Face to Face Hand-off: Improving Transfer to the PICU After Cardiac Surgery at the University of Virginia

Purpose:
The transfer of children after cardiac surgery to the Pediatric Intensive Care Unit is a critical step in ensuring smooth post-operative management. To improve an ineffective hand-off system, a new process was evaluated that begins in the operating room and concludes at the bedside in the PICU.

Significance:
A standardized,process-driven system that emphasizes face-to-face communication can be implemented for transferring patients to the PICU. It improves upon how various providers view efficiency of handoff,ability to ask questions at each step and overall capability of improving patient care.

Strategy and Implementation:
In an effort to improve what was thought to be a poor,ineffective system we developed a comprehensive,face-to-face,standard hand-off process.The hand-off begins with the Anesthesiologist,Surgeon and PICU RN in the OR and concludes at the bedside with the interdisciplinary team in the PICU. A checklist was designed to ensure completion of steps. The checklist demonstrates the actual process and includes a diagram that indicates the physical presence of each provider during hand-off.A surgical summary report was built in the EMR to reduce variation of communication in the process.The report is completed by the Anesthesiologist real-time and reviewed by the receiving team in the PICU. The PDSA methodology was followed to design and evaluate the new process. The process was evaluated real-time by the use of observer checklists to evaluate quality metrics and timing in all subsequent patients admitted to the PICU following surgery.

Evaluation:
To evaluate the accuracy and efficiency of the process,key measures identified:1)% adherence to the checklist2)Turnaround time for process steps3)Stratification of outcomes to complexity of surgery being performed based on risk adjustment for congenital heart surgery (RACHS)4)Provider feedback.

Implications for Practice:
A team huddle provides comprehensive,timely,&reliable transfer of information.Pre/Post Pilot Provider Satisfaction:Observed(n=79 surgical cases)Providers Feel The Process is Efficient:58%/69%Providers Feel Comfortable Asking Questions:53%/75% Providers Feel The Process Improves Patient Care:19%/94%