Fig. 36.1
Transitions across surgical care. Figure reprinted with permission from the American Society of Anesthesiologists (asahq.org/psh)
Each transition of care, from one phase in the surgical pathway to another, presents an opportunity for medical error . For surgical patients, the process from diagnosis to surgery involves numerous transitions in care. From the time of diagnosis, the patient encounters a variety of clinicians, from primary care to diagnostic specialists. The surgical referral and scheduling process may be arduous and can occur over weeks to months. Following surgery, care may be provided in many different settings, including the PACU, the ICU, rehabilitation, long-term care facilities, and finally the patient’s home. There are often numerous caregivers helping with recovery, but the care teams are frequently not well integrated [6].
This chapter will discuss recent advances and remaining challenges in improving the quality of surgical care transitions to ensure patient safety during the major phases of surgical care , from surgical scheduling to discharge and in the period of recuperation and recovery following discharge.
The Transition into the Operating Room
The Surgery Is Scheduled
Whether initially encountered in the hospital or clinic , one of the first hurdles encountered is accurate translation of surgical diagnostic and planning information to the scheduling of surgery. Errors in surgical case scheduling result in incorrect room and equipment preparation, as well as inappropriate planning on the part of the surgeon and surgical team. Although some variability between scheduled and actual procedures due to progression of disease or unexpected intraoperative findings cannot be avoided, accurate case scheduling is integral to OR efficiency, and errors have the potential to lead to increases in OR time, wasted supplies, and opened but unused surgical instruments, ultimately diminishing patient and staff satisfaction and increasing costs [7, 8].
A recent study by Pariser et al. analyzed the delays in start time and changes in total case time associated with incorrectly scheduled surgical cases [9]. The authors analyzed 14,970 surgical cases, 3.3 % of which were found to be incorrectly scheduled. Incorrectly scheduled cases were shown to lead to OR delays, longer turnover times, and cases going beyond scheduled length (mean 26 min). For those surgeons who have high heterogeneity of practice, the implementation of a more robust, multilayered scheduling process allows more detail to be conveyed in the OR scheduling system and increases scheduling reliability [9].
One of the most significant consequences of incorrectly scheduled cases is their connection to surgical errors, such as wrong-site surgery. Several studies have linked the surgical scheduling process to the downstream occurrence of wrong-site surgery [10–14]. Wu et al. looked at over 17,000 scheduled surgeries and found that wrong-side errors were the most common (N = 55, 36 %). In plastic surgery wrong-side errors were most common, whereas general surgery had mostly wrong-approach booking errors (N = 16, 43 %). Most surgical booking errors were caught in the holding area or the OR (N = 122, 81 %). The remaining errors were caught in the admitting or assessment areas (N = 28, 18 %) [10]. Abecassis et al. [11] performed a systematic review of the literature reporting root causes of wrong-site surgery, and surgical scheduling was found to be the most vulnerable aspect of the process with reports of 39 % of wrong-site surgeries attributable to errors in surgical scheduling [15].
Despite these challenges, many of the surgical scheduling processes are amenable to operational interventions to reduce communications errors and improve surgical scheduling accuracy [16]. Effective application of lean processes and root cause analyses have been shown to assist with the identification of key drivers in the process and in the implementation of interventions to reduce surgical listing errors and improve the accuracy of scheduled operative times, such as centralized scheduling [5, 16–18]. Simon describes the transition from paper to electronic surgical scheduling for orthopedic procedures. The development and implementation of the new scheduling system was guided by lean problem-solving and facilitated by a multidisciplinary work group [19]. The new system saw a reduction in lag time between surgical planning and the patient notification that surgery would be needed from three days to less than one day. Site/side discrepancies went from 4 % for clinic procedures and 2 % for operative procedures to zero for each [19]. Patient satisfaction also increased, with Press Ganey scores increasing by 20 %. Even with an electronic system, several checks need to be in place to prevent surgeons or office staff from clicking or selecting the wrong surgery [19].
Sign In/Time-Out/Sign Out
The WHO Surgical Safety Checklist
According to The Joint Commission, wrong-site surgery was the most common sentinel event reported between 2004 and 2010 [15]. The Joint Commission has been working for decades to standardize and implement guidelines known as the Universal Protocol as a verification step to ensure the accuracy of all patient information at the transition to the OR prior to the start of the procedure [15]. The World Health Organization (WHO) developed and implemented a surgical safety checklist that contains three components, the sign in, time-out, and sign out, which apply to three phases of surgery, respectively: before induction of anesthesia, before skin incision, and after the completion of surgery before the patient leaves the OR. Each phase involves a verification process with all members of the surgical team, who must be in agreement with one another before the procedure can continue. Use of the WHO surgical safety checklist has been linked to improvements in patient outcomes, compliance with standard processes of care, and the quality of teamwork in the OR [20, 21]. Although the WHO provides informational materials on how to conduct the safety checklists, OR teams are frequently not provided with this information in a structured educational format. Instead, individual centers and surgical specialties decide for themselves how to use the checklists, including who will lead them, when they are initiated, and what measures are in place to ensure compliance [22].
The result is wide variability. Observational studies of surgical time-outs and sign outs in the United States, United Kingdom, and Australia have demonstrated that the sign in, time-out, and sign out are often abbreviated, with absent or non-participating team members. Time-out checks are often completed after commencement of the procedure or are skipped entirely [23–25]. Additionally, current approaches to ensuring compliance with the WHO checklists are often executed in a yes/no manner, and team members rarely actively participate checklists in completion of the process [26].
Adherence to a presurgical checklist , along with the time-out, has been shown to reduce morbidity and mortality [20, 27]. Though effective when performed correctly, in our studies, we conducted a multi-site study of video observations of the use of the surgical safety checklist in the OR prior to donor hepatectomies [28] and found that sign-in was performed 83 % of the time and the complete sign-in protocol was performed for only 20 % of the procedures. The elements most frequently omitted were antibiotics given (75 %) followed by team introduced (50 %) and procedure to be performed (50 %). The full team was focused on the sign-in 80 % of the time. The time-out occurred in 100 % of the videoed procedures; however adherence to the institutional protocol occurred 38 % of the time. The most frequently omitted were procedural equipment (62 %) and patient positioning 50 % followed by site marked (32 %). The full team was focused on the time-out for 75 % of the procedures [28]. Other studies have demonstrated use in only 70 % of procedures and large variation in their use [29]. The result is the surgical team having incomplete patient information and surgical errors leading to harm in surgical patients. Dixon Woods et al. have shown that unless surgical team members are engaged in the surgical checklist process, little to no gain may be achieved with surgical checklists [30].
Postoperative Transitions
The transfer of care after surgery to the PACU or ICU presents special challenges to providers on both the delivering and receiving teams. The OR anesthesia and surgical team must physically transport the patient, along with any monitoring equipment from the surgical procedure. The physical transition occurs, while team members also simultaneously provide continuous monitoring, perform additional therapeutic tasks, and avoid potential pitfalls such as physical hallway obstructions [31]. Upon arrival at the receiving unit, the technology and support are transferred to stationary equipment, while knowledge of the patient is transmitted, in an environment that is often chaotic and busy, and to a team largely unfamiliar with the patient. This knowledge transfer involves cross-disciplinary staff with varied experience; the delivering team members with their diverse yet important perspectives of the course of surgery; and the receiving team concurrently stabilizing, assessing, and making care plans for the patient [32]. It is not surprising, under these circumstances, that postoperative transitions are plagued by technical and communication errors with deleterious effects on patient outcomes [33–38].
Transitions involving the ICU lead to more errors and adverse events when compared to other hospital units, and a significant percentage of these adverse events occurring in the ICU are potentially life threatening to the patient [39].
Our group investigated risks of patient harm during OR-to-ICU handoffs, using liver transplant recipients as a model for a failure modes, effects, and criticality analysis (FMECA) . We identified 37 individual steps in the OR-to-ICU handoff process . In total, 81 process failures were identified, 22 of which were determined to be critical and 36 of which relied on weak safeguards, such as informal human verification. Process failures with the greatest risk of harm were lack of preliminary OR-to-ICU communication, team member absence during handoff communication , and transport equipment malfunction [40]. Post hoc analysis revealed the need for early OR-to-ICU communication, the challenge of the competing demands and relative prioritization of clinical care versus participation in handoff communication, and the role of interpersonal relationships within and between OR and ICU teams. The limited common ground reduced the likelihood of correct interpretation of important handover information, which may contribute to adverse events [6]. Institutional culture and interdepartmental relationships were also reported to greatly influence behavior during this transition [41]. Members of the OR and ICU teams described different priorities for a high-quality handoff process, including the optimal timing and content of handoff communication, as well as whether handoff communication should take priority over initiation of clinical care in the ICU. The varied opinions among participants demonstrate the potential success of interventions that clarify roles, responsibilities, and expectations [42]. This study also determined attributes of high-quality OR-to-ICU transitions to include the following:
– Communication from the OR to the ICU of the start time of the surgery.
– Communication of the start time of closing by the anesthesia resident following first instance of counts.
– The ICU charge nurse calls the ICU resident and charge respiratory therapist.
– The charge respiratory therapist assigns the respiratory therapist to bring the vent to the ICU.
– The primary surgeon, fellow, anesthesiologist, and resident conduct a huddle.
– The OR nurse communicates to the ICU that the procedure has ended and that they are preparing to transfer to the ICU.
– The surgical and ICU teams perform the verbal transfer.
– The surgical fellow completes the surgical/ICU transition note [43].
Finally, interpersonal dynamics between team members were reported to affect care transition quality, and there was a general recognition that even a single “difficult” team member could compromise patient safety by discouraging open communication [43].
Postanesthesia Care Unit (PACU)
ICU and PACU have different challenges in safely transitioning care of a surgical patient. The PACU is the standard location for the initial recovery of the postoperative patient. The concept of the PACU was first introduced in 1923, yet far less research has been done examining transfers to the PACU than transfers to the ICU. Postoperative patients are at higher risk for complications or death when their surgical teams exhibited less briefing and information sharing during the transition [44]. Studies of postoperative transitions to the PACU have repeatedly demonstrated that the process is largely informal, unstructured, and incomplete. This involves the risk of losing relevant information and may result in increased rates of complications. A recent prospective analysis of PACU transfers found that critical aspects of care such as fluid and pain management were transferred in less than 20 % of the transitions [44, 45]. The shortest handover lasted only 1 s. Although it is difficult to define exactly what constitutes adequate length of time for a handover, the longest was only 300 s.
The Transition of the Postoperative Patient from the ICU or PACU to the General Floor
An ICU-to-ward patient transfer consists of several steps, beginning with a consult request for patient transfer from the ICU service and with the initial patient assessment by the receiving physician(s) following the patient’s arrival on the ward. During the transfer process, there is often conflict between the need to physically settle the patient and the need to receive information, and the perceived needs of the postoperative patient may supersede the need for information exchange [46, 47]. There is also frequently confusion as to who is responsible for receiving which specific information. Physician-to-physician and nurse-to-nurse communications occur at different phases of the transition, with respective groups communicating different aspects of the care plan, and the overall transition process, whether from the ICU or PACU to the general floor or from the hospital to home, may take several hours, further contributing to fragmented care [48].
Li et al. conducted a prospective observational study of physician handoff for 112 ICU-to-ward patient transfers and showed a significant deficiency in physician-to-physician communication despite overall satisfaction with the handoff process by involved providers and patient families [49]. Helling et al. recently examined incidents of unexpected clinical deterioration in surgical patients on standard nursing units. Of 111 of these, 90 % had been recently discharged from an ICU or PACU, overall mortality was 27 %, demonstrating the potential severity of these issues [50].
While ICU staff typically notified and explained to patients and families that a transfer to the general ward was pending, there was a general lack of interactive physician communication during the patient transfers, and physician-to-physician communication was largely unstandardized. In addition, during transfers there was ambiguity with regards to physician responsibility for patient care. Finally, 35.7 % of these transfers took place during night and weekend shifts, despite an increased incidence of physician cross coverage duties and reduced numbers of residents and ancillary staff. Important information that was often missing in handoff documents included pending investigations, recommendations arising from specialist consultations, and changes of important medications [49].
The length of time that a patient stays in the PACU is variable. While it is common practice for PACU discharge policies to stipulate a minimum length of stay, beyond that, a surgical patient’s readiness for discharge traditionally relies upon a nursing assessment of the appropriateness of physiological parameters. Recently, guidelines for the management of patients in the PACU and assessing their readiness for transfer have been proposed. Twenty-four essential criteria were identified through expert consensus [51]. In Canada, criteria considered essential for assessing when a patient is clinically stable and ready for transition from PACU included those related to (1) cardiac and respiratory function, such as blood pressure, pulse, respiratory rate, oxygen saturation, end-tidal CO2, arrhythmia, shortness of breath, respiratory stability, and tachycardia; (2) mental status, such as alertness, level of consciousness, sedation level, and coordination; and (3) postsurgical factors, such as pain, surgical bleeding, temperature, postoperative urinary retention, urine output, nausea and vomiting, and functional status. No corollary has been proposed in the United States, and there are currently no widely accepted professional guidelines for PACU transition [51].
Critical care transition program (CCTP) is an overarching term which includes rapid response teams, medical emergency teams, critical care outreach teams, or ICU nurse liaison programs that provide follow-up for patients discharged from the ICU. CCTPs appear to reduce the risk of ICU readmission in patients discharged from ICU to a general hospital ward. A meta-analysis of studies on CCTP demonstrated a reduced risk of ICU readmission (risk ratio, 0.87 [95 % CI, 0.76–0.99]; p = 0.03; I2 = 0 %); however, no significant reduction in hospital mortality (risk ratio, 0.84 [95 % CI, 0.66–1.05]; p = 0.1; I2 = 16 %) is associated with a CCTP. The rarity of the outcome (unexpected mortality) may have resulted in insufficient power to detect a significant difference. The risk of ICU readmission was similar whether the transition program was included within an outreach team or a nurse liaison program and did not depend on the presence of an intensivist [52].
Shift and Service Handoff Transitions
Communication, teamwork, and shift and service change transitions are a major challenge in healthcare and require a mention in the context of care transitions [53]. Transitions in patient care also involve the transfer of responsibility between work shifts in the contexts of the ICU, PACU, and the general floor. These interactions are particularly error prone due to a multitude of factors [54, 55]. Incomplete information exchange, nonstandardized formats, time pressures and other human factors, fragmented teams , and environmental distractions and conditions contribute to the overall failures of communication at the root of the problem. Missing, incorrect, or incomplete patient care information exchange is common in handoffs and includes medications, labs and tests to be performed and results, information regarding diagnoses, and the patient’s plan of care. Physicians, nurses, and other care providers report direct patient harm due to handoffs and cite competing demands, frequent interruptions, and the lack of transfer of critical information as contributing factors [54–56].
The Discharge Transition
The Discharge Transition Process : What Is Involved?
Patients who have undergone surgical procedures often have self-care concerns and information needs in the preparation for the discharge transition from the hospital. The most common concerns are related to the incision/wound care, pain management, activity level, monitoring for complications, symptom management, elimination, medications, and quality of life. Because of their clinical knowledge of the perioperative experience, advanced practice nurses have a critical role in the development of discharge-educational programs for postoperative patients and caregivers. Because unmet discharge needs can contribute to poor patient outcomes and readmission, it is critical that clinical staff nurses and social workers accurately identify patients’ informational needs and find ways to meet these needs, especially with aging populations, new/advanced surgical procedures, vulnerability/poverty, and literacy and health literacy levels of patients [57, 58]. Patient understanding of and adherence to discharge instructions and appropriate follow-up care are critical to successful discharge transition and recovery [59]. However, there are key challenges in the postoperative discharge transition including, coordination with others of the patient’s care providers and ensuring the restoration of any home medications that may have been discontinued during the surgical admission.
Risks Associated with the Postoperative Discharge Transition
There is no universally accepted definition of recovery after surgery, and it is well accepted that the recovery process is variable and dependent on many patient and operative procedural factors. While this variation is acceptable for long-term recovery after surgery, short-term recovery is often marked by discharge from the hospital and is an important benchmark of postoperative care quality. The surgical discharge is a critical transition of care, as effective discharge failure often results in an emergency room visit or readmission, both of which are care quality concerns.
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