1. Improving Perioperative Handoffs – A Case Study in Implementation
May 7, 2017
International Anesthesia Research Society Annual Meeting
Aalok Agarwala, M.D., M.B.A.
Division Chief, General Surgery Anesthesia
Associate Director, Quality and Safety
Instructor in Anesthesia, Harvard Medical School

2. Outline About MGH Background Aim Our Critical Elements
Measures of Success
The Checklist
Results
Key Factors for Success

3. The Massachusetts General Hospital

4. Anesthesia at MGH
Operating Rooms: 58 NORA Sites: 28 # Anesthetics/Year: ~70,000 Faculty: 135 Residents: 75 Fellows: 24 CRNAs: 50

5. Intraop Handoffs: Background
Preventable errors & anesthetic mgmt.
~10% of errors involved a relief anesthetist
~1% could be attributed to the handoff process
Cooper JB et al. Anesthesiology 1982;56:
Previous handoff protocols at MGH
Cooper JB. (J Clin Anesth 1989;1:228-31)
Goldhaber-Fiebert, 2006
Rudolph JW, 2008
Still no standardized intraoperative handoff process in 2012

6. Improving Intraoperative Handoffs
Aim:
To improve the relay and retention of patient information by providing a simple, standardized structure for the handoff between anesthesia clinicians for intraoperative transfers of care

7. Our Critical Elements Small group of motivated front-line clinicians
Training with quality improvement principles and tools
Dedicated project planning time

8. The Team

9. Our Critical Elements Small group of motivated front-line clinicians
Training with quality improvement principles and tools
Dedicated project planning time
Measures of success part of initial plan

10. Measures of Success
Improvement in Information Relay - Measured by direct observation
Improvement in Information Retention – Measured with specific questions
Departmental Satisfaction - Survey about perceived handoff quality before and 8 months after introduction of the new process

11. Our Critical Elements Small group of motivated front-line clinicians
Training with quality improvement principles and tools
Dedicated project planning time
Measures of success part of initial plan
Leadership buy-in and support
A QI “Coach” to help the team, regular check-ins
Timeline for project completion

12. Timeline

13. Our Critical Elements Small group of motivated front-line clinicians
Training with quality improvement principles and tools
Dedicated project planning time
Measures of success part of initial plan
Leadership buy-in and support
A QI “Coach” to help the team, regular check-ins
Timeline for project completion
Development of checklist/process by consensus
Resources available to make checklist electronic

14. Electronic Handoff Checklist

15. Our Critical Elements Small group of motivated front-line clinicians
Training with quality improvement principles and tools
Dedicated project planning time
Measures of success part of initial plan
Leadership buy-in and support
A QI “Coach” to help the team, regular check-ins
Timeline for project completion
Development of checklist/process by consensus
Resources available to make checklist electronic
Measurement and report-out to stakeholders

16. Results: Information Relay
Item
No checklist
With checklist
p-value
Vasopressors
44%
85%
<0.01
Antiemetics
15%
46 %
<0.02
Antibiotics
63%
97%
<0.001
Lines
80%
100%
Blood loss
57%
Urine output
52%
Fluids administered
70%
90%
=0.06
Potential concerns
92%
<0.002
Postoperative plan
43%
Introduction of anesthetist 3%
51%

17. Results: Information Retention
Question
Without Checklist
With Checklist
p-value
Amount of fluid administered
72%
97%
=0.008
Muscle relaxant used
63%
=0.003
Antibiotic used
75%
=0.020
Time next antibiotic dose due
39%

18. Results: Departmental Satisfaction
Quality of Communication
Before
After
p-value
Outstanding/Good
63%
87%
<0.001
Identification of Concerns
61%
85%

19. Results: Checklist Adoption Rate

20. Results: Maintenance

21. Conclusions
The checklist improved relay and retention of critical information
Use was associated with perception of improved communication
Voluntary use remained steady
Impact on improved patient outcomes not known

22. Why did it work this time?
Front-line clinicians leading the effort
Leadership support
IT resources available
Quality Improvement “Coach”
Strict Timeline
Measurable outcomes
Results shared with department
Key Factor: A group of motivated individuals

23. Acknowledgements
Project Team: Guido Musch, MD, PhD, Paul Firth, MBChB, Lisa Warren, MD, Meredith Albrecht, MD, PhD
Chief: Jeanine Wiener-Kronish, MD
IT Support: Bill Driscoll and team
Coach: Bob Gibbons, PhD – MIT Sloan
Our predecessors: Jeff Cooper, PhD, Jenny Rudolph, PhD, Sara Goldhaber-Fiebert, MD
Reference: Agarwala AV, Firth PG, Albrecht MA, Warren L, Musch G. An Electronic Checklist Improves Transfer and Retention of Critical Information at Intraoperative Handoff of Care. Anesth Analg 2015;120:96–104