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The Importance of Simulation: Preventing Hand-off Mistakes
The Importance of Simulation: Preventing Hand-off Mistakes
AHRQ C O M M E N TA R Y
CAROLYN M. CLANCY, MD
O
ne aspect of health care that carries a high risk of adverse events is the hand off—the point at which the patient is transferred, either physically to a different part of the hospital or administratively when a new member of the care team takes responsibility. This is a period of great risk to the patient, because hand offs often occur in a chaotic environment where much is happening at once and opportunities to impart critical information, which may not be reflected on the medical chart, can be limited. The communication and teamwork failures associated with hand offs may be among the most important contributors to preventable adverse events in health care. Nurses, particularly perioperative nurses, end up shouldering a great deal of responsibility for hand offs—and taking an unfair amount of blame when things go wrong. This is because nurses contribute most strongly to the care process when they work as team members on behalf of the patient. Unfortunately, educational silos, authority gradients, role specialization, and incentives that favor individual rather than team performances pose structural barriers that underlie ineffective communication. As a crucial component of safe care, effective communication among clinicians—including between physicians and nurses at the bedside—is starting to receive the attention it deserves. Because hand offs in particular can be so dangerous, the Agency for Healthcare Research and Quality (AHRQ) is devoting attention and resources to study how they can be made safer. This effort includes funding simulation re-
© AORN, Inc, 2008
search to analyze real-life medical situations, which are recreated so that health care providers can practice new procedures and techniques before performing them on patients. Simulation is important because, in a variety of clinical settings, it allows health care practitioners and teams to acquire valuable experience safely without placing patients at risk. In addition to gaining this experience, simulation allows researchers to analyze processes that tend to be practiced by rote in order to discover opportunities for improvement Effective that may not be easily detectable during an communication actual patient encounter. In 2006, AHRQ awardamong clinicians is ed nearly $5 million for 19 new projects that focus starting to receive on assessing and evaluating the roles that medical the attention simulation can play to improve the safety and it deserves. quality of health care delivery. It is hoped that these projects will inform providers, health educators, payers, policymakers, patients, and the public about the effective use of simulation in improving patient safety.
POSTANESTHESIA HAND OFFS: RIPE FOR STUDY The simulation study related to hand offs may be great interest to nurses. Matthew Weinger, MD, professor of anesthesiology, biomedical informatics, and medical education at Vanderbilt University School of Medicine, Nashville, Tennessee, leads a team of
OCTOBER 2008, VOL 88, NO 4 • AORN JOURNAL • 625
OCTOBER 2008, VOL 88, NO 4
researchers who are using simulation learning to evaluate and improve communication between anesthesia care providers and nurses as care transitions from the OR to the postanesthesia care unit (PACU). This research has led to the development of a simulation-based training system to improve the quality of hand offs and enhance the culture of communication within the PACU. In addition, researchers have taken a unique approach to evaluating the effect of this tool on the communication culture and patient outcomes. This is important because communication is central to safe, high quality care, and it is critically important that nurses’ input be respected and that nurses feel respected in all aspects of the care process.
Communication is central to safe, high quality care, and it is critically important that nurses’ input be respected and that nurses feel respected in all aspects of the care process.
The training session, a two-hour course called Simulation Training for Rapid Assessment and Improved Teamwork (STRAIT), is targeted at hand offs between anesthesia care providers and PACU nurses. This particular clinical hand-off situation was chosen because it involves interprofessional communication about critical patients. Importantly for the purposes of study and analysis, it is a well-defined and logistically feasible encounter amenable to study and improvement. This two-year study, which is projected to end in September 2009, involves two busy Vanderbilt University Medical Center PACU— one as the initial intervention site, the other as a parallel control site. Midway through the project, the second PACU received the intervention. The primary hypothesis of this quali-
626 • AORN JOURNAL
AHRQ Commentary
ty improvement project is that simulationbased communication training of anesthesia and PACU nursing personnel will significantly improve the quality of actual PACU hand offs. The secondary hypothesis is that the training will enhance the overall culture of communication and quality of care in the PACU.
EARLY RESULTS ARE PROMISING One of the project’s aims was to develop a simulation-based training intervention directed initially toward PACU hand offs. This aim was addressed by evaluating changes in simulated hand-off performance by individual clinicians before and after the training intervention on specific dimensions of hand-off effectiveness. In addition, the observed clinicians rate their own hand offs. Trained nurses also rate the hand offs, using the Handoff Scoring Form. A second aim has been to determine whether the implementation of the simulation initiative improves the quality of PACU hand offs. The primary means to measure this are preintervention and postintervention ratings by trained observers of actual PACU hand offs using the Handoff Scoring Form. To reinforce desired behaviors, aggregate results of observations of actual hand offs are fed back to clinicians in the intervention PACUs. It is still too early to say what this will reveal, although preliminary results are promising. The third aim was to study the effect of a single-focused initiative to improve hand offs on broader aspects of teamwork in the PACU and on institutional outcomes. Researchers are assessing the effect of the intervention on the communication culture of the units as well as on PACU-specific process and outcome measures. A communication culture survey,1 based on a subcomponent of the Safety Attitudes Questionnaire, was administered to all anesthesia care providers and PACU nurses before the intervention commenced and again midway through the scheduled training. A final survey will be performed at the end of the study. Of all the components of this wide-ranging study, the communication culture survey may hold the most long-term promise. This survey asks respondents to rate, on a scale of 1 to 5,
AHRQ Commentary
such issues as whether it is easy to ask questions in the PACU when there is something they do not understand and whether nurse input is well received. These are the types of issues that must constantly be assessed in any OR or PACU—or, for that matter, in any part of the care process. Communication is foundational to safe, high quality care, and it is critically important that nurses’ input be respected—and that nurses understand this. Because improving communication between and among care
OCTOBER 2008, VOL 88, NO 4
teams is the central focus of this study, its results bear watching.
AGENCY
FOR
CAROLYN M. CLANCY MD DIRECTOR HEALTHCARE RESEARCH AND QUALITY
REFERENCE 1. The Communication Culture Survey. Vanderbilt Medical Center. http://www.mc.vanderbilt.edu /cprq/Communication%20Survey%20Questions.pdf. Accessed August 19, 2008.
Web-Based Pharmacist Care Helps Control Hypertension
P
atients who monitor their blood pressure (BP) at home may gain better control of their hypertension when they can consult with a pharmacist online, according to research in the June 25, 2008, issue of JAMA. The Electronic Communications and Home Blood Pressure Monitoring study included 778 patients, ages 25 to 75 years, who were randomly assigned to one of three groups: • usual care—group 1; • home BP monitoring and web site training— group 2; or • home BP monitoring, web site training, and online pharmacist care—group 3. After the 2.5-year study period, 78% of partici-
pants (ie, 730 patients) were included in the follow up. Results indicated that 36% of patients in group 2 showed improved BP control, which was considered nonsignificant when compared to the 31% of patients who improved in group 1. Significantly, 56% of patients in group 3 showed improvement in BP control, leading the researchers to conclude that online pharmacist care helps patients gain better control of their hypertension. Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, web communication, and pharmacist care on hypertension control. JAMA. 2008;299(24): 2857-2867.
Whole Milk Found to be an Effective Contrast Agent
W
hole milk is just as effective as diluted 0.1% barium suspension as a contrast agent in patients undergoing a pelvic or abdominal computed tomography (CT), according to a May 29, 2008, news release from the American Roentgen Ray Society. Recent study results indicate that using whole milk also is cost-effective and easier on the patient than the diluted barium suspension. Researchers evaluated 215 patients undergoing abdominal and pelvic CT. Whole milk was given to 115 patients, and barium suspension was given to 100 patients. All patients were given IV contrast media. Two radiologists reviewed the images and scored them based on the degree of bowel disten-
sion and bowel wall visibility. The findings indicated that images taken of patients given whole milk were just as useful as those taken of patients given the diluted barium. Patient questionnaire responses also indicated a better patient acceptance of the whole milk. Based on the findings, researchers believe whole milk and barium are both valuable in diagnosing small bowel disorders and in evaluating pancreatic and biliary abnormalities. Whole milk is effective and cost-effective as oral contrast agent [news release]. Leesburg, VA: American Roentgen Ray Society; May 29, 2008. http://www.arrs.org/pressroom /info.cfm?prID=308. Accessed June 2, 2008.
AORN JOURNAL •
627
AHRQ C O M M E N TA R Y
CAROLYN M. CLANCY, MD
O
ne aspect of health care that carries a high risk of adverse events is the hand off—the point at which the patient is transferred, either physically to a different part of the hospital or administratively when a new member of the care team takes responsibility. This is a period of great risk to the patient, because hand offs often occur in a chaotic environment where much is happening at once and opportunities to impart critical information, which may not be reflected on the medical chart, can be limited. The communication and teamwork failures associated with hand offs may be among the most important contributors to preventable adverse events in health care. Nurses, particularly perioperative nurses, end up shouldering a great deal of responsibility for hand offs—and taking an unfair amount of blame when things go wrong. This is because nurses contribute most strongly to the care process when they work as team members on behalf of the patient. Unfortunately, educational silos, authority gradients, role specialization, and incentives that favor individual rather than team performances pose structural barriers that underlie ineffective communication. As a crucial component of safe care, effective communication among clinicians—including between physicians and nurses at the bedside—is starting to receive the attention it deserves. Because hand offs in particular can be so dangerous, the Agency for Healthcare Research and Quality (AHRQ) is devoting attention and resources to study how they can be made safer. This effort includes funding simulation re-
© AORN, Inc, 2008
search to analyze real-life medical situations, which are recreated so that health care providers can practice new procedures and techniques before performing them on patients. Simulation is important because, in a variety of clinical settings, it allows health care practitioners and teams to acquire valuable experience safely without placing patients at risk. In addition to gaining this experience, simulation allows researchers to analyze processes that tend to be practiced by rote in order to discover opportunities for improvement Effective that may not be easily detectable during an communication actual patient encounter. In 2006, AHRQ awardamong clinicians is ed nearly $5 million for 19 new projects that focus starting to receive on assessing and evaluating the roles that medical the attention simulation can play to improve the safety and it deserves. quality of health care delivery. It is hoped that these projects will inform providers, health educators, payers, policymakers, patients, and the public about the effective use of simulation in improving patient safety.
POSTANESTHESIA HAND OFFS: RIPE FOR STUDY The simulation study related to hand offs may be great interest to nurses. Matthew Weinger, MD, professor of anesthesiology, biomedical informatics, and medical education at Vanderbilt University School of Medicine, Nashville, Tennessee, leads a team of
OCTOBER 2008, VOL 88, NO 4 • AORN JOURNAL • 625
OCTOBER 2008, VOL 88, NO 4
researchers who are using simulation learning to evaluate and improve communication between anesthesia care providers and nurses as care transitions from the OR to the postanesthesia care unit (PACU). This research has led to the development of a simulation-based training system to improve the quality of hand offs and enhance the culture of communication within the PACU. In addition, researchers have taken a unique approach to evaluating the effect of this tool on the communication culture and patient outcomes. This is important because communication is central to safe, high quality care, and it is critically important that nurses’ input be respected and that nurses feel respected in all aspects of the care process.
Communication is central to safe, high quality care, and it is critically important that nurses’ input be respected and that nurses feel respected in all aspects of the care process.
The training session, a two-hour course called Simulation Training for Rapid Assessment and Improved Teamwork (STRAIT), is targeted at hand offs between anesthesia care providers and PACU nurses. This particular clinical hand-off situation was chosen because it involves interprofessional communication about critical patients. Importantly for the purposes of study and analysis, it is a well-defined and logistically feasible encounter amenable to study and improvement. This two-year study, which is projected to end in September 2009, involves two busy Vanderbilt University Medical Center PACU— one as the initial intervention site, the other as a parallel control site. Midway through the project, the second PACU received the intervention. The primary hypothesis of this quali-
626 • AORN JOURNAL
AHRQ Commentary
ty improvement project is that simulationbased communication training of anesthesia and PACU nursing personnel will significantly improve the quality of actual PACU hand offs. The secondary hypothesis is that the training will enhance the overall culture of communication and quality of care in the PACU.
EARLY RESULTS ARE PROMISING One of the project’s aims was to develop a simulation-based training intervention directed initially toward PACU hand offs. This aim was addressed by evaluating changes in simulated hand-off performance by individual clinicians before and after the training intervention on specific dimensions of hand-off effectiveness. In addition, the observed clinicians rate their own hand offs. Trained nurses also rate the hand offs, using the Handoff Scoring Form. A second aim has been to determine whether the implementation of the simulation initiative improves the quality of PACU hand offs. The primary means to measure this are preintervention and postintervention ratings by trained observers of actual PACU hand offs using the Handoff Scoring Form. To reinforce desired behaviors, aggregate results of observations of actual hand offs are fed back to clinicians in the intervention PACUs. It is still too early to say what this will reveal, although preliminary results are promising. The third aim was to study the effect of a single-focused initiative to improve hand offs on broader aspects of teamwork in the PACU and on institutional outcomes. Researchers are assessing the effect of the intervention on the communication culture of the units as well as on PACU-specific process and outcome measures. A communication culture survey,1 based on a subcomponent of the Safety Attitudes Questionnaire, was administered to all anesthesia care providers and PACU nurses before the intervention commenced and again midway through the scheduled training. A final survey will be performed at the end of the study. Of all the components of this wide-ranging study, the communication culture survey may hold the most long-term promise. This survey asks respondents to rate, on a scale of 1 to 5,
AHRQ Commentary
such issues as whether it is easy to ask questions in the PACU when there is something they do not understand and whether nurse input is well received. These are the types of issues that must constantly be assessed in any OR or PACU—or, for that matter, in any part of the care process. Communication is foundational to safe, high quality care, and it is critically important that nurses’ input be respected—and that nurses understand this. Because improving communication between and among care
OCTOBER 2008, VOL 88, NO 4
teams is the central focus of this study, its results bear watching.
AGENCY
FOR
CAROLYN M. CLANCY MD DIRECTOR HEALTHCARE RESEARCH AND QUALITY
REFERENCE 1. The Communication Culture Survey. Vanderbilt Medical Center. http://www.mc.vanderbilt.edu /cprq/Communication%20Survey%20Questions.pdf. Accessed August 19, 2008.
Web-Based Pharmacist Care Helps Control Hypertension
P
atients who monitor their blood pressure (BP) at home may gain better control of their hypertension when they can consult with a pharmacist online, according to research in the June 25, 2008, issue of JAMA. The Electronic Communications and Home Blood Pressure Monitoring study included 778 patients, ages 25 to 75 years, who were randomly assigned to one of three groups: • usual care—group 1; • home BP monitoring and web site training— group 2; or • home BP monitoring, web site training, and online pharmacist care—group 3. After the 2.5-year study period, 78% of partici-
pants (ie, 730 patients) were included in the follow up. Results indicated that 36% of patients in group 2 showed improved BP control, which was considered nonsignificant when compared to the 31% of patients who improved in group 1. Significantly, 56% of patients in group 3 showed improvement in BP control, leading the researchers to conclude that online pharmacist care helps patients gain better control of their hypertension. Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, web communication, and pharmacist care on hypertension control. JAMA. 2008;299(24): 2857-2867.
Whole Milk Found to be an Effective Contrast Agent
W
hole milk is just as effective as diluted 0.1% barium suspension as a contrast agent in patients undergoing a pelvic or abdominal computed tomography (CT), according to a May 29, 2008, news release from the American Roentgen Ray Society. Recent study results indicate that using whole milk also is cost-effective and easier on the patient than the diluted barium suspension. Researchers evaluated 215 patients undergoing abdominal and pelvic CT. Whole milk was given to 115 patients, and barium suspension was given to 100 patients. All patients were given IV contrast media. Two radiologists reviewed the images and scored them based on the degree of bowel disten-
sion and bowel wall visibility. The findings indicated that images taken of patients given whole milk were just as useful as those taken of patients given the diluted barium. Patient questionnaire responses also indicated a better patient acceptance of the whole milk. Based on the findings, researchers believe whole milk and barium are both valuable in diagnosing small bowel disorders and in evaluating pancreatic and biliary abnormalities. Whole milk is effective and cost-effective as oral contrast agent [news release]. Leesburg, VA: American Roentgen Ray Society; May 29, 2008. http://www.arrs.org/pressroom /info.cfm?prID=308. Accessed June 2, 2008.
AORN JOURNAL •
627