An Implementation Science Approach to Handoff Redesign in a Cardiac Surgery Intensive Care Unit

Journal Pre-proof An Implementation Science Approach to Handoff Redesign in a Cardiac Surgery Intensive Care Unit Tracy R. Geoffrion, MD, MPH, Isaac Lynch, MD, William Hsu, MBA, Eleanor Phelps, MA, RN, Abu Minhajuddin, PhD, Edward Tsai, MD, MBA, Andrew Timmons, MD, Philip E. Greilich, MD, MSc PII:

S0003-4975(19)31617-0

DOI:

https://doi.org/10.1016/j.athoracsur.2019.09.047

Reference:

ATS 33188

To appear in:

The Annals of Thoracic Surgery

Received Date: 28 January 2019 Revised Date:

28 August 2019

Accepted Date: 12 September 2019

Please cite this article as: Geoffrion TR, Lynch I, Hsu W, Phelps E, Minhajuddin A, Tsai E, Timmons A, Greilich PE, An Implementation Science Approach to Handoff Redesign in a Cardiac Surgery Intensive Care Unit, The Annals of Thoracic Surgery (2019), doi: https://doi.org/10.1016/j.athoracsur.2019.09.047. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by The Society of Thoracic Surgeons

An Implementation Science Approach to Handoff Redesign in a Cardiac Surgery Intensive Care Unit Short Running Title: Handoff Redesign and Implementation

Tracy R. Geoffrion, MD, MPH, Isaac Lynch, MD, William Hsu, MBA, Eleanor Phelps MA, RN, Abu Minhajuddin, PhD, Edward Tsai, MD, MBA, Andrew Timmons, MD, Philip E. Greilich, MD, MSc

1. University of Texas Southwestern Medical Center, Dallas, TX

Meeting Presentation: Society of Thoracic Surgeons Association Annual Meeting, January 2019

Corresponding Author: Tracy R. Geoffrion, MD, MPH University of Texas Southwestern Medical Center Cardiothoracic Surgery 5323 Harry Hines Blvd Dallas, TX 75390-8879 Email: [email protected]

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ABSTRACT Background: The ability of handoff redesign to improve short-term outcomes is well established, yet an effective approach for achieving widespread adoption is unknown. An implementation science-based approach capable of influencing the leading indicators of widespread adoption was used to redesign handoffs from the cardiac operating room to the intensive care unit.

Methods: A transdisciplinary, unit-based team used a 12-step implementation process. The steps were divided into four phases: planning, engaging, executing, and evaluating. Based on unit-determined best practices, a “handoff bundle” was designed. This included team training, structured education with video illustration, and cognitive aids. Fidelity and acceptability were measured before, during, and after the handoff bundle was deployed.

Results: Redesign and implementation of the handoff process occurred over 12 months. Multiple rapid cycle process improvements led to reductions in the handoff duration from 12.6 to 10.7 minutes; p < 0.014). Fidelity to unit-determined handoff best practices was assessed based on a sample of the cardiac surgery population pre- and postimplementation. Twenty-three handoff best practices (information and tasks) demonstrated improvements compared to the pre-implementation period. Provider satisfaction scores 2.5 years after implementation remained high compared to the redesign phase (87 vs. 84) (p = 0.133).

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Conclusions: The use of an implementation-based approach for handoff redesign can be effective for improving the leading indicators of successful adoption of a structured handoff process. Future quality improvement studies addressing sustainability and widespread adoption of this approach appear warranted, and should include the relationships to improved care coordination and reduced preventable medical errors.

Word Count: 250

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Transfers of care or “handoffs” are defined as a process of transferring information, authority, and responsibility from the transferring clinical team to the receiving team to facilitate continuity of patient care. This is a time of potential danger for patients as poor communication can lead to missed information, delays in care, and increased adverse events. Handovers in high-stakes environments such as the operating room (OR) and intensive care unit (ICU) are exceptionally risky and errorprone. [1-3] In response, the Joint Commission, Accreditation Council for Graduate Medical Education, and American Association of Medical Colleges mandated that organizations design, teach, and implement a more structured transfer of care process. [4-6] A 2013 Scientific Statement commissioned by the American Heart Association identified multiple causes for team communication failures and underscored the need to investigate methods that improve the reliability of care transfers. [7] Recent transfer of care research demonstrates improved information exchange and patient outcomes when the process is more structured. [8-15] The literature suggest that multi-modal, interventions that include protocol development, cognitive aids, and a standardized curriculum using a variety of teaching modalities (e.g., self-study, video illustration, and experiential activities) can reduce information omissions and improve the overall quality of the transfer of care process. Handoffs are team-based activities, providing opportunities to create shared understanding which is crucial to reducing errors. Previous studies indicate that a more structured handoff process including communication-enhancing cognitive aids, can decrease medical error rates by nearly a quarter and the occurrence of preventable

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adverse events by almost a third. [9,16] The handoff cognitive aid should be tailored to the specific patient population as needs differ and unnecessary data elements can distract users. Proper implementation is vital to the success of a redesigned handoff process. Implementation science provides a framework for understanding the context, assessing performance, informing implementation, and facilitating the adoption of a new practice within a system. [17,18] Planning, engaging, executing, and evaluating are required for successful implementation of best practices. [19, 20] Research has demonstrated the need for a well-defined implementation process when attempting widespread adoption of safe surgery checklists. [21] In one study, risk-adjusted mortality was reduced only by those institutions that completed a robust implementation process. [17] Additionally, a special report from the American College of Cardiology and the American Heart Association showed that the use of implementation science, specifically the strategies of educational outreach and audit with feedback, were effective in improving both process of care and clinical outcomes. [22] This project evaluates the impact of a unit-based team using an implementation science approach to redesign handoffs in the cardiothoracic surgery ICU. Patients and Methods The University of Texas Southwestern Medical Center, Williams P. Clements University Hospital, is an academic 460-bed tertiary referral center that performs over 600 cardiothoracic cases per year. This project was approved by the Institutional Review Board as Quality Improvement research and the University of Texas System

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Patient Safety Committee provided external validation of the approach and partial funding for its completion. The redesign and implementation of the CVICU handoff process took place over 12 months, from February 2016 to January 2017, and the “handoff bundle” was deployed in September of 2016. Baseline (pre-implementation) data was collected from January 2015 through June 2016. The post-implementation period was October 2016 through March 2018. Fidelity to unit-determined cardiothoracic OR to CVICU handoff best practices was conducted using video recordings of 64 pre-intervention and 62 post-intervention handoffs. Cardiac surgical cases with planned post-operative patient transfers to the CVICU were included. Handoffs that occurred during the day shift were selected for video recording based on availability of research staff.

Implementation Process for Handoff Redesign In response to ongoing concerns regarding post-surgical handoff practices in our institution, the ECHO-ICU (Enhanced Communication during Handover from OR to ICU) team was formed to develop the “ideal” handoff process for the Cardiovascular Intensive Care Unit (CVICU). This transdisciplinary, unit–based team was facilitated by an institutionally supported guidance team comprised of a health system quality officer (physician), nurse coordinator, data analyst, subject matter experts (human factors, ergonomics, quality improvement) and a project manager. The 12-step implementation process is summarized in Figure 1. First, an ideal handover process was co-created to ensure that essential information was relayed between providers. A series of rapid-

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cycle process improvements were conducted to optimize the execution. Systems-based interventions incorporated workflow prompts to enhance communication, strengthen teamwork, and increase the reliability of the transfer of care. [17-19] These included team training, standardized education, video illustration, and cognitive aids. The project team relied heavily on implementation science themes of understanding behavior, developing strategies to change behavior, and engaging stakeholders. The team tested iterative changes using plan-do-study-act cycles (PDSA) commonly used in healthcare quality improvement research. [23] This repeated testing and the incremental approach allowed the project team to align interventions within the context of handovers from the OR to the CVICU.

The Handoff Process An outline of the most recent iteration of the handoff process is demonstrated by the Handoff Coordinator Tool in Appendix 2. The process flow for handoffs before and after the intervention is illustrated in Figure 2. The minimum required participants include the transferring anesthesiologist and surgical representative (MD or surgical first assist), receiving intensivist, ICU nurse, and respiratory therapist. Depending on available unit staffing, additional nurses may be present. Physician trainees could represent the anesthesia, surgical, or ICU teams. The Handoff Coordinator is typically a charge nurse who assists during the receiving of new patients.

Measures of the Handoff Process

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The redesign and implementation process was assessed prospectively in the pre- and post-implementation phases of the redesign process. A modified Delphi process was conducted to achieve consensus among frontline clinicians on the critical handover elements. The team established 57 critical handoff items: 34 informational and 23 task-related elements. These are detailed in Appendix 1. Data on handoff fidelity to unit-determined best practice was collected using a novel transfer of care evaluation tool. A trained independent observer, who did not participate in patient care, accompanied the transfer team from the OR to the ICU. Following informed consent, video recordings of simulated handoffs and randomly selected live handovers were evaluated by expert observers with validated inter-rater reliability. [24] The accuracy of information transferred was confirmed with collective agreement by the trained observers. A sample of 124 observed handoff events (62 at each time point) pre- and 6 months post-implementation is sufficient to examine the primary hypothesis that the redesign and implementation process will produce at least a 50% improvement in the fidelity to unit-determined best practices. Acceptability was measured using a provider satisfaction survey administered to clinicians involved in the handoff immediately after the completion of an event. The survey contained 5 questions rating the usefulness of the information presented, handover coordination and timing, global organization of the material, thoroughness of the handoff, and confidence that the receiving team has all of the necessary information to provide care (Appendix 3). The degree of satisfaction was measured using a 100mm visual analog scale and individual point estimate was scaled in millimeters (0-100). Subjective information was also collected.

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Times for the handoffs were collected during the pre and post-implementation phases from the video recordings. These included: time from room entry to initiation of the handoff process, duration of the handoff process, and total time from in room until completion of handoff. Data believed to have a causal relationship with improved care coordination was collected from the Society of Thoracic Surgery (STS) database for designing future outcome studies. These included time-to-extubation, initial ICU length of stay (LOS), and the observed-to-expected ratios (O/E) of prolonged ventilation (>24 hours), short length of stay (<6 days), and long length of stay (>14 days). [25]

Statistical Analysis Fidelity to the critical handoff elements was quantitatively analyzed by calculating a total conformance score out of 57 (the total number of elements). Scores before and after implementation were compared using a t-test. Data-driven analysis further stratified conformance elements by defining them as follows: “Improved” elements had initial fidelity of less than 30% with an absolute increase of greater than 30% (∆ > +30%) in the post-intervention period. “Preserved” elements had pre and postimplementation conformance of greater than 70%. “Unaffected” elements had pre and post- implementation conformance of less than 30%. “Reduced” elements had preimplementation conformance of greater than 50%, but a greater than 20% absolute decrease (∆ > -20%) in conformance post-implementation. Acceptability of the new handoff was measured using provider satisfaction scores and time required to perform the process. Mean satisfaction scores were subdivided by

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provider type (all providers, sending providers, and receiving providers) and analysis of variance by provider type was performed. The mean time to perform the handoff process pre and post-intervention was compared with a two-tailed Fisher Test. Patient demographics and operative characteristics were summarized for the study period as a whole for context. Risk adjusted organizational outcomes were compared between the pre and post-intervention periods for descriptive purposes using the observed-to-expected (O/E) ratios for prolonged ventilation (>24 hours), short ICU length of stay (< 6 days), and long ICU length of stay (>14 days). These were calculated by dividing the observed incidence by the average of the predicted risk from STS database for cases with risk models. Patients who were extubated before arrival in the ICU were excluded from the time-to-extubation analysis. Statistical analyses were performed using SAS 9.4 and Excel v1808.

Results Patient demographics and surgical characteristics are shown in Table 1. These are descriptive and do not reflect differences in the pre and post implantation populations.

Time for Handoff Procedure Following implementation of the new handoff process, the time from ICU room entry to the start of the handoff process was reduced from 4.5 ± 1.38 minutes to 3.2 ± 0.9 minutes (p<0.001). The duration of the handoff process was reduced to 7.2 ± 2.1 minutes compared to 7.7 ± 2.7 minutes at baseline, but this difference was not significantly different (p=0.30). The time in room to completion of handoff was reduced

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from 12.6 ± 3.6 minutes to 10.7 ± 2.2 minutes after deployment of the handoff bundle (p < 0.014).

Acceptability of Redesign Process Provider satisfaction was used as a marker for acceptability of the new handoff system. During the redesign phase, 82 provider satisfaction surveys were collected for 24 unique patient handoffs with a mean score of 84 (± 11) out of 100. Six months after deployment of the handoff bundle, 98 provider satisfaction surveys from 25 unique handoffs had a mean score of 80 (±15). Two and a half years after implementation of the handoff bundle, 81 provider satisfaction surveys (25 unique handoffs) were collected with a mean score of 87 (±14). The decrease in mean provider satisfaction survey scores 6 months after the handoff bundle was statistically significant (p <0.02), but the increase in mean score 2.5 years later was not statistically significant (p=0.133). When analyzed by provider type, sending providers had a mean score of 82 ± 14 and receiving providers had the same mean score of 82 (±12) with no significant difference between the two groups (p = 0.76). This finding persisted when data during the redesign phase and six months later were analyzed separately. For perspective, mean provider satisfaction score at baseline on another ICU in our institution, naïve to handoff improvement, was 60 (±12) out of 100.

Fidelity to Institutionally-Determined Handoff Best Practices At baseline, the overall conformance score for the 57 handoff best practices was 18.5 ± 4.0 which significantly improved to 32.8 ± 9.5 following the redesign and

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implementation of the handover bundle (p <0.0001). A qualitative summary of the degree of change in the elements showed that 23 elements improved, 17 were preserved, 15 were unaffected, and two were reduced, suggesting that the new handoff process did not disrupt previously accepted standards for the transfer of care in the institution. (Figure 3) This suggests that fidelity to handoff best practices is improved in the early post-intervention period. Elements deemed most valuable (13 of 23) were reassessed 2.5 years post-implementation. All demonstrated sustained improvement.

Organizational Outcomes Data summarizing the time to extubation and initial ICU length of stay for the entire cohort and the STS risk model patients is shown in Table 2. The expected risk of implies the disease burden was greater pre-implementation, but there is a pattern of outcome improvement over the time period studied. Our data showed less prolonged ventilation and shorter lengths of stay post-implementation of the handoff bundle, but causal link is not able to be determined within the context of this manuscript.

Comment The transfer of care process relies on accurate communication between transferring and receiving teams. Increasing specialization in medicine coupled with limited resources and reductions in trainee work hours has led to an increased number of clinical handoffs. [1, 26-28] Communication during transfers of care has been identified as prone to error [1,4,7] and care transfers between the OR and ICU are especially risky. [1, 29] Several studies on handoffs have reported clinically relevant outcomes. Agarwal et al. demonstrated a significant reduction in major complications 12

and increases in early extubation following enactment of a standardized handover tool. Zavalkoff et al. found a non-significant trend towards lower incidence of high-risk events. [12, 13] The successful implementation and sustainability of a reliable transfer of care process lies in the approach taken for developing and adapting that process. Previously published work has shown that a checklist forced upon clinical teams is rarely successful, [20, 32] thus aligning the goals of the project team with the technical and non-technical needs of the clinical providers is paramount. The most effective interventions were multi-dimensional, integrating protocols, cognitive aids, sterile cockpits, and education. [8,10,12-15, 25-27, 30-31] A review by Segall et al. in 2012 identified only four studies in which an intervention tool for handovers was developed and formally assessed for impact on effectiveness, efficiency, and teamwork. [3] Factors such as equipment availability, the use of cognitive aids to support information transfer, and effective control of the physical environment (e.g., sterile cockpit during handoff report) increased the quality of transfers of care. [7, 8, 10-12] Prior studies have demonstrated the efficacy of using cognitive aids to facilitate information transfer from the OR team to the ICU team. [10,12-15, 26-27] Standardized protocols executed verbally with written tools have consistently demonstrated a reduction in the number of omitted elements deemed necessary for successful transfers of care. [10,12-13, 26-27]

Limitations The primary limitation of this study is the observational nature of the data collection, which was intended for quality improvement research. The lack of formal

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randomization in selection of handoffs evaluated could affect the nature of surgical cases and patient population and impart bias. Video recordings were conducted with a camera in the ICU patient room that was easily visible to team members, which may have produced a Hawthorne effect. “Era effects” during the study period present a possible confounder in outcomes data though turnover in the primary handoff participants was <10% over this period. Clinical outcomes were not the primary endpoint for this study. The clinical data collected was intended to inform the design of future outcome studies and should not be used to imply any effect given the possible presence of confounding variables. Differences in individual surgeon practice concerning post-operative care could also have influenced clinical outcomes. Use of O/E ratio for risk adjustment was limited to populations that have risk models. Potential strategies to address this include the use of risk strata based on estimates available for all surgical patients [31-33]. Finally, any concurrent quality improvement activity could have influenced the results.

Conclusion A process grounded in the constructs of implementation science with tenets of high reliability should increase the likelihood of achieving sustainable and widespread adoption of a more structured handoff process. This improvement in information transfer has the potential to improve outcomes and reduce medical errors affecting patients undergoing cardiothoracic surgery. Pragmatic methods for reliably measuring medical errors are needed and are currently being piloted at our institution. Lower levels of satisfaction during the early post-implementation phase underscore the need

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for early introduction of an audit and feedback system to keep frontline clinicians informed and engaged in the change process. Sustainability requires frequent ongoing education of team members and committed leadership who guide an associated culture change within the institution. Further research is required to support a causal link between structured handoffs, care coordination, and patient and organizational outcomes. If done thoughtfully, improving health care delivery processes could be as beneficial to outcomes as scientific advances by allowing us to provide effective care that is both efficient and reproducible.

Advice to Readers Desiring to Improve Their Institutional Handoffs 1. Create a transdisciplinary project team to redesign the handoff process. 2. Obtain institutional support for process redesign and implementation... 3. Perform a needs assessment to identify the evidence-to-practice gaps. 4. Survey provider satisfaction with the handoff process and define unit specific best practices. 5. Create a multimodal bundle of educational interventions supporting the redesign. 6. Develop a timely audit system and respond to feedback with further improvements. 7. Identify representatives who demonstrate interest and commitment to champion the change and ensure sustainability. 8. Be persistent and enthusiastic with continued education to promote a cultural change within the institution in regards to handoff practices.

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Acknowledgment The ECHO-ICU Collaborative is composed of students, trainees, faculty, and staff from the Departments of Anesthesiology and Cardiovascular & Thoracic Surgery, Nursing Services, and the Office of Quality Safety and Outcomes Education. The authors would like to individually recognize Kenni Landgraf, Choafan Yuan, MS, Jerzy Lysikowski, PhD, Amanda Fox, MD, Steven Hill, MD, Susan Hernandez, BSN, MBA, Emma Minnis, BSN, MBA, and Michael Jessen, MD for their support.

Disclosures This work was funded, in part, by a grant from the University of Texas System Patient Safety Committee (Research Grant Award, OGC Grant # 162292) and Clements University Hospital Nursing Services.

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References 1. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care 2010; 19:493-497. 2. Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf 2008; 34:563-570. 3. Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg 2012; 115:102115. 4. Commission J. The joint commission announces the 2006 national patient safety goals and requirements. Jt Comm Perspect 2005; 25:1-10. 5. ACGME. Accreditation council of graduate medical education program requirements for graduate medical education in internal medicine. 2013. 6. Association of American Medical Colleges. Core entrustable professional activities for entering residency. 2014; 50-54. 7. Wahr JA, Prager RL, Abernathy JH, et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation 2013; 128:1139-1169. 8. Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anesth 2007; 17:470-480. 9. Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA 2013; 310:2262-2270.

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10. Joy BF, Elliott EL, Hardy C, et al. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med 2011; 12:304-308. 11. Craig R, Moxey L, Young D, Spenceley NS, Davidson MG. Strengthening handover communication in pediatric cardiac intensive care. Paediatric Anaesthesia 2012; 22:393-399. 12. Agarwal HS, Saville BR, Slayton JM, et al. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance. Crit Care Med 2012; 40:2109-2115. 13. Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Handover after pediatric heart surgery: a simple tool improves information exchange. Pediatr Crit Care Med 2011; 12:309-313. 14. Karakaya A, Moerman AT, Peperstraete H, Francois K, Wouters PF, de Hert SG. Implementation of a structured information transfer checklist improves postoperative data transfer after congenital cardiac surgery. Eur J Anaesthesiol 2013; 30:764-769. 15. Petrovic MA, Aboumatar H, Baumgartner WA, et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac Vasc Anesth 2012; 26:11-16. 16. Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014; 371:1803-1812. 17. Haynes AB, Edmondson L, Lipsitz SR, et al. Mortality trends after a voluntary checklist-based surgical safety collaborative. Ann of Surg. 2017; 266(6): 929.

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18. Peters DH, Tran NT, Taghreed A. Implementation research in health: a practical guide. Geneva, Switzerland: WHO Document Production services. 2013. 19. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009; 4:50. 20. Carroll C, Patterson M, Wood S, Booth A, Rick J, Balain S. A conceptual framework for implementation fidelity. Implement Sci 2007; 2:40. 21. Haugen AS, Sevdalis N, Søfteland E. Impact of the World Health Organization Surgical Safety Checklist on Patient Safety. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2019 22. Chan WV, Pearson TA, Bennett GC, et al. ACC/AHA special report: clinical practice guideline implementation strategies: a summary of systematic reviews by the NHLBI Implementation Science Work Group: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017; 69(8): 1076-92. 23. Speroff T, O'Connor GT. Study designs for PDSA quality improvement research. Qual Manag Health Care 2004; 13:17-32. 24. Gisev N, Bell JS, Chen TF. Interrater agreement and interrater reliability: key concepts, approaches, and applications. Res Social Adm Pharm 2013; 9:330-338. 25. Shahian DM, O’Brien SM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1 –coronary artery bypass grafting surgery. Ann Thorac Surg 2009; 88:S2-22.

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26. Vergales J, Addison N, Vendittelli A, et al. Face-to-face handoff: improving transfer to the pediatric intensive care unit after cardiac surgery. Am J Med Qual 2015; 30:119125. 27. Chen JG, Wright MC, Smith PB, Jaggers J, Mistry KP. Adaptation of a postoperative handoff communication process for children with heart disease: a quantitative study. Am J Med Qual 2011; 26:380-386. 28. Pronovost P, Needham D, Bereholtz S, et al. An intervention to decrease catheterrelated bloodstream infections in the ICU. N Engl J Med 2006; 355:2725-2732. 29. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of the recurrent types and effects. Qual Saf Health Care 2004; 12:330-334. 30. Greilich P, Yu S, Davidov M, et al. Reliability of an evaluation tool for assessing transfers of care (“handoffs”) from the or to the ICU following cardiac surgery. 36th Annual Meeting of the Society of Cardiovascular Anesthesiologists. 2014. 31. Kaufman J, Twite M, Barrett C, et al. A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period. Jt Comm J Qual Patient Saf 2013; 39:306-311. 32. Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost P. Reality check for checklists. Lancet 2009; 374:444-445. 33. Englum BR, Saha-Chaudhuri P, Shahian DM, et al. The impact of high-risk cases on hospitals’ risk-adjusted coronary artery bypass grafting mortality rankings. Ann Thor Surg. 2015; 99(3): 856-62.

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33. Shahian DM, O'Brien SM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1—coronary artery bypass grafting surgery. Ann Thor Surg. 2009; 88(1): S2-2. 34. Shahian DM, Edwards FH. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: introduction. Ann Thor Surg. 2009; 88(1): S1.

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Table 1: Patient Demographics and Operative Characteristics Patient Demographics

N (%)

Age > 75 years

277 (15)

Female gender

624 (34)

Non-Caucasian

451 (24)

Hypertension

1414 (76)

Dyslipidemia

1319 (71)

Diabetes mellitus

682 (37)

Chronic Lung disease

375 (20)

Creatinine >1.5mg/dL

331 (18)

Dialysis

91 (5)

Prior Myocardial infarction

517 (28)

NYHA Class ≥ III

591 (32)

Cerebrovascular Disease

320 (17)

ASA classification > 3 Operative Characteristics

1,500 (81)

N (%)

Operative priority Non-Elective

565 (31)

Urgent

453 (24)

Emergent

91 (5)

Operation type CABG

447 (24)

Valve

761 (41)

Aorta

120 (6)

Other Cardiac Procedure

433 (23)

CPB Utilization

1306 (71)

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Table 2: Organizational Outcomes Pre

Post

Implementation

Implementation

Mechanical ventilation, median hours (IQR)

14.7 (29)

9.0 (29)

ICU LOS, median days (IQR)

3.1 (3.8)

2.5 (3.8)

Mechanical ventilation, median hours

8.9 (14)

4.4 (7.3)

ICU LOS, median days

2.9 (2.7)

2.0 (2.1)

Expected % mortality

2.9

2.1

Expected % morbidity/mortality

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16

0.166/0.146

0.109/0.108

1.14

1.01

0.376/0.395

0.640/0.435

0.95

1.47

0.116/0.091

0.080/0.069

1.27

1.16

All Cardiac Cases

O/E cases

Prolonged Ventilation O/E incidence O/E ratio Short Length of Stay O/E incidence O/E ratio Long Length of Stay O/E incidence O/E ratio

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Figure Legends Figure 1: Steps for Handoff Redesign and Implementation Figure 2: Process Maps Pre- and Post-Implementation Figure 3: Changes in Fidelity to Locally-Determined Handoff Best Practice

Appendices Legends Appendix 1: 57 Institutionally-Determined Handoff Best Practices Appendix 2: Handoff Coordinator Visual Aid Appendix 3: Provider Satisfaction Survey

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