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Face-to-Face Handoff: Improving Transfer to the Pediatric Intensive Care Unit After Cardiac Surgery

Sunday, October 21, 2012
Room 210 (Morial Convention Center)
Jeffrey E. Vergales, MD1, Nancy G. Addison, RN1, Evelyn A. Nicholson, RN1, D. Jeannean Carver, MD1, Victor C. Baum, MD2 and James J. Gangemi, MD3, (1)Pediatrics, University of Virginia, Charlottesville, VA, (2)Anesthesiology, University of Virginia, Charlottesville, VA, (3)Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA

Purpose: The transfer of children after cardiac surgery to the intensive care unit (ICU) is a critical step in ensuring smooth post-operative management.  This requires excellent communication and coordination among a variety of providers to make certain details are not overlooked and the handoff process is accurate, complete and efficient. 

Methods:   We sought to develop a comprehensive, primarily face-to-face, handoff process that begins initially in the operating room and concludes at the bedside in the ICU.  The system involves formalized process steps, utilizing a variety of essential providers across multiple disciplines, with the goal of improving overall accuracy and efficiency.  After an initial trial period to accommodate unforeseen problems, the final process was evaluated by the use of observer checklists to evaluate quality metrics and timing in all subsequent patients admitted to the ICU following cardiac surgery.

Results:   Prior to initiation of the new system, only 73% of providers at our institution believed that information transfer was smooth from one unit to another.  Similarly, only 41% believed the process to be standard among all providers, and just 58% believed there was good interdisciplinary communication and efficiency at the time of transfer.  30 cases were observed after the new system was finalized.  The admitting nurse travelled to the operating room near the completion of the case to receive face-to-face handoff prior to assisting in the transport to the ICU.  The total time to stabilize, secure and transport the patient was not prolonged (mean of 26.0 minutes ± 8.5) and was not statistically significant when stratified across RACHS-1 categories (p=0.82), meaning that even the most complex patients were able to be transported efficiently.   Similarly, the time from patient arrival in the ICU to completion of handoff was rapid (mean of 7.8 minutes ± 4.2) and also did not differ when stratified to complexity of the surgery (p=0.30).  This step included the stabilization of lines, drains and airways, drawing necessary labs, reporting of an initial arterial blood gas, obtaining a chest radiograph and initiation of face-to-face handoff among all providers caring for the child.  Accuracy of information was assured by the use of a standardized electronic post-operative note completed during the case by the anesthesiologist, with 100% compliance, and available prior to the patient’s arrival in the ICU.  Further, all subspecialties and ancillary services involved were able to be present 90% of the time for the final steps of the handoff.     

Conclusion:   A standardized process-driven system, that emphasizes face-to-face communication, can be implemented for transferring patients to the ICU after cardiac surgery.  It can improve efficiency and accuracy of the information in addition to improving overall communication between the many providers caring for these critical patients.