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A Multidisciplinary Handoff Process to Standardize the Transfer of Care Between the Intensive Care Unit and the Operating Room

Karamchandani, Kunal, MD, FCCP; Fitzgerald, Karima, MD; Carroll, David, DO; Trauger, Mary E., RN, C-LSSBB; Ciccocioppo, Lisa A., BSBA, PMP; Hess, Wendell, BSN, RN, CCRN; Prozesky, Jansie, MBChB; Armen, Scott B., MD, FACS, FCCP, FCCM

doi: 10.1097/QMH.0000000000000187
Quality Improvement

Objective: Critically ill patients are at high risk for adverse events on transfer between intensive care unit and operating room. Patient safety concerns were raised within our institution during such transfers, and absence of a standardized patient handoff process was identified as an area of concern.

Methods: The current state of the patient transfer processes between the intensive care units (ICUs) and the operating rooms (ORs) was mapped and failure modes were identified. A multidisciplinary team was convened and a standardized handoff process and tool (checklist) was developed. Adherence to the process and care team satisfaction was assessed at the end of a 60-day pilot period.

Results: The process was successfully implemented hospital-wide covering all adult and pediatric ICUs. We observed a 90% compliance rate with ICU to the OR transfers and 95% compliance rate with transfers from OR to the ICU during the 60-day pilot period. The care team expressed overall satisfaction with the process and identified potential areas of improvement.

Conclusion: A standardized patient handoff process between the ICU and the ORs can be successfully implemented in a large academic medical center. Universal application of this quality improvement tool can reduce patient harm, improve communication between providers, and enhance patient safety.

Departments of Anesthesiology & Perioperative Medicine (Drs Karamchandani and Carroll and Ms Prozesky) and Surgery (Drs Fitzgerald and Armen), Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania; and Department of Quality Systems Improvement (Mss Trauger and Ciccocioppo) and Surgical Anesthesia Intensive Care Unit (Mr Hess), Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania.

Correspondence: Kunal Karamchandani MD, FCCP, Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, 500 University Dr, Hershey, PA 17033 (

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The authors declare no conflicts of interest.

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