PACU Handover QI
Matthew Price, MD
Kalle Dardas, CRNA MSN
Lori Shannon, CRNA MS
Project Genesis
Approached by hospital surgical
administration August 2017 to
develop a Quality Improvement
Project – PACU Handover
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3
Perioperative Services Priorities
Patient Safety
• President and Vice President of Surgical
Services endorsed effort
• Engaged multidisciplinary team to begin a
deep dive into current state and develop
future state
1. Joint Commission-National Patient
Safety Goal
2. ASPIRE - Handoffs are a vulnerable
moment for patient safety
3. APSF - PACU complications rate of
23% compared to intraoperative
complications rate of 5%
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National Support
Evidence
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GOALS FOR PACU HANDOVER
• Identify a standardized process
• Set clear expectations for providers
• Utilize a standardized tool
• Engage and educate providers
• Compliance
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Handover – OR to PACU
• Multidisciplinary Meetings – Fall 2017
• Preliminary audits – April 2018
• Education and video presentation – May 2018
• Implementation of Standardized Tool – June
2018
• Audit Process – July 2018
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Multidisciplinary Meetings
• Lack of Teamwork
– Lack of respect
– No discussion regarding
plan of care
– Focus on computer
– Many distractions
• Lack of standardization
– No consistency
– No tool
– No time out
• :
– No history from pre
op
– Unreliable
information
• Production Pressure
– Quick turn-over time
– Priorities not aligned
• Technology
– Staff without phones
– Focus on computer
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Findings of Current Environment:
Multidisciplinary Meetings
• Priorities aligned
• Standardization of information
– Handover Tool
– Standardize process
• Effective Communication
– Respectful
– Accurate
– Collegial
– Professional
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Ideal Environment Goals:
Preliminary Audits
• Assessed current state of PACU handover
• 55 total audits completed
• Audit team = 2 CRNAs, 4 PACU RNs
• Audit tools developed:
– APSF
– Joint Commission publication
– MPOG
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Preliminary Audit Findings
• Initial interaction
– Chaotic
– Distractions
– Report not face-to-face
– Premature start of report
• Omission of key data
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Airway: 02, Pulse Oximetry
Monitors: BP, EKG, Temp
(Provider names and roles: PACU RN and anesthesia team members)
"Are you ready for verification and report?"
Computer Verification and ALLERGIES
Background
Communication Barriers/Special Needs
Pertinent PMH/PSH/Labs
Discussion of surgical / procedure course
Anesthetic Management
Airway management (ETT/LMA)
Type of anesthetic
Intraoperative labs
Anesthetic Complications
Medications
Preoperative Meds (Betablocker, Resp treatment, Insulin, Abx)
Sedation medications & amount administered. Reversal administered?
Muscle relaxants: Time/Amount administered. Reversal administered?
Intraoperative Pain Management
PONV Risk & Meds Administered
Intake & Output
Vascular access
Total Intraoperative Fluids/Blood Products Administered
Urine Output/EBL
Expectations / Plans
Identify primary anesthesia concerns for this patient
Allow opportunity for questions/acknowledgement of understanding of
report from receiving PACU team
Anesthesia to PACU Report:
Contact Precautions?
Initial
Introduction
Education
• Presented at multiple staff meetings
• Laminated Standardized tool at each PACU bay
• Multiple postings in common CRNA areas
• Video demonstration and power point
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Implementation
• Pilot process in 2 of our 4 PACUs
• Education coaching during handover process
in PACU
• Plan to begin process in final 2 PACUs in
September 2018
• Continue audit schedule for one year
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Audit Process
• Most important way to ensure compliance is
to continually audit the process
• Audit Team = 1 manager, 3 RNs and 1 CRNA
• 5 BH audits/month per team member (25
total)
• 4 MPOG audits per month – Surgical Quality
Nurse Clinicians
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Results
• Began July 9, 2018
• Continue to educate
• Audit/coaching at the same time
• Added to the orientation mandatories
• Negative Feedback – too long, not necessary
for each patient case, slows work flow
• Positive Feedback – thorough, easy to follow,
similar to what we’ve been doing
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Challenges
• Compliance with tool
• Changing the culture
• Skipping information
• Viewing the educational video
• Audits
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Video Demonstration
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