Improving Patient Safety Improving Patient Safety and and

Mitigating Risks in the PACUMitigating Risks in the PACU

Myrna Mamaril, MS, RN, CPAN, CAPA, FAANMyrna Mamaril, MS, RN, CPAN, CAPA, FAAN

Advocacy: Call to Action!Advocacy: Call to Action! 2002 Institute of Medicine (IOM) Report: 2002 Institute of Medicine (IOM) Report: To Err is To Err is

Human: Building a Safer Health SystemHuman: Building a Safer Health System Nurses are the largest group of healthcare Nurses are the largest group of healthcare

providersproviders Play a significant advocacy rolePlay a significant advocacy role 2003 IOM Report2003 IOM Report: Keeping Patients Safe: : Keeping Patients Safe:

Transforming the Work Environment of NursesTransforming the Work Environment of Nurses Examined the work environment of nurses and Examined the work environment of nurses and

patient outcomespatient outcomes Since 2005, mores than 200 patients have died Since 2005, mores than 200 patients have died

from Alarm Fatiguefrom Alarm Fatigue

What do you think of when What do you think of when you hear the word --you hear the word --

“Fatigue” ?“Fatigue” ?

Let’s examine the risk factors Let’s examine the risk factors of nurse fatigueof nurse fatigue

Perianesthesia Nursing PracticePerianesthesia Nursing PracticeCulture of Postanesthesia Nursing: Culture of Postanesthesia Nursing:

Worked Hours & Risk of FatigueWorked Hours & Risk of Fatigue

Duty to provide care – focus is on the patient first.Duty to provide care – focus is on the patient first. Flow of patients out of the Operating RoomFlow of patients out of the Operating Room Unpredictability of the OR schedule – cases go later than Unpredictability of the OR schedule – cases go later than

expectedexpected Emergencies – unpredictable and require staff to provide Emergencies – unpredictable and require staff to provide

care.care. Overflow issues – when there are no inpatient surgical Overflow issues – when there are no inpatient surgical

beds the surgical patient needs to board in the PACUbeds the surgical patient needs to board in the PACU On call – does hospital management understand that On call – does hospital management understand that

many times the same nurses that are working during the many times the same nurses that are working during the day also take call on nights, weekends and holidays?day also take call on nights, weekends and holidays?

Dissemination StrategiesDissemination Strategies

Educate our members on nurse fatigue, the consequences, Educate our members on nurse fatigue, the consequences, the prevention, and the Countermeasuresthe prevention, and the Countermeasures

Publications in Breathline and JoPANPublications in Breathline and JoPAN Clinical Clips Column JOPAN, Oct 07Clinical Clips Column JOPAN, Oct 07 “ “Keeping our nurses and patients safe”Keeping our nurses and patients safe” Ellen SullivanEllen Sullivan Pathophysiology Column JOPAN, Dec 07Pathophysiology Column JOPAN, Dec 07 “ “Fatigue: When the “Little Engine That Could” Just Can’t AnymoreFatigue: When the “Little Engine That Could” Just Can’t Anymore Kim NobleKim Noble Safety Column JoPAN, Feb 08Safety Column JoPAN, Feb 08 “ “Fatigue: Do you understand the Safety Risks?”Fatigue: Do you understand the Safety Risks?” Jackie RossJackie Ross Poster Session Celebrate Successful Practices Poster Session Celebrate Successful Practices ASPAN National Conference May 2008ASPAN National Conference May 2008 Develop as a Position Statement Reference: ASPAN Fatigue Evaluation Develop as a Position Statement Reference: ASPAN Fatigue Evaluation

Checklist to be used by the membership to assess their current situation Checklist to be used by the membership to assess their current situation

ASPAN FATIGUE CHECKLISTASPAN FATIGUE CHECKLIST                 

                      ASPAN recognizes   ASPAN recognizes fatigue among nursesfatigue among nurses as a potentially dangerous factor that can impact safe nursing as a potentially dangerous factor that can impact safe nursing practice and patient safety. Evidence reports personal and professional contributors to nurse fatigue that can practice and patient safety. Evidence reports personal and professional contributors to nurse fatigue that can

affect patient outcomes, as well as the nurse’s health and job performance.  Nationally-known nurse researchers affect patient outcomes, as well as the nurse’s health and job performance.  Nationally-known nurse researchers in fatigue, Dr. Trinkoff and Dr. Rogers, presented evidence on fatigue to an ASPAN strategic work team in in fatigue, Dr. Trinkoff and Dr. Rogers, presented evidence on fatigue to an ASPAN strategic work team in August 2007.  From this review, a list of factors related to nurse fatigue, as well as its consequences, was August 2007.  From this review, a list of factors related to nurse fatigue, as well as its consequences, was

comprised and includes:comprised and includes:

Professional (scheduling) factorsProfessional (scheduling) factors: :   on-call hours 6,7, required (mandatory) overtime,1,2,3,6, few or no on-call hours 6,7, required (mandatory) overtime,1,2,3,6, few or no breaks during shift 1,2,6, high number of total hours worked in a week,2,3,6,7 shift length >12.5 hours,1,2,3,6,7 breaks during shift 1,2,6, high number of total hours worked in a week,2,3,6,7 shift length >12.5 hours,1,2,3,6,7

number of weekends worked per month1,7 working non-day shifts,1,5,7 worked when scheduled off, 1,2 number of weekends worked per month1,7 working non-day shifts,1,5,7 worked when scheduled off, 1,2 inadequate numbers of staff.3inadequate numbers of staff.3

Personal factorsPersonal factors::    Working more than one job6, voluntary overtime,1,2,3,6  working while sick1, inadequate Working more than one job6, voluntary overtime,1,2,3,6  working while sick1, inadequate rest.1,4,6, rest.1,4,6,

Job performanceJob performance:: struggle to remain awake,2,5,,fell asleep at work,2 and some effects on decision-making struggle to remain awake,2,5,,fell asleep at work,2 and some effects on decision-making and critical-thinking: decreased vigilance,2 increased risk of errors,2,3 lapses of attention,5 delayed reaction and critical-thinking: decreased vigilance,2 increased risk of errors,2,3 lapses of attention,5 delayed reaction

time.2  time.2 

Nurse healthNurse health::  Musculoskeletal injury (MSD),1,6 injury by needlestick,6,7 psychological strain,4 sleep impairment/deprivation,4,5    Musculoskeletal injury (MSD),1,6 injury by needlestick,6,7 psychological strain,4 sleep impairment/deprivation,4,5  “spillover” of work strain into non-work time,4 “unhealthful” behaviors (excessive caffeine or alcohol, smoking, inadequate diet, no exercise),6 “spillover” of work strain into non-work time,4 “unhealthful” behaviors (excessive caffeine or alcohol, smoking, inadequate diet, no exercise),6

drowsy driving.9 drowsy driving.9

PurposePurpose: : Inquiry into the topic of nurse fatigue and patient outcomes continues.  The Inquiry into the topic of nurse fatigue and patient outcomes continues.  The Nursing Organization Alliance (NOA) Nursing Organization Alliance (NOA) recommended recommended that every specialty nursing organization educate their members about nurse fatigue and its effects on nursing practice. The that every specialty nursing organization educate their members about nurse fatigue and its effects on nursing practice. The American Nurses American Nurses

AssociationAssociation (ANA) developed a position statement which recommends every nurse, as an ethical responsibility, should “carefully consider” (ANA) developed a position statement which recommends every nurse, as an ethical responsibility, should “carefully consider” her/his fatigue level and has the duty to evaluate personal “readiness to provide competent care.”11  Selected evidence was reviewed with her/his fatigue level and has the duty to evaluate personal “readiness to provide competent care.”11  Selected evidence was reviewed with

intention to educate ASPAN members on nurse fatigue and its factors, and the implications of fatigue on the safety of the perianesthesia patient intention to educate ASPAN members on nurse fatigue and its factors, and the implications of fatigue on the safety of the perianesthesia patient and nurse.and nurse.

Assessment: Assessment:  Factors linked with nurse fatigue were compiled into the following       checklist to educate about fatigue risks. ASPAN Factors linked with nurse fatigue were compiled into the following       checklist to educate about fatigue risks. ASPAN offers this evidence-based resource to healthcare providers for purposes of personal education and self-assessment. offers this evidence-based resource to healthcare providers for purposes of personal education and self-assessment. All of the factorsAll of the factors listed listed below can be used in your self-assessment. Some of these fatigue factors can also be assessed by peers and managers and are objective in below can be used in your self-assessment. Some of these fatigue factors can also be assessed by peers and managers and are objective in nature.  Those factors are indicated with an (O).nature.  Those factors are indicated with an (O).      Research has shown that a person can recover from sleep deprivation after two consecutive Research has shown that a person can recover from sleep deprivation after two consecutive

nights of adequate sleep (6-8 hours), even after several days of working 12-hour shifts.10  Consider that evidence as you complete the following nights of adequate sleep (6-8 hours), even after several days of working 12-hour shifts.10  Consider that evidence as you complete the following checklist.checklist.

To assess fatigue risks and consequences, recall your most To assess fatigue risks and consequences, recall your most recent work experience, then recent work experience, then circlecircle each factor that applies to each factor that applies to

your current situation:your current situation:A. Consider your SCHEDULEA. Consider your SCHEDULE

I worked the following: I worked the following:

1. more than 12.5 concurrent hours in a 24 hour period. 1. more than 12.5 concurrent hours in a 24 hour period. (O)(O)2. more than my scheduled hours in the past 48-72 hours. (O)2. more than my scheduled hours in the past 48-72 hours. (O)((OvertimeOvertime is defined as a worked shift/actual hours worked as is defined as a worked shift/actual hours worked as exceeding exceeding scheduledscheduled hours, whether voluntary or mandated). hours, whether voluntary or mandated).

3. more than 40 hours in the week. 3. more than 40 hours in the week. (O) (O) on-call” hours during which I returned to work for patient care. on-call” hours during which I returned to work for patient care.

((On-call On-call hours are an addition to regularly scheduled hours hours are an addition to regularly scheduled hours and may result in overtime, evening or night shift work, and may result in overtime, evening or night shift work,

weekend hours, and significantly increase the total number of weekend hours, and significantly increase the total number of hours worked each week). (0) hours worked each week). (0)

5. an evening or night shift. 5. an evening or night shift. (O)(O)6. returned to work after fewer than 10 hours off since my last 6. returned to work after fewer than 10 hours off since my last

shift. shift. (O)(O)

B.  Consider your WORK ENVIRONMENT:B.  Consider your WORK ENVIRONMENT:            My work style includes:             My work style includes:

1. Work without breaks  1. Work without breaks  (O)(O)2. Work at a high pace. 2. Work at a high pace. ((Work paceWork pace is the speed at which is the speed at which decisions and nursing assessments are made and actions decisions and nursing assessments are made and actions

are planned).are planned). 3. Experience of psychological strain while at work.3. Experience of psychological strain while at work.    

((Psychological strainPsychological strain includes emotional demands of work, includes emotional demands of work, mental effort, and relationships with peers and/or mental effort, and relationships with peers and/or

supervisors). supervisors). 4. Work when I was scheduled OFF. 4. Work when I was scheduled OFF. (O)(O)

C.   Consider your SLEEP and related ISSUES: C.   Consider your SLEEP and related ISSUES:    

         Regarding sleep, I have:          Regarding sleep, I have:   

1. Difficulty staying awake while at work.1. Difficulty staying awake while at work.2. Fallen asleep at work2. Fallen asleep at work

3. Slept fewer than 6-7 hours before returning to 3. Slept fewer than 6-7 hours before returning to work.work.

D.  D.   Consider your PERSONAL ISSUES: Consider your PERSONAL ISSUES:  In my personal life, I have:  In my personal life, I have:

1. Worked while sick in the past few days1. Worked while sick in the past few days2. Experienced drowsiness while driving2. Experienced drowsiness while driving3. Experienced recent mood changes at 3. Experienced recent mood changes at workwork4. Worked more than 1 job.4. Worked more than 1 job.

ASPAN Position StatementASPAN Position Statement

SWT will update and strengthen position statement SWT will update and strengthen position statement utilizing primary fatigue evidence utilizing primary fatigue evidence

Incorporate ASPAN Fatigue Evaluation Checklist Incorporate ASPAN Fatigue Evaluation Checklist in the in the “ “2008-2010 ASPAN Standards of 2008-2010 ASPAN Standards of PeriAnesthesia Nursing Practice”PeriAnesthesia Nursing Practice”

Fatigue CountermeasuresFatigue Countermeasures Employer Responsibilities

Appropriate scheduling practices Appropriate scheduling practices

including sufficient rest periods including sufficient rest periods between shifts, avoidance of more than between shifts, avoidance of more than 3-4 consecutive night shifts.3-4 consecutive night shifts.

Avoidance of early shift start times.Avoidance of early shift start times.

Control over overtime and the use of Control over overtime and the use of extended shiftsextended shifts

Provision of adequate break periods Provision of adequate break periods during the shift, and the institution of during the shift, and the institution of policies that allow night shift workers policies that allow night shift workers to sleep during their breaksto sleep during their breaks

Employee Responsibilities

Refuse to work more than 12 Refuse to work more than 12 consecutive hours or more than 40 consecutive hours or more than 40 Hrs. per week.Hrs. per week.

Arrive at work “fit for duty,” having Arrive at work “fit for duty,” having obtained more than at least 6-7 obtained more than at least 6-7 hours of sleephours of sleep

Therapeutic use of caffeineTherapeutic use of caffeine

Take regular breaks, if insufficient Take regular breaks, if insufficient staffing to take staffing to take

Dr Ann RogersDr Ann RogersBaltimore, MDBaltimore, MD

August 24, 2007August 24, 2007

PACU Nurse’s Ethical PACU Nurse’s Ethical ResponsibilityResponsibility

Ensure work practices are healthy and fit Ensure work practices are healthy and fit for duty to make cognitive decisions in the for duty to make cognitive decisions in the best interest of the patient best interest of the patient

Elements of NegligenceElements of Negligence Duty to the patientDuty to the patient Breach the duty to the patientBreach the duty to the patient CausationCausation HarmHarm

What do you think of when What do you think of when you hear the word --you hear the word --

“Fatigue” ?“Fatigue” ?

Let’s examine the risk factors Let’s examine the risk factors of alarm fatigueof alarm fatigue

Alarm FatigueAlarm Fatigue The Joint Commission proposal: 2014 National The Joint Commission proposal: 2014 National

Patient Safety Goal on Alarm ManagementPatient Safety Goal on Alarm Management Results from “alarm” sounding so constant that Results from “alarm” sounding so constant that

health care providers become desensitized, health care providers become desensitized, either not noticing them or ignoring them either not noticing them or ignoring them altogetheraltogether

Peds PACU explored alarm data from the 32 Peds PACU explored alarm data from the 32 physiologic monitors and discover:physiologic monitors and discover:

3463 times the oxygen saturation alarm was 3463 times the oxygen saturation alarm was activated in one dayactivated in one day

ACCN ACCN

Alarm fatigue is a complex issue: Alarm fatigue is a complex issue: Unique set of circumstances and vulnerabilitiesUnique set of circumstances and vulnerabilities

— Hospital and organizational cultureHospital and organizational culture— Nuisances specific to patient unitNuisances specific to patient unit

Many variations of common problemsMany variations of common problems

— Apathy for “leads off” and “low battery” alarmsApathy for “leads off” and “low battery” alarms— Communication breakdownsCommunication breakdowns— Competing prioritiesCompeting priorities

Alarm data areAlarm data are difficult to obtaindifficult to obtain

AACN 2013AACN 2013

AACNAACN

Alarm Integration ModelAlarm Integration Model Clinical device alarms are transmitted to a Clinical device alarms are transmitted to a

central system.central system. System communicates with caregiver via System communicates with caregiver via

devices such as a pager or telephone.devices such as a pager or telephone. System has potential to:System has potential to:

— Relay alarms onlyRelay alarms only— Attempt to filter out nuisance alarmsAttempt to filter out nuisance alarms— AACN 2013AACN 2013

Johns Hopkins HospitalJohns Hopkins Hospital Demonstrated that the number of non-actionable alarms can be Demonstrated that the number of non-actionable alarms can be

reduced: reduced: — Thereby decreasing caregivers’ alarm burden without Thereby decreasing caregivers’ alarm burden without

compromising patient safety by making modest default parameter compromising patient safety by making modest default parameter changes; changes;

— Standardizing care policies and equipment; and Standardizing care policies and equipment; and — Providing reliable secondary alarm notification. Providing reliable secondary alarm notification. The organization invested the time to understand the problem.The organization invested the time to understand the problem.— Studied and tested various solutions Studied and tested various solutions — Shared knowledge among various staff and departments Shared knowledge among various staff and departments The project was a collaborative effort, involving contributions from The project was a collaborative effort, involving contributions from

nurses, physicians, clinical engineers, and IT personnel, as well nurses, physicians, clinical engineers, and IT personnel, as well as the cooperation of the hospital’s monitor vendoras the cooperation of the hospital’s monitor vendor

Peds PACU Alarm ActivityPeds PACU Alarm Activity

One 24 hr. Day SurveillanceOne 24 hr. Day Surveillance 70-80 Pediatric Patients/Day70-80 Pediatric Patients/Day 1032 SPO2 Probe Alarms1032 SPO2 Probe Alarms 957 Lead Fail Alarms957 Lead Fail Alarms 695 HR LO Alarms695 HR LO Alarms 478 SPO2 LO Alarms478 SPO2 LO Alarms 341 Respiratory Rate Alarms 401 Alarms341 Respiratory Rate Alarms 401 Alarms 311 HR HI Alarms311 HR HI Alarms 60 Apnea Alarms60 Apnea Alarms

Unit-Based Initiative: Revamping Unit-Based Initiative: Revamping Alarm ManagementAlarm Management

Peds PACU Staff analyzed alarm parameters & alarm Peds PACU Staff analyzed alarm parameters & alarm levels to determine if they are appropriately set & avoid levels to determine if they are appropriately set & avoid duplication.duplication.

Alarm parameters should be set to actionable levels to Alarm parameters should be set to actionable levels to decrease the number of false or “nuisance” alarms decrease the number of false or “nuisance” alarms occurring and increase the likelihood of the alarm being occurring and increase the likelihood of the alarm being an actionable alarm so it will not be ignored.an actionable alarm so it will not be ignored.

Nurses must be trained to individualize alarm parameters Nurses must be trained to individualize alarm parameters & levels so alarms that occur are meaningful and & levels so alarms that occur are meaningful and actionableactionable

Institutions would do well to establish an institution wide Institutions would do well to establish an institution wide standard for management of physiologic monitor alarmsstandard for management of physiologic monitor alarms

Case Studies on Alarm FatigueCase Studies on Alarm Fatigue

53 year old male admitted to the PACU 53 year old male admitted to the PACU with OSAwith OSA

2 year old female undergoing a 2 year old female undergoing a circumcisioncircumcision

38 year old female undergoing an 38 year old female undergoing an abdominal hysterectomyabdominal hysterectomy

5 year old male undergoing T&A5 year old male undergoing T&A

Unwanted SedationUnwanted Sedation

Postanesthesia care nurses should always Postanesthesia care nurses should always be vigilant in assessing the potential for be vigilant in assessing the potential for postoperative opioid-induced respiratory postoperative opioid-induced respiratory depression.depression.

1. Inadequate gas exchange1. Inadequate gas exchange

2. Demand for oxygen exceeds supply2. Demand for oxygen exceeds supply

3. Failure of lungs to remove carbon 3. Failure of lungs to remove carbon dioxidedioxide

“Serial sedation and respiratory assessments are recommended to evaluate patient response during opioid

therapy by any route of administration.” 1 [Level 1]

Regular sedation and respiratory assessments during wakefulness and sleep 1 [Level 1]

Sedation scales with acceptable reliability & validity should be used. 1 [Level 1]

Unwanted or advancing sedation from opioids is often a sign that the patient may be at higher risk for respiratory depression, suggesting the need for increased frequency of assessment of sedation levels and respiratory status. 1 [Level 1]

“Respirations should be counted for a full minute and qualified according to rhythm and depth of chest excursion while the patient is in a restful/sleep state in a quiet unstimulated environment.” 1 [Level

1]

“Serial sedation and respiratory assessments are recommended to evaluate patient response during opioid

therapy by any route of administration.” 1 [Level 1]

“Patients should not be transferred between levels of care near peak effect of medication.” 1, 10 [Level 1, Level 2]

D. Patients found to have signs of respiratory depression, evidence of advancing sedation, poor respiratory effort or quality, snoring or other noisy respiration of desaturation should be aroused immediately and instructed to take deep breaths. 1, 8 [Level 1; Level 3-c]

E. “Technology-supported monitoring (i.e., continuous pulse oxymetry and capnography) can be effective for patients at high risk for unwanted advancing sedation and respiratory depression.” 1 [Level 1]

“Technology monitoring systems that integrate with medication delivery features, such as modular ETCO2 devices, may interfere with individualizing analgesia therapy or effective analgesia.” 1 [Level 1]

“Serial sedation and respiratory assessments are recommended to evaluate patient response during opioid

therapy by any route of administration.” 1 [Level 1]

F. More vigilant monitoring of sedation and respiratory status should be performed when patients may be a greatest risk for adverse events:

i. Peak of medication effect 1 [Level 1]

ii. During the first 24 hours after surgery 1, 8 [Level 1; Level 3-c]

iii. After an increase in the dose of an opioid 1 [Level 1]

iv. Coinciding with aggressive titration of opioids 1 [Level 1]

v. Recent or rapid change in end-organ function (specifically hepatic, renal, and/or pulmonary) 1 [Level 1]

vi. When moving from one opioid to another or one route of

administration to another 1 [Level 1]

vii. Within the first 6 hours after anesthesia 8 [Level 3-c]

viii. During the hours of midnight to 6AM 8 [Level 3-c]

 

Additive Effect of OpioidsAdditive Effect of Opioids

Morphine – End metabolitesMorphine – End metabolites Fentanyl – 80-100 times more potent than Fentanyl – 80-100 times more potent than

morphinemorphine Hydromophone (Dilaudid) 5-7 times more Hydromophone (Dilaudid) 5-7 times more

potent than morphinepotent than morphine

Why is Handoff So Important?Why is Handoff So Important?

PACU nurse’s duty to advocate PACU nurse’s duty to advocate for safe transfer or safe for safe transfer or safe

discharge!discharge!

Improving Perioperative HandoffsImproving Perioperative Handoffs

Inside:Inside:- Why improve hand offs?Why improve hand offs?- Video clip of a poor hand offVideo clip of a poor hand off- Highlights of baseline studyHighlights of baseline study- New hand off protocolNew hand off protocol- New hand off content checklistsNew hand off content checklists

Why Improve Handoffs?Why Improve Handoffs?

High risk periods for miscommunicationHigh risk periods for miscommunication Associated with increased risk for patient Associated with increased risk for patient

adverse events. adverse events. In a recent analysis of 240 malpractice cases In a recent analysis of 240 malpractice cases

involving medical errors, >66% involved involving medical errors, >66% involved teamwork breakdownsteamwork breakdowns errors due to hand offs were twice as errors due to hand offs were twice as

prevalent among physician trainees. prevalent among physician trainees.

Weinberger,S.E. 2006; Laine,C. 1993; Petersen,L.A. 1994; Sinha,M., 2007; Orwitz,L.I. 2006

Why improve postoperative hand Why improve postoperative hand offs?offs?

Few examples from PACU events:Few examples from PACU events:

Isolation status not reported to PACU so isolation Isolation status not reported to PACU so isolation precautions were not observed and other PACU precautions were not observed and other PACU patients were put at risk (multiple instances)patients were put at risk (multiple instances)

Multiple reports of missing information issues prior Multiple reports of missing information issues prior to patient arrival, and after admission to unit. to patient arrival, and after admission to unit.

Missing information issues regarding future care Missing information issues regarding future care plan plan

Need to use Peds examples

Improving Perioperative Hand offsImproving Perioperative Hand offs

Inside:Inside:- Why improve hand offs?Why improve hand offs?- Video clip of a poor hand offVideo clip of a poor hand off- Highlights of baseline studyHighlights of baseline study- New hand off protocolNew hand off protocol- New hand off content checklistsNew hand off content checklists

What did you observe?What did you observe?

NoisyNoisy Overlapping conversationsOverlapping conversations Side conversationsSide conversations Completely unstructuredCompletely unstructured Silos of careSilos of care Lack of TeamworkLack of Teamwork

Improving Perioperative Hand Offs:Improving Perioperative Hand Offs:Johns Hopkins Baseline Study Johns Hopkins Baseline Study

JHH Descriptive Study

Surveyed 82 nurses & physicians

Studied hand off problems

Conducted a series of focus groups to discuss potential interventions

Top 5 issues:Top 5 issues: Different communication Different communication

stylesstyles Providers not at bedsideProviders not at bedside Simultaneous tasks of Simultaneous tasks of

technology and technology and information transferinformation transfer

Reduced opportunity to Reduced opportunity to ask questionsask questions

Handoff Content Checklist: SurgeryHandoff Content Checklist: Surgery

□ Actual Surgery Performed

□ Surgical findings (anticipated & unanticipated)

□ Surgical complications

□ Drains/tubes — location, number, and type

□ Special instructions

e.g. “chest tubes to suction for 12 hrs”

“remove NGT in 6 hours”

“nasal cannula sutured in naris” etc.

2011 JHH PACU Studies

Handoff Content Checklist: SurgeryHandoff Content Checklist: Surgery

□ Actual Surgery Performed

□ Patient Disposition (home, floor, IMC/ICU) and if to be discharged provide discharge instructions

□ Responsible 1° service (medicine, ortho etc.)

□ Who to Page

Conclusion: “The thing that I am most concerned about in this patient is __________.”

2011 JHH PACU Studies

Handoff Content Checklist: NursingHandoff Content Checklist: Nursing

□ Actual surgery performed

□ Isolation Type (if applicable): Contact, Airborne …

□ Lines - IV , CVP, Art line , PiC Line ...

□ Drains - Foley, JP, Davol, Neprostomy tube …

□ Skin Inspection e.g. alteration of skin integrity, pressure points, location,…

□ Packing: rectal, vaginal, nasal...

□ Special Equipment/ Others: Iceman, Vac machine, SCD Sleeves /TED …

2011 JHH PACU Studies

Handoff Content Checklist: NursingHandoff Content Checklist: Nursing

□ Actual Surgery Performed

□ Special needs: Wheelchair, chemo, pacemaker/shunt re-program necessary

□ Psychosocial / behavioral issues

□ Family Information: Spouse, children …

□ Belongings and Valuables

□ Events / Concerns

Conclusion: “The thing that I am most concerned about in this patient is __________.”

2011 JHH PACU Studies

Handoff Content Checklist: AnesthesiaHandoff Content Checklist: Anesthesia

Preop:□ History of Present Illness

□ Allergies and CODE status

□ Meds- specify which taken prior to surgery (esp. beta blockers, sedatives, antibiotics)

□ Baseline vital signs; height; weight

□ Baseline physical exam – neurologic, demeanor etc.

□ Baseline labs

2011 JHH PACU Studies

Handoff Content Checklist: AnesthesiaHandoff Content Checklist: Anesthesia

Intraop:

□ Airway – intubation technique, abnormalities etc.

□ Lines – size, location etc.

□ Procedures – blocks, spinal etc.

□ Fluid totals

□ Paralytic status - relaxed, reversed

□ Labs

□ Meds: Narcotic totals, antibiotics, anticoagulant, anticonvulsant , reversal agents etc.

□ Key events - e.g. unexpected episode of SVT/hypotension/hypoxia etc.

Conclusion: “The thing that I am most concerned about in this patient is __________.” 2011 JHH PACU Studies

Handoff of CareHandoff of Care

“The thing that I am most concerned about in this patient is: this patient received 500 mcg and 40mg Morphine in the OR. Please note the patient needed to be reversed twice – one in the OR and 1 hour ago in the PACU.

The patient had an anterior cervical fusion Be sure to watch for snoring as that is a sign of

partial airway obstruction”.

Advocacy:Advocacy: “From Silence to “From Silence to

Voice”Voice”““Today’s nurses have a critical Today’s nurses have a critical

opportunity to affect the future of opportunity to affect the future of nursing….nursing….

Nurses can have a profound impact on Nurses can have a profound impact on healthcare if, and only if, they will healthcare if, and only if, they will work together and speak out.”work together and speak out.”

Dorothy NovellaDorothy Novella