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PATIENT SAFETY: Handoffs between ICU and OR

There is a lot of literature describing problems with, and best practices for, the transfer of care of post-surgical patients moving into the intensive care unit setting.  However, after conducting a comprehensive literature search, the authors of this brief commentary found no comparable literature about the reverse type of handoff – for patients going from the special care unit into surgery.  They suggest that a checklist be adopted and give an example of one such checklist.  They also recommend that a verbal handoff be required.

What do I like about this article?  The authors are authoritative (Mount Sinai and Johns Hopkins medical schools) and I like the actual example of the handoff checklist.  Also, I like it that they appear to be filling a gap in the medical literature – at least at the time that they wrote this commentary.

Source: Evans, A.S., Yee, M.S., and Hogue, C.W. (2014, Mar.). Often overlooked problems with handoffs: From the intensive care unit to the operating room.  Anesthesia & Analgesia, 118(3), 687-689.  Click here for free full text: http://journals.lww.com/anesthesia-analgesia/Fulltext/2014/03000/Often_Overlooked_Problems_with_Handoffs___From_the.31.aspx  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

HANDOFFS: Nurse shift-to-shift reports at the bedside

When hospital nursing shifts change, there is a need to inform the incoming caregivers about the condition and needs of the patients on the unit.  There is renewed interest in the traditional practice of having this handoff done at the patient bedside.  This pilot study was done on one nursing unit at an academic medical center that had low patient satisfaction scores.  After the change there was an initial improvement in patient satisfaction scores, although it was found to be challenging to sustain the improvement over the longer term.  The project was deemed successful in that the bedside shift report model was later adopted at each of the hospitals in the system.

Source: Wakefield, D.S., and others.  Making the transition to nursing bedside shift reports.  The Joint Commission Journal on Quality and Patient Safety;38(6):243-253, June 2012.  Click here to view archive of issues of this journal: http://www.ingentaconnect.com/content/jcaho/jcjqs  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

VROOM! VROOM! Patient safety at 200 mph

Kuala Lumpur.  Shanghai.  Monte Carlo.  OR/ICU patient transfer.  Wait!  What do exotic locales have to do with handing off patients from the operating room to an intensive care unit?  Believe it or not, the common denominator is Formula One racing – more specifically, the Formula One pit crews who service the high-performance racing cars and their drivers with split-second timing precision during pit stops.  Two British physicians at the Great Ormand Street Hospital for Children (www.gosh.nhs.uk) in London were the first to draw an analogy between the timing and interaction of pit crews and the communication and hand-off protocols between surgery and ICU in their own facility.  After interviewing the head of the Ferrari pit crew, these two racing aficionados developed a patient transfer protocol that emphasized checklists and teamwork and resulted in measurable improvements.   The analogy was further amplified by subsequent research involving interviewing additional racing teams and focused on three key areas: preliminary staff training with briefings and checklists; active management and using technology to enhance communication; and post-transfer review of records to refine and reinforce the patient transfer protocol.  So whether at 200 miles per hour or 60 beats per second, safety relies on precision performance of each and every task.


Saver, Cynthia.  Handoffs: what ORs can learn from Formula One race crews.  OR Manager.  27(4):1, 11-13, April 2011.

Catchpole, Ken, and others.  Patient handovers within the hospital: translating knowledge from motor racing to healthcare.  Quality & Safety in Health Care.  19(4):318-322, August 2010.

Catchpole, Ken, and others.  Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.  Paediatric Anaesthesia.  17(5):470-478, May 2007.     

For more on Formula 1 pit crews and pit stops, check out http://www.formula1.com/inside_f1/understanding_the_sport/5289.html and http://www.dummies.com/how-to/content/the-anatomy-of-a-formula-one-pit-stop.html.