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Multitasking During Patient Handover in the Recovery Room

van Rensen, Elizabeth L. J., MPH, PhD*; Groen, Emily S. Thieme, MD; Numan, Sandra C.; Smit, Marjon J., MD; Cremer, Olaf L., MD, PhD; Tates, Kiek, MA, PhD*; Kalkman, Cor J., MD, PhD

doi: 10.1213/ANE.0b013e31826996a2
Economics, Education, and Policy
Free
SDC

BACKGROUND: Loss of information occurs frequently during handover and affects the continuity of care. Improving handovers is therefore a key patient safety goal. After surgery, the patient is transferred to the postanesthesia care unit (PACU), and handover to the nurse includes both handover of monitoring equipment (connecting electrocardiogram, calibrating arterial lines, infusion pumps, etc.) and patient/procedure-specific information. Multitasking is likely to increase the risk of information loss during handover. It is unknown to what extent the transfer of equipment and information occurs simultaneously or sequentially in daily practice.

METHODS: A nationwide questionnaire on the subject of patient handover was returned by 494 health care practitioners concerned with handovers from operating room (OR) to PACU. In addition, 101 handovers from the OR to the PACU were videotaped in 2 academic hospitals (n = 20), 3 teaching hospitals (n = 43) and 1 community hospital (n = 38). The occurrence of simultaneous or sequential transfer of equipment and information was recorded by two independent observers.

RESULTS: Simultaneous handover of equipment and information was the preference for a minority of respondents to the national survey (11%, 95% confidence interval, 8% to 14%). Self-reported simultaneous handover was 43% (39% to 47%). In the videotaped handovers, simultaneous handover was used for 65% (56% to 74%), which was even higher in the academic centers. The simultaneous handovers were no more than 0.2 minute faster than sequential handovers (P = 0.38).

CONCLUSIONS: In most videotaped handovers from OR to the PACU, there was simultaneous transfer of equipment and information. Although most health care providers are unaware of it, this form of multitasking during patient handover in the PACU is common. Future studies should evaluate whether this multitasking also leads to loss of critical patient information and reduced patient safety.

Published ahead of print September 13, 2012

From the *Center for Patient Safety, University Medical Center Utrecht, Utrecht, The Netherlands; Division of Perioperative Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Intensive Care Center, University Medical Center Utrecht, Utrecht, The Netherlands.

Kiek Tates is currently affiliated with the Department of Communication and Information Sciences, Tilburg University, Tilburg, The Netherlands.

Accepted for publication June 14, 2012

Published ahead of print September 13, 2012

Funding: This study was supported by a grant of ZonMw-The Netherlands Organization for Health Research and Development (project number 8140.0001) and by the Center for Patient Safety, University Medical Center Utrecht, The Netherlands.

The authors declare no conflict of interest.

Reprints will not be available from the authors.

Address correspondence to Elizabeth L. J. van Rensen, MPH, PhD, Center for Patient Safety, Huispost D01.343, P.O.Box 85500, 3508 GA Utrecht, The Netherlands. Address e-mail to e.l.j.vanrensen@umcutrecht.nl.

The Joint Commission reported that communication failure was a root cause in >60% of sentinel events.1 Patient handover is a specific form of medical communication during wich information about the patient flows from one health care provider to another.2 However, loss of information can occur, leading to poor continuity of care.3–7 In one study in the emergency department, 30% of the information provided by emergency medical services personnel during handover was not documented by the in-hospital clinicians. Moreover, more than half of the available clinically relevant information appeared not to have been provided during the handover.5

In psychology research, multitasking is known to increase the risk for loss of information.8–10 In health care, gaps in information flow due to multitasking have been demonstrated.11 During patient handovers from the operating room (OR) to the postanesthesia care unit (PACU), multitasking is likely to occur. These handovers include both handover of monitoring equipment (connecting electrocardiogram, connecting and calibrating arterial lines, transfer of infusion pumps, etc.) and of verbal information. Furthermore, after surgery, the anesthesia team may be pressured to start the next case to reduce turnover time. Qualitative studies observed that handovers in the PACU were characterized as being event-driven, time-pressured, prone to concurrent distractions, and inconsistent with often incomplete information transfer.12,13

During transfer, it is likely that PACU nurses will focus on connecting the patient to the patient monitors and ventilator, which may distract from listening carefully to the verbal handover when given concurrently. It is unknown how often such multitasking occurs in the PACU in daily practice. To that end, we examined self-reported multitasking by a nationwide questionnaire. Furthermore, we videotaped handovers from the OR to the PACU in various hospitals, and observed to what extent the transfer of equipment and patient/procedure specific information occurs simultaneously or sequentially in daily practice.

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METHODS

Study Design

The protocol of this observational study was submitted to the University Medical Center Utrecht IRB. The IRB issued a formal waiver because this study was considered health care improvement. All professionals were given the opportunity to object to being filmed. The anesthesia providers and the recovery nurses were aware that the handovers were being videotaped for quality improvement, but were not aware of the objective of this study (assessing simultaneous versus sequential handover of equipment and verbal information).

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Data Collection

Self-reported handover. A nationwide questionnaire was sent via e-mail and by regular mail to 1437 health care providers and returned by 494 (248 anesthesiologists, 52 anesthetic nurses, 100 PACU nurses, 83 anesthesia residents and 11 others). Most respondents were working in an academic (35%) or a tertiary medical teaching hospital (29%). A call to participate in the survey and link to the questionnaire was placed on the Website of the Dutch Association of PACU nurses. An announcement of the questionnaire was published in the national magazine for PACU nurses.

The questionnaire was designed to evaluate current practice and to elicit opinions on the subject of patient handover (Appendix 1, translated copy of questions). The questionnaire was Web-based using PHP scripting language (server side scripting) and was protected with a username/password combination (Base64 encryption). Data were saved online in a secured database (MySQL).

Observed handover. Handovers were videotaped in 6 different hospitals caring for patients with a wide range of severity (academic, teaching and community hospitals). A total of 101 handovers from OR to the PACU were videotaped in 2 academic settings (1 specialized for children) (n = 20), 3 teaching hospitals (n = 43) and 1 community hospital (n = 38). In each participating hospital, consecutive handovers were videotaped for several hours during 2 or 3 separate days. Resulting in >100 different health care providers being videotaped.

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Data Processing and Analysis

The videotapes were coded by 2 independent observers (k = 0.93). The observers indicated whether the handover of information was simultaneous with the transfer of equipment or whether this was done sequentially. We defined multitasking as simultaneous transfer of equipment and transfer of information. A handover video typically showed a PACU nurse who is connecting and calibrating monitoring equipment, while at the same time an anesthetic nurse or anesthesiologist is providing verbal handover information. At that time no or hardly any eye contact can be observed, because the PACU nurse is watching the monitoring equipment and therefore standing with her back to the anesthetic nurse or anesthesiologist. Furthermore, there are hardly any questions asked (Appendix 2, illustration of a sequential handover and a simultaneous handover).

To determine the extent of overlapping activities, we scored the time during which both transfer equipment and information occurred simultaneously (as percentage of total speaking time).

The observers scored which items were mentioned during the handover.

Unpaired 2 group t-test was used to test for differences between the groups. Levene’s test was used to test for equality of variances (P = 0.35). Chi-square test was applied to test for differences in answers between functions in the questionnaire. Ninety-five percent confidence intervals (CIs) were calculated.

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RESULTS

Self-Reported Handovers

In the questionnaire, 43% (95% CI 39% to 47%) of respondents reported that simultaneous transfer of information and equipment occurred during handover from OR to the PACU in their institution. According to 14% (11% to 17%) of the respondents there was no standard handover procedure and handovers took place either simultaneously or sequentially in their institution (Figure 1). The PACU nurses reported a significantly higher percentage of simultaneous handovers (68%) than did the other 3 types of providers (anesthetic nurses: 44%; anesthesia residents: 25% and anesthesiologists: 40%) (P < 0.0001).

Figure 1

Figure 1

A minority of respondents of the questionnaire indicated that they would prefer a simultaneous handover (11%; 8% to 14%) over the sequential process. Furthermore, the majority mentioned that handovers should be performed face-to-face with the verbal information transfer supported by written information.

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Observed Handovers

Simultaneous transfer of equipment and information was observed in 65% (56% to 74%) of the videotaped handovers from OR to PACU (Table 1). The percentage of simultaneous handovers in the 2 academic settings was significantly higher than that in the other hospitals (95% vs 58%; P = 0.007) (Figure 2). The simultaneous handovers were no more than 0.2 minute faster than sequential handovers (P = 0.38) (95% upper confidence limit) (Table 1 Appendix 3, graphic presentation of durations sequential and simulations handovers).

Table 1

Table 1

Figure 2

Figure 2

Appendix 3

Appendix 3

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DISCUSSION

A minority of health providers indicated a preference for simultaneous handover of equipment and information when transferring or receiving a patient from the OR. On the other hand, almost half of respondents reported multitasking during handovers in the survey. Interestingly, the observational results of the present study in 6 hospitals revealed that most handovers from OR to the PACU include simultaneous transfer of equipment and information. Future studies should evaluate whether multitasking also contributes to loss of safety-critical information.

Like Smith et al., we observed that the handover of information in the PACU often took place among a multitude of other activities.13 Our results are in keeping with those of other authors who showed that in the emergency room, handovers are characterized by frequent interruptions and multiple concurrent tasks.11,14,15

The present study has limitations. First, our sample of hospitals was based on willingness to participate and therefore we cannot exclude, the possibility that the selection of hospitals where handovers were recorded might have influenced our results. However, we videotaped handovers in a purposive sample of 6 different hospitals in various regions of the country, the possibility including both urban and rural areas.

Second, the presence of the video camera might have affected the behavior of the health care providers via a Hawthorne effect that elicits “best behavior.” Although this is likely to have occurred, the researchers were present on the wards for several days so that everyone was used to their presence. Also, the participants were unaware of the study purpose, and neither simultaneous nor sequential handover was perceived to be “desired behavior.”

How likely is it that the simultaneous handovers observed in our study contribute to loss of information and thereby pose a risk for patient safety? From psychology research, it is known that multitasking is in fact “switch-tasking,” because the brain is unable to perform more than one complex task at the same time.16 Simultaneous handovers were no more than 0.2 minute faster than the sequential handovers. Therefore, rather than simultaneously performing all tasks at once, what really happens during multitasking is a rapid change of focus between competing tasks, which increases the risk of errors.17 It is therefore likely that in health care, multiple concurrent tasks may produce clinical errors by disrupting memory processes.15 Future studies should be performed to evaluate safety differences.

In conclusion, simultaneous transfer of patient information and equipment during patient handover is common in the PACU. We have shown that there is a discrepancy between the incidence of simultaneous handover of equipment and information from self-report versus that observed during actual handovers. The finding that most health care providers would prefer a sequential handover of equipment and information is of interest with respect to improving handovers.

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APPENDIX 1. TRANSLATED COPY OF QUESTIONNAIRE

Question 1. What is your profession?

  • —Anaesthetic nurse
  • —Recovery nurse
  • —Anaesthesia residents
  • —Anesthesiologist
  • —Other

Question 2. In which type of hospital are you working?

  • —Academic hospital
  • —Tertiary medical teaching hospital
  • —Community hospital

Question 3. What is the standard handover procedure from the OR to the recovery?

  • —There is no standard procedure
  • —First transfer of monitor equipment, then transfer of information
  • —Transfer of equipment and information occur simultaneously
  • —First transfer of information, then transfer of monitor equipment

Question 4. What is your preferred handover procedure?

  • —I have no preference
  • —First transfer of monitor equipment, then transfer of information
  • —Transfer of equipment and information occur simultaneously
  • —First transfer of information, then transfer of monitor equipment
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APPENDIX 2. ILLUSTRATION OF SEQUENTIAL AND SIMULTANEOUS HANDOVER

Where RN = recovery nurse; AN = anesthetic nurse.

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Sequential Handover

  • 0:00 RN+AN connecting saturation, infusion pump, blood pressure, oxygen, ECG
  • 0:52 AN verbal transfer of patient identification, type of surgery and anesthesia
  • 1:04 AN verbal transfer of operation details and postoperative policy
  • 1:34 RN confirms information
  • 1:36 AN verbal transfer anesthetic details
  • 1:48 RN question related to anesthetic details
  • 1:52 AN answers question
  • 1:55 AN verbal transfer of postoperative policy
  • 2:08 RN confirms information
  • 2:18 AN asks if everything is clear
  • 2:20 RN confirms
  • 2:27 AN talks to patient
  • 2:37 AN walks away
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Simultaneous Handover

  • 0:00 RN1+AN connecting infusion pump and ECG
  • 0:24 AN verbal transfer of patient identification, type of surgery and medical history while connecting oxygen
  • RN connecting saturation and blood pressure
  • 0:45 AN verbal transfer of type of anesthesia
  • RN asks AN to open flow of oxygen
  • 0:57 AN checks infusion pump
  • RN closes curtain
  • RN2 checks medical record
  • 1:07 RN asks if patient has been catherised
  • AN says no
  • 1:17 RN walks away
  • AN verbal transfer of postoperative policy
  • 1:30 RN checks medication of colleague
  • AN verbal transfer of operation details
  • 1:43 RN talks to patient
  • RN2 asks for anesthetic details
  • 1:53 RN checks medical record
  • AN verbal transfer of additional oxygen
  • 2:02 RN asks for anesthetic details
  • 2:05 AN answers question
  • 2:10 AN walks away
  • 2:34 RN talks to patient
  • AN comes back and verbal transfer of blood loss to RN2
  • 2:42 AN walks away
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DISCLOSURES

Name: Elizabeth L. J. van Rensen, MPH, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and prepare the manuscript.

Attestation: Elizabeth L. J. van Rensen attests to having approved the final manuscript and is the archival author.

Name: Emily S. Thieme Groen, MD.

Contribution: This author helped conduct the study and analyze the data.

Attestation: Emily S. Thieme Groen attests to having approved the final manuscript.

Name: Sandra C. Numan.

Contribution: This author helped conduct the study.

Attestation: Sandra C. Numan attests to having approved the final manuscript.

Name: Marjon J. Smit, MD.

Contribution: This author helped conduct the study.

Attestation: Marjon J. Smit attests to having approved the final manuscript.

Name: Olaf L. Cremer, MD, PhD.

Contribution: This author helped design the study.

Attestation: Olaf L. Cremer attests to having approved the final manuscript.

Name: Kiek Tates, MA, PhD.

Contribution: This author helped design the study and analyze the data.

Attestation: Kiek Tates attests to having approved the final manuscript.

Name: Cor J Kalkman, MD, PhD.

Contribution: This author helped conduct the study.

Attestation: Cor J. Kalkman attests to having approved the final manuscript.

This manuscript was handled by: Franklin Dexter, MD, PhD.

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ACKNOWLEDGMENTS

We would like to thank all the participating hospitals for their cooperation: Medical Center Alkmaar (P.G.C. Koenders, P. Koenis, E. Löske, C.T.L.M. Nyst, V. Sai A Tjin), ZGT Almelo (L. van den Broek, A.T. Leyssius, M. Mulstege, N. Verdonk, H. Verheij, M.L. Verstraaten, J. Visschedijk, F. Vooys), Elkerliek Hospital Helmond (A. Bruinsma, J. van Es), Canisius-Wilhelmina Hospital Nijmegen (H.W.E.M. de Man-Hermsen, MMJ Snoeck), Isala Klinieken Zwolle (M.E. Hoogendoorn, A.J. Nieboer, AJ Spanjersberg, AAM Stappenbeld), UMC Utrecht WKZ (B.J. Hartman, S. Langhout, E.H.M. Quirijns, DBM van der Werff) and UMC Utrecht AZU (T.D. Boontje, R.G. Hoff, K.M.A. Suijker).

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