Informatics Tools and Patient Handovers
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Smart-Templates and Post-Operative Patient Handovers A QI + Research Project Aalap Shah, MD Surgical Services Chair, Housestaff Quality and Safety Committee R4, Department of Anesthesiology and Pain Medicine University of Washington Medical Center
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The patient handoff is a contemporaneous, interactive process of passing patient-specific information from one caregiver to another to ensure the continuity and safety of patient care. It is well recognized that the handoff is a point of vulnerability where valuable patient information can be distorted and omitted [1, 2]. A plethora of studies in the nursing literature have identified a variety of problems, including incomplete or inaccurate information [3-6], uneven quality [7], repeated interruptions and lack of anticipatory guidance [8]. Many reports have focused on characterizing the weaknesses with non-operative patient handovers, the use of handoff checklists and aviation safety models for specific groups of patients [1,5,9], and the pre- and post-implementation comparisons. [10-12] However, few studies have focused on prospective cohort studies validating and testing patient information management systems such as smart-templates in the setting of handover quality. [10] Electronic templates containing patient information help to standardize the type of information conveyed during interactions, discourages ambiguous findings,[13] improves provider satisfaction and improves continuity of care.[14] Within the department, we developed the transfer template (T2) to address the issues in provider workflow and efficiency. With the press of a button, the T2 template automatically extracts live information from the anesthetic record, pertinent fields from the PAC note and laboratory values from IView, and provides a concise output of these relevant details.
Transcript of Informatics Tools and Patient Handovers
Smart-Templates and Post-Operative
Patient HandoversA QI + Research Project
Aalap Shah, MDSurgical Services Chair, Housestaff Quality and Safety Committee
R4, Department of Anesthesiology and Pain MedicineUniversity of Washington Medical Center
Table of Contents• IT/Handoffs Overview [s3-21]
• Patient Handoffs [s3-6]• UW PACU Handoff [s7-13]• UW ICU Handoff (eff. 2/2014) [s14]• EHRs/Meaningful Use [s15-21]
• PAST Template [s22-32]
• Case Example [s28-32]
• T2 Template [s33]
• Handover IT: Objectives [s34]
• Handover IT as a QI Project [s35-50]
• Handover IT as a Research Project [s51-62]
• Future Directions [s63-64]
Patient Handoffs• “Transfer of information, responsibility, and
authority from one health care provider to another.”
• ACGME 2003 – • Duty hour restrictions Increased # of handoffs
• Gawande 2003• Review of 100 incident reports from 45 surgeons• 60% of events in OR+PACU
• 43% due to communication failure; of which 2/3 were due to inadequate handoffs.
Patient Handoffs• Joint Commission 2006 –• Requirement for standardized handoff approach at
accredited institutions
• Joint Commission + WHO 2008 –• Highlighted role for standardized processes to
identify and reduce handoff-related errors
• Institute of Medicine 2008 – • Increased focus on handoff processes to improve
patient safety
Patient HandoffsObstacles
Different media (Nagpal 2010, Mistry 2005)
Taped/written reports verbal bedside reportsEMR/PHR Integration
Lack of institutional standardization (Mistry 2008, Nagpal 2010)
Descriptive reports structured templatesSpecialty and location-specific handoff tools, physician vs. nurse
Information Omission (Nagpal 2011, Catchpole 2007, Zavalkoff 2011)
Poor Setting (Smith 2008, 2010, Chen 2011)
Interruptions/MisunderstandingsRoom Delays/”Rushed” Inaccurate clinical assessment
Unclear task assignments and “anticipatory guidance” (Joy 2011)
Patient HandoffsResearch and Data Collection Methods
Pre-/Post- Implementation Studies (Catchpole 2007, Joy 2011, Jukkala 2012, Mistry 2008) Six Sigma, Model for Improvement
Focus group (Bosmans 2013)
Observational/Cross-Sectional (Chen 2011)
RCT (Van Eaton 2005, 2010)
Surveys (Flanagan 2009, Bernstein 2010)
UW PACU Handoff
Case Example
PMHx:
– A-fib
– DM2
– HTN
– GERD
– Morbid Obesity (BMI 35.4)
– Chronic LBP
– Hypothyroidism
– Hearing Loss
PSHx:
– h/o Breast Ca s/p R. lumpectomy, chemorx
– Lipoma removal 2002 PONV
– Tonsillectomy/Adenoidectomy
Rx:
– Coumadin 5mg Daily
– HCTZ 25mg Daily
– Ranitidine 150mg Daily
– Vicodin 5/325 1 tab q4-6 hours
– Lisinopril 5mg Daily
– Metoprolol 25 mg Daily
– Metformin 500mg BID
– Levothyroxine 125 mcg Daily
SocHx:
– Tobacco use (1ppd x 20 years)
– Alcohol use (3-5 glasses wine/day)
ROS:
- +palpitations w/exercise, +myopia, +heartburn, +tingling in b/l 1st/2nd digits, recent URI (2 days)
PE:
– VS: HR 79, BP 145/89, RR 16 shallow, Temp 36.7, Sp2 98% on RA
– Wt: 96.4kg, Ht: 165cm
– Airway: Mallamapati II, , TMD < 6, Loose #11, NC 15.5in
– Respiratory: UATS
– CV: IRIR, no gallops
– Abd: +Murphy’s sign. Hypoactive BT
– Ext: Varicose veins, no edema
– Neuro: +numbness in b/l feet, + carotid bruit
– Skin: Lumpectomy incision healed.
– FS: >4 (3 flights of stairs back pain)
Labs:
– Na 139, K 3.3, Cl 109, HCO3 29, BUN 12, Cr 1.1
– WBC 8.3, Hct 35, Hgb 12, Plt 171
– PT 13.5 , PTT 35, INR 2.1
• Studies
– Referred for sleep study
– EKG: IRIR HR 67-98
– TTE: nl chamber size, wall motion,valves, and EF
58yo F presents to clinic for laparoscopic cholecystectomy on xx/2014, 3weeks prior to DOS Postprandial symptoms ED visit last week Gallstones/GBW thickening
UW PACU Handoff
Surgery ClinicVisit
I. Pre-Anesthesia/Clinic Visit
Phone interview
Need PAC
Visit?
Add’l studies?
Chart review
Pre-op phone
call
Pt. arrives on DOS
Yes
Referral visits
Pre-op phone
call
UW PACU HandoffPAC Note
6-8 sheets of paper, only 60% vital to patient care
UW PACU Handoff
PACU
ICU
IIa. Day before Surgery Pt. arrives on DOS
IIb. Day of Surgery
Providers
assigned cases
I. Pre-operative data collection and plan formation- PAC Note- Cerner- OSH Records- ?EpicII. D/w attending
Need to see:- Preop Nurse- Surgeon- Anesthesia- OR Nurse
OR CaseDispo
UW PACU HandoffIII. PACU
Un-planned ICU
Arrive in PACU,Bay
Assigned
Handover- Attach O2- Monitors- Positioning- MD: Verbal handoff- RN: SSHR filled
Stable for Dispo?
(Aldrete)
Monitor in PACU
CODE/still unstable?
Home
Floor Tx
Orders in?Bed avail?
Yes! To floor,,.
Yes! Go home,,.Outpt Rx ready?
No Oh helll no
Limbo
Limbo
RN-RN handover
RN-RN handover
UW PACU Handoff Information Omissions (March 27, 2014) (n=63)
Pre-study nurse surveys: Multiple disturbances/interruption Providers almost always “rushed” Inconsistency with PACU arrival tasks (monitors, O2, patient
positioning) prior to handoff
Data re: PACU and 24hr events pending
Name -- Airway management 3%
Status/Code 68% Induction Meds 16%
PMHx 36% Lines 24%
Home Rx 24% Resident name/pager 100%
Allergies 10% Anticipatory Guidance 82%
UW ICU Handoff
John Lang, MDAlan Artru, MD
EHRs: Meaningful UseElectronic Health Records Today:
The Positives Standardized Accessibility (Dykes 2007)
Funding and Support (Steinbrook 2009)
The Perceived Positives Workflow facilitation Efficiency Accuracy (Steinbrook 2009)
Patient Care
EHRs: Meaningful Use
Medscape. July 16, 2014
EHRs: Meaningful Use• National Alliance of HIT –• Office of National Coordinator – 2004• “Majority of Americans to have EHRs by 2014”
• ARRA 2009 – • $19.2B (of $>170B) stimulus package allocated to
Healthcare IT
EHRs: Meaningful Use• Center for Medicare/Medicaid Services (CMS)• 2010 – standards for “certified “EHR• 2011 – incentive payments for EHR “meaningful
use” attestation• 2015 – Medicare payment deductions for
providers not showing meaningful use
• National Committee for Quality Assurance (NCQA)• Health Effectiveness Data and Information Set
(HEDIS) – 2012• 35 quality measures to facilitate reporting of
accountable care organization (ACO) benchmark data
EHRs: Meaningful Use
Medscape. July 16, 2014
EHRs: Meaningful Use
Medscape. July 16, 2014
EHR Templates Improvement in physician note quality scores (Fielstein 2006)
Facilitation for secondary data use (Bonney 2013)
Automatized process of information transfer and extraction by domain (Siebens 2001)
Discourages ambiguous findings in notes (Bosmans 2012)
Highlights important findings
Improved patient rapport and continuity of care (Co 2010, Millery 2011)
PAST Template Automatic and timely consolidation of data from
disparate systems Anesthesia Information Management Systems (Merge/AIMS) Cerner Powerchart MINDScape
Data access/processing from Cerner EHR via AMALGA
Stand-alone web-based program (SQL Serve Reporting Services)
Access granted with Cerner/ORCA User ID/Password (HIPAA-compliant)
*It is NOT a replacement for:- your own patient assessments - other clinician’s evaluations in the EHR- any perioperative communication (i.e. day-before phone call)
PAST TemplateKey:Gray highlighted fields [ ]:
extracted from PAC noteYellow highlighted fields [ ] :
labs/studies electronically extracted from Cerner/PowerChart.
Green highlighted fields [ ]: extracted from DOCUSYS server
Text in blue direct links to the Cerner PowerChart/Mindscape
where studies can be retrieved (XML format)Text in red
fields which will require revision of the PAC note template in order to accurately extract information.
I. Quantitative Information
- Numeric data, studies, vitals, etc. all represented in one section- CPT/ICD already present Facilitates rapid input into DOCUSYS- Improves information reporting (Surgeons, PACU)
DEVELOPMENT
PAST Template
II. Medical/Surgical History
- Diagnosis-linked fields pull in medications and problems by organ system- Airway management and complication information extracted from previous DOCUSYS anesthetic record
DEVELOPMENT
PAST Template
III. Anesthetic Issue “Dashboard”
- PAC note components (ROS, PE, Labs) directly transferred from PAC note i- Issue and timeframe-based organization assist with prioritization and contribute to thorough and rapid patient assessments
DOS Checklist for provider and Pre-Op Nursing Staff
All coded fields from the PAC note categorized by issue. Only positive findings will “light up” in the final template
DEVELOPMENT
PAST Template
1-7days prior
to DOS
DEVELOPMENT
PAST Template
Information automatically extracted from sourcesto populate template
Case Example
PMHx:
– A-fib
– DM2
– HTN
– GERD
– Morbid Obesity (BMI 35.4)
– Chronic LBP
– Hypothyroidism
– Hearing Loss
PSHx:
– h/o Breast Ca s/p R. lumpectomy, chemorx
– Lipoma removal 2002 PONV
– Tonsillectomy/Adenoidectomy
Rx:
– Coumadin 5mg Daily
– HCTZ 25mg Daily
– Ranitidine 150mg Daily
– Vicodin 5/325 1 tab q4-6 hours
– Lisinopril 5mg Daily
– Metoprolol 25 mg Daily
– Metformin 500mg BID
– Levothyroxine 125 mcg Daily
SocHx:
– Tobacco use (1ppd x 20 years)
– Alcohol use (3-5 glasses wine/day)
ROS:
- +palpitations w/exercise, +myopia, +heartburn, +tingling in b/l 1st/2nd digits, recent URI (2 days)
PE:
– VS: HR 79, BP 145/89, RR 16 shallow, Temp 36.7, Sp2 98% on RA
– Wt: 96.4kg, Ht: 165cm
– Airway: Mallamapati II, , TMD < 6, Loose #11, NC 15.5in
– Respiratory: UATS
– CV: IRIR, no gallops
– Abd: +Murphy’s sign. Hypoactive BT
– Ext: Varicose veins, no edema
– Neuro: +numbness in b/l feet, + carotid bruit
– Skin: Lumpectomy incision healed.
– FS: >4 (3 flights of stairs back pain)
Labs:
– Na 139, K 3.3, Cl 109, HCO3 29, BUN 12, Cr 1.1
– WBC 8.3, Hct 35, Hgb 12, Plt 171
– PT 13.5 , PTT 35, INR 2.1
• Studies
– Referred for sleep study
– EKG: IRIR HR 67-98
– TTE: nl chamber size, wall motion,valves, and EF
58yo F presents to clinic for laparoscopic cholecystectomy on xx/2014, 3weeks prior to DOS Postprandial symptoms ED visit last week Gallstones/GBW thickening
Case Example
I. Quantitative Information
DEVELOPMENT
Case Example
II. Medical/Surgical History
DEVELOPMENT
Case Example
III. Anesthetic Issue “Dashboard”DEVELOPMENT
DEVELOPMENT
Transfer Template (T2)
DEVELOPMENT
Push F7 on OR Anesthesia computers to display T2
Handover IT: Objectives Engagement of nurses and providers in the development of web-based
informatics application to improve the handover process.
Decreased information omissions related to the patient’s relevant medical history on the Surgical Services Handoff Report (SSHR) (purple sheet), prior to patient discharge or ward transfer.
Improvement in the quality of the provider-nurse handover process as gauged by third-party (nurse educator) evaluators and tested handover evaluation tools in the recovery room.
Decreased incidence of minor complications in the immediate post-operative period, as well as within the first 24 hours of floor transfer.
Improved intraoperative evidence-based anesthetic plans based on identifying at-risk patients (ex: multiple agent therapy for PONV prophylaxis, decreased volatile gas administration for patients with lower MAC requirements)
QI, RESEARCH
“Provider” = any person administering an anesthetic (attendings, CRNA, residents)
Handover IT: QIApproach: IHI Model For Improvement
QI
Handover IT: QIPatient Task Factors Staff Factors
Team Factors
Organization Environment
1.) Omission of Information (OI)2.) Poor handover quality3.) PACU adverse events
Cause/Effect Chart
- OSH records not available- Language barriers - Complex pt/multiple medical issues-Incorrect/incomplete info presented at clinic visit
- Incorrect info in EHR- Chart review instead of [needed] clinic visit
-Multiple intraop handovers (anesthesia)-PACU nurse task burden/”shift change”-Provider/nurse
- Burden of PAC documentation- Time-consuming EHR review- Case to follow, pressure to be efficient
- Lack of or miscommunication between residentand attending re: anesthetic plans
-Multiple sources of info in EHR-No standardized -Printouts/jotting down illegible notes
-Noisy/clustered -Staff or pt. interruptions-Chart/SSHR not available
Handover IT: QI
Accuracy of Post-Operative Handovers
QI
Handover IT: QIAIMS Statement:
SpecificStretchMeasurableAchievableRealisticTimely
Our team aims to decrease the rate of post-operative verbal handover OI in all checklist fields to ≤ 15% within 6 months of study start (e.g. June 30, 2015) in ASA3+ patients being admitted to UWMC after elective surgery.
QI
Handover IT: QI
Assemble A Team Research: G. Alec Rooke, MD PhD,
Gail Van Norman, MD PAC Clinic coordinators: G. Alec Rooke, MD PhD IT: Dr. Bala Nair, Shu-Fang Newman (Programmer) CQI Coordinator: Karen McElhinney Nurse educator (CNE) team: TBA
QI
Outcome MeasuresPrimary Outcomes
• OI (%), Run Chart
• Quality (via Handoff CEX)
• # of minutes until patient is transferred from PACU to inpatient floor
QI
Pre-Anesthesia
Intraoperative
Post-Anesthesia
Demographics Airway Access
Condition Antibiotics Disposition
Allergies Induction Rx Sign-Out
Medications BP Rx Anticipatory Plans
PMHx Pain/PONV Rx
Fluids
Outcome MeasuresPrimary Outcomes• 1) OI Run chart
QI
Outcome MeasuresPrimary Outcomes• 2) Handoff CEX
QI
Secondary Outcomes (PACU)• 3) PACU adverse events
PONV • Incidence of PONV in Group 1 and Group 2• # of medications administered• # of emesis episodes
Pain• # of separate pain medication administrations• Maximum pain score recorded by patients• Total opioid consumption (in milligrams)
Outcome Measures
QI
Outcome Measures• PACU adverse events (cont’d)
Sedation scores (Aldrete score) • 15 minutes, 1 hour, and 2 hours
Hypotension (SBP < 90 and/or MAP <60)• # of patients with hypotensive episodes• # of individual pressor (blood pressure-
elevating) medication administrations• Total pressor consumption (in milligrams)
QI
Outcome Measures• PACU adverse events (cont’d)
Respiratory compromise• # of patients with respiratory depression
(RR < 8)• # of narcan administration events• # of desaturations
QI
Process Measures•% attendance/participation at training sessions•% of PACU nurses using template for signout at 3 months
•% provider (resident/CRNA/attending for signout at 3 months
QI
Balance Measures• Administrative time expense • Whiteboard involvement
• Provider time expense• Handover time, OR turnover time
• Developmental/Programming Costs• Nursing/Provider satisfaction• Evaluation of PHI integrity (to be determined
after 2nd PDSA cycle)
QI
Handover IT: QI
Problem/ Processes
Improvements/ Interventions
Omission of Information (OI)
PAST, T2
Handover Quality
PAST, T2
PACU adverse events
PAST
QI
Handover IT: QI• Pre-Implementation• IRB, etc.• PACU Nursing Survey• Online training module/instructional video• Provider Recruitment• Departmental, Class, or Group E-mail
QI
Handover IT: QI• Implementation• Focus Groups (x4), 1.5 hr sessions• Focus on Qualitative Input
• Foster provider-nurse partnership and ownership
• Identify hospital-wide barriers and ways to facilitate implementation
• Revise product
• Pizza
• Departmental announcements• Online modules/LMS Gateway• Model for Improvement – PDSA Cycles
QI
Handover IT: Research• Study Design:• Prospective RCT• Single-blinded (PACU nurse/provider aware)• IRB needed: access to patient PACU data, intent to
publish QI data outside UWMC
• Study Population: N=64 dyads (provider-PACU nurse interactions + patient); 32 dyads/group• “Provider” = CA2 or CA3 resident or CRNA (>2yrs)• “PACU Nurse” = 1:1 nurse who is routinely in PACU• “Patient” = ASA 3+ with planned post-op
admission
RESEARCH
Handover IT: Research• Intervention:• Control Group: Provider preference in patient pre-op
preparation and handover
• Intervention Group: PAST for patient pre-op preparation, PAST + T2 for handover • Will receive additional instructional video (15 minutes)
• Templates visible by both PACU nurse and provider
• Recruitment:• E-mails, GR announcements
• Consent:• Written consent from providers
• Nursing staff to receive educational session during pre-implementation phase,
RESEARCH
Handover IT: Research• Workflow• 1 day prior to DOS: Coordinate with
Whiteboard/AIC • Providers notified 1 day prior to surgery re: control vs
intervention group
• DOS: Provider brings pt. to PACU• Audio recorders (numbered) distributed to each nurse
prior to provider/patient coming from OR
• Monitors, positioning, O2 after arrival, etc.
• If provider is in intervention group, provider instructs PACU nurse to open PAST template
• Verbal handoff, recording with pt. name and ID.
RESEARCH
Workflow
RESEARCH
15-min video tutorial
Handover IT: Research
RESEARCHRESEARCH
PACU
ICU
Ia. Day before Surgery Pt. arrives on DOS
Ib. Day of Surgery
Providers
assigned cases
I. Pre-operative data collection and plan formation- PAC Note- Cerner- OSH Records- ?EpicIII. D/w attending
Need to see:- Preop Nurse- Surgeon- Anesthesia- OR Nurse
OR CaseDispo
I. Access/downloadPASTII. Additional chart review T2 used
for intraop handoffs
T2 printed before arrival
Handover IT: Research
RESEARCH
PACU
Arrive in PACU,Bay
Assigned
Handoff- Attach O2- Monitors- Positioning
- PAST Handoff at PACU computer
- Anticipatory planning- PACU orders revised,
if needed
Un-planned ICU
Stable for Dispo?
(Aldrete)
Monitor in PACU
CODE/still unstable?
Home
Floor Tx
Orders in?Bed avail?
Yes! To floor,,.
Yes! Go home,,.Outpt Rx ready?
No Oh helll no
Limbo
Limbo
RN-RN handover
RN-RN handover
Handover IT: Research
RESEARCH
Handover IT: ResearchData Storage/Access
Audio recorders (containing PHI) stored in locked desk in Anesthesia QI office
Handover audio evaluations:OI: Recordings compared against PAC note and ORCA
medication listQuality: Recordings graded via Likert Scale in
Handover CEX (previously validated evaluation tool)PACU events: Recordings compared against
completed PACU charting in CERNER IView.
Handover IT: Research
Pre-Anesthesia
Intraoperative
Post-Anesthesia
Demographics Airway Access
Condition Antibiotics Disposition
Allergies Induction Rx Sign-Out
Medications BP Rx Anticipatory Plans
PMHx Pain/PONV Rx
Fluids
Primary Outcomes
• OI (%)
• Quality (via Handoff CEX)
• # of minutes until patient is transferred from PACU to inpatient floor
Handover IT: ResearchSecondary Outcomes
PACU adverse eventsPONVPain ScoresSedation scoresHypotensionRespiratory depression
RESEARCH
Handover IT: Research• Data Collection:• Audio recordings: End of OR Day• PACU data: Weekly review of patient charts
• Analyses• Power analysis for study sample• Handoff CEX scores nonparametric tests of mean• Handover and PACU times Mann-Whitney U test• PACU outcomes Fisher-Exact Test
RESEARCH
Timeline September 2014 –
Submit IRB PAST/T2 rollout
October-December 2014 – Provider Recruitment Focus Groups Template revisions/feedback Create 15-minute instructional video
January-May 2015 (Resident Research Track)– Data collection and analyses
June 2015 – Manuscript preparation
Widespread implementation of PAST template at UW as well as affiliated hospitals.
Institute a web-based handover report/checklist form to replace the paper-based Surgical Services Handoff Report (SSHR)
Integrate surgical handoff/anticipatory guidance into electronic handoff tools (i.e. the T2)
Decrease post-operative major + minor complications related to provider communication error
Research/QI: Long-Term Objectives
Research/QI
HSQC IntegrationHigh Value Theme – Empowering PACU nurses to
standardize handoffs
Surgical subspecialty education about anesthetic workflow
Non-handover-related aims to improve efficiency of patient disposition (avoid “limbo”)
Documentation standardization modules
HMC PACU QI Champions
