Journal of Clinical Anesthesia (2014) 26, 530–538
Original Contribution
Simulation-based education with deliberate practice may improve intraoperative handoff skills: a pilot study Erin W. Pukenas MD, FAAP (Assistant Professor of Anesthesiology)a,⁎, Gregory Dodson DO (Chief Resident)a , Edward R. Deal DO (Assistant Professor of Anesthesiology)a , Irwin Gratz DO (Professor of Anesthesiology)a , Elaine Allen PhD (Professor of Epidemiology Biostatistics) b , Amanda R. Burden MD (Assistant Professor of Anesthesiology)a a
Department of Anesthesiology, Cooper Medical School of Rowan University, One Cooper Plaza, Camden, NJ 08103, USA Department of Epidemiology and Biostatistics, University of California, San Francisco, Box 0560 UCSF, San Francisco, CA, 94143-0560, USA b
Received 13 November 2012; revised 10 March 2014; accepted 11 March 2014
Keywords: Anesthesiologists; Deliberate practice; Handoff education; Intraoperative communication; Residency training; Simulation
Abstract Study Objective: To examine the results of simulation-based education with deliberate practice on the acquisition of handoff skills by studying resident intraoperative handoff communication performances. Design: Preinvention and postintervention pilot study. Setting: Simulated operating room of a university-affiliated hospital. Measurements: Resident handoff performances during 27 encounters simulating elective surgery were studied. Ten residents (CA-1, CA-2, and CA-3) participated in a one-day simulation-based handoff course. Each resident repeated simulated handoffs to deliberately practice with an intraoperative handoff checklist. One year later, 7 of the 10 residents participated in simulated intraoperative handoffs. All handoffs were videotaped and later scored for accuracy by trained raters. A handoff assessment tool was used to characterize the type and frequency of communication failures. The percentage of handoff errors and omissions were compared before simulation and postsimulation-based education with deliberate practice and at one year following the course. Main Results: Initially, the overall communication failure rate, defined as the percentage of handoff omissions plus errors, was 29.7%. After deliberate practice with the intraoperative handoff checklist, the communication failure rate decreased to 16.8%, and decreased further to 13.2% one year after the course. Conclusions: Simulation-based education using deliberate practice may result in improved intraoperative handoff communication and retention of skills at one year. © 2014 Elsevier Inc. All rights reserved.
⁎ Correspondence: Erin W. Pukenas, MD, Assistant Professor of Anesthesiology, Cooper University Hospital, Department of Anesthesiology One Cooper Plaza, Camden, NJ 08103, USA. Tel.: +1-856-968-7334; fax: +1-856-968-9554. E-mail address: [email protected] (E.W. Pukenas). http://dx.doi.org/10.1016/j.jclinane.2014.03.015 0952-8180/© 2014 Elsevier Inc. All rights reserved.
Intraoperative handoff skills
1. Introduction The medical handoff, defined as the transfer of patient care responsibility and information, is a common and risky perioperative event [1]. Eighty percent of serious, preventable adverse events are associated with communication failure. More than half of these events are attributed to handoff error [2]. Since the advent of restricted resident duty hours, as required by the Accreditation Council for Graduate Medical Education (ACGME), transfer of patient information and care between providers is occurring with greater frequency [3]. The surgical patient is especially vulnerable to loss of critical information, as multiple handoff exposures transpire throughout the perioperative period and care is transferred among nursing, surgery, and anesthesia staff [4,5]. In the intraoperative phase alone, anesthesia providers are permanently relieved in approximately one third of cases.1 The ACGME mandates that all residency programs minimize trainee transfer of care and educate residents on systematic handoff processes [6]. There is little available literature describing when and how physicians learn techniques for delivering handoffs, and these skills historically have not been systematically or deliberately taught [7]. Research has shown that interns and residents desire a structured, systematic educational program focused on handoff communication [8]. As transfer of care education begins to take its place in residency curricula, several groups have reported improved handoff quality and patient outcomes after implementation [9,10]. Educational methods have included video and role-play scenarios, didactic lectures, direct observation, and formal evaluation of handoffs [9,10]. Simulation-based education is a unique learning environment for identification and resolution of patient safety threats in an effective, no-risk educational forum [11]. Simulationbased handoff training has resulted in improved critical information transfer and treatment goals in the intensive care unit (ICU) [12], and perceived effectiveness for operating room (OR) to Postanesthesia Care Unit (PACU) transitions.2 The addition of deliberate practice to simulation-based education may improve acquisition and performance of clinical skills [13–18] and improve patient care [16–18]. Deliberate practice involves focused, repeated practice and feedback from an instructor so that errors may be corrected and performance improved. A predetermined mastery standard focused on a measured performance outcome must be met.
1 Merkel MJ. Transfer of care: that’s what we do all the time, right? American Society of Anesthesiologists Newsletter. Park Ridge (IL): American Society of Anesthesiologists; 2012;76(10):12-6. 2 Weinger MB, Slagle JM, Kuntz A, et al. Improving actual handover behavior with a simulation-based training intervention [Abstract]. In: Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2010;54:957-61.
531 The combination of simulation-based education with deliberate practice to achieve a mastery standard is highly effective in promoting procedural skill acquisition and adherence to Advanced Cardiac Life Support (ACLS) algorithms among medical learners [19–26]. A deliberate practice model using simulation-based education has not been applied to handoff education. Handoff research and educational methods specific to the perioperative period have centered on the postoperative handoff [27,28]. Several postanesthesia handoff processes have been developed to reduce communication errors in the Pediatric ICU and the Cardiac Surgical ICU [27,29]. The intraoperative period, however, is not well studied and literature addressing the unique considerations of the intraoperative handoff is limited. In addition, there are minimal data detailing methods to integrate handoff training into the anesthesiology residency curriculum. The aim of this study, therefore, was to explore the characteristics and patterns of anesthesia residents’ intraoperative handoffs and to determine if the use of simulation-based education with deliberate practice improved trainee handoff performance during a simulated intraoperative scenario. Performance one year following the handoff simulation-based education was analyzed to determine retention of skills.
2. Materials and methods Twenty-seven simulated OR scenarios involving 10 anesthesiology residents (CA1 - CA3) were evaluated in this study, which was approved by the Institutional Review Board of Cooper University Health Care. Each subject completed a survey of patient safety attitudes and a test developed specifically for this course to assess knowledge of handoff skills. Elements assessed on the pretest included current handoff practices, organization, and content. Each resident read a patient stem and entered a simulated OR to receive a handoff from an attending anesthesiologist (anesthesiologist #1) managing an uneventful laparoscopic appendectomy. The resident continued caring for the patient for the simulated duration of the case, at which time another anesthesiologist (anesthesiologist #2) arrived to obtain the report. Several key events ensued during residents’ time in the OR, including patients’ hemodynamic instability, a request for additional vascular access by the surgeon, and escalation in postsurgical care from the PACU to the ICU. Residents were expected to communicate these additional details, in addition to the full history, to the oncoming relief provider (anesthesiologist #2). A reflective video debriefing session was conducted by two trained simulation instructors for each resident. Residents were individually given feedback on their performance. A group debrief session was also held, at which time the barriers to effective handoff communication were explored and common errors and omissions addressed.
532 Residents actively engaged in identifying solutions to improving handoff communication. A written intraoperative handoff checklist, to serve as a cognitive aid, was created by the residents and approved by the faculty. Each resident then returned to the simulation laboratory to practice handing off cases with the newly created intraoperative handoff checklist until they achieved a minimum passing score. Residents were able to practice handing off cases as often and for as long as was required to achieve this score. Two additional two-hour sessions were scheduled for residents to practice handing off cases, and all residents met the minimum passing score during those sessions. Each resident completed a posttest and course evaluation. Key items assessed on the posttest included knowledge of handoff definitions/initiatives and changes in personal practice that were likely to occur as a result of the session.
2.1. Testing after a one-year interval One year following the simulation-based education handoff course, residents returned to the simulation laboratory for a retest in the simulator followed by a refresher course. The CA-3s from the previous year, all of whom completed matriculation, were not retested. A survey was conducted to assess changes in attitudes and personal practice since the last simulation-based education course. Residents again participated in a simulated OR scenario where the intraoperative handoff was videotaped. Residents were given the option of using the handoff checklist that they had created the previous year.
2.2. Handoff assessment tool All simulated handoffs were videotaped and analyzed. Three academic anesthesiologists with experience in simulation were surveyed prior to the handoff course, and a checklist of critical handoff items was compiled. This checklist was compared with a validated, published perioperative checklist [30] and preliminary intraoperative checklist models. A final handoff assessment tool consisting of 27 items was created for scoring purposes. The handoff assessment tool was designed to be detailed in order to capture and characterize a wide range of handoff errors and omissions (Table 1).
2.3. Video review and statistical analysis Three additional academic anesthesiologists were trained to review the videotaped simulated handoff sessions. All reviewers were oriented to the handoff assessment tool and formally trained in methods of rating the simulated handoffs. Each video was reviewed in its entirety to ensure that all information was correctly transmitted from anesthesiologist #1 to the resident. All videotaped sessions were reviewed independently by the video raters and results were compared.
E.W. Pukenas et al. There were only two discrepancies among the video raters; these were resolved by consensus after group videotape review. Key elements of each handoff were scored as correct, incorrect, or omitted. “Communication failures” were defined as the sum of incorrect and omitted items. Comparisons between precourse, postcourse, and one year follow-up times were analyzed using one-way analysis of variance with multiple comparisons using Scheffé’s test. Overall, comparisons were determined to be statistically significant if the Scheffé multiple comparison test had a P-value of 0.05 or less. All analyses used SAS version 9.2 statistical software (SAS Institute, Cary, NC, USA).
3. Results 3.1. Handoff knowledge gaps and communication patterns None of the participating residents had any previous handoff training or education. No subjects were able accurately to state the Joint Commission’s handoff definition nor were they aware that improved patient handoff communication was a Joint Commission national patient safety goal. Twenty percent of participants were not confident in their ability to give a handoff. All reported routinely providing postoperative handoffs in their practice and ranked them as highly important. Even though all residents also ranked intraoperative handoffs as important, 20% reported they do not always provide an intraoperative patient handoff when being relieved for a short-term break (defined as relief for 15 min or less). All trainees indicated that handoffs for intraoperative breaks are less thorough than for permanent relief or provider change. The perception that relief providers are not receptive to intraoperative handoff communication was reported by 85% of the residents. When asked, pretraining, which information they routinely provide during an intraoperative handoff, 90% of residents reported airway details and past medical history, 70% stated vascular access, and 60% said allergies. Videotaped precourse simulation sessions showed that no residents completed all items on the handoff assessment tool. Seventy percent of residents transmitted incorrect information and all omitted some information. Seventy percent of residents either failed to transmit or erroneously transmitted information pertaining to the airway, and 60% miscommunicated vascular access details (Fig. 1). The most common omissions included anesthetic maintenance (14.7%), volume status (11.7%), airway details (10.3%), and vascular access (10.3%) (Fig. 2a). The most common errors were airway details, including airway type, size, location, and laryngoscopic view (5.8%) and vascular access, including size and location (5.8%) (Fig. 2b). The total communication failure rate approached 30%, corresponding to an average of nearly 8 communication failures per resident.
Intraoperative handoff skills Table 1
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Handoff assessment tool Correct information Correct information Incorrect information Information omitted by subject communicated communicated for the simulated by subject by subject patient/case
Age Gender Allergies Procedure Indication for procedure Medical history Preoperative interventions Anesthesia induction type Induction medications Airway (eg, oral ETT) Size of airway Secured location of airway Laryngoscopy details Laryngoscopic view Anesthesia maintenance Last dose of patient medications (eg, beta blockade, opioids) Surgical progress Intraoperative events Last dose of antibiotics Type of vascular access Size of vascular access Location of vascular access Intraoperative fluids Estimated blood loss Urine output Disposition Opportunity to ask questions ETT = endotracheal tube.
3.2. Deliberate practice with an intraoperative handoff checklist The intraoperative handoff checklist created by the residents is shown in Fig. 3. Subject headings included preoperative phase, induction, intraoperative phase, and postoperative plan. Ten residents were scored on the 27-item
handoff assessment tool. The items on the handoff assessment tool, created by practicing anesthesiologists, and the checklist, created by residents, were not identical. Content differences were discussed and essential handoff elements were considered postcourse. Prior to simulation-based training with deliberate practice, resident subjects had a combined communication failure rate
Fig. 1 Reported versus actual intraoperative handoff content. Assessment of handoff content prior to and following the initial simulation exercise; n = 10. PMH = past medical history.
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A
B
Fig. 2 Improvement of communication among specific categories from preinvention to postintervention. (A) Omitted handoff categories. (B) Incorrect handoff categories. EBL = estimated blood loss, I/Os = fluid inputs/outputs.
Fig. 3
Intraoperative handoff checklist. EBL = estimated blood loss, IV = intravenous.
Intraoperative handoff skills
Fig. 4
535
Improvement in communication after deliberate practice integration (% ± 95% CI).
of 29.7% (79/266). After practice with the newly created intraoperative handoff checklist, this rate decreased to 16.8% [45/268; P b 0.01; 95% CI (0.05, 0.19)]. After deliberate practice with the handoff checklist, the total number of incorrect items decreased from 11 to 5 [P = 0.129; 95% CI (-0.006, 0.05)] and the total number of omissions decreased by 41%, from 68 to 40 [P b 0.01; 95% CI (0.03, - 0.17)]. At the conclusion of the course, all residents were aware of the Joint Commission’s recommendations for standardized handoff communication and the ACGME requirements for handoff education.
3.3. Change in practice As a result of the handoff course, trainees stated they intended to change their handoff practices. Improvement strategies included developing a more systematic approach (50%) or being more thorough in giving handoffs (30%). All reported their high likelihood of the use of the checklist to organize future handoffs. At one year after the simulation-based education, all residents reported giving a complete handoff during intraoperative breaks 100% of the time. All reported changes to their practice after the simulation-based education course, including giving a complete report despite time limitations or reflecting negative feedback from the handoff receiver. All residents reported using the paper checklist immediately following the simulation-based education and committing its structure to memory for use in the clinical setting over the past year to guide the handoff process. Seven of the 10 original residents (excluding graduated CA-3s) repeated a simulated OR scenario with an intraoperative handoff one year after the simulation-based education. None of the residents chose to use the checklist in paper form to perform the simulated handoff but were observed by raters during the video analysis to have organized handoff content according to the checklist. Analysis of the recorded handoffs yielded an error rate of 2.1%. The most common omissions were anesthetic maintenance and procedure
details. The most common error was position of the endotracheal tube. The total communication failure rate at one year post-simulation-based education was 13.2%. When compared with the precourse and immediate postcourse values, there was significant improvement in communication at one year (P b 0.01). Fig. 4 shows the communication failure rates at all time intervals. Data were further stratified to analyze the CA-1 and CA-2 groups, allowing each trainee to serve as his/her own historical control. A significant difference was found when comparing precommunication with postcommunication to one-year communication failures within each group (CA-1 and CA-2; P b 0.001). In addition, the safety attitudes questionnaire was repeated at one year. Residents indicated they were more confident in their clinical intraoperative handoff performance and in the content of information to include in an intraoperative handoff. They were more likely to report that others were more receptive to their handoffs than before the simulation-based education course (Table 2).
4. Discussion Communication among medical providers is essential in establishing a culture of patient safety [30]. Interventions to improve health care communication significantly impact quality of care [31]. The objective of this pilot study was to characterize current handoff knowledge and practices of our anesthesiology residents and to evaluate the use of simulation-based education to improve intraoperative handoff skills. We also examined the effect of simulation-based education using deliberate practice on handoff performance and retention of skills after one year. A recent review of the handoff literature outlined evidence-based recommendations for delivering patient information safely and effectively [28]. Strategies included the “use of structured checklists to guide communication and ensure completeness of information” [1,27,29,32–36] and
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Table 2 Barriers to effective intraoperative handoff communication Barrier statement
Percentage of participants who agree/strongly agree (pretest, n = 10)
Percentage of participants who agree/strongly agree (at one yr, n = 7)
Handoffs are tedious and take too much time to complete. Handoffs make extra work. I’m not sure what to include in a handoff. There are too many distractions when I’m giving a handoff. Handoffs can be insulting to the receiver. Handoffs are not medically necessary. I feel others are not receptive to my handoffs. There are too many time pressures to give an effective handoff. I lack confidence in giving an adequate handoff.
40%
14%
10%
0%
10%
0%
40%
42%
30%
0%
0%
0%
80%
14%
30%
14%
20%
0%
provision of “formal team or handover training” [1,27,33,37,38]. Both verbal and nonverbal communication is critical in successful teamwork, yet many clinicians have not received formal training in communication and interpersonal skills [39]. A greater impact on patient care may result from increased emphasis on interpersonal and behavioral improvement rather than training that focuses only on technical aspects of care [40]. The best methods to teach intricate communication processes such as handoffs have yet to be identified [41]. The results of our study suggested that simulation-based education with deliberate practice may be one approach to the teaching of handoff skills to be adapted to residents’ clinical practice. Prior to the course, our residents’ selfassessment of their clinical performance reflected perceived high rates of information transfer during their intraoperative handoffs. However, in the simulation laboratory, vital patient details were lost during their handoffs, and a discrepancy was identified between perceived and actual communication. Based on these findings, our residents analyzed their
communication failures and created a standardized handoff process in the form of a written checklist. Deliberate practice with the intraoperative handoff checklist improved handoff communication immediately after the course. In addition, the communication pattern after one year appears to have demonstrated continued improvement beyond what was originally observed. While the resident subjects in this study did stop using the checklist in written form, they were observed to have memorized its content and structure. The repeated use of this tool during real patient care may have been additional deliberate practice and may have contributed to the continued improvement demonstrated in this study. This effect has been observed in other programs that used simulation-based education with deliberate practice [42]. An important goal of medical education is not simply acquisition or maintenance of skills and knowledge, but constant improvement that continues after the student’s exposure to the educational intervention [17,42–44]. Given the significant improvement in communication after stratification of data to exclude the advanced CA-3 s, we may be able to attribute at least some of the continued improvement to the simulation-based education with deliberate practice intervention. Other changes in clinical communication practices that we observed may be a result of training in the simulationbased education learning environment. Practice in the simulation laboratory may bolster resident confidence and permit residents to make mistakes without clinical repercussions. Discussing and exploring communication barriers in a safe forum and inviting residents to be part of the solution were reported to us as very empowering. All of our residents subsequently changed their handoff practice to include a more thorough intraoperative handoff and use of the checklist as a framework for handoff communication. Those who previously did not give an intraoperative handoff are now communicating routinely with relief providers, even for short-term relief. We are beginning to see some evidence of a culture change, as evidenced by the improvement in the one-year results of the barriers/attitudes survey. We believe that intraoperative handoff communication is clinically underemphasized and an important source of medical error. Prior to the handoff course, our residents reported routinely giving a more complete postoperative handoff than intraoperative handoff despite ranking each of equal importance. We found that handoff communication in our simulated OR was error-prone and rife with omissions, suggesting that poor intraoperative handoff communication may be occurring at a concerning rate. Despite the overall significant improvement in the number of omissions and errors, we were surprised that for some of the elements such as airway, anesthetic, and surgical progress, postcourse results were not markedly improved. This finding raises the question about which information should be emphasized within the intraoperative handoff, and what information determines a high-quality handoff. A systematic and
Intraoperative handoff skills evidence-based intraoperative handoff communication protocol has yet to be identified, although efforts are ongoing. Elements such as essential content and standardization processes warrant further exploration. We acknowledge the limitations of this study. As a small residency program, we had a limited number of subjects and some residents were lost to follow-up after graduation. Also, a Hawthorne effect may have been present, as all subjects provided consent for video and audio recording [45]. In addition, as residents progress through training, communication patterns and skills may be expected to improve. We attempted to eliminate recall bias by altering details of the presimulation, postsimulation, and one-year simulation scenarios without changing the complexity of the case. We also attempted to produce high-fidelity scenarios, and our residents did report a sense of realism with actions and behaviors aligned with the clinical arena. Despite these limitations, intraoperative handoff skills were improved and retained over time following simulation-based education with deliberate practice. Assessment of current handoff patterns may benefit institutions in designing the most relevant educational processes. The approach may not be universal, as communication patterns and patient safety attitudes may vary across sites. Knowledge of the current communication culture and handoff content elements likely may be beneficial in tailoring an educational program to fit the needs of anesthesiology trainees. Simulation-based education with deliberate practice may be an effective method to fulfill handoff recommendations and satisfy ACGME requirements. Future work will further define the intraoperative handoff and its implications to patient safety. Research on the most effective educational methods to teach intraoperative handoffs may have a significant impact on reducing medical error.
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Original Contribution
Simulation-based education with deliberate practice may improve intraoperative handoff skills: a pilot study Erin W. Pukenas MD, FAAP (Assistant Professor of Anesthesiology)a,⁎, Gregory Dodson DO (Chief Resident)a , Edward R. Deal DO (Assistant Professor of Anesthesiology)a , Irwin Gratz DO (Professor of Anesthesiology)a , Elaine Allen PhD (Professor of Epidemiology Biostatistics) b , Amanda R. Burden MD (Assistant Professor of Anesthesiology)a a
Department of Anesthesiology, Cooper Medical School of Rowan University, One Cooper Plaza, Camden, NJ 08103, USA Department of Epidemiology and Biostatistics, University of California, San Francisco, Box 0560 UCSF, San Francisco, CA, 94143-0560, USA b
Received 13 November 2012; revised 10 March 2014; accepted 11 March 2014
Keywords: Anesthesiologists; Deliberate practice; Handoff education; Intraoperative communication; Residency training; Simulation
Abstract Study Objective: To examine the results of simulation-based education with deliberate practice on the acquisition of handoff skills by studying resident intraoperative handoff communication performances. Design: Preinvention and postintervention pilot study. Setting: Simulated operating room of a university-affiliated hospital. Measurements: Resident handoff performances during 27 encounters simulating elective surgery were studied. Ten residents (CA-1, CA-2, and CA-3) participated in a one-day simulation-based handoff course. Each resident repeated simulated handoffs to deliberately practice with an intraoperative handoff checklist. One year later, 7 of the 10 residents participated in simulated intraoperative handoffs. All handoffs were videotaped and later scored for accuracy by trained raters. A handoff assessment tool was used to characterize the type and frequency of communication failures. The percentage of handoff errors and omissions were compared before simulation and postsimulation-based education with deliberate practice and at one year following the course. Main Results: Initially, the overall communication failure rate, defined as the percentage of handoff omissions plus errors, was 29.7%. After deliberate practice with the intraoperative handoff checklist, the communication failure rate decreased to 16.8%, and decreased further to 13.2% one year after the course. Conclusions: Simulation-based education using deliberate practice may result in improved intraoperative handoff communication and retention of skills at one year. © 2014 Elsevier Inc. All rights reserved.
⁎ Correspondence: Erin W. Pukenas, MD, Assistant Professor of Anesthesiology, Cooper University Hospital, Department of Anesthesiology One Cooper Plaza, Camden, NJ 08103, USA. Tel.: +1-856-968-7334; fax: +1-856-968-9554. E-mail address: [email protected] (E.W. Pukenas). http://dx.doi.org/10.1016/j.jclinane.2014.03.015 0952-8180/© 2014 Elsevier Inc. All rights reserved.
Intraoperative handoff skills
1. Introduction The medical handoff, defined as the transfer of patient care responsibility and information, is a common and risky perioperative event [1]. Eighty percent of serious, preventable adverse events are associated with communication failure. More than half of these events are attributed to handoff error [2]. Since the advent of restricted resident duty hours, as required by the Accreditation Council for Graduate Medical Education (ACGME), transfer of patient information and care between providers is occurring with greater frequency [3]. The surgical patient is especially vulnerable to loss of critical information, as multiple handoff exposures transpire throughout the perioperative period and care is transferred among nursing, surgery, and anesthesia staff [4,5]. In the intraoperative phase alone, anesthesia providers are permanently relieved in approximately one third of cases.1 The ACGME mandates that all residency programs minimize trainee transfer of care and educate residents on systematic handoff processes [6]. There is little available literature describing when and how physicians learn techniques for delivering handoffs, and these skills historically have not been systematically or deliberately taught [7]. Research has shown that interns and residents desire a structured, systematic educational program focused on handoff communication [8]. As transfer of care education begins to take its place in residency curricula, several groups have reported improved handoff quality and patient outcomes after implementation [9,10]. Educational methods have included video and role-play scenarios, didactic lectures, direct observation, and formal evaluation of handoffs [9,10]. Simulation-based education is a unique learning environment for identification and resolution of patient safety threats in an effective, no-risk educational forum [11]. Simulationbased handoff training has resulted in improved critical information transfer and treatment goals in the intensive care unit (ICU) [12], and perceived effectiveness for operating room (OR) to Postanesthesia Care Unit (PACU) transitions.2 The addition of deliberate practice to simulation-based education may improve acquisition and performance of clinical skills [13–18] and improve patient care [16–18]. Deliberate practice involves focused, repeated practice and feedback from an instructor so that errors may be corrected and performance improved. A predetermined mastery standard focused on a measured performance outcome must be met.
1 Merkel MJ. Transfer of care: that’s what we do all the time, right? American Society of Anesthesiologists Newsletter. Park Ridge (IL): American Society of Anesthesiologists; 2012;76(10):12-6. 2 Weinger MB, Slagle JM, Kuntz A, et al. Improving actual handover behavior with a simulation-based training intervention [Abstract]. In: Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2010;54:957-61.
531 The combination of simulation-based education with deliberate practice to achieve a mastery standard is highly effective in promoting procedural skill acquisition and adherence to Advanced Cardiac Life Support (ACLS) algorithms among medical learners [19–26]. A deliberate practice model using simulation-based education has not been applied to handoff education. Handoff research and educational methods specific to the perioperative period have centered on the postoperative handoff [27,28]. Several postanesthesia handoff processes have been developed to reduce communication errors in the Pediatric ICU and the Cardiac Surgical ICU [27,29]. The intraoperative period, however, is not well studied and literature addressing the unique considerations of the intraoperative handoff is limited. In addition, there are minimal data detailing methods to integrate handoff training into the anesthesiology residency curriculum. The aim of this study, therefore, was to explore the characteristics and patterns of anesthesia residents’ intraoperative handoffs and to determine if the use of simulation-based education with deliberate practice improved trainee handoff performance during a simulated intraoperative scenario. Performance one year following the handoff simulation-based education was analyzed to determine retention of skills.
2. Materials and methods Twenty-seven simulated OR scenarios involving 10 anesthesiology residents (CA1 - CA3) were evaluated in this study, which was approved by the Institutional Review Board of Cooper University Health Care. Each subject completed a survey of patient safety attitudes and a test developed specifically for this course to assess knowledge of handoff skills. Elements assessed on the pretest included current handoff practices, organization, and content. Each resident read a patient stem and entered a simulated OR to receive a handoff from an attending anesthesiologist (anesthesiologist #1) managing an uneventful laparoscopic appendectomy. The resident continued caring for the patient for the simulated duration of the case, at which time another anesthesiologist (anesthesiologist #2) arrived to obtain the report. Several key events ensued during residents’ time in the OR, including patients’ hemodynamic instability, a request for additional vascular access by the surgeon, and escalation in postsurgical care from the PACU to the ICU. Residents were expected to communicate these additional details, in addition to the full history, to the oncoming relief provider (anesthesiologist #2). A reflective video debriefing session was conducted by two trained simulation instructors for each resident. Residents were individually given feedback on their performance. A group debrief session was also held, at which time the barriers to effective handoff communication were explored and common errors and omissions addressed.
532 Residents actively engaged in identifying solutions to improving handoff communication. A written intraoperative handoff checklist, to serve as a cognitive aid, was created by the residents and approved by the faculty. Each resident then returned to the simulation laboratory to practice handing off cases with the newly created intraoperative handoff checklist until they achieved a minimum passing score. Residents were able to practice handing off cases as often and for as long as was required to achieve this score. Two additional two-hour sessions were scheduled for residents to practice handing off cases, and all residents met the minimum passing score during those sessions. Each resident completed a posttest and course evaluation. Key items assessed on the posttest included knowledge of handoff definitions/initiatives and changes in personal practice that were likely to occur as a result of the session.
2.1. Testing after a one-year interval One year following the simulation-based education handoff course, residents returned to the simulation laboratory for a retest in the simulator followed by a refresher course. The CA-3s from the previous year, all of whom completed matriculation, were not retested. A survey was conducted to assess changes in attitudes and personal practice since the last simulation-based education course. Residents again participated in a simulated OR scenario where the intraoperative handoff was videotaped. Residents were given the option of using the handoff checklist that they had created the previous year.
2.2. Handoff assessment tool All simulated handoffs were videotaped and analyzed. Three academic anesthesiologists with experience in simulation were surveyed prior to the handoff course, and a checklist of critical handoff items was compiled. This checklist was compared with a validated, published perioperative checklist [30] and preliminary intraoperative checklist models. A final handoff assessment tool consisting of 27 items was created for scoring purposes. The handoff assessment tool was designed to be detailed in order to capture and characterize a wide range of handoff errors and omissions (Table 1).
2.3. Video review and statistical analysis Three additional academic anesthesiologists were trained to review the videotaped simulated handoff sessions. All reviewers were oriented to the handoff assessment tool and formally trained in methods of rating the simulated handoffs. Each video was reviewed in its entirety to ensure that all information was correctly transmitted from anesthesiologist #1 to the resident. All videotaped sessions were reviewed independently by the video raters and results were compared.
E.W. Pukenas et al. There were only two discrepancies among the video raters; these were resolved by consensus after group videotape review. Key elements of each handoff were scored as correct, incorrect, or omitted. “Communication failures” were defined as the sum of incorrect and omitted items. Comparisons between precourse, postcourse, and one year follow-up times were analyzed using one-way analysis of variance with multiple comparisons using Scheffé’s test. Overall, comparisons were determined to be statistically significant if the Scheffé multiple comparison test had a P-value of 0.05 or less. All analyses used SAS version 9.2 statistical software (SAS Institute, Cary, NC, USA).
3. Results 3.1. Handoff knowledge gaps and communication patterns None of the participating residents had any previous handoff training or education. No subjects were able accurately to state the Joint Commission’s handoff definition nor were they aware that improved patient handoff communication was a Joint Commission national patient safety goal. Twenty percent of participants were not confident in their ability to give a handoff. All reported routinely providing postoperative handoffs in their practice and ranked them as highly important. Even though all residents also ranked intraoperative handoffs as important, 20% reported they do not always provide an intraoperative patient handoff when being relieved for a short-term break (defined as relief for 15 min or less). All trainees indicated that handoffs for intraoperative breaks are less thorough than for permanent relief or provider change. The perception that relief providers are not receptive to intraoperative handoff communication was reported by 85% of the residents. When asked, pretraining, which information they routinely provide during an intraoperative handoff, 90% of residents reported airway details and past medical history, 70% stated vascular access, and 60% said allergies. Videotaped precourse simulation sessions showed that no residents completed all items on the handoff assessment tool. Seventy percent of residents transmitted incorrect information and all omitted some information. Seventy percent of residents either failed to transmit or erroneously transmitted information pertaining to the airway, and 60% miscommunicated vascular access details (Fig. 1). The most common omissions included anesthetic maintenance (14.7%), volume status (11.7%), airway details (10.3%), and vascular access (10.3%) (Fig. 2a). The most common errors were airway details, including airway type, size, location, and laryngoscopic view (5.8%) and vascular access, including size and location (5.8%) (Fig. 2b). The total communication failure rate approached 30%, corresponding to an average of nearly 8 communication failures per resident.
Intraoperative handoff skills Table 1
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Handoff assessment tool Correct information Correct information Incorrect information Information omitted by subject communicated communicated for the simulated by subject by subject patient/case
Age Gender Allergies Procedure Indication for procedure Medical history Preoperative interventions Anesthesia induction type Induction medications Airway (eg, oral ETT) Size of airway Secured location of airway Laryngoscopy details Laryngoscopic view Anesthesia maintenance Last dose of patient medications (eg, beta blockade, opioids) Surgical progress Intraoperative events Last dose of antibiotics Type of vascular access Size of vascular access Location of vascular access Intraoperative fluids Estimated blood loss Urine output Disposition Opportunity to ask questions ETT = endotracheal tube.
3.2. Deliberate practice with an intraoperative handoff checklist The intraoperative handoff checklist created by the residents is shown in Fig. 3. Subject headings included preoperative phase, induction, intraoperative phase, and postoperative plan. Ten residents were scored on the 27-item
handoff assessment tool. The items on the handoff assessment tool, created by practicing anesthesiologists, and the checklist, created by residents, were not identical. Content differences were discussed and essential handoff elements were considered postcourse. Prior to simulation-based training with deliberate practice, resident subjects had a combined communication failure rate
Fig. 1 Reported versus actual intraoperative handoff content. Assessment of handoff content prior to and following the initial simulation exercise; n = 10. PMH = past medical history.
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A
B
Fig. 2 Improvement of communication among specific categories from preinvention to postintervention. (A) Omitted handoff categories. (B) Incorrect handoff categories. EBL = estimated blood loss, I/Os = fluid inputs/outputs.
Fig. 3
Intraoperative handoff checklist. EBL = estimated blood loss, IV = intravenous.
Intraoperative handoff skills
Fig. 4
535
Improvement in communication after deliberate practice integration (% ± 95% CI).
of 29.7% (79/266). After practice with the newly created intraoperative handoff checklist, this rate decreased to 16.8% [45/268; P b 0.01; 95% CI (0.05, 0.19)]. After deliberate practice with the handoff checklist, the total number of incorrect items decreased from 11 to 5 [P = 0.129; 95% CI (-0.006, 0.05)] and the total number of omissions decreased by 41%, from 68 to 40 [P b 0.01; 95% CI (0.03, - 0.17)]. At the conclusion of the course, all residents were aware of the Joint Commission’s recommendations for standardized handoff communication and the ACGME requirements for handoff education.
3.3. Change in practice As a result of the handoff course, trainees stated they intended to change their handoff practices. Improvement strategies included developing a more systematic approach (50%) or being more thorough in giving handoffs (30%). All reported their high likelihood of the use of the checklist to organize future handoffs. At one year after the simulation-based education, all residents reported giving a complete handoff during intraoperative breaks 100% of the time. All reported changes to their practice after the simulation-based education course, including giving a complete report despite time limitations or reflecting negative feedback from the handoff receiver. All residents reported using the paper checklist immediately following the simulation-based education and committing its structure to memory for use in the clinical setting over the past year to guide the handoff process. Seven of the 10 original residents (excluding graduated CA-3s) repeated a simulated OR scenario with an intraoperative handoff one year after the simulation-based education. None of the residents chose to use the checklist in paper form to perform the simulated handoff but were observed by raters during the video analysis to have organized handoff content according to the checklist. Analysis of the recorded handoffs yielded an error rate of 2.1%. The most common omissions were anesthetic maintenance and procedure
details. The most common error was position of the endotracheal tube. The total communication failure rate at one year post-simulation-based education was 13.2%. When compared with the precourse and immediate postcourse values, there was significant improvement in communication at one year (P b 0.01). Fig. 4 shows the communication failure rates at all time intervals. Data were further stratified to analyze the CA-1 and CA-2 groups, allowing each trainee to serve as his/her own historical control. A significant difference was found when comparing precommunication with postcommunication to one-year communication failures within each group (CA-1 and CA-2; P b 0.001). In addition, the safety attitudes questionnaire was repeated at one year. Residents indicated they were more confident in their clinical intraoperative handoff performance and in the content of information to include in an intraoperative handoff. They were more likely to report that others were more receptive to their handoffs than before the simulation-based education course (Table 2).
4. Discussion Communication among medical providers is essential in establishing a culture of patient safety [30]. Interventions to improve health care communication significantly impact quality of care [31]. The objective of this pilot study was to characterize current handoff knowledge and practices of our anesthesiology residents and to evaluate the use of simulation-based education to improve intraoperative handoff skills. We also examined the effect of simulation-based education using deliberate practice on handoff performance and retention of skills after one year. A recent review of the handoff literature outlined evidence-based recommendations for delivering patient information safely and effectively [28]. Strategies included the “use of structured checklists to guide communication and ensure completeness of information” [1,27,29,32–36] and
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Table 2 Barriers to effective intraoperative handoff communication Barrier statement
Percentage of participants who agree/strongly agree (pretest, n = 10)
Percentage of participants who agree/strongly agree (at one yr, n = 7)
Handoffs are tedious and take too much time to complete. Handoffs make extra work. I’m not sure what to include in a handoff. There are too many distractions when I’m giving a handoff. Handoffs can be insulting to the receiver. Handoffs are not medically necessary. I feel others are not receptive to my handoffs. There are too many time pressures to give an effective handoff. I lack confidence in giving an adequate handoff.
40%
14%
10%
0%
10%
0%
40%
42%
30%
0%
0%
0%
80%
14%
30%
14%
20%
0%
provision of “formal team or handover training” [1,27,33,37,38]. Both verbal and nonverbal communication is critical in successful teamwork, yet many clinicians have not received formal training in communication and interpersonal skills [39]. A greater impact on patient care may result from increased emphasis on interpersonal and behavioral improvement rather than training that focuses only on technical aspects of care [40]. The best methods to teach intricate communication processes such as handoffs have yet to be identified [41]. The results of our study suggested that simulation-based education with deliberate practice may be one approach to the teaching of handoff skills to be adapted to residents’ clinical practice. Prior to the course, our residents’ selfassessment of their clinical performance reflected perceived high rates of information transfer during their intraoperative handoffs. However, in the simulation laboratory, vital patient details were lost during their handoffs, and a discrepancy was identified between perceived and actual communication. Based on these findings, our residents analyzed their
communication failures and created a standardized handoff process in the form of a written checklist. Deliberate practice with the intraoperative handoff checklist improved handoff communication immediately after the course. In addition, the communication pattern after one year appears to have demonstrated continued improvement beyond what was originally observed. While the resident subjects in this study did stop using the checklist in written form, they were observed to have memorized its content and structure. The repeated use of this tool during real patient care may have been additional deliberate practice and may have contributed to the continued improvement demonstrated in this study. This effect has been observed in other programs that used simulation-based education with deliberate practice [42]. An important goal of medical education is not simply acquisition or maintenance of skills and knowledge, but constant improvement that continues after the student’s exposure to the educational intervention [17,42–44]. Given the significant improvement in communication after stratification of data to exclude the advanced CA-3 s, we may be able to attribute at least some of the continued improvement to the simulation-based education with deliberate practice intervention. Other changes in clinical communication practices that we observed may be a result of training in the simulationbased education learning environment. Practice in the simulation laboratory may bolster resident confidence and permit residents to make mistakes without clinical repercussions. Discussing and exploring communication barriers in a safe forum and inviting residents to be part of the solution were reported to us as very empowering. All of our residents subsequently changed their handoff practice to include a more thorough intraoperative handoff and use of the checklist as a framework for handoff communication. Those who previously did not give an intraoperative handoff are now communicating routinely with relief providers, even for short-term relief. We are beginning to see some evidence of a culture change, as evidenced by the improvement in the one-year results of the barriers/attitudes survey. We believe that intraoperative handoff communication is clinically underemphasized and an important source of medical error. Prior to the handoff course, our residents reported routinely giving a more complete postoperative handoff than intraoperative handoff despite ranking each of equal importance. We found that handoff communication in our simulated OR was error-prone and rife with omissions, suggesting that poor intraoperative handoff communication may be occurring at a concerning rate. Despite the overall significant improvement in the number of omissions and errors, we were surprised that for some of the elements such as airway, anesthetic, and surgical progress, postcourse results were not markedly improved. This finding raises the question about which information should be emphasized within the intraoperative handoff, and what information determines a high-quality handoff. A systematic and
Intraoperative handoff skills evidence-based intraoperative handoff communication protocol has yet to be identified, although efforts are ongoing. Elements such as essential content and standardization processes warrant further exploration. We acknowledge the limitations of this study. As a small residency program, we had a limited number of subjects and some residents were lost to follow-up after graduation. Also, a Hawthorne effect may have been present, as all subjects provided consent for video and audio recording [45]. In addition, as residents progress through training, communication patterns and skills may be expected to improve. We attempted to eliminate recall bias by altering details of the presimulation, postsimulation, and one-year simulation scenarios without changing the complexity of the case. We also attempted to produce high-fidelity scenarios, and our residents did report a sense of realism with actions and behaviors aligned with the clinical arena. Despite these limitations, intraoperative handoff skills were improved and retained over time following simulation-based education with deliberate practice. Assessment of current handoff patterns may benefit institutions in designing the most relevant educational processes. The approach may not be universal, as communication patterns and patient safety attitudes may vary across sites. Knowledge of the current communication culture and handoff content elements likely may be beneficial in tailoring an educational program to fit the needs of anesthesiology trainees. Simulation-based education with deliberate practice may be an effective method to fulfill handoff recommendations and satisfy ACGME requirements. Future work will further define the intraoperative handoff and its implications to patient safety. Research on the most effective educational methods to teach intraoperative handoffs may have a significant impact on reducing medical error.
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