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Journal for Healthcare Quality
A Standard Handoff Improves Cardiac Surgical Patient Transfer: Operating Room to Intensive Care Unit Jennifer L. Dixon, Hayden W. Stagg, Hania Wehbe-Janek, Chanhee Jo, William C. Culp, Jr, Jay G. Shake
Background: Patient handoffs are high-risk times associated with sentinel events. Effective handoff processes may enhance patient safety and team member communication. This study assesses the impact of a standardized protocol for handoffs from the cardiac surgery operating room to intensive care unit (ICU). Methods: Using a prospective pre–post study design, a formalized handoff process was developed including critical handoff elements and a standardized handoff procedure, script, and checklist. Data were collected from 60 handoff observations (30 pre and 30 post), evaluating 52 unique parameters, and survey of providers on perspectives of the handoff process. Results were compared by chi-square test, two sample t-test, or nonparametric Mann–Whitney test. Statistical significance was defined as P # .05. Results: Provider’s perspectives showed improved satisfaction with the standardized handoff process through improved responses in 19 of 22 survey items (P , .001). Median time until ventilator connection, ICU monitor transfer, first cardiac index, and chest radiograph were reduced after implementation. Completion of handoff process components also improved after implementation for 36 of 47 nontime parameters. Conclusions: A standard checklist-driven handoff process can dramatically improve key data transmission and reduce time of critical patient care steps during the high-risk period of patient handoff in a cardiac surgical ICU.
Keywords cardiac surgery patient safety postoperative care quality care management
Journal for Healthcare Quality Vol. 37, No. 1, pp. 22–32 © 2015 National Association for Healthcare Quality
The first several hours immediately after cardiac surgery, patients require heightened observational vigilance and complex critical care decision making. They are frequently maintained on vasoactive agents and mechanical ventilation for support during cardiac recovery after cardiopulmonary bypass and general anesthesia. However, during this period, they must also undergo a transfer of location and an exchange of medical history and responsi-
bility from the anesthesiologist and surgeon to the critical care team. Confounding this, patients are often hemodynamically labile and must be moved from the operating room (OR) to the intensive care unit (ICU) using portable monitoring equipment, which requires two separate changes in machinery. Thus, patient handoffs are high-risk times associated with sentinel events with a root cause often attributable to communication errors. A patient handoff has been defined as “the process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver” (Patterson and Wears, 2010). Of communication errors that occur in the healthcare setting, 43% occur during handoffs and 39% occur during intrahospital transfers (Ong and Coiera, 2011). Increased awareness of patient harm due to medical errors came to light with To Err is Human over 10 years ago (Kohn et al., 2000), but there have been few widely adopted changes that can show improvement in patient care outcomes. The Joint Commission Review of Sentinel Events Data reported the most frequently identified root causes that included human factors, leadership, and communication (Joint Commission, 2013). Additionally, within cardiothoracic surgery, the Locating Errors through Networked Surveillance (LENS) project has been formed to identify critical areas of improvement. Areas identified included poorly organized policies and protocols for care and processes, lack of training, and lack of standardization (Gurses et al., 2010; Martinez et al., 2010). Therefore, the development and implementation
Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
Vol. 37 No. 1 January/February 2015
of improved techniques for optimal communication are essential in eliminating potential for patient harm. Standardized handoff processes have been shown to enhance patient safety and communication between team members (Petrovic et al., 2012a, 2012b). Common barriers include incomplete transfer of information, inaccurate information, lack of consistency or organization, distractions during the transfer, inconsistent or incomplete teams, and poor standardization (Segall et al., 2012). Checklists are emerging as a reliable method for standardized communication because of decreased mortality (Haynes et al., 2009; Neily et al., 2010). Technical errors and verbal omissions have been shown to decrease after implementation of handoff protocols for pediatric cardiac surgery patients, without an increase in the duration of the handoff procedure, measured by direct observation of OR-to-ICU handoffs (Catchpole et al., 2007; Joy et al., 2011). The duration of key time sensitive action items including time to monitor hookup, laboratory draw, and chest radiograph are decreased with similar standardization handoff processes (Mistry et al., 2008). Checklists used in other clinical contexts have been shown to reduce complications and mortality through increased communication at the time of surgery with the World Health Organization’s Sign in, Time out, and Sign out process (Haynes et al., 2009). The Veteran’s Affairs system showed a decrease in surgical mortality after the implementation of a dedicated training system on teamwork, challenging each other to identify safety risks, checklistguided preoperative and postoperative debriefings, and effective communication (Neily et al., 2010). The purpose of this study was to assess the impact of a standardized checklistdriven protocol for our cardiac surgery OR-to-ICU handoff, using a prospective pre–post study design, as a quality improvement process. Before this intervention, poor handoffs accounted for a loss of information and gaps in care, which potentially contributed to adverse
23
patient outcomes and sentinel events. Patients were delivered to the ICU with little prearrival notice to the ICU team, therefore leaving little to no time to prepare for arrival of the patient. The handoff was nonstructured and included random elements delivered in an unorganized manner. There were often many interruptions or absences of crucial team members, leading to a duplication of handoff processes and repetition, resulting in increased overall handoff times. We hypothesized that implementing a standardized protocoldriven handoff process would reduce the number of data transmission failures during care transfer without substantially prolonging the handoff duration.
Materials and Methods Setting and Study design A prospective pre-post study design was approved by the institutional review board. The setting is a single-institution 635-bed teaching hospital, with a dedicated 14-bed cardiovascular surgery ICU. A multidisciplinary team including intensivists, surgeons, anesthesiologists, pharmacists, advanced practice nurses, physician assistants, respiratory therapists, and ICU nurses developed a formal handoff process based on the current literature (Petrovic et al., 2012a, 2012b; Segall et al., 2012). The process included critical handoff elements and a standardized handoff procedure, script, and detailed checklist for the surgeon and anesthesia provider (Figures 1 and 2) modified from those originally proposed by Petrovic et al., 2012b. The handoff procedure mandated that all team members be present at bedside from start to end, including anesthesia provider, surgeon or representative, ICU nurse, ICU intensivist, physician’s assistant or advanced practice nurse, and respiratory therapist. Communication errors are shown to occur during the transfer of critically ill patients due to failure to communicate arrival time and resources required (Ong and Coiera, 2011). Therefore, in addition to the protocol, a “heads-up” call was instituted to the ICU team 30 minutes before leaving
Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
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Journal for Healthcare Quality
Figure 1. Surgeon’s report checklist. *Modified from Petrovic et al., 2012a.
Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
Vol. 37 No. 1 January/February 2015
25
Figure 2. Anesthesia provider’s report checklist. *Modified from Petrovic et al., 2012a.
Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
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Journal for Healthcare Quality
Table 1. Survey Results
I am satisfied with the current OR-to-ICU handoff Important information is always communicated in the handoff transfer process The anesthesiologist report is complete during the handoff process The handoff is clearly heard by all members of the receiving team The OR-to-ICU handoff process provides safe transfer of care Effective communication occurs during the handoff process
Preintervention handoffs (N = 61)
Postintervention handoffs (N = 55)
P
2.9
3.95
,.0001
2.79
3.87
,.0001
2.84
4.16
,.0001
2.56
3.91
,.0001
2.98
4.09
,.0001
2.84
4.09
,.0001
Values are represented mean Likert scale score where 1 = strongly disagree to 5 = strongly agree. the OR, as well as a “we are leaving now” call as the team was about to leave the operation room. This enabled all team members to make allowances in their schedule to be present in the ICU room on arrival of the patient and during the handoff process. A scripted protocol was developed along with handoff checklists for providers, in an order that key items were not be missed or excluded. Additional commentary was discouraged unless it was felt to be important to the care of the patient.
Handoff Protocol On arrival of the patient and team to the ICU bedside, the anesthesiologist initiated the handoff by introducing the patient and then assisted the ICU nurse in the transfer
of equipment from the portable monitor to the ICU machinery. This was only undertaken once the patient was deemed stable enough for equipment transfer by the anesthesiology team leader. All hemodynamic or medical management decisions during the handoff were the responsibility of this senior anesthesiology provider (usually the Cardiac Anesthesiology Attending or Cardiac Anesthesiology Fellow). After completion of the monitor transfer and ensuring that the patient had adequate vital signs, the surgeon first gave a report of the procedure details, surgical findings, drains and pacing wires, and completed with instructions and what worried him most, in essence suggesting areas of potential complications to watch for in the early postoperative period (Figure 1). Surgeon
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Vol. 37 No. 1 January/February 2015
27
Table 2. Median Duration of Handoff and Key Steps Preintervention handoffs (N = 30)
Postintervention handoffs (N = 30)
P
60 210
30 160
.002 .004
708 1980 480
690 1235 600
.889 .036 .149
Time until ventilator hookup Time until cardiac monitor hookup Time until first cardiac index Time until chest x-ray obtained Duration of handoff All values represented in seconds.
representative (a physician assistant or resident who assisted and was present for the entire surgical procedure) could also provide this report. The anesthesiologist followed with a more thorough list, including pertinent medical history, most recent laboratory work, medications given, vasoactive requirements, and also concluded with providing information on what worried him most about the patient (Figure 2). Finally, the ICU team including both the nurse and intensivist had a chance to clarify any questions and discuss the postoperative plans.
Data Collection Before implementation of the new protocol, baseline data were obtained (see below). Subsequently, instructional sessions were provided to nurses, physicians, and ancillary staff involved in the care of cardiac surgery patients. A 3-month education and adjustment period was provided for adequate acclimation to the new process before collecting the postintervention data. Since its inception, all new hospital personnel obtain training on the standardized handoff process. The process was evaluated using two techniques: preintervention and postintervention staff surveys and direct observation of the handoff process with two independent observers. Preintervention observations were preformed from March to May 2012, and postintervention period was from September to December 2012. Surveys were anonymously distributed to ICU nurses, anesthesia providers, surgeons,
surgical physician assistants, and critical care physicians (n = 75) with an approximate response rate of 80% (61) before intervention (February 2012) and 73% (55) on completion of the study (December 2012). Surveys included 22 questions taken from previously validated surveys, with responses measured on a 5-point Likert scale, scored 1 to 5, strongly disagree to strongly agree, respectively. Themes addressed by the survey include satisfaction, completeness, degree of patient safety, and effectiveness with the new process. Direct handoff observations were performed by two individual observers. Thirty observations were done both before and after intervention for a total of 60 observations. This number was selected based on previous literature and felt adequate to implement a quality improvement process (Petrovic et al., 2012). This project was not powered to attempt to show a difference in outcomes with respect to hard end points such as realized complications or death. Handoffs were monitored for 52 unique parameters and assessed for the time required for ventilator transfer, time to first cardiac index and chest radiograph, and duration of the process. The parameters selected for monitoring were identified to be the most crucial pieces of patient information based on previous handoff literature (Patterson and Wears, 2010; Petrovic et al., 2012). Observations covered roughly one third of the cases performed during the study periods. Results were tabulated by percentages or descriptive statistics and compared by chi-square test, two-sample t-test, or
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Journal for Healthcare Quality
Table 3. Handoff Observation Outcomes Parameter During monitor-line setup, full attention of team and all members present Surgeons reporting the findings and complications of surgery Surgeon reporting any special instructions Surgeon reporting what worries him most Anesthesiologist lists approximate time of last opiates and antibiotic dose The post-handoff briefing was completed without interruption Discussion of postoperative care
Preintervention handoffs (N = 30)
Postintervention handoffs (N = 30)
P
3% (1)
93% (28)
,.0001
41% (12)
97% (29)
,.0001
17% (5)
79% (23)
,.0001
10% (3)
90% (27)
,.0001
3% (1)
90% (26)
,.0001
3% (1)
90% (27)
,.0001
3% (1)
83% (25)
,.0001
Values are represented as total percentage (frequency observed “yes”).
nonparametric Mann–Whitney test. Statistical significance was defined as P # .05.
Results Survey Results In the baseline survey, a deficit in patient care was appreciated by providers across all specialties. Before the intervention, the average responses were negative. The survey questions were designed so that higher score would reflect better handoff or task performance. The mean scores ranged between disagree to neutral (between 2 and 3 on the 5-point Likert scale) for questions such as “the handoff is clearly heard by all members of the receiving team” (mean, 2.56 6 0.95), “the physical transfer between the OR and ICU
is an efficient process” (mean, 2.82 6 1.09), and “the hospital does a good job training individuals about the handoff process” (mean, 2.71 6 0.93). In the follow-up survey, providers’ perspectives of the process improved in 19 of 22 survey questions (P , .001). Table 1 shows some of the most notable improvements captured by the survey. Improved perceptions were still present after analyzing the survey questions for each of 3 groups of responders: surgeons, anesthesia providers, and nursing and support staff (statistical improvement in 17, 11, and 20 out of 22 questions for each respective cohort, respectively). The surgeon group was the smallest, and therefore a larger improvement was needed to reach significance when compared with the other two groups. The amount of improvement on
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Vol. 37 No. 1 January/February 2015
question scoring was similar between the three groups.
Observation Results Dramatic changes were found on comparison of the data from observations before and after the handoff protocol implementation. The time required for key steps in transfer of care of the patient all decreased including median time until ventilator connection (60–30 s, P = .002), ICU monitor transfer (3.5–2.7 min, P = .004), first cardiac index (11.8–11.5 min, P = .889), and chest radiograph (33–20.6 min, P = .036) after implementation (Table 2). The total duration of handoff increased by 2 minutes with a preintervention handoff of 8 minutes compared with average of 10 minutes postintervention (P = 0.149). By extending the time of handoff by 2 minutes, completion of handoff process components improved after implementation for 40 of 47 nontime parameters and this was significant for 37 of 47 items (P , .001). Table 3 represents seven key areas of improvement. The change was substantial and many occurrences improved from rarely performed to almost always performed.
Discussion Traditionally, patient transfers have involved multiple parallel handoffs between specialty types (nurse to nurse only and physician to physician). The involvement of a multidisciplinary handoff process presents a difficult challenge with respect to communication. Our institution has suggested a benefit of the team handoff through increased employee satisfaction and improved patient care parameters. A recent review article concluded that to increase patient safety, we must build a culture of safety, increase teamwork, and monitor performance (Martinez et al., 2011). Improved satisfaction from the follow-up survey may be a result of employees sensing an improvement in the culture of safety. During the education period, there were several training sessions that emphasized the importance of patient safety and participation of all team members.
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The scripts or checklists were useful in reminding providers to include all key elements. Healthcare providers often get bogged down in transfer of details, but for effective communication, it is important to discuss the direction of patient care and anticipated adverse events. The perceived best addition to our handoff protocol was for team members to state what worried them most about the patient, which could lead to mitigation of adverse events. Finally, for optimal implementation, the environment needs to be one where all team members are allowed the opportunity to speak or ask questions without hierarchical structure (Segall et al., 2012). This was encouraged by our process development and educational phase; however, the protocol clearly defined the order of speakers to prevent confusion as to whose turn it was to speak. Similar implementation of standard handoff for cardiac patients transferring from the OR to ICU have been reported (Petrovic et al., 2012a, 2012b); however, our study includes a more in-depth survey of the providers involved including anesthesiologists, nurses, surgeons, and intensivists. Our handoff protocol improved employee satisfaction; however, additional large prospective studies are needed to demonstrate improved patient outcomes with a standardized handoff process. The only previous published study powered enough to investigate a decrease in complications showed a 50% reduction in postoperative complications (24%–12%, P , .001) after implementation of standard handoff procedure in pediatric cardiac surgery patients (Agarwal et al., 2012). A limitation to the study includes a possibility of producing a Hawthorne effect by data collection through direct observations. Observers were physically present for the handoff, and team members knew that they were being observed with the intention of studying the OR-to-ICU handoff process. However, team members were not aware of the metrics being measured. This was felt to be a small limitation given that providers universally provided positive feedback through postintervention surveys. Additionally, sustainability of this newly adopted process will need further evaluation.
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Journal for Healthcare Quality
Attempts were made to eliminate novelty biases by allowing for an adequate period (3 months) for adoption and adaptation to the new handoff procedure. Final survey data were collected approximately 6 months after implementation, showing that the procedure contained elements that allow for short-term sustainability.
Conclusions Improved communication is a key component in reducing medical errors. Our healthcare providers universally appreciated improvements in patient care and expressed improved satisfaction with the patient handoff process. Institution of a checklistdriven handoff process has dramatically improved key data transmission. In addition, it reduced the time of critical patient care steps during the high-risk period of patient handoff in a cardiac surgical ICU.
References Agarwal, H.S., Saville, B.R., & Slayton, J.M., 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. Catchpole, K.R., de Leval, M.R., & McEwan, A., et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatric Anaesth 2007;17:470–478. Gurses, A.P., Kim, G., & Martinez, E.A., et al. Identifying and categorizing patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. BMJ Qual Saf 2012;21:810–818. Haynes, A.B., Weiser, T.G., & Berry, W.R., et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med 2009;360:491–499. Joint Commission. The Joint Commission, sentinel event data; root causes by event type 20042012. Available at: www.jointcommission.org/ assets/1/18/Root_Causes_Event_Type_04_ 4Q2012.pdf. Accessed May 22, 2013. Joy, B.F., Elliott, E., & 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. Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. To err is human: building a safer health care
system. Washington, DC: National Academy Press, 2000. Martinez, E.A., Marsteller, J.A., & Thompson, D.A., et al. The Society of cardiovascular anesthesiologists’ Focus Initiative: locating errors through networked surveillance (LENS) project Vision. Anesth Analgesia 2010; 110:307–311. Martinez, E.A., Thompson, D.A., & Errett, N.A., et al. Review article: high stakes and high risk: a focused qualitative review of hazards during cardiac surgery. Anesth Analgesia 2011;112:1061–1074. Mistry, K.P., Jaggers, J., & Lodge, A.J., et al. Using Six Sigma Methodology to improve handoff communication in high-risk patients. In: Henriksen, K, Battles, JB, Keyes, MA, & Grady, ML, eds. Advances in patient safety: new directions and alternative approaches (volume 3: performance and tools). Rockville, MD: Agency for Healthcare Research and Quality (US), 2008. Neily, J., Mills, P.D., & Young-Xu, Y., et al. Association between implementation of a medical team training program and surgical mortality. J Am Med Assoc 2010;304: 1693–1700. Ong, M.S., & Coiera, E. A systematic review of failures in handoff communication during intrahospital transfers. Joint Comm J Qual Saf 2011;37:274–284. Patterson, E.S., & Wears, R.L. Patient handoffs: standardized and reliable measurement tools remain elusive. Joint Comm J Qual Saf 2010;36:52–61. Petrovic, M.A., Martinez, E.A., & Aboumatar, H. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Joint Comm J Qual Saf 2012a;38:135–142. Petrovic, M.A., Aboumatar, H., & Baumgartner, W. A., et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac Vasc Anesth 2012b;26: 11–16. Segall, N., Bonifacio, A.S., & Schroeder, R.A., et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analgesia 2012;115:02–115.
Authors’ Biographies Jennifer L Dixon, MD. Dr. Dixon is a General Surgery Resident at Baylor Scott & White Memorial Hospital in Temple, TX. Hayden Stagg, MD. Dr. Stagg is a General Surgery Resident at Baylor Scott & White Memorial Hospital in Temple, TX. Hania Wehbe-Janek PhD. Dr. Wehbe-Janek is Assistant Professor within the Department of Academic
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Vol. 37 No. 1 January/February 2015
Operations at Baylor Scott & White Memorial Hospital in Temple, TX. She has special research interests in patient safety and quality, as well as resident education. Chanhee Jo, PhD. Dr. Jo was a statistician at Baylor Scott & White Memorial Hospital but has left the institution. William C. Culp, Jr, MD. Dr. Culp is Associate Professor of anesthesiology specializing in cardiac anesthesiologist at Baylor Scott & White Memorial Hospital in Temple, TX. Jay Shake MD, FACS. Dr. Shake is Assistant Professor in the departments of Critical Care and Cardiothoracic Surgery at Baylor Scott & White Memorial Hospital in Temple, TX. He has research interests in quality improvement and outcomes assessment. For more information on this article, contact Jay G. Shake at [email protected] Meeting presentation: American College of Surgeons, 99th Annual Surgical Congress; October 2013. The authors declare no conflicts of interest.
Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and take the online posttest at http://www.nahq.org/education/content/ jhq-ce.html. This continuing education offering, JHQ 252, will provide 1 contact hour to those who complete it appropriately.
Core CPHQ Examination Content Area IV. Patient Safety A standard handoff improves cardiac surgical patient transfer: operating room to intensive care unit. Journal for Healthcare Quality Continuing Education
Objectives 1. Design a protocol for handoff of patients after the cardiac operating room.
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2. Describe how postoperative checklists can assist in patient handoff process. 3. List the benefits of standardized postoperative handoffs.
Multiple Choice Questions 1. Sentinel events are associated with all the following except a. Bad communication b. High-quality patient care c. Intrahospital transfers d. Duplication of handoffs 2. Which of the following is not a barrier to implementing handoff protocols a. Consistent team members b. Distractions during the transfer c. Inaccurate information d. Poor standardization 3. Critical components of the surgeons report should include all of the following except a. The procedure performed b. Operative tubes and drains c. Most recent laboratory values d. What worries the surgeon about the patient 4. Critical components of the anesthesiologist report should include all of the following except a. The procedure performed b. Pertinent past medical history c. Most recent laboratory values d. What worries the anesthesiologist the most 5. Standardized handoffs after the cardiac OR have been shown to a. Increase duration of monitor hookup b. Increase employee satisfaction c. Worsen relationship between nursing and physicians d. Worsen patient outcomes 6. Ideal implementation of a standard handoff protocol a. Does not require adaptation for individual hospital settings b. Requires no individual or group training c. Requires no checklists d. Requires development by an interdisciplinary team
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Journal for Healthcare Quality
7. The handoff process a. Improves employee perception of patient care b. Increases the handoff time by greater than 10 minutes c. Increase the time for critical steps such as postoperative labs d. Creates difficult workflow 8. In terms of employee perceptions a. Employees are generally not interested in patient safety b. Employees are often aware of current deficits in patient care c. Standardized handoffs are not valued by employees d. Employees have difficulty conforming to checklists
9. Key effective components of the handoff include all except a. Stating what providers are most worried about b. Clear roles and order of the handoff c. Presence of all key team members d. Interruptions to ask questions 10. A standardized handoff after cardiac surgery a. Decreases the completeness of the anesthesiologist report b. Increases the rate of effective communication c. Increases the work for all providers d. Decreases the amount of information communicated
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Journal for Healthcare Quality
A Standard Handoff Improves Cardiac Surgical Patient Transfer: Operating Room to Intensive Care Unit Jennifer L. Dixon, Hayden W. Stagg, Hania Wehbe-Janek, Chanhee Jo, William C. Culp, Jr, Jay G. Shake
Background: Patient handoffs are high-risk times associated with sentinel events. Effective handoff processes may enhance patient safety and team member communication. This study assesses the impact of a standardized protocol for handoffs from the cardiac surgery operating room to intensive care unit (ICU). Methods: Using a prospective pre–post study design, a formalized handoff process was developed including critical handoff elements and a standardized handoff procedure, script, and checklist. Data were collected from 60 handoff observations (30 pre and 30 post), evaluating 52 unique parameters, and survey of providers on perspectives of the handoff process. Results were compared by chi-square test, two sample t-test, or nonparametric Mann–Whitney test. Statistical significance was defined as P # .05. Results: Provider’s perspectives showed improved satisfaction with the standardized handoff process through improved responses in 19 of 22 survey items (P , .001). Median time until ventilator connection, ICU monitor transfer, first cardiac index, and chest radiograph were reduced after implementation. Completion of handoff process components also improved after implementation for 36 of 47 nontime parameters. Conclusions: A standard checklist-driven handoff process can dramatically improve key data transmission and reduce time of critical patient care steps during the high-risk period of patient handoff in a cardiac surgical ICU.
Keywords cardiac surgery patient safety postoperative care quality care management
Journal for Healthcare Quality Vol. 37, No. 1, pp. 22–32 © 2015 National Association for Healthcare Quality
The first several hours immediately after cardiac surgery, patients require heightened observational vigilance and complex critical care decision making. They are frequently maintained on vasoactive agents and mechanical ventilation for support during cardiac recovery after cardiopulmonary bypass and general anesthesia. However, during this period, they must also undergo a transfer of location and an exchange of medical history and responsi-
bility from the anesthesiologist and surgeon to the critical care team. Confounding this, patients are often hemodynamically labile and must be moved from the operating room (OR) to the intensive care unit (ICU) using portable monitoring equipment, which requires two separate changes in machinery. Thus, patient handoffs are high-risk times associated with sentinel events with a root cause often attributable to communication errors. A patient handoff has been defined as “the process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver” (Patterson and Wears, 2010). Of communication errors that occur in the healthcare setting, 43% occur during handoffs and 39% occur during intrahospital transfers (Ong and Coiera, 2011). Increased awareness of patient harm due to medical errors came to light with To Err is Human over 10 years ago (Kohn et al., 2000), but there have been few widely adopted changes that can show improvement in patient care outcomes. The Joint Commission Review of Sentinel Events Data reported the most frequently identified root causes that included human factors, leadership, and communication (Joint Commission, 2013). Additionally, within cardiothoracic surgery, the Locating Errors through Networked Surveillance (LENS) project has been formed to identify critical areas of improvement. Areas identified included poorly organized policies and protocols for care and processes, lack of training, and lack of standardization (Gurses et al., 2010; Martinez et al., 2010). Therefore, the development and implementation
Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
Vol. 37 No. 1 January/February 2015
of improved techniques for optimal communication are essential in eliminating potential for patient harm. Standardized handoff processes have been shown to enhance patient safety and communication between team members (Petrovic et al., 2012a, 2012b). Common barriers include incomplete transfer of information, inaccurate information, lack of consistency or organization, distractions during the transfer, inconsistent or incomplete teams, and poor standardization (Segall et al., 2012). Checklists are emerging as a reliable method for standardized communication because of decreased mortality (Haynes et al., 2009; Neily et al., 2010). Technical errors and verbal omissions have been shown to decrease after implementation of handoff protocols for pediatric cardiac surgery patients, without an increase in the duration of the handoff procedure, measured by direct observation of OR-to-ICU handoffs (Catchpole et al., 2007; Joy et al., 2011). The duration of key time sensitive action items including time to monitor hookup, laboratory draw, and chest radiograph are decreased with similar standardization handoff processes (Mistry et al., 2008). Checklists used in other clinical contexts have been shown to reduce complications and mortality through increased communication at the time of surgery with the World Health Organization’s Sign in, Time out, and Sign out process (Haynes et al., 2009). The Veteran’s Affairs system showed a decrease in surgical mortality after the implementation of a dedicated training system on teamwork, challenging each other to identify safety risks, checklistguided preoperative and postoperative debriefings, and effective communication (Neily et al., 2010). The purpose of this study was to assess the impact of a standardized checklistdriven protocol for our cardiac surgery OR-to-ICU handoff, using a prospective pre–post study design, as a quality improvement process. Before this intervention, poor handoffs accounted for a loss of information and gaps in care, which potentially contributed to adverse
23
patient outcomes and sentinel events. Patients were delivered to the ICU with little prearrival notice to the ICU team, therefore leaving little to no time to prepare for arrival of the patient. The handoff was nonstructured and included random elements delivered in an unorganized manner. There were often many interruptions or absences of crucial team members, leading to a duplication of handoff processes and repetition, resulting in increased overall handoff times. We hypothesized that implementing a standardized protocoldriven handoff process would reduce the number of data transmission failures during care transfer without substantially prolonging the handoff duration.
Materials and Methods Setting and Study design A prospective pre-post study design was approved by the institutional review board. The setting is a single-institution 635-bed teaching hospital, with a dedicated 14-bed cardiovascular surgery ICU. A multidisciplinary team including intensivists, surgeons, anesthesiologists, pharmacists, advanced practice nurses, physician assistants, respiratory therapists, and ICU nurses developed a formal handoff process based on the current literature (Petrovic et al., 2012a, 2012b; Segall et al., 2012). The process included critical handoff elements and a standardized handoff procedure, script, and detailed checklist for the surgeon and anesthesia provider (Figures 1 and 2) modified from those originally proposed by Petrovic et al., 2012b. The handoff procedure mandated that all team members be present at bedside from start to end, including anesthesia provider, surgeon or representative, ICU nurse, ICU intensivist, physician’s assistant or advanced practice nurse, and respiratory therapist. Communication errors are shown to occur during the transfer of critically ill patients due to failure to communicate arrival time and resources required (Ong and Coiera, 2011). Therefore, in addition to the protocol, a “heads-up” call was instituted to the ICU team 30 minutes before leaving
Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
24
Journal for Healthcare Quality
Figure 1. Surgeon’s report checklist. *Modified from Petrovic et al., 2012a.
Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
Vol. 37 No. 1 January/February 2015
25
Figure 2. Anesthesia provider’s report checklist. *Modified from Petrovic et al., 2012a.
Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
26
Journal for Healthcare Quality
Table 1. Survey Results
I am satisfied with the current OR-to-ICU handoff Important information is always communicated in the handoff transfer process The anesthesiologist report is complete during the handoff process The handoff is clearly heard by all members of the receiving team The OR-to-ICU handoff process provides safe transfer of care Effective communication occurs during the handoff process
Preintervention handoffs (N = 61)
Postintervention handoffs (N = 55)
P
2.9
3.95
,.0001
2.79
3.87
,.0001
2.84
4.16
,.0001
2.56
3.91
,.0001
2.98
4.09
,.0001
2.84
4.09
,.0001
Values are represented mean Likert scale score where 1 = strongly disagree to 5 = strongly agree. the OR, as well as a “we are leaving now” call as the team was about to leave the operation room. This enabled all team members to make allowances in their schedule to be present in the ICU room on arrival of the patient and during the handoff process. A scripted protocol was developed along with handoff checklists for providers, in an order that key items were not be missed or excluded. Additional commentary was discouraged unless it was felt to be important to the care of the patient.
Handoff Protocol On arrival of the patient and team to the ICU bedside, the anesthesiologist initiated the handoff by introducing the patient and then assisted the ICU nurse in the transfer
of equipment from the portable monitor to the ICU machinery. This was only undertaken once the patient was deemed stable enough for equipment transfer by the anesthesiology team leader. All hemodynamic or medical management decisions during the handoff were the responsibility of this senior anesthesiology provider (usually the Cardiac Anesthesiology Attending or Cardiac Anesthesiology Fellow). After completion of the monitor transfer and ensuring that the patient had adequate vital signs, the surgeon first gave a report of the procedure details, surgical findings, drains and pacing wires, and completed with instructions and what worried him most, in essence suggesting areas of potential complications to watch for in the early postoperative period (Figure 1). Surgeon
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Vol. 37 No. 1 January/February 2015
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Table 2. Median Duration of Handoff and Key Steps Preintervention handoffs (N = 30)
Postintervention handoffs (N = 30)
P
60 210
30 160
.002 .004
708 1980 480
690 1235 600
.889 .036 .149
Time until ventilator hookup Time until cardiac monitor hookup Time until first cardiac index Time until chest x-ray obtained Duration of handoff All values represented in seconds.
representative (a physician assistant or resident who assisted and was present for the entire surgical procedure) could also provide this report. The anesthesiologist followed with a more thorough list, including pertinent medical history, most recent laboratory work, medications given, vasoactive requirements, and also concluded with providing information on what worried him most about the patient (Figure 2). Finally, the ICU team including both the nurse and intensivist had a chance to clarify any questions and discuss the postoperative plans.
Data Collection Before implementation of the new protocol, baseline data were obtained (see below). Subsequently, instructional sessions were provided to nurses, physicians, and ancillary staff involved in the care of cardiac surgery patients. A 3-month education and adjustment period was provided for adequate acclimation to the new process before collecting the postintervention data. Since its inception, all new hospital personnel obtain training on the standardized handoff process. The process was evaluated using two techniques: preintervention and postintervention staff surveys and direct observation of the handoff process with two independent observers. Preintervention observations were preformed from March to May 2012, and postintervention period was from September to December 2012. Surveys were anonymously distributed to ICU nurses, anesthesia providers, surgeons,
surgical physician assistants, and critical care physicians (n = 75) with an approximate response rate of 80% (61) before intervention (February 2012) and 73% (55) on completion of the study (December 2012). Surveys included 22 questions taken from previously validated surveys, with responses measured on a 5-point Likert scale, scored 1 to 5, strongly disagree to strongly agree, respectively. Themes addressed by the survey include satisfaction, completeness, degree of patient safety, and effectiveness with the new process. Direct handoff observations were performed by two individual observers. Thirty observations were done both before and after intervention for a total of 60 observations. This number was selected based on previous literature and felt adequate to implement a quality improvement process (Petrovic et al., 2012). This project was not powered to attempt to show a difference in outcomes with respect to hard end points such as realized complications or death. Handoffs were monitored for 52 unique parameters and assessed for the time required for ventilator transfer, time to first cardiac index and chest radiograph, and duration of the process. The parameters selected for monitoring were identified to be the most crucial pieces of patient information based on previous handoff literature (Patterson and Wears, 2010; Petrovic et al., 2012). Observations covered roughly one third of the cases performed during the study periods. Results were tabulated by percentages or descriptive statistics and compared by chi-square test, two-sample t-test, or
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Journal for Healthcare Quality
Table 3. Handoff Observation Outcomes Parameter During monitor-line setup, full attention of team and all members present Surgeons reporting the findings and complications of surgery Surgeon reporting any special instructions Surgeon reporting what worries him most Anesthesiologist lists approximate time of last opiates and antibiotic dose The post-handoff briefing was completed without interruption Discussion of postoperative care
Preintervention handoffs (N = 30)
Postintervention handoffs (N = 30)
P
3% (1)
93% (28)
,.0001
41% (12)
97% (29)
,.0001
17% (5)
79% (23)
,.0001
10% (3)
90% (27)
,.0001
3% (1)
90% (26)
,.0001
3% (1)
90% (27)
,.0001
3% (1)
83% (25)
,.0001
Values are represented as total percentage (frequency observed “yes”).
nonparametric Mann–Whitney test. Statistical significance was defined as P # .05.
Results Survey Results In the baseline survey, a deficit in patient care was appreciated by providers across all specialties. Before the intervention, the average responses were negative. The survey questions were designed so that higher score would reflect better handoff or task performance. The mean scores ranged between disagree to neutral (between 2 and 3 on the 5-point Likert scale) for questions such as “the handoff is clearly heard by all members of the receiving team” (mean, 2.56 6 0.95), “the physical transfer between the OR and ICU
is an efficient process” (mean, 2.82 6 1.09), and “the hospital does a good job training individuals about the handoff process” (mean, 2.71 6 0.93). In the follow-up survey, providers’ perspectives of the process improved in 19 of 22 survey questions (P , .001). Table 1 shows some of the most notable improvements captured by the survey. Improved perceptions were still present after analyzing the survey questions for each of 3 groups of responders: surgeons, anesthesia providers, and nursing and support staff (statistical improvement in 17, 11, and 20 out of 22 questions for each respective cohort, respectively). The surgeon group was the smallest, and therefore a larger improvement was needed to reach significance when compared with the other two groups. The amount of improvement on
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Vol. 37 No. 1 January/February 2015
question scoring was similar between the three groups.
Observation Results Dramatic changes were found on comparison of the data from observations before and after the handoff protocol implementation. The time required for key steps in transfer of care of the patient all decreased including median time until ventilator connection (60–30 s, P = .002), ICU monitor transfer (3.5–2.7 min, P = .004), first cardiac index (11.8–11.5 min, P = .889), and chest radiograph (33–20.6 min, P = .036) after implementation (Table 2). The total duration of handoff increased by 2 minutes with a preintervention handoff of 8 minutes compared with average of 10 minutes postintervention (P = 0.149). By extending the time of handoff by 2 minutes, completion of handoff process components improved after implementation for 40 of 47 nontime parameters and this was significant for 37 of 47 items (P , .001). Table 3 represents seven key areas of improvement. The change was substantial and many occurrences improved from rarely performed to almost always performed.
Discussion Traditionally, patient transfers have involved multiple parallel handoffs between specialty types (nurse to nurse only and physician to physician). The involvement of a multidisciplinary handoff process presents a difficult challenge with respect to communication. Our institution has suggested a benefit of the team handoff through increased employee satisfaction and improved patient care parameters. A recent review article concluded that to increase patient safety, we must build a culture of safety, increase teamwork, and monitor performance (Martinez et al., 2011). Improved satisfaction from the follow-up survey may be a result of employees sensing an improvement in the culture of safety. During the education period, there were several training sessions that emphasized the importance of patient safety and participation of all team members.
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The scripts or checklists were useful in reminding providers to include all key elements. Healthcare providers often get bogged down in transfer of details, but for effective communication, it is important to discuss the direction of patient care and anticipated adverse events. The perceived best addition to our handoff protocol was for team members to state what worried them most about the patient, which could lead to mitigation of adverse events. Finally, for optimal implementation, the environment needs to be one where all team members are allowed the opportunity to speak or ask questions without hierarchical structure (Segall et al., 2012). This was encouraged by our process development and educational phase; however, the protocol clearly defined the order of speakers to prevent confusion as to whose turn it was to speak. Similar implementation of standard handoff for cardiac patients transferring from the OR to ICU have been reported (Petrovic et al., 2012a, 2012b); however, our study includes a more in-depth survey of the providers involved including anesthesiologists, nurses, surgeons, and intensivists. Our handoff protocol improved employee satisfaction; however, additional large prospective studies are needed to demonstrate improved patient outcomes with a standardized handoff process. The only previous published study powered enough to investigate a decrease in complications showed a 50% reduction in postoperative complications (24%–12%, P , .001) after implementation of standard handoff procedure in pediatric cardiac surgery patients (Agarwal et al., 2012). A limitation to the study includes a possibility of producing a Hawthorne effect by data collection through direct observations. Observers were physically present for the handoff, and team members knew that they were being observed with the intention of studying the OR-to-ICU handoff process. However, team members were not aware of the metrics being measured. This was felt to be a small limitation given that providers universally provided positive feedback through postintervention surveys. Additionally, sustainability of this newly adopted process will need further evaluation.
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Journal for Healthcare Quality
Attempts were made to eliminate novelty biases by allowing for an adequate period (3 months) for adoption and adaptation to the new handoff procedure. Final survey data were collected approximately 6 months after implementation, showing that the procedure contained elements that allow for short-term sustainability.
Conclusions Improved communication is a key component in reducing medical errors. Our healthcare providers universally appreciated improvements in patient care and expressed improved satisfaction with the patient handoff process. Institution of a checklistdriven handoff process has dramatically improved key data transmission. In addition, it reduced the time of critical patient care steps during the high-risk period of patient handoff in a cardiac surgical ICU.
References Agarwal, H.S., Saville, B.R., & Slayton, J.M., 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. Catchpole, K.R., de Leval, M.R., & McEwan, A., et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatric Anaesth 2007;17:470–478. Gurses, A.P., Kim, G., & Martinez, E.A., et al. Identifying and categorizing patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. BMJ Qual Saf 2012;21:810–818. Haynes, A.B., Weiser, T.G., & Berry, W.R., et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med 2009;360:491–499. Joint Commission. The Joint Commission, sentinel event data; root causes by event type 20042012. Available at: www.jointcommission.org/ assets/1/18/Root_Causes_Event_Type_04_ 4Q2012.pdf. Accessed May 22, 2013. Joy, B.F., Elliott, E., & 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. Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. To err is human: building a safer health care
system. Washington, DC: National Academy Press, 2000. Martinez, E.A., Marsteller, J.A., & Thompson, D.A., et al. The Society of cardiovascular anesthesiologists’ Focus Initiative: locating errors through networked surveillance (LENS) project Vision. Anesth Analgesia 2010; 110:307–311. Martinez, E.A., Thompson, D.A., & Errett, N.A., et al. Review article: high stakes and high risk: a focused qualitative review of hazards during cardiac surgery. Anesth Analgesia 2011;112:1061–1074. Mistry, K.P., Jaggers, J., & Lodge, A.J., et al. Using Six Sigma Methodology to improve handoff communication in high-risk patients. In: Henriksen, K, Battles, JB, Keyes, MA, & Grady, ML, eds. Advances in patient safety: new directions and alternative approaches (volume 3: performance and tools). Rockville, MD: Agency for Healthcare Research and Quality (US), 2008. Neily, J., Mills, P.D., & Young-Xu, Y., et al. Association between implementation of a medical team training program and surgical mortality. J Am Med Assoc 2010;304: 1693–1700. Ong, M.S., & Coiera, E. A systematic review of failures in handoff communication during intrahospital transfers. Joint Comm J Qual Saf 2011;37:274–284. Patterson, E.S., & Wears, R.L. Patient handoffs: standardized and reliable measurement tools remain elusive. Joint Comm J Qual Saf 2010;36:52–61. Petrovic, M.A., Martinez, E.A., & Aboumatar, H. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Joint Comm J Qual Saf 2012a;38:135–142. Petrovic, M.A., Aboumatar, H., & Baumgartner, W. A., et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac Vasc Anesth 2012b;26: 11–16. Segall, N., Bonifacio, A.S., & Schroeder, R.A., et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analgesia 2012;115:02–115.
Authors’ Biographies Jennifer L Dixon, MD. Dr. Dixon is a General Surgery Resident at Baylor Scott & White Memorial Hospital in Temple, TX. Hayden Stagg, MD. Dr. Stagg is a General Surgery Resident at Baylor Scott & White Memorial Hospital in Temple, TX. Hania Wehbe-Janek PhD. Dr. Wehbe-Janek is Assistant Professor within the Department of Academic
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Vol. 37 No. 1 January/February 2015
Operations at Baylor Scott & White Memorial Hospital in Temple, TX. She has special research interests in patient safety and quality, as well as resident education. Chanhee Jo, PhD. Dr. Jo was a statistician at Baylor Scott & White Memorial Hospital but has left the institution. William C. Culp, Jr, MD. Dr. Culp is Associate Professor of anesthesiology specializing in cardiac anesthesiologist at Baylor Scott & White Memorial Hospital in Temple, TX. Jay Shake MD, FACS. Dr. Shake is Assistant Professor in the departments of Critical Care and Cardiothoracic Surgery at Baylor Scott & White Memorial Hospital in Temple, TX. He has research interests in quality improvement and outcomes assessment. For more information on this article, contact Jay G. Shake at [email protected] Meeting presentation: American College of Surgeons, 99th Annual Surgical Congress; October 2013. The authors declare no conflicts of interest.
Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and take the online posttest at http://www.nahq.org/education/content/ jhq-ce.html. This continuing education offering, JHQ 252, will provide 1 contact hour to those who complete it appropriately.
Core CPHQ Examination Content Area IV. Patient Safety A standard handoff improves cardiac surgical patient transfer: operating room to intensive care unit. Journal for Healthcare Quality Continuing Education
Objectives 1. Design a protocol for handoff of patients after the cardiac operating room.
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2. Describe how postoperative checklists can assist in patient handoff process. 3. List the benefits of standardized postoperative handoffs.
Multiple Choice Questions 1. Sentinel events are associated with all the following except a. Bad communication b. High-quality patient care c. Intrahospital transfers d. Duplication of handoffs 2. Which of the following is not a barrier to implementing handoff protocols a. Consistent team members b. Distractions during the transfer c. Inaccurate information d. Poor standardization 3. Critical components of the surgeons report should include all of the following except a. The procedure performed b. Operative tubes and drains c. Most recent laboratory values d. What worries the surgeon about the patient 4. Critical components of the anesthesiologist report should include all of the following except a. The procedure performed b. Pertinent past medical history c. Most recent laboratory values d. What worries the anesthesiologist the most 5. Standardized handoffs after the cardiac OR have been shown to a. Increase duration of monitor hookup b. Increase employee satisfaction c. Worsen relationship between nursing and physicians d. Worsen patient outcomes 6. Ideal implementation of a standard handoff protocol a. Does not require adaptation for individual hospital settings b. Requires no individual or group training c. Requires no checklists d. Requires development by an interdisciplinary team
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Journal for Healthcare Quality
7. The handoff process a. Improves employee perception of patient care b. Increases the handoff time by greater than 10 minutes c. Increase the time for critical steps such as postoperative labs d. Creates difficult workflow 8. In terms of employee perceptions a. Employees are generally not interested in patient safety b. Employees are often aware of current deficits in patient care c. Standardized handoffs are not valued by employees d. Employees have difficulty conforming to checklists
9. Key effective components of the handoff include all except a. Stating what providers are most worried about b. Clear roles and order of the handoff c. Presence of all key team members d. Interruptions to ask questions 10. A standardized handoff after cardiac surgery a. Decreases the completeness of the anesthesiologist report b. Increases the rate of effective communication c. Increases the work for all providers d. Decreases the amount of information communicated
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