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Postoperative handoff communication in practice:
An observational study based on an SBAR
Abraraw Lehuluante RN, Spec. Primary Care Nursing; Msc, Nursing Science Spring 2013
Theatre Care, Thesis of 15 credits for a Degree of Master of Medical Science (60
credits), 15.0 Credits
Advisor: Inger Öster; RNT, Ph.D
Table of contents Abstract
Abstrakt
Background ................................................................................................................................................... 1
Patient safety and care- related adverse events: a birds-eye- view ............................................................ 1
The place of handoff communication in causing CRAE ........................................................................... 2
The quest for safer handoff methods ......................................................................................................... 4
SBAR: a synopsis of its development and use in handoff communication ............................................... 5
SBAR: its use in postoperative nursing handoff communication ............................................................. 6
Aim ................................................................................................................................................................ 7
Study design .................................................................................................................................................. 7
Method of data collection .......................................................................................................................... 7
Method of data analysis and interpretation ............................................................................................... 8
Ethical considerations ................................................................................................................................ 8
Results ........................................................................................................................................................... 9
Patient characteristics ................................................................................................................................ 9
Postoperative handoffs ............................................................................................................................. 9
Table 1: patient characteristics .............................................................................................................. 9
Table 2: patients with no SN- delivered postoperative handoffs ......................................................... 10
Table 3: observation checklist with contents of handoff communication .......................................... 12
Discussion ................................................................................................................................................... 14
Method discussion ....................................................................................................................................... 17
Conclusion and recommendation ................................................................................................................ 18
Reference ..................................................................................................................................................... 19
Appendix i
Abstract
Background: The health, psychosocial and economic costs of care- related adverse events
(CRAE) have been known for quite some time. One of the main causes of preventable CRAE has
been communication failures on the part of care- giving staff. It has been known that surgical
patients are more prone to CRAE and one of the efforts that have been made to reduce CRAE has
been the introduction of standardized handoff communication tools such as the situation,
background, assessment, and recommendation (SBAR) mnemonic. However, there is scantiness
in research regarding the extent and content of surgical nurses’ (SN) handoff communication
compared with SBAR. Aim: The aim of this study was to explore the extent to which SN made
postoperative handoff reports as well as to describe the agreement in structure and content
between SN handoff reports and the SBAR adapted for postoperative handoff communication.
Study design: A non- participant observation method was used to collect data as handoff
communications took place at a post- anesthesia intensive care unit (PAICU). Both SN and
PAICU nurses were acquainted with SBAR and recommended to use the SBAR version adapted
to use by their respective clinics. Data was collected by a checklist prepared from a SBAR
version adapted to use in postoperative settings. Collected data was analyzed quantitatively
complemented by field notes. Results: SN made postoperative handoffs in 9 (41%) of the 22
observations made at the PAICU. The amount of information delivered per patient ranged from
6.7 to 36.7 % making the average amount of information omitted per patient to 76%. The mean
handoff time was 60. 8s (Std ± 20.9s). Conclusion: The results of this study have shown that the
responsibility of delivering postoperative patient- related information was not discharged
adequately. The structures and contents of handoff communications were also found to be
inadequate. There is a need for further research to design adequate communication tool that either
specify the part of patient- related information that each member of the multi professional team
can handle adequately and deliver effectively and responsibly or make this information delivery a
collective responsibility and specify how best it can be transferred between clinics.
Key word: intensive care, postoperative handoff, SBAR, communication, adverse events
Abstrakt
Bakgrund: Hälsomässiga, psykosociala och ekonomiska kostnaderna av vårdrelaterade skador
(CRAE) har varit kända sedan länge. En av de viktigaste orsakerna till CRAE har varit bristfällig
kommunikation bland vårdpersonal. Det har varit känt att kirurgiska patienter är mer benägna att
drabbas av CRAE och en av de ansträngningarna som gjorts för att minska CRAE har varit
införandet av standardiserade kommunikationsverktyg så som situationen, bakgrund, utvärdering
och rekommendation (SBAR) mnemonik. Det finns emellertid brist på specifika studier som
fokuserade på i vilken utstreckning operationssköterskor (SN) sköter postoperativa rapporter
samt hur strukturerade och innehållsrika sådana rapporter kan vara. Syfte: Syftet med studien var
att undersöka i vilken utsträckning SN sköter postoperativa överrapporteringar samt att beskriva
hur pass överrapporteringarnas struktur och innehåll överensstämmer med en SBAR version som
tagits fram för postoperativ överraportering. Studiedesign: En icke - deltagande observation
metod användes för att samla in data då postoperativa rapporter lämnades över till sköterskor som
jobbade på intensivvårdsavdelning (PAICU). Både SN och PAICU sjuksköterskor var bekanta
med SBAR och använder en anpassad SBAR version som rekommenderades av respektive
kliniker. Data samlades in genom at utforma en checklista från en SBAR version som är anpassad
för användning i postoperativa överrapporteringar. Insamlade data analyserades kvantitativt och
kompletterades med fältanteckningar. Resultat: SN gjorde postoperativa överrapporteringar
under 9 (41 %) av de 22 observationer som gjordes på PAICU. Mängden information som
överrapporterades per patient varierade från 6,7 till 36,7 % vilket gjorde den genomsnittliga
mängden per patient till 76 %. Den genomsnittliga överrepporteringstiden per patient var 60. 8s
(Std ± 20.9s). Slutsats: Denna studie har visat att postoperativa patientrelaterad information ej
överrapporterades fullt ut. Strukturen samt innehållen i överrapporteringarna var ej adekvat. Det
finns ett behov av ytterligare forskning för att utforma lämpliga kommunikationsverktyg som
antingen specificerar den del av patientrelaterad information som varje medlem i det
multiprofessionella operationsteamet kan hantera och leverera på ett effektivt och ansvarsfullt sätt
eller göra överrapporteringen ett kollektivt ansvar och specificera hur bäst det kan överföras
mellan kliniker/vårdavdelningar.
Key word: intensivvård, postoperativ överrapportering, SBAR, kommunikation, vårdrelaterade skador
1
Background
Patient safety and care- related adverse events: a birds-eye- view
Ensuring the safety and wellbeing of the care- receiving patient is often deemed to be a clear priority of the care profession in general
and the nursing profession in particular (Richardson & Storr , 2010; Smeds et al. 2013). Patient safety has much to do with protecting
the patient from care- related physical and psychic injuries or sufferings (The Swedish Patient Safety Act (2010:659), [Online]).The
World Health Organization (WHO) defines patient safety as “ …the absence of preventable harm to a patient during the process of
health care” (WHO, [Online]). The Hippocratic “first, do no harm” has been well known within the medical profession for centuries.
However, care- related adverse events (CRAE) have continued to occur (Öhrn, 2012).
Although studies in patient safety and CRAE existed since the 1950s, it was during the past two decades that the problem started to
attract much attention (WHO, 2002; Öhrn, 2012; Toffoletto & Ruiz , 2013).The report entitled “To Err Is Human: Building a Safer
Health System” that was authored by the Institute of Medicine (IOM) has been often cited as the ground breaking work that brought
to light the seriousness of the problem of unsafe care (Öhrn, 2012; Toffoletto & Ruiz , 2013). The report revealed that 44,000 to
98,000 Americans died annually mainly due to care- related incidents that were largely preventable (Toffoletto & Ruiz, 2013). After
this report a number of international, regional and national investigations were conducted in CRAE and means of reducing them
(WHO, 2002; Farley et al., 2008; Perneger, 2008; Soop et al.; 2009). For example, a European study done by the year 2000 revealed
that every tenth patient in hospitals in Europe suffered from preventable harm and CRAE related to his or her care (WHO, 2002). In an
Australian study covering more than 14,000 admissions that led to 17% CRAE, 11% of those events were associated with
communication problems (Riesenberg, Leitzsch & Cunningham, 2010). Even though patient safety has been ensured by law in
Sweden, unsafe care affects about 100 000 patients every year (The National Board of Health and Welfare, [Online]; The Swedish
Patient Safety Act 2010:659, [Online])). A Swedish study that included 1967 patients in 28 hospitals revealed that 12.3 % of the
patients were affected by CRAE among which 70 % were preventable. Moreover, the report specified that 55% of the incidents of
2
these preventable events led to impairments or disabilities that were resolved during the time of admission or within a month from
discharge. Some other 33% of them were resolved within a year, 9% of the preventable events led to permanent disability, and 3% of
the CRAE contributed to deaths (Soop et al., 2009). Besides the tremendous effects of CRAE on the quality of life of individual
patients and their relatives, their enormous economic consequences did not pass unnoticed. The US 1.5 million CRAE occur annually
among which 26% are preventable. The cost of such preventable CRAE reaches 910 million dollar annually (Pham et al., 2012)
The place of handoff communication in causing CRAE
Although there are questions and controversies around its definition and connotation, (Cohen & Hilligoss, 2010) the term “handoff ”
often refers to a contemporaneous, interactive process of passing patient specific information from one caregiver to another for the
purpose of ensuring the continuity and safety of patient care (Wayne et al., 2008). It is not only a transfer of information but
professional responsibility, accountability and authority for some or all aspects of care for a patient or groups of patients, to another
person or professional group on a temporary or permanent basis (Abraham et al., 2011; Manser & Foster ; 2011). Handoff
communication is a natural part of patient care and as such a potential moment of risk that can lead to CRAE that compromise patient
safety (Manser & Foster; 2011).
The single most important outcome of reports of CRAE has been the urge to investigate the root causes of these failures. Such kind of
investigation triggered by reports like “To Err Is Human…” was the 2004 Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) investigation in root causes of near- miss and CRAE. In the JCAHO root cause analysis of infant deaths and
permanent disabilities, for example, faulty or delayed communication was found to cause 72% of the CRAE (Guise & Lowe, 2006).
JCAHO report further revealed that CRAE due to communication failures increased from 65% in 2004 to 70 % 2005, with 50% of
those events happening during the hand-off communication (Sandlin, 2007)
Vulnerability to CRAE is much higher in surgical patients since patients are more exposed to handoff errors than patients in other
clinical specialties (Amato-Vealey, Barba & Vealey 2008; Ong & Coiera, 2011). Surgical patients often pass a number of checkpoints
3
and transitions that occur throughout pre- intra - and postoperative care. It suffices to have in mind the number of caring staff that not
only exchange hands but also exchange information when a surgical patient goes through pre- intra- and postoperative care as well as a
number of clinics and intermediary units. Besides, care provided in all phases of the perioperative process is often characterized by
rapid turnover, the demand for increased speed and efficiency, and the need to accelerate throughput for the surgical patient (Amato-
Vealey, Barba & Vealey 2008). Such speedy transfers are often followed by speedy handoffs and thereby broader chances for
communication failure.
Lingard et al. (2004) found that communication failures in operation rooms (OR) occurred in approximately 30% of cases during team
exchanges and a third of these resulted in effects which jeopardized patient safety. The authors observed 421 communication events of
which 129 were categorized as being tainted with communication failures. Failure types included untimeliness in reporting, missing or
inaccurate information, and information exchange where key individuals were excluded. It is not difficult to discern that such
communication failures can lead to further errors and CRAE as patients transfer to post- anesthesia intensive care unit (PAICU) and
from there to clinics and/or outpatient care settings. Studies have indicated that information breakdown is frequent when patients
transfer from one to another clinic than within a clinic (Ong & Coiera, 2011)
A review of 38 articles that focused on communication failures showed that information transfer failures were common in surgical care
and were distributed across the continuum of care (Nagpal et al., 2010 a). Greenberg et al. (2007) found 81 communication
breakdowns in 60 surgical cases leading to reported CRAE. Of these errors 38% occurred during the preoperative phase, 30% during
the intraoperative and 32% during the postoperative period. The authors found that the majority of these breakdowns occurred during
verbal communications involving one transmitter and one receiver. Nagpal et al. (2010 b) followed 20 patients through the surgical
journey and found that preoperative and postoperative handoffs were poor, incurring an information loss of 61.7% and 52.4%
respectively. Preoperative verbal handoff from the ward to the OR was completed for only 45% of the patients. They found that only
66% of the patient-specific information, 67% of the anesthetic information, and 30% of the essential surgical information was
transferred.
4
The quest for safer handoff methods
After studies and reports in communication breakdowns unveiled subsequent CRAE the quest for better and safer communication
methods started to be heard louder. Problems associated with patient handoff have been an international concern for some time and
countries like Australia, the UK and Northern Ireland had reviewed this issue, and developed risk reduction recommendations (WHO,
2007). In the USA, following the JCAHO report, calls for standardized approach to handoff communications were made (Odom-
Forren, 2007; Mascioli et.al. 2009). Accreditation Council on Graduate Medical Education (a comparable counterpart to The Swedish
National Board of Health and Welfare) had formalized the requirement of proficiency in communication skills (Horwitz, Moin &
Green, 2007). WHO has joined the call for standardization in handoff communication (Wacogne & Diwakar; 2010).
The question of how, where and what a handoff communication should include has also been a matter of discussion. Research
literature shows that there are different ways and means of conducting handoff communication depending on location and the mode of
communication. Information can be delivered verbally (either in person or by using devices for voice messages), in a pre-typed
handover document etc. It can be delivered at a bedside, at the nurses’ station, or in a staff room (Kerr 2002; O’Connell & Penney
2001).Each type of handoff communication and communication setting can have its own advantages/disadvantages. However, written
handoff communication can by no means be a substitute to face to face communication since it gives no room to discussions and
opportunities to ask questions (Rothrock, 2011)
It has been suggested that the information communicated during handoff should be current, complete and concise and the receiving
caregiver should be given an opportunity to read back, repeat back, and ask questions as needed (Sandlin ,2007; Mascioli et.al. 2009;
(Rothrock , 2011). It has been further suggested that adequate time should be given for the handoff period and interruptions should be
limited. Minimal content requirements include current condition of the patient, recent changes in condition, pertinent history, test
results, current vital signs, diagnosis, planned treatment, response to treatment already given, and plans for future treatment (Sandlin
,2007; Rothrock , 2011) . Communication is said to be ineffective and potentially dangerous if it’s incomplete, confusing, unclear,
misunderstood, not standardized, misinterpreted, or nonexistent (Mascioli et.al. 2009).
5
There were clear efforts made by healthcare systems to learn from other institutions and organizations that had standardized
communication tools for safety. The aviation industry and military institutions were mentioned in the research literature as potential
sources of experience in safety measures (Leonard, Graham & Bonacum; 2004; Guise & Lowe; 2006, Catchpole et al. 2007).As
mentioned below, these efforts yielded some results.
Efforts made to improve handoff communication have led to some innovative ways of organizing information. Several mnemonics
such as SBAR (Situation, Background, Assessment , Recommendation); I PASS the BATON (Introduction , Patient Assessment,
Situation, Safety, Background, Actions, Timing , Ownership, Next), SHARQ first version ( Situation, History , Assessment,
Recommendations, Questions), 5 Ps (Patient, Plan, Purpose of Plan, Problem, Precaution ), EIDET (Acknowledge the patient,
Introduce yourself, Duration of the procedure, Explanation of process and what happens next, Thank you for choosing our hospital
(note: handoff done at bedside), SIGNOUT (Sick or do not resuscitate/ do not intubate patient, Identifying data (name, age, gender,
diagnosis), General hospital course, New events of the day, Overall health status/clinical condition, Upcoming possibilities with plan,
rationale, Tasks to complete overnight with plan ) etc. have been some of them (Sandlin, 2007; Riesenberg, Leitzsch & Little 2009).
SBAR: a synopsis of its development and use in handoff communication
SBAR was adapted from the U.S. Nuclear Navy safety communication tools and developed by Michael Leonard to be used in care
settings (Haig, Sutton & Whtington, 2006; Frankel, Leonard, & Denham, 2006). Following reports that revealed the contribution of
communication breakdown on near- miss and CRAE efforts were made to reduce the risks. A small patient safety workgroup within
Kaiser Permanente (Colorado) was constituted and during a brainstorming session, Doug Bonacum (a captain and a former safety
officer in the US Navy nuclear submarine), described the SBAR version he developed and used in the Navy (Heinrichs, Bauman &
Dev, 2012). Michael Leonard and co-workers Doug Bonacum and Suzanne Graham, adapted a SBAR version that could be uses in
healthcare (Moorman, 2005; Haig, Sutton & Whtington, 2006 Heinrichs, Bauman & Dev; 2012).
6
Amato-Vealey, Barba, and Vealey (2008) wrote that the SBAR communication mnemonic was meant to specify four central
components of a handoff communication. According to them the person who hands –over should:
1) Situation- explains what was going on with the patient; identify oneself and the patient, and state the problem of the patient.
2) Background- explain the patient’s background; review the chart before speaking up if the situation allows; anticipate questions
the other care provider may have.
3) Assessment- provides one’s observations and evaluations of the patient’s current state.
4) Recommendation- makes an informed suggestion based on sound information for the continued care of the patient.
Following its application in care settings, SBAR has been recommended by various international and local institutions to be use in
health care. The WHO has recommended the use of it (WHO, 2007). SBAR has been recommended by The Swedish Association of
Local Authorities and Regions (SALAR), The Swedish National Board of Health and Welfare, and The Swedish Association of Health
Professionals (Socialstyrelsen [Online]; SKL [Online]; Vårdförbundet [Online]).
SBAR: its use in postoperative nursing handoff communication
The research literature offers little in relating postoperative nursing with the use of an adapted SBAR that was meant to suit the
delivery of information from a surgical nurse (SN) to a nurse working in a post- anesthesia intensive care unit (PAICU). While
research literature unanimously deemed postoperative handoff communication as a moment of communication failure that in turn can
jeopardize patient safety, little has so far been said about the share of SN in this regard or the way SN can avoid making
communication errors. Reports of postoperative communication errors did not specifically differentiate the role SN plaid while
mistakes were made, although, as a member of the surgical team, SN could not avoid accountabilities.
The only research literature that has been quoted by teaching literature for SN and that has related postoperative nursing handoff with
the use of SBAR in postoperative settings was authored by Amato-Vealey, Barba & Vealey (2008) (cited in Rothrock, 2011). The
authors asserted that the surgical nurse should be as specific as possible about the OR events that have occurred while reporting to
PAICU nurse. They considered the passing of patient’s past medical history as important. Components of this handoff communication,
7
according to the authors, should include presenting information on how the patient tolerated the procedure, whether the procedure went
as planned, whether the patient was hemodynamically stable, whether the patient experienced any intraoperative complications, any
medication the patient received and his/her therapeutic responses, and the patient’s current comfort level.
As mentioned above, handoff communication is not only a transfer of information but also a transfer of responsibility and the
concomitant authority that enable the nurse to shoulder that responsibility. Although communication failure has been reported to occur
in postoperative settings little has been done to focus on to what extent SN discharge their responsibilities. Besides there is scantiness
in the research literature concerning the extent to which contents of real time postoperative patient handoff communications tally with
the contents of the SBAR version that has been recommended for postoperative handoff communication.
Aim The aim of this study was to explore to what extent SN discharge their responsibilities by making postoperative handoff
communication as well as to describe the agreement (in structure and content) between the SBAR adapted to postoperative handoff
communication and SN actual postoperative handoff communications.
Study design
Method of data collection
Non- participant observation method was chosen as a method of data collection. This observation method is suitable to collect data
during verbal communications by using checklists and rating scales (Polit & Beck, 2006). The observation was chosen to be non-
participant since this believed to allow the observer to be detached from activities focus on the phenomena observed. The setting
chosen to make the observations was a PAICU in a teaching hospital situated in Northern Sweden where patients aged three months
and above underwent both elective and emergency surgery. Both SN that delivered patients to the PAICU postoperatively and critical
care nurses that received patients at PAICU were acquainted with SBAR by their respective clinics earlier on.
8
Data was mainly collected by using a checklist adapted from the postoperative SBAR version proposed to use by Amato-Vealey,
Barba & Vealey (2008). The first version of the checklist was tested in the selected setting for its feasibility and inclusiveness.
Following the tests adjustments were made to include items such as patient- related data and whether SN discharges their
responsibilities by making handoff communications.
The sampling method chosen was convenient sampling where every postoperative handoff communication that was expected to take
place while the observer was not preoccupied by another observation was considered as eligible. The study was conducted for seven
days (two days used to make clinical test of the checklist included) of different length between the end of October and the middle of
December 2013. Data was collected by using the checklist during and immediately after each handoff communication. The non-
participant observer also took short notes not to miss relevant information as handoff communications took place. Total handoff time
was measured by using digital stopwatch. Patient- related data such as age and type of operation were mainly retrieved during handoff
communications.
Method of data analysis and interpretation
Collected data was analyzed by using descriptive statistical methods. The use of statistical methods in analyzing data collected by
observations has been well known in the research literature (Polit & Beck, 2006nagpa; Ilan et al., 2012). Field notes were used to
compile and analyze data that had to do with, for example, the types of surgery the patients underwent, assessment of the handoff
environment and whether chances were given to PAICU nurses to ask questions during handoffs. A complete handoff communication
was considered to fulfilled 30 out of the 30 handoff items included in the checklist and omissions were calculated on the basis that.
Ethical considerations
Consent was sought and obtained from the leadership for both the involved surgical and acute care units. The integrity of nurses and
patients as well as data from the observations was treated according to the 1964 Helsinki declaration and its subsequent revised
versions that are meant to protect study participants (World Medical Association, 2013).
9
Results
Patient characteristics
A total of 22 observations involving 10 male and 12 female patients were made at the PAICU. The patients were aged from 8 months
to 79 years with a median age of 46 years. A total of 6 patients (27 %) were under 10 years (table 1).
Postoperative handoffs Among the 22 patients that were fetched to the PAICU, only 11(50%) of them were accompanied by both anesthetist nurses (AN) and
SN. Of those 11 patients, SN made postoperative hand- over reports only for 9 patients (41% of the total number of patients). During
two of these 11 occasions SN left the PAICU area without making hand- over reports.
Table 1: patient characteristics
Age (year/s) Sex Type of operation
0,67 F Reconstruction, pharyngeal flap (soft palate)
1 M adenotonsillectomy
7 F Reconstruction of the hard palate by bone transplantation from crista iliaca.
8 F Ultrasound-guided botulinum toxin injection in the Iliopsoas muscle (pat had spastic paraplegia).
8 M Aspiration of bone marrow biopsy (becken bone) under anesthesia
11 F Teeth extraction and extirpation of cysts in the upper jaw.
30 F Episcleral sealing and episcleral circlage (left eye) due to retinal detachment.
33 F Extirpation of benign tumor (cyst) from right lower jaw bone
39 F Functional endoscopic sinus surgery (FESS), Ethmoidal
39 F Replacement of earlier breast prothesis
44 M Fixation with plat, proximal humeral fractures (right )
48 F Laparoscopic re-operation for uterine bleeding
54 M Repositioning of an open fracture with osteosynthetic material (plates and screws), ankle (talocrural region)
59 M Excision of malignant tumors, (right ear), removal of three Affected neck lymph nodes and skin transplantation to the operatation site.
60 M Removal of plates and screws, right shoulder
60 F Insertion of intrathecal catheter for infusion due to pain from metastasis in cervical and thoracic spines
64 M Laparoscopic splenectomy
68 F Vitrectomy
71 F Extirpation of pathological bit of bone from caput humeri (right)
74 M Removal of earlier osteosyntesis (plates and screws) from earlier fixation, foot (left).
75 M Percutaneous transluminal embolization of an abdominal blood vessel (unspecified!)
79 M Wound revision (crown) and skin transplantation to the crown
10
Handoffs were not made in a total of 13 (59 %) cases and these involved 9 female and 4 male patients. No handoff reports were made
for all of the pediatric patients (n= 6) (table 2). In other words, SN accompanied and delivered postoperative reports to PAICU nurses
during 9 (41 %) of the 22 occasions that involved a total of 6 male and 3 female patients (table 3).
Table 2: patients with no SN- delivered postoperative handoffs
Age Sex Type of operation Remarks
0,67 F Reconstruction, pharyngeal flap (soft palate) Parents/relatives were not available at the PAICU
7 F Reconstruction of the hard palate by bone transplantation from crista iliaca. Parents/relatives were not available at the PAICU
68
F
Vitrectomy
The SN forgot to bring patient document from the ophthalmological clinic
and went to fetch it. Never returned to the PAICU again
11 F Teeth extraction and extirpation of cysts in the upper jaw. Parents were not at the PAICU when the child arrived
8
F
Ultrasound-guided botulinum toxin injection in the Iliopsoas muscle (pat had
spastic paraplegia).
Parents waiting at the PAICU
8 M Aspiration of bone marrow biopsy (becken bone) under anesthesia Mother waiting at the PAICU
33 F Extirpation of benign tumor (cyst) from right lower jaw bone
30 F Episcleral sealing and episcleral circlage (left eye) due to retinal detachment.
1 M adenotonsilectomy Parents contacted by PAICU nurse
39 F Replacement of earlier breast prothesis
60 M Removal of plates and screws, right shoulder
60
F
Insertion of intrathecal catheter for infusion due to pain from metastasis in cervical
and thoracic spines
75
M
Percutaneous transluminal embolization of an abdominal blood vessel (Blood
vessel unspecified in postop. document )
The surgical nurse came, but left without making a handoff report
Handoff communications did neither follow SBAR nor were structured. In reports there identification of patients were made, reporting
used to start by the identification of patients. Then, SN would take up whatever point in SBAR (often information about dressing
material used) and continue the report to some length.
No SN started the handoff communication by introducing herself/himself. Patients were identified in 6 of the 9 occasions. Types of
invasive/ surgical procedures were mentioned in 67.8 % of the cases.
11
When it comes to items that were included under ‘Background”, SN reported about local anesthetics used (often Carbocain or Marcain
with Adrenalin) in 77. 8% of cases and the kind of material used in wound dressing in 55.5% of cases. Of the items included under
“Situation” urine production during the intra operative period or the amount of urine taped immediately before the start of the surgical
procedures was mentioned at 3 occasions (33%). Information about surgical complications (rather the absence of any complication)
was mentioned ones only ones.
Among the items included under “Recommendation”, SN informed PAICU nurses about the need to make hemodynamic controls
(specifically control of blood pressure in a hypertonic patient) ones, continuation in specific medication (pain killer) ones, the needs
for continued wound dressing and types of dressing materials to be used in 6 of the 9 occasions. Types of suture material used were
mentioned in 4 of the occasions where wound dressing was mentioned. In none of these occasions mention was made when and how
non- absorbable suture materials could be removed. Patients’ needs for mobilization were mentioned and recommendations in patients’
nutrition were mentioned 3 and 4 times respectively.
The amount of information delivered per patient ranged from 6.7 to 36.7 % with the mean percentage of 24 %. The average amount of
information omitted was 76%. It is important to note that these calculations were based on frequencies and did not include qualities of
reports. It was not methodologically possible to investigate and report whether each delivered handoff information contained errors or
not.
but one occasion where there was time for questions and answers. The initiative however came from the PAICU nurse. All of the
handoff communications were ended without SN inviting/giving time for PAICU to ask questions. Often there were tendencies from
the side of SN (such as being in haste, being in the urge to leave the PAICU area) that could have discouraged PAICU nurses from
asking questions.
12
Table 3: observation checklist with contents of handoff communication
Patient data
Age 44 39 54 74 79 64 71 59 48
Sex M F M M M M F M F
Type of operation
Fix
atio
n w
ith
pla
t, p
rox
imal
hu
mer
al
frac
ture
s (r
igh
t )
Fu
nct
ion
al e
ndo
sco
pic
sin
us
surg
ery
(FE
SS
), E
thm
oid
al
Rep
osi
tion
ing
of
an o
pen
fra
ctu
re w
ith
ost
eosy
nte
tic
mat
eria
l, (
talo
cru
ral
reg
ion
)
Rem
ov
al o
f ea
rlie
r o
steo
synte
sis
(pla
tes
and
scr
ews)
fro
m e
arli
er f
ixat
ion
, fo
ot
(lef
t).
wo
und
rev
isio
n (
cro
wn
) a
nd s
kin
tran
spla
nta
tio
n t
o t
he
cro
wn
Lap
aro
sco
pic
sp
len
ecto
my
Ex
tirp
atio
n p
ath
olo
gic
al b
on
e (c
apu
t
hu
mer
i ri
gh
t)
Ex
cisi
on
, m
alig
nan
t tu
mo
rs,
(rig
ht
ear)
,
rem
ov
al o
f th
ree
affe
cted
nec
k l
ym
ph
no
des
, an
d s
kin
tra
nsp
lan
tati
on
to
th
e
op
erat
ion
sit
e.
Lap
aro
sco
pic
re-
op
erat
ion
fo
r u
teri
ne
ble
edin
g
Situation
1) The nurse has presented herself No No No No No No No No No
2) The nurse has identified the patient
2:1) By name only - - - No - No - No -
2:2)By age only - - - No - No - No -
2:3) By personal number only - - - No - No - No -
2:4) By name, age and personal number Yes Yes Yes No Yes No Yes No Yes
3) Type of operative/ invasive procedure, named Yes Yes Yes Yes No No No Yes Yes
Background
1) Type of anesthesia administered mentioned No Yes Yes Yes No Yes Yes Yes Yes
2) Intraoperative medication mentioned No No No No No No No No No
3) Surgical cite information (dressing material, drainage,
packing etc.)
No
Yes
No
Yes
No
No
Yes
Yes
Yes
4) The way the patient was positioned during surgery named. No No No No No No No No No
Assessment
1) Most recent vital signs reported
1:1) Blood pressure No No No No No No No No No
1:2)Pulse rate No No No No No No No No No
1:3)Blood oxygen level No No No No No No No No No
1:4) Breathing rate No No No No No No No No No
1:5) Body temperature No No No No No No No No No
1:6) Urine output No No No No Yes No Yes No Yes
2) Changes that occurred during and after the surgery reported
2:1) Hemodynamic changes (blood losses etc.) mentioned No No No No No No No No No
2:2) Changes in skin color No No No No No No No No No
13
* Each reported item was given one point and the sum of the items under each patient was divided by 30, i.e. the sum total point for a
complete SBAR report.
**Seconds
Patient data
Age 44 39 54 74 79 64 71 59 48
Sex M F M M M M F M F
Assessment contd.
2:3)Changes in neurological status No No No No No No No No No
2:4) Surgical complication/s is/are reported No Yes No No No No No No No
2:5) Level of pain/ pain management intervention/s named No No No No No No No No No
Recommendation
1)Recommended controls in vital /neurological/
hematological etc. signs/controls are mentioned
No
No
No
Yes
No
No
No
No
No
2) Recommendation/continuation in specific medications
mentioned No No No Yes No No No No No
3)Recommendation/continuation in wound dressing, suture
removal, drainage management/removal mentioned No No Yes No Yes Yes Yes Yes Yes
4) Recommendations in pat. mobilization mentioned Yes No No No No No No Yes Yes
5) Nutritional recommendation are mentioned Yes Yes No No No No No Yes Yes
6) Date/time of discharge mentioned No No No No No No No No No
7)Date and time for readmission/ x-ray control /next visit/
mentioned No No No No No No No No No
8)Contact information about parents/relatives mentioned No No No No No No No No No
Time was given for questions and answers No No No No No No No Yes No
Total information delivered in %* 23 30 23 16.7 20 6.7 26.7 33 36.7 Total hand-off time 47s** 85s 47s 60s 65s 30s 32s 125s 56s
The handoff environment
Tal
ks
fro
m t
he
per
son
nel
des
k.
On
- go
ing
han
d-o
ver
at
a n
earb
y b
ed
Per
son
nel
tal
kin
g w
ith
oth
er p
atie
nts
.
Sn
ori
ng p
atie
nt
Rin
gin
g t
elep
ho
ne,
nu
rse
fro
m o
ther
cli
nic
s
tak
ing
rep
ort
s fr
om
a P
AIC
U n
urs
e.
per
sonn
el t
alk
ing w
ith
p
atie
nt
in n
ext
bed
,
rin
gin
g t
elep
ho
ne,
Qu
ite
situ
atio
n,
firs
t p
atie
nt
fo
r th
e d
ay
Tal
ks
and t
elep
ho
ne
con
ver
sati
ons
go
ing o
n
Sim
ult
aneo
us
han
do
ff c
om
mu
nic
atio
n t
o
PA
ICU
nu
rse
takin
g p
lace
nex
t bed
.
Has
sle
and
dis
turb
ing
co
mm
oti
ons
n ,
pat
ien
t ar
riv
ed f
rom
th
e su
rgic
al u
nit
14
Total handoff time varied ranging from 30 to 125s with and means handoff time of 60. 8s (Std ± 20.9s). Total handoff time included
moments of quietness; time lapsed while nurses browsed through documents, and conversations (questions and answers). There was
The specific environmental situations that existed during the handoff communications are summarized in table 3. Even if all of the
handoff communications were conducted uninterrupted, the environmental situations were far from optimal for quite conversations.
Reports were made amidst other activities that were going on simultaneously.
Discussion
The aims of this study were to explore whether SN discharge their responsibilities by making postoperative handoff communication
and to describe to describe the comparability of SN postoperative handoff communications with the recommendations made in SBAR.
To the knowledge of this author, little has been done to study handoff communications between SN and PAICU nurses in
postoperative settings.
As indicated above SN made postoperative hand-overs in 9 (41%) of the 22 patients. That involved more male patients (n= 6) than
females (n=3) but no pediatric patients. Although it is difficult to say whether the gender of the patient affected handoff information
about the patient concerned, the female gender was more represented in those occasion where no handoff communication was made.”
The vice versa is true for male patients. Analysis of collected data has shown that on average 79% of relevant information was omitted
from handoff reports. Generally, there is no doubt that a handoff communication of such frequency, magnitude and content is
suboptimum. Given this fact it is hard to say if SN had discharged their responsibilities in handing over patient- related postoperative
information to PAICU staff.
Compared to most preoperative stats patients enter the PAICU in a vulnerable, semiconscious state where they cannot contribute
much in their care (Ross & Ranum, 2009). On the other hand, they have increased care needs that require closer monitoring that often
depend on what happened before and during the intraoperative period. As mentioned earlier, omissions and absence of or the transfer
15
of erroneous care- related information can lead not only to suboptimal patient care but also CRAE that otherwise could have been
minimized/avoided had proper hand-over communications were made. Patients but also patients’ relatives expect to be safe while
being cared for (Halm, 2013). To meet that expectation is impossible without the contribution of careful and complete handoff
communication.
In those 13 occasions (59%) where SN did not deliver postoperative information at the PAICU, patients were accompanied by AN
(often together with assistant nurses). Although AN can deliver useful postoperative handoff information that would not necessarily
cover all the information that otherwise could be delivered by SN and thereby make the handoff information more wholesome. SN are
well- situated and well- versed in, among others, information involving the surgical site, blood loss during the invasive procedure, type
of osteosynthesis material used, outcome of the surgical procedure etc. SN can give such necessary and detailed information not only
to PAICU nurses but also to parents/relatives who may anxiously be waiting to hear such information. To let AN take the
responsibility to deliver all relevant postoperative information can be neither realistic nor an expedite way of working in a team.
Besides, research has shown that even information delivered by AN was by no means free from errors (Anwari, 2002; Smith et al.,
2008; Nagpa et al. 2010 c).
As indicated above, handoff communications were not made for all of the pediatric cases. However, pediatric patients have no lesser
needs when it comes to the handing over of care- related information. Let alone with the absence of some relevant patient-related
information there is always a chance of omitting relevant information or giving erroneous information when every attempt is made to
transfer information. Handoff processes for critically ill children to PAICU may be prone to error. The contributing factors mentioned
in the literature include the fact that the handoff often takes place in a busy, distraction-rich environment; that PAICU staff may have
no prior knowledge of the patient’s medical history and thus depend on the handoff process for critical information; that patients are
often clinically unstable during the immediate admission period, which limits time for reviewing the medical record (Chen et al.,
2011). Communication errors in pediatric surgical handoffs occurred in 100% of events, with an average of 6.6 errors per handoff
16
(Chen et al., 2011). Minimizing the chance of omissions or errors in handoff communication may therefor include the making of
attempts by all involved in the care of the pediatric patient to transfer information.
The results of this study have indicated that SN did not identify themselves but also patients (in at least three occasions) during
handoffs. It is difficult to say whether SN were already known to PAICU staff given the fact that the SN meet and work with the
PAICU staff regularly. While there were more efforts made to mention the identity of patients, some patients were not identified to the
PAICU staff. There were no excuses for taking any risk/s/consequence/s that could follow with lack of proper identification of
patients no matter how minimum the risks deemed to be. Types of operative procedures were mentioned in the majority of cases even
if that were not always accompanied by reports of the outcome of the operative procedure, other assessments related to the operative
procedure, and relevant recommendations that have to do with the entire patient and go far beyond information about the surgical site
and wound dressing.
Generally, details in handoff information did not vary dramatically across the items summarized under S-B-A-R. However, the near
non- existence of detailed intraoperative information (summarized under “Assessment”) cannot be left unnoticed. The average handoff
time was about one minute. Although length of details can vary depending on the individual patient’s pre- intra- and postoperative
situation the shortness in the length of handoff time in the study reflected the general lack of details. Although not comparable with
this study in aim and study design, Chen et al. (2011) reported an average handoff time of 4 minutes while studying handoff
communication in pediatric patients.
The handoff communication was done in an environmental characterized by disturbing sound and commotion. However the
disturbance did not cause interruptions in the handoff process. The concerned patients but also other patients and their relatives in the
nearby beds were within hearing distance and could have listened to handoff reports had they had the attentions and interests to listen
to what were reported.
17
The results of this study has indicated a clear need in improving safety culture. Safety culture is but a product of individual and group
values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency
of health safety management. Improving safety culture involves, among others, improving staff perceptions of the quality of handoffs,
teamwork across units, and teamwork within units (Pham et al. 2012). Such improvements can serve the purpose of clinics and
clinicians, most importantly care- receiving patients.
Method discussion
Non- participant observation method is said to make study subjects become conscious of the presence of the observer and thereby
‘stimulate’ them to show the behavior the observer wants to witness. This author, although known to some of the SN and PAICU
nurses that seemed not to influence the observed behavior.
The adapted SBAR used as a checklist had a number of shortcomings. First, it did not have items that include patients’ background or
the reason why the surgical procedure was needed. Secondly, it has items that, despite genuine efforts, no SN can have full control or
knowledge. Items such as intravenous medications, results from hemodynamic and blood oxygen monitoring etc. would be easily
noticed and reported by AN. Thirdly, despite the fact that the contents of a handoff communication are results of the perioperative
period and as such involve team members, the SBAR adapted for postoperative use neither take this into account nor advise the need
for team members to discuss contents of handoff communication before delivery. Fourthly, the SBAR version does not take into
account whether certain items are applicable for the individual patient and/or the specific surgical procedure performed. For instance, a
tooth extraction done on an otherwise healthy girl under anesthesia (due to patient’s psychic state) may not necessarily include
information around needs of rehabilitation. Such items that otherwise could have been removed as inapplicable, might have
accentuated calculated results of omissions and thereby led to biases.
18
Conclusion and recommendation
The results of this study have shown that SN did not discharge their responsibility adequately by reporting patient- related information
postoperatively. The structures and contents of handoff communications were also found to be inadequate.
These and other results of this study are indicative of the fact that being acquainted with SBAR cannot guaranty the use of it. The
author of this study was surprised by the lack of demands for thorough reports on the side of PAIC staff. Nor did critical care nurses
made impressions of initiating discussions by asking questions, demanding detailed information in some areas etc. Even if more
research that can cover perioperative periods and settings can reach a comfortable conclusion, this study has implied the need for a
radical change in safety culture. There is also a need for further research to design adequate communication tools that either specify the
part of patient- related information that each and every member of the multi professional surgical team can handle and deliver
effectively and responsibly or make this information delivery a collective responsibility and specify how best it can be transferred
during handoffs.
19
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23
Appendix i
Patient information Age
Sex
Type of operation
Situation Yes No Remarks
1) The nurse has presented herself
2) The nurse has identified the patient
2:1) By name only
2:2)By age only
2:3) By personal number only
2:4) By name, age and personal number
3) Type of operative/ invasive procedure, named
Background
1) Type of anesthesia administered mentioned
2) Intraoperative medication mentioned
3) Surgical cite information (dressing material, drainage, packing etc.)
4) The way the patient was positioned during surgery is named.
Assessment
1) Most recent vital signs reported
1:1) Blood pressure
1:2)Pulse rate
1:3)Blood oxygen level
1:4) Breathing rate
1:5) Body temperature
1:6) Urine output
2) Changes that occurred during and after the surgery are reported
2:1) Hemodynamic changes (blood losses etc.) mentioned
2:2) Changes in skin color
2:3)Changes in neurological status
2:4) Surgical complication/s is/are reported
2:5) Level of pain and pain management intervention/s named
Recommendation
1)Recommended controls in vital /neurological/ hematological etc. signs/controls are mentioned
2) Recommendation/continuation in specific medications mentioned
3)Recommendation/continuation in wound dressing, suture removal, drainage management/removal mentioned
4) Recommendations in pat. mobilization mentioned
5) Nutritional recommendations are mentioned
6) Date/time of discharge mentioned
7)Date and time for reCRAEmission/ x-ray control /next visit/ mentioned
8)Contact information about parents/relatives mentioned