Background: High-volume and increasing demands for faster turnaround times have compromised patient safety during transition from the pre-procedure/admitting phase of care to the intraoperative phase of care. The ongoing complaint from staff is failure to ensure that an accurate and complete handoff report is received and/or given. Caregivers in the ambulatory care procedure center have repeatedly failed to relay the most pertinent data during transition from the admitting phase of care to the intraoperative phase of care. The results of poor communication and documentation has resulted in patients being sedated for a procedure without patient consent and/or sedated without a designated driver confirmed. Patient safety is compromised and resources are wasted. Electronic health records further posed a unique challenge in that handoff reports were not documented in the appropriately designated part of the electronic medical record. Based on Joint Commission Standards 20101 for inpatient handoff reporting, the unit-based team was sought for a comparable solution in the outpatient gastroenterology and surgery center.
Methodology: The unit-based team used a rapid improvement model to trial 3 tests of change.
The first test used the TeamSTEPPS2 approach from the Agency for Healthcare Research and Quality by implementing daily huddles in the pre-operative areas of care with the intent of reinforcing face-to-face handoff reporting. Although this was a good start, it didn’t ensure communication to all staff due to daily changes in staff assignment areas. The second test was to trial written notes of any exceptions to the normal plan of care as most patients are healthy individuals coming in for routine colonoscopies, upper endoscopies, and/or elective minor surgical procedures. The final trial used a patient completed form to be used as part of handoff reporting with the idea that the patient begins it and the nurses complete it.
Analysis: With each test of change, barriers to compliance were identified, and then, if needed, either discarded or altered and retested. Huddles were effective for the situation monitoring process as indicated in the TeamSTEPPS guide. The goal was to keep staff alert and focused on expectations. The note-taking approach was helpful when staff left the patient care area and another caregiver assumed care during the admitting phase. The relieving nurse is able to provide a more complete report in the absence of the primary nurse. The patient-completed form was trialed and discarded.
Results: The best method of adequate handoff reporting identified was face-to-face, caregiver-to-caregiver bedside report with resulting written evidence in the patient medical record in the handoff section of the chart. Although this standard primarily applies to the inpatient setting, it is now an informal standard in the outpatient setting. Patients’ electronic medical records are randomly audited to ensure staff compliance. The final outcome included a 9% increase in documented verbal handoff reporting over a 1-year period and no further incidences of patient sedation without consent.