Informatics Tools and Patient Handovers - Aalap Shah

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Smart-Templates and Post-Operative Patient Handovers :

Smart-Templates and Post-Operative Patient Handovers A QI + Research Project Aalap Shah, MD Surgical Services Chair, Housestaff Quality and Safety Committee R4, Department of Anesthesiology and Pain Medicine University of Washington Medical Center

Table of Contents:

Table of Contents IT/Handoffs Overview [s3-21] Patient Handoffs [s3-6] UW PACU Handoff [s7-13] UW ICU Handoff (eff. 2/2014) [s14] EHRs/Meaningful Use [s15-21] PAST Template [s22-32] Case Example [s28-32] T2 Template [s33] Handover IT: Objectives [s34] Handover IT as a QI Project [s35-50] Handover IT as a Research Project [s51-62] Future Directions [s63-64]

Patient Handoffs:

Patient Handoffs “Transfer of information, responsibility, and authority from one health care provider to another.” ACGME 2003 – Duty hour restrictions  Increased # of handoffs Gawande 2003 Review of 100 incident reports from 45 surgeons 60% of events in OR+PACU 43% due to communication failure; of which 2/3 were due to inadequate handoffs.

Patient Handoffs:

Patient Handoffs Joint Commission 2006 – Requirement for standardized handoff approach at accredited institutions Joint Commission + WHO 2008 – Highlighted role for standardized processes to identify and reduce handoff-related errors Institute of Medicine 2008 – Increased focus on handoff processes to improve patient safety

Patient Handoffs:

Patient Handoffs Obstacles Different media ( Nagpal 2010, Mistry 2005) Taped/written reports  verbal bedside reports EMR/PHR Integration Lack of institutional standardization (Mistry 2008, Nagpal 2010) Descriptive reports  structured templates Specialty and location-specific handoff tools, physician vs. nurse Information Omission ( Nagpal 2011, Catchpole 2007, Zavalkoff 2011) Poor Setting (Smith 2008, 2010, Chen 2011) Interruptions/Misunderstandings Room Delays/”Rushed” Inaccurate clinical assessment Unclear task assignments and “anticipatory guidance” (Joy 2011)

Patient Handoffs:

Patient Handoffs Research and Data Collection Methods Pre-/Post- Implementation Studies (Catchpole 2007, Joy 2011, Jukkala 2012, Mistry 2008) Six Sigma, Model for Improvement Focus group ( Bosmans 2013) Observational/Cross-Sectional (Chen 2011) RCT (Van Eaton 2005, 2010) Surveys (Flanagan 2009, Bernstein 2010)

UW PACU Handoff:

UW PACU Handoff

Case Example:

Case Example PMHx : A-fib DM2 HTN GERD Morbid Obesity (BMI 35.4) Chronic LBP Hypothyroidism Hearing Loss PSHx : h/o Breast Ca s/p R. lumpectomy, chemorx Lipoma removal 2002  PONV Tonsillectomy/Adenoidectomy Rx: Coumadin 5mg Daily HCTZ 25mg Daily Ranitidine 150mg Daily Vicodin 5/325 1 tab q4-6 hours Lisinopril 5 mg Daily Metoprolol 25 mg Daily Metformin 500mg BID Levothyroxine 125 mcg Daily SocHx : Tobacco use (1ppd x 20 years) Alcohol use (3-5 glasses wine/day) ROS: +palpitations w/exercise, +myopia, +heartburn, +tingling in b/l 1 st /2 nd digits, recent URI (2 days) PE: VS: HR 79, BP 145/89, RR 16 shallow, Temp 36.7, Sp2 98% on RA Wt : 96.4kg, Ht : 165cm Airway: Mallamapati II, , TMD < 6, Loose #11, NC 15.5in Respiratory: UATS CV: IRIR, no gallops Abd : +Murphy’s sign. Hypoactive BT Ext: Varicose veins, no edema Neuro : +numbness in b/l feet, + carotid bruit Skin: Lumpectomy incision healed. FS: >4 (3 flights of stairs  back pain) Labs: Na 139, K 3.3, Cl 109, HCO3 29, BUN 12, Cr 1.1 WBC 8.3, Hct 35, Hgb 12, Plt 171 PT 13.5 , PTT 35, INR 2.1 Studies Referred for sleep study EKG: IRIR HR 67-98 TTE: nl chamber size, wall motion,valves , and EF 58yo F presents to clinic for laparoscopic cholecystectomy on xx/ 2014, 3weeks prior to DOS Postprandial symptoms  ED visit last week  Gallstones/GBW thickening

UW PACU Handoff:

UW PACU Handoff Surgery Clinic Visit I. Pre-Anesthesia/Clinic Visit Phone interview Need PAC Visit? Add’l studies? Chart review Pre-op phone call Pt. arrives on DOS Yes Referral visits Pre-op phone call

UW PACU Handoff:

UW PACU Handoff PAC Note 6-8 sheets of paper, only 60% vital to patient care

UW PACU Handoff:

UW PACU Handoff PACU ICU IIa . Day before Surgery Pt. arrives on DOS IIb . Day of Surgery Providers assigned cases I. Pre-operative data collection and plan formation PAC Note Cerner OSH Records ?Epic II. D/w attending Need to see: - Preop Nurse - Surgeon - Anesthesia - OR Nurse OR Case Dispo

UW PACU Handoff:

UW PACU Handoff III. PACU Un-planned ICU Arrive in PACU, Bay Assigned Handover Attach O2 Monitors Positioning MD: Verbal handoff RN: SSHR filled Stable for Dispo ? ( Aldrete ) Monitor in PACU CODE/still unstable? Home Floor Tx Orders in? Bed avail? Yes! To floor,,. Yes! Go home,,. Outpt Rx ready? No  Oh helll no Limbo Limbo RN-RN handover RN-RN handover

UW PACU Handoff:

UW PACU Handoff Information Omissions (March 27, 2014) (n=63) Pre-study nurse surveys: Multiple disturbances/interruption Providers almost always “rushed” Inconsistency with PACU arrival tasks (monitors, O2, patient positioning) prior to handoff Data re: PACU and 24hr events pending Name -- Airway management 3% Status/Code 68% Induction Meds 16% PMHx 36% Lines 24% Home Rx 24% Resident name/pager 100% Allergies 10% Anticipatory Guidance 82%

UW ICU Handoff:

UW ICU Handoff John Lang, MD Alan Artru , MD

EHRs: Meaningful Use:

EHRs: Meaningful Use Electronic Health Records Today: The Positives Standardized Accessibility (Dykes 2007) Funding and Support ( Steinbrook 2009) The Perceived Positives Workflow facilitation Efficiency Accuracy ( Steinbrook 2009 ) Patient Care

EHRs: Meaningful Use:

EHRs: Meaningful Use Medscape. July 16, 2014

EHRs: Meaningful Use:

EHRs: Meaningful Use National Alliance of HIT – Office of National Coordinator – 2004 “Majority of Americans to have EHRs by 2014” ARRA 2009 – $19.2B (of $>170B) stimulus package allocated to Healthcare IT

EHRs: Meaningful Use:

EHRs: Meaningful Use Center for Medicare/Medicaid Services (CMS) 2010 – standards for “certified “EHR 2011 – incentive payments for EHR “meaningful use” attestation 2015 – Medicare payment deductions for providers not showing meaningful use National Committee for Quality Assurance (NCQA) Health Effectiveness Data and Information Set (HEDIS) – 2012 35 quality measures to facilitate reporting of accountable care organization (ACO) benchmark data

EHRs: Meaningful Use:

EHRs: Meaningful Use Medscape. July 16, 2014

EHRs: Meaningful Use:

EHRs: Meaningful Use Medscape. July 16, 2014

EHR Templates:

EHR Templates Improvement in physician note quality scores ( Fielstein 2006) F acilitation for secondary data use ( Bonney 2013) Automatized process of information transfer and extraction by domain ( Siebens 2001) Discourages ambiguous findings in notes ( Bosmans 2012) Highlights important findings Improved patient rapport and continuity of care (Co 2010, Millery 2011)

PAST Template:

PAST Template Automatic and timely consolidation of data from disparate systems Anesthesia Information Management Systems (Merge/AIMS) Cerner Powerchart MINDScape Data access/processing from Cerner EHR via AMALGA Stand-alone web-based program (SQL Serve Reporting Services) Access granted with Cerner/ORCA User ID/Password (HIPAA-compliant) * It is NOT a replacement for: - your own patient assessments - other clinician’s evaluations in the EHR - any perioperative communication (i.e. day-before phone call)

PAST Template:

PAST Template Key: Gray highlighted fields [ ] : extracted from PAC note Yellow highlighted fields [ ] : labs / studies electronically extracted from Cerner/ PowerChart . Green highlighted fields [ ] : extracted from DOCUSYS server Text in blue direct links to the Cerner PowerChart /Mindscape where studies can be retrieved (XML format ) Text in red fields which will require revision of the PAC note template in order to accurately extract information.

PAST Template:

I. Quantitative Information - Numeric data, studies, vitals, etc. all represented in one section - CPT/ICD already present  Facilitates rapid input into DOCUSYS - Improves information reporting (Surgeons, PACU) DEVELOPMENT PAST Template

PAST Template:

II. Medical/Surgical History - Diagnosis-linked fields pull in medications and problems by organ system - A irway management and complication information extracted from previous DOCUSYS anesthetic record DEVELOPMENT PAST Template

PAST Template:

III. Anesthetic Issue “Dashboard” - PAC note components (ROS, PE, Labs) directly transferred from PAC note i - Issue and timeframe-based organization assist with prioritization and contribute to thorough and rapid patient assessments DOS Checklist for provider and Pre-Op Nursing Staff A ll coded fields from the PAC note categorized by issue. Only positive findings will “light up” in the final template DEVELOPMENT PAST Template

PAST Template:

1-7days prior t o DOS DEVELOPMENT PAST Template Information automatically extracted from sources to populate template

Case Example:

Case Example PMHx : A-fib DM2 HTN GERD Morbid Obesity (BMI 35.4) Chronic LBP Hypothyroidism Hearing Loss PSHx : h/o Breast Ca s/p R. lumpectomy, chemorx Lipoma removal 2002  PONV Tonsillectomy/Adenoidectomy Rx: Coumadin 5mg Daily HCTZ 25mg Daily Ranitidine 150mg Daily Vicodin 5/325 1 tab q4-6 hours Lisinopril 5 mg Daily Metoprolol 25 mg Daily Metformin 500mg BID Levothyroxine 125 mcg Daily SocHx : Tobacco use (1ppd x 20 years) Alcohol use (3-5 glasses wine/day) ROS: +palpitations w/exercise, +myopia, +heartburn, +tingling in b/l 1 st /2 nd digits, recent URI (2 days) PE: VS: HR 79, BP 145/89, RR 16 shallow, Temp 36.7, Sp2 98% on RA Wt : 96.4kg, Ht : 165cm Airway: Mallamapati II, , TMD < 6, Loose #11, NC 15.5in Respiratory: UATS CV: IRIR, no gallops Abd : +Murphy’s sign. Hypoactive BT Ext: Varicose veins, no edema Neuro : +numbness in b/l feet, + carotid bruit Skin: Lumpectomy incision healed. FS: >4 (3 flights of stairs  back pain) Labs: Na 139, K 3.3, Cl 109, HCO3 29, BUN 12, Cr 1.1 WBC 8.3, Hct 35, Hgb 12, Plt 171 PT 13.5 , PTT 35, INR 2.1 Studies Referred for sleep study EKG: IRIR HR 67-98 TTE: nl chamber size, wall motion,valves , and EF 58yo F presents to clinic for laparoscopic cholecystectomy on xx/ 2014, 3weeks prior to DOS Postprandial symptoms  ED visit last week  Gallstones/GBW thickening

Case Example:

Case Example I. Quantitative Information DEVELOPMENT

Case Example:

Case Example II. Medical/Surgical History DEVELOPMENT

Case Example:

Case Example III. Anesthetic Issue “Dashboard” DEVELOPMENT

PowerPoint Presentation:

DEVELOPMENT

Transfer Template (T2):

Transfer Template (T2) DEVELOPMENT Push F7 on OR Anesthesia computers to display T2

Handover IT: Objectives:

Handover IT: O b jectives Engagement of nurses and providers in the development of web-based informatics application to improve the handover process. Decreased information omissions related to the patient’s relevant medical history on the Surgical Services Handoff Report (SSHR) (purple sheet), prior to patient discharge or ward transfer. Improvement in the quality of the provider-nurse handover process as gauged by third-party (nurse educator) evaluators and tested handover evaluation tools in the recovery room. Decreased incidence of minor complications in the immediate post-operative period, as well as within the first 24 hours of floor transfer. Improved intraoperative evidence-based anesthetic plans based on identifying at-risk patients (ex: multiple agent therapy for PONV prophylaxis, decreased volatile gas administration for patients with lower MAC requirements) QI, RESEARCH “Provider” = any person administering an anesthetic ( attendings , CRNA, residents)

Handover IT: QI:

Handover IT: QI Approach: IHI Model For Improvement QI

Handover IT: QI:

Handover IT: QI Patient Task Factors Staff Factors Team Factors Organization Environment 1.) Omission of Information (OI) 2.) Poor handover quality 3.) PACU adverse events Cause/Effect Chart - OSH records not available Language barriers Complex pt /multiple medical issues Incorrect/incomplete info presented at clinic visit - Incorrect info in EHR - Chart review instead of [needed] clinic visit Multiple intraop handovers (anesthesia) PACU nurse task burden/”shift change” Provider/nurse - Burden of PAC documentation - Time-consuming EHR review - Case to follow, pressure to be efficient - Lack of or miscommunication between resident and attending re: anesthetic plans Multiple sources of info in EHR No standardized Printouts/jotting down illegible notes Noisy/clustered Staff or pt. interruptions Chart/SSHR not available

Handover IT: QI:

Handover IT: QI Accuracy of Post-Operative Handovers QI

Handover IT: QI:

Handover IT: QI AIMS Statement: S pecific S tretch M easurable A chievable R ealistic T imely Our team aims to decrease the rate of post-operative verbal handover OI in all checklist fields to ≤ 15% within 6 months of study start (e.g. June 30, 2015) in ASA3+ patients being admitted to UWMC after elective surgery. QI

Handover IT: QI:

Handover IT: QI Assemble A Team Research: G. Alec Rooke , MD PhD, Gail Van Norman, MD PAC Clinic coordinators: G. Alec Rooke , MD PhD IT: Dr. Bala Nair, Shu -Fang Newman (Programmer) CQI Coordinator: Karen McElhinney Nurse educator (CNE) team: TBA QI

Outcome Measures:

Outcome Measures Primary Outcomes OI (%), Run Chart Quality (via Handoff CEX) # of minutes until patient is transferred from PACU to inpatient floor QI Pre-Anesthesia Intraoperative Post-Anesthesia Demographics Airway Access Condition Antibiotics Disposition Allergies Induction Rx Sign-Out Medications BP Rx Anticipatory Plans PMHx Pain/PONV Rx Fluids

Outcome Measures:

Outcome Measures Primary Outcomes 1) OI Run chart QI

Outcome Measures:

Outcome Measures Primary Outcomes 2) Handoff CEX QI

Outcome Measures:

Secondary Outcomes (PACU) 3) PACU adverse events PONV Incidence of PONV in Group 1 and Group 2 # of medications administered # of emesis episodes Pain # of separate pain medication administrations Maximum pain score recorded by patients Total opioid consumption (in milligrams ) Outcome Measures QI

Outcome Measures:

Outcome Measures PACU adverse events (cont’d) Sedation scores ( Aldrete score) 15 minutes, 1 hour, and 2 hours Hypotension (SBP < 90 and/or MAP <60) # of patients with hypotensive episodes # of individual pressor (blood pressure-elevating) medication administrations Total pressor consumption (in milligrams) QI

Outcome Measures:

Outcome Measures PACU adverse events (cont’d) Respiratory compromise # of patients with respiratory depression (RR < 8) # of narcan administration events # of desaturations QI

Process Measures:

Process Measures % attendance/participation at training sessions % of PACU nurses using template for signout at 3 months % provider (resident/CRNA/attending for signout at 3 months QI

Balance Measures:

Balance Measures Administrative time expense Whiteboard involvement Provider time expense Handover time , OR turnover time Developmental/Programming Costs Nursing/Provider satisfaction Evaluation of PHI integrity (to be determined after 2 nd PDSA cycle) QI

Handover IT: QI:

Handover IT: QI Problem/ Processes Improvements/ Interventions Omission of Information (OI) PAST, T2 Handover Quality PAST, T2 PACU adverse events PAST QI

Handover IT: QI:

Handover IT: QI Pre-Implementation IRB, etc. PACU Nursing Survey Online training module/instructional video Provider Recruitment Departmental, Class, or Group E-mail QI

Handover IT: QI:

Handover IT: QI Implementation Focus Groups (x4), 1.5 hr sessions Focus on Qualitative Input Foster provider-nurse partnership and ownership Identify hospital-wide barriers and ways to facilitate implementation Revise product Pizza Departmental announcements Online modules/LMS Gateway Model for Improvement – PDSA Cycles QI

Handover IT: Research:

Handover IT: Research Study Design: Prospective RCT Single-blinded (PACU nurse/provider aware) IRB needed: access to patient PACU data, intent to publish QI data outside UWMC Study Population: N=64 dyads (provider-PACU nurse interactions + patient ); 32 dyads/group “Provider” = CA2 or CA3 resident or CRNA (>2yrs) “PACU Nurse” = 1:1 nurse who is routinely in PACU “Patient” = ASA 3+ with planned post-op admission RESEARCH

Handover IT: Research:

Handover IT: Research Intervention: Control Group: Provider preference in patient pre-op preparation and handover Intervention Group: PAST for patient pre-op preparation, PAST + T2 for handover Will receive additional instructional video (15 minutes) Templates visible by both PACU nurse and provider Recruitment: E-mails, GR announcements Consent: Written consent from providers Nursing staff to receive educational session during pre-implementation phase, RESEARCH

Handover IT: Research:

Handover IT: Research Workflow 1 day prior to DOS : Coordinate with Whiteboard/AIC Providers notified 1 day prior to surgery re: control vs intervention group DOS : Provider brings pt. to PACU Audio recorders (numbered) distributed to each nurse prior to provider/patient coming from OR Monitors, positioning, O2 after arrival, etc. If provider is in intervention group, provider instructs PACU nurse to open PAST template Verbal handoff, recording with pt. name and ID. RESEARCH

Workflow:

Workflow RESEARCH 15-min video tutorial

Handover IT: Research:

Handover IT: Research RESEARCH RESEARCH PACU ICU Ia. Day before Surgery Pt. arrives on DOS Ib. Day of Surgery Providers assigned cases I. Pre-operative data collection and plan formation PAC Note Cerner OSH Records ?Epic III. D/w attending Need to see: - Preop Nurse - Surgeon - Anesthesia - OR Nurse OR Case Dispo I. Access/download PAST II. Additional chart review T2 used for i ntraop handoffs T2 printed before arrival

Handover IT: Research:

Handover IT: Research RESEARCH PACU Arrive in PACU, Bay Assigned Handoff Attach O2 Monitors Positioning PAST Handoff at PACU computer Anticipatory planning PACU orders revised, if needed Un-planned ICU Stable for Dispo ? ( Aldrete ) Monitor in PACU CODE/still unstable? Home Floor Tx Orders in? Bed avail? Yes! To floor,,. Yes! Go home,,. Outpt Rx ready? No  Oh helll no Limbo Limbo RN-RN handover RN-RN handover

Handover IT: Research:

Handover IT: Research RESEARCH

Handover IT: Research:

Handover IT: Research Data Storage/Access Audio recorders (containing PHI) stored in locked desk in Anesthesia QI office Handover audio evaluations: OI: Recordings compared against PAC note and ORCA medication list Quality: Recordings graded via Likert Scale in Handover CEX (previously validated evaluation tool) PACU events: Recordings compared against completed PACU charting in CERNER IView.

Handover IT: Research:

Handover IT: Research Pre-Anesthesia Intraoperative Post-Anesthesia Demographics Airway Access Condition Antibiotics Disposition Allergies Induction Rx Sign-Out Medications BP Rx Anticipatory Plans PMHx Pain/PONV Rx Fluids Primary Outcomes OI (%) Quality (via Handoff CEX) # of minutes until patient is transferred from PACU to inpatient floor

Handover IT: Research:

Handover IT: Research Secondary Outcomes PACU adverse events PONV Pain Scores Sedation scores Hypotension Respiratory depression RESEARCH

Handover IT: Research:

Handover IT: Research Data Collection: Audio recordings: End of OR Day PACU data: Weekly review of patient charts Analyses Power analysis for study sample Handoff CEX scores  nonparametric tests of mean Handover and PACU times  Mann-Whitney U test PACU outcomes  Fisher-Exact Test RESEARCH

Timeline:

Timeline September 2014 – Submit IRB PAST/T2 rollout October-December 2014 – Provider Recruitment Focus Groups Template revisions/feedback Create 15-minute instructional video January-May 2015 (Resident Research Track)– Data collection and analyses June 2015 – Manuscript preparation

Research/QI: Long-Term Objectives:

Widespread implementation of PAST template at UW as well as affiliated hospitals. Institute a web-based handover report/checklist form to replace the paper-based Surgical Services Handoff Report (SSHR) Integrate surgical handoff/anticipatory guidance into electronic handoff tools (i.e. the T2) Decrease post-operative major + minor complications related to provider communication error Research/QI: Long-Term Objectives Research/QI

HSQC Integration:

HSQC Integration High Value Theme – Empowering PACU nurses to standardize handoffs Surgical subspecialty education about anesthetic workflow Non-handover-related aims to improve efficiency of patient disposition (avoid “limbo”) Documentation standardization modules HMC PACU QI Champions

References:

References email me: Aalap Shah shaha3@uw.edu Aalap.c.shah@gmail.com

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