, S., Borchardt, R.A. and Tollinche, L.E. (2017) Does Checklist Implementation Improve Quantity of Data Transfer: An Observation in Postanesthesia Care Unit (PACU). Open Journal of Anesthesiology, 7, 69-82. https://doi.org/10.4236/ojanes.2017.74007
1) PACU: Post Anesthesia Care Unit
2) MSKCC: Memorial Sloan Kettering Cancer Center
3) EHR: Electronic Health Record
4) AIMS: Anesthetic Incident Monitoring Study
5) IRB: Institutional Review Board
6) CRNA: Certified Registered Nurse Anesthetist
7) MDD: Minimal Detectable Difference
8) SD: Standard Deviation