Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach.

BACKGROUND: Patient handovers (handoffs) following surgery have often been characterized by poor teamwork, unclear procedures, unstructured processes, and distractions. A study was conducted to apply a human-centered approach to the redesign of operating room (OR)-to-ICU patient handovers in a broad surgical ICU (SICU) population. This approach entailed (1) the study of existing practices, (2) the redesign of the handover on the basis of the input of hand over participants and evidence in the medical literature, and (3) the study of the effects of this change on processes and communication. METHODS: The Durham [North Carolina] Veterans Affairs Medical Center SICU is an 11-bed mixed surgical specialty unit. To understand the existing process for receiving postoperative patients in the SICU, ethnographic methods-a series of observations, surveys, interviews, and focus groups-were used. The handover process was redesigned to better address providers' work flow, information needs, and expectations, as well as concerns identified in the literature. RESULTS: Technical and communication flaws were uncovered, and the handover was redesigned to address them. For the 49 preintervention and 49 postintervention handovers, the information transfer score and number of interruptions were not significantly different. However, staff workload and team behaviors scores improved significantly, while the hand over duration was not prolonged by the new process. Handover participants were also significantly more satisfied with the new handover method. CONCLUSIONS: An HCD approach led to improvements in the patient handover process from the OR to the ICU in a mixed adult surgical population. Although the specific handover process would unlikely be optimal in another clinical setting if replicated exactly, the HCD foundation behind the redesign process is widely applicable.

Pulmonary artery catheter.

Since its inception, the pulmonary artery catheter has enjoyed widespread use in both medical and surgical critically ill patients. It has also endured criticism and skepticism about its benefit in these patient populations. By providing information such as cardiac output, mixed venous oxygen saturation, and intracardiac pressures, the pulmonary artery catheter may improve care of the most complex critically ill patients in the intensive care unit and the operating room. With its ability to transduce pressures through multiple ports, one of the primary clinical uses for pulmonary artery catheters is real-time intracardiac pressure monitoring. Correct interpretation of the waveforms is essential to confirming correct placement of the catheter to ensure accurate data are recorded. Major complications related to catheter placement are infrequent, but misinterpretation of monitored data is not uncommon and has led many to question the utility of the pulmonary artery catheter. The evidence to date suggests that the use of the catheter does not change mortality in many critically ill patients and may expose these patients to a higher rate of complications. However, additional clinical trials are needed, particularly in the most complex critically ill patients, who have generally been excluded from many of the research trials performed to date.

FOCUS: the Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.

The Society of Cardiovascular Anesthesiologists (SCA) introduced the FOCUS initiative (Flawless Operative Cardiovascular Unified Systems) in 2005 in response to the need for a rigorous scientific approach to improve quality and safety in the cardiovascular operating room (CVOR). The goal of the project, which is supported by the SCA Foundation, is to identify hazards and develop evidence-based protocols to improve cardiac surgery safety. A hazard is anything that has the potential to cause a preventable adverse event. Specifically, the strategic plan of FOCUS includes 3 goals: (1) identifying hazards in the CVOR, (2) prioritizing hazards and developing risk-reduction interventions, and (3) disseminating these interventions. Collectively, the FOCUS initiative, through the work of several groups composed of members from different disciplines such as clinical medicine, human factors engineering, industrial psychology, and organizational sociology, has identified and documented significant hazards occurring daily in our CVORs. Some examples of frequent occurrences that contribute to reduce the safety and quality of care provided to cardiac surgery patients include deficiencies in teamwork, poor OR design, incompatible technologies, and failure to adhere to best practices. Several projects are currently under way that are aimed at better understanding these hazards and developing interventions to mitigate them. The SCA, through the FOCUS initiative, has begun this journey of science-driven improvement in quality and safety. There is a long and arduous road ahead, but one we need to continue to travel.

Can we make postoperative patient handovers safer? A systematic review of the literature.

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

Unusual cause of superior vena cava syndrome diagnosed with transesophageal echocardiography.

PURPOSE: An unusual case of superior vena cava (SVC) syndrome caused by an infected right atrial-SVC junction thrombus may be diagnosed using transesophageal echocardiography. CLINICAL FEATURES: A 59-yr-old male with end-stage renal disease requiring hemodialysis presented with fungemia and later developed facial and bilateral upper extremity edema. Transesophageal echocardiography revealed subtotal occlusion of the SVC at its junction with the right atrium. The mass was surgically removed with cardiopulmonary bypass support. Pathological examination of the mass confirmed the presence of a large fungal colony of Candida species mixed in the thrombus. The patient's signs and symptoms of SVC obstruction resolved, and he was discharged from the hospital four weeks later in stable condition. CONCLUSION: Although usually caused by extrinsic tumour compression, SVC syndrome can result from intravascular caval obstruction. This etiology should also be considered in the differential diagnosis, particularly in patients with intravascular devices. Transesophageal echocardiography is a valuable diagnostic tool in these cases.

ABO blood group and bleeding after coronary artery bypass graft surgery.

Low circulating von Willebrand factor levels increase the risk of bleeding after cardiac surgery. Patients with blood group O may be at greatest risk owing to lower baseline levels of von Willebrand factor compared with patients with other blood groups, and perioperative hemodilution during cardiac surgery may reduce von Willebrand factor to critical levels in these patients. This study tested the hypothesis that patients with blood group O are at increased risk for postoperative bleeding following cardiac surgery, and determined whether the blood group affected perioperative assessment of primary hemostasis. Using multivariate linear regression models that included preoperative and intraoperative covariates, the risk factors for postoperative bleeding were evaluated in 877 patients undergoing primary, nonemergent coronary artery bypass surgery at a university hospital. In a subset of these patients, we measured perioperative in-vitro bleeding times (PFA-100 analyzer) to determine whether there were measurable differences in primary hemostasis between patients with blood type O and those with other blood groups. Patients with blood group O did not have increased bleeding after cardiac surgery compared with patients with other blood types. In addition, while blood group O patients had laboratory evidence for abnormal primary hemostasis before surgery, there were no measurable differences in postoperative primary hemostasis in patients with different blood types. In conclusion, although we identified clinical and procedural factors that were independently associated with bleeding, blood group was not one of these factors.

Arterial and central venous pressure monitoring.

Pressure monitoring systems influence the contour of the displayed wave-forms and, on occasion, can introduce significant artifact in the pressure traces. It is important to understand the technical details of invasive pressure monitoring to interpret better the information presented. Careful observation of the arterial pressure waveform can provide information about ventricular function, the arterial system, and ventricular preload. In particular, systolic pressure variation during the respiratory cycle in mechanically ventilated patients is a clinically useful indicator of volume status. CVP monitoring is also used to assess intravascular volume, but this measurement is significantly influenced by ventricular compliance and intrathoracic pressure. Under most clinical circumstances, a trend in CVP values or its change with therapeutic maneuvers is more reliable than a single measurement. Like arterial pressure waveforms, CVP waveform morphology can provide important information about clinical pathophysiology.

Is the valve OK or not? Immediate evaluation of a replaced aortic valve.

Transesophageal echocardiography is a crucial tool in intraoperative evaluation of newly implanted/repaired heart valves because suspected valvular malfunction needs to be identified and sometimes surgically corrected. Although color Doppler is often adequate in evaluating the expected regurgitant jets, as well as excluding pathologic paravalvular leaks, spectral Doppler techniques are the most commonly used methods for estimating transvalvular gradients in the operating room. However, these methods are subject to a variety of confounding factors, including subvalvular gradients and pressure recovery. Other methods of valve area estimation should also be used when evaluating a prostethic aortic valve, including the continuity equation and the left ventricular outflow tract/aortic valve velocity ratio.

Multimodal detection of perioperative myocardial ischemia.

Cardiac anesthesiologists have the responsibility to detect myocardial ischemia in a timely manner, which can be a challenging task in the perioperative environment. Transesophageal echocardiography pulmonary artery catheterization, and electrocardiography are the 3 major methods available for monitoring perioperative ischemia. Echocardiography, the newest and most sophisticated method, has been shown to be highly sensitive for detecting ischemia associated with systolic dysfunction. Echocardiography can detect wall-motion abnormalities before electrocardiographic changes develop in patients who are likely to experience supply-mediated ischemia. Perioperative ischemia that occurs after bypass and is detected using transesophageal echocardiography has been found to be related to an adverse outcome. However, the use of echocardiography has some limitations, including the detection of abnormalities not induced by ischemia and the presence of ischemia in areas not visible in the view selected. Pulmonary artery catheterization can provide information about systolic dysfunction, diastolic dysfunction, and mitral regurgitation, but the sensitivity and safety of catheterization have been questioned. Electrocardiography can be a superb monitoring device as long as clinicians pay adequate attention to lead selection and placement, filter selection, and gain adjustment. The optimal monitoring approach should integrate all 3 available monitoring systems in order to increase the likelihood of detecting both supply- and demand-mediated ischemia.

Effects of positive-pressure ventilation, pericardial effusion, and cardiac tamponade on respiratory variation in transmitral flow velocities.

OBJECTIVE: To determine the effects of positive-pressure ventilation and experimentally induced pericardial effusion and tamponade on transmitral flow velocities in dogs. DESIGN: Descriptive. SETTING: University laboratory. PARTICIPANTS: Eleven tracheally intubated and mechanically ventilated dogs. INTERVENTIONS: Experimental pericardial effusion and cardiac tamponade were created by pericardial injection of warm saline. MEASUREMENTS AND MAIN RESULTS: Hemodynamic parameters and pericardial pressures were monitored in the 11 dogs. Pulsed-wave Doppler tracings of mitral valve flow were obtained at the leaflet tips along with hemodynamic measurements at 4 stages: control, effusion (no decrease in mean arterial pressure), tamponade (>or=40% decrease in mean arterial pressure), and tamponade relief (after evacuation of pericardial fluid). Maximal variation (36%) in transmitral flow velocity over the respiratory cycle during positive-pressure ventilation was seen in the control stage. In the effusion and tamponade stages, variation in transmitral flow velocity decreased progressively to 29% (p = 0.1804, not significant) and 16% (p < 0.0001), respectively. CONCLUSION: Intrathoracic pressure and lung volume changes caused by positive-pressure ventilation influence transmitral flow velocity patterns. Respiratory variation in transvalvular flow is pronounced during standard positive-pressure mechanical ventilation, decreases in the presence of pericardial effusion, and becomes almost nonexistent when cardiac tamponade is present. These findings show that the echocardiographic criteria used to diagnose cardiac tamponade based on mitral valve inflow patterns are different during positive-pressure ventilation from spontaneously breathing subjects.

Lithium dilution cardiac output measurement: a clinical assessment of central venous and peripheral venous indicator injection.

OBJECTIVE: The lithium indicator dilution technique has been shown to measure cardiac output (CO) accurately by using central venous injection of lithium chloride (Li-CCO). This study aimed to compare the measurement of CO by using peripheral venous administration of lithium chloride (Li-PCO) with Li-CCO. DESIGN: Prospective, observational human study. SETTING: Surgical intensive care unit. PATIENTS: Thirty-one patients were studied after major surgery. All patients had arterial, central, and peripheral venous catheters. A total of 24 patients had pulmonary artery catheters. MEASUREMENTS: Serial measurements of Li-CCO and Li-PCO were made during hemodynamically stable conditions. CO was also measured using thermodilution (TDCO) when a pulmonary artery catheter was present. Data were analyzed by linear regression, the generalized estimating equation, and the comparison method described by Bland and Altman. MAIN RESULTS: There were 93 Li-CCOs, 93 Li-PCOs, and 216 TDCOs recorded. The ranges of COs were similar: Li-CCO, 2.36-11.52 L/min (mean, 5.22 L/min; n = 31); Li-PCO, 1.63-9.99 L/min (mean, 5.22 L/min; n = 31), and TDCO, 3.28-10.4 L/min (mean, 5.75 L/min; n = 24). There was good linear correlation between Li-CCO and Li-PCO (R2 =.845). The mean difference for Li-CCO-Li-PCO was very small and insignificant (p =.97), and the limits of agreement were acceptable (mean difference +/- sd, 0.0005 +/- 0.64 L/min). The mean difference for Li-CCO-Li-PCO was smaller if the peripheral injection site was proximal rather than distal to the wrist (p =.053). Li-PCO and Li-CCO values were lower than simultaneously obtained TDCO measurements (Li-PCO-TDCO, -0.538 +/- 0.95 L/min, p =.003; Li-CCO-TDCO, -0.526 +/- 0.67 L/min, p =.0001). CONCLUSIONS: Li-PCO gives a measurement that agrees well with Li-CCO. Accuracy of Li-PCO is probably improved if a proximal arm vein is used. Li-PCO provides accurate measurements of CO without the risks of pulmonary artery or central venous catheterization.