Dr. Matthew Weinger, M.D. is heading a multidisciplinary project team to evaluate and improve communication and coordination between nurses and physicians during hospital-based transitions of care. Taking advantage of existing organizational patient safety initiatives, the intervention has been integrated into ongoing efforts to improve transfers of care (handoffs). Institutional experience and the literature suggest that handoffs are a “high risk” situation that can cause gaps in care due to communication/teamwork failures, which may be the most important contributors to preventable adverse events in healthcare.
The training initiative, called STRAIT (Simulation Training for Rapid Assessment and Improved Teamwork), is targeted at anesthesia provider–post-anesthesia care unit (PACU) nurse handoffs. This particular clinical handoff situation was chosen because it involves interprofessional communication about a critical patient and, importantly, because it is a well-defined and logistically feasible encounter amenable to study and improvement. However, our approach to developing and evaluating STRAIT will have wide applicability to other intra-facility patient transfers. Moreover, the PACU handoff allowed us to incorporate hybrid simulation techniques (e.g., high-fidelity manikins, simulated patients, and simulated clinicians (the latter to expose trainees to standardized conflict situations).
This two-year study involves two busy VUMC PACUs; one as the initial intervention site, the other as a parallel control site. Midway through the project, the second PACU received the intervention. The primary hypothesis of this quality improvement project is that simulation-based communication training of anesthesia and PACU nursing personnel will significantly improve the quality of actual PACU handoffs. The secondary hypothesis is that the training will enhance the overall culture of communication and quality of care in the PACU. Thus, the Specific Aims of this project are:
Aim 1: To develop a simulation-based training intervention, STRAIT, directed initially toward PACU handoffs.
Aim 2: To determine if the implementation of the STRAIT initiative improves the quality of PACU handoffs.
- Aim 3: To study the impact of a single focused initiative to improve handoffs on broader aspects of teamwork in the PACU and on institutional outcomes.
Our multicomponent handoff improvement intervention includes: 1) a 45-minute multimedia webinar addressing the knowledge surrounding effective handoffs; 2) a 2-hour simulation-based experiential learning experience incorporating facilitated debriefing by nurse and anesthesiologist educators; 3) development and implementation of an automatically computer-generated PACU Handoff Report (PDF) form; and 4) feedback on actual handoff effectiveness to the participating units.
Specific Aim 1 is addressed by evaluating changes in simulated handoff performance in individual clinicians before and after the training intervention on specific dimensions of handoff effectiveness. In addition, the observed clinicians rate their own handoffs. Handoffs are rated by trained nurses using a highly reliable validated Handoff Scoring Form.
For Specific Aim 2, the primary measure is pre- and post-intervention ratings by trained observers of actual PACU handoffs using the same Handoff Scoring Form. To reinforce desired behaviors, aggregate results of observations of actual handoffs are fed back to clinicians in the intervention PACUs (some preliminary data (PDF) are available).
In Specific Aim 3, the effect of the intervention on the communication culture of the units as well as on PACU-specific process and outcome measures is being assessed. A Communication Culture Survey (PDF) (based on a subcomponent of the Safety Attitudes Questionnaire) has been administered to all anesthesia providers and PACU nurses before the intervention commenced and mid-way through the scheduled training. A final survey will be performed at the end of the study.
For more information, please contact Andrew Kline at firstname.lastname@example.org.