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A Partially Structured Postoperative Handoff Protocol Improves Communication in 2 Mixed Surgical Intensive Care Units

Findings From the Handoffs and Transitions in Critical Care (HATRICC) Prospective Cohort Study

Lane-Fall, Meghan B. MD, MSHP*,†,‡,§,||,¶; Pascual, Jose L. MD, PhD, FCCM#; Peifer, Hannah G. EMT-B, BA*; Di Taranti, Laura J. BA*; Collard, Meredith L. BA, BSN, RN*; Jablonski, Juliane DNP, RN, CCRN, CCNS**; Gutsche, Jacob T. MD*; Halpern, Scott D. MD, PhD‡,¶,††; Barg, Frances K. PhD, MEd*,‡‡,§§; Fleisher, Lee A. MD*,†,‡ HATRICC study team (Kimberly Allen, BSN, RN; Mark Barry, MD; Sruthi Buddai, BA; Tyler Chavez, BA; Mahrukh Choudhary, BA; Della George; Megan Linehan, DO; Enrique Torres Hernandez; Jerome Watts, BA

doi: 10.1097/SLA.0000000000003137
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Objective: To assess the effectiveness of standardizing operating room (OR) to intensive care unit (ICU) handoffs in a mixed surgical population.

Summary of Background Data: Standardizing OR to ICU handoffs improves information transfer after cardiac surgery, but there is limited evidence in other surgical contexts.

Methods: This prospective interventional cohort study (NCT02267174) was conducted in 2 surgical ICUs in 2 affiliated hospitals. From 2014 to 2016, we developed, implemented, and assessed the effectiveness of a new standardized handoff protocol requiring bedside clinician communication using an information template. The primary study outcome was number of information omissions out of 13 possible topics, recorded by trained observers. Data were analyzed using descriptive statistics, bivariate analyses, and multivariable regression.

Results: We observed 165 patient transfers (68 pre-, 97 postintervention). Before standardization, observed handoffs had a mean 4.7 ± 2.9 information omissions each. After standardization, information omissions decreased 21.3% to 3.7 ± 1.9 (P = 0.023). In a pre-specified subanalysis, information omissions for new ICU patients decreased 36.2% from 4.7 ± 3.1 to 3.0 ± 1.6 (P = 0.008, interaction term P = 0.008). The decrement in information omissions was linearly associated with the number of protocol steps followed (P < 0.001). After controlling for patient stability, the intervention was still associated with reduced omissions. Handoff duration increased after standardization from 4.1 ± 3.3 to 8.0 ± 3.9 minutes (P < 0.001). ICU mortality and length of stay did not change postimplementation.

Conclusion: Standardizing OR to ICU handoffs significantly improved information exchange in 2 mixed surgical ICUs, with a concomitant increase in handoff duration. Additional research is needed to identify barriers to and facilitators of handoff protocol adherence.

*Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA

§Center for Healthcare Improvement and Patient Safety, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

||Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program, Indianapolis, IN

Palliative and Acute Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

#Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

**Hospital of the University of Pennsylvania, Philadelphia, PA

††Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

‡‡Family Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

§§Department of Anthropology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA.

Reprints: Meghan B. Lane-Fall, MD, MSHP, 3400 Spruce Street, 680 Dulles (Anesthesia), Philadelphia, PA 19104. E-mail: Meghan.Lane-Fall@uphs.upenn.edu.

Funding for this study was provided by Anesthesia Patient Safety Foundation, Rochester, MN. Meghan Lane-Fall currently receives salary support from the Robert Wood Johnson Foundation (Harold Amos Medical Faculty Development Program).

The HATRICC study is registered on ClinicalTrials.gov (NCT02267174, registered October 2014, last updated August 2016).

The authors declare no conflicts of interest within 36 months of the submission date of this manuscript.

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