Six Sigma Methodology and Postoperative Information Reporting: A Multidisciplinary Quality Improvement Study With Interrupted Time-Series Regression.

OBJECTIVE: The postoperative handover is often compromised by reporting inconsistencies between different specialties. We describe a multidisciplinary quality improvement initiative to improve postoperative information reporting. DESIGN: A quality improvement project with interrupted time-series data collection was undertaken in the postanesthesia care unit between January 2015 and August 2015. We utilized Six Sigma methodology to engage multispecialty stakeholders in identifying deficiencies in the existing postoperative handover process in January 2015. A standardized handover process including a checklist and electronic handover note was implemented within a postanesthesia care unit in June 2015. Direct observations of handovers were conducted to determine reporting accuracy, handover duration, and specialty representative attendance. Segmented linear and logistic regression analyses were used for interrupted time-series data. SETTING: Single postanesthesia care unit at an academic tertiary referral center. PARTICIPANTS: Physician trainees in anesthesia (n = 82) and surgical subspecialties (n = 139), certified registered nurse anesthetists (n = 57), and recovery room registered nurses (n = 139). RESULTS: Cumulative handover scores increased by 18.3 points in the postimplementation period (n = 70) when compared to preimplementation handovers (n = 69), a finding which remained statistically significant after adjusting for preintervention time trends (difference 16 points; 95% confidence intervals 3-31; p = 0.021). No statistically significant difference in handover duration was seen between cohorts (6.8 minutes vs 6.1 minutes, difference 0.5 minutes; 95% confidence intervals -2.8 to 3.7; p = 0.78). Three years postimplementation, there was consistent use of a modified electronic handover note and surgical subspecialty attendance during handover. CONCLUSIONS: A standardized handover process was associated with improved information reporting among different surgical disciplines without significantly lengthening handover duration.

An electronic handoff tool to facilitate transfer of care from anesthesia to nursing in intensive care units.

Checklists are commonly used to structure the communication process between anesthesia nursing healthcare providers during the transfer of care, or handoff, of a patient after surgery. However, intraoperative information is often recalled from memory leading to omission of critical data or incomplete information exchange during the patient handoff. We describe the implementation of an electronic anesthesia information transfer tool (T2) for use in the handover of intubated patients to the intensive care unit. A pilot observational study auditing handovers against a pre-existing checklist was performed to evaluate information reporting and attendee participation. There was a modest improvement in information reporting on part of the anesthesia provider, as well as team discussions regarding the current hemodynamic status of the patient. While T2 was well-received, further evaluation of the tool in different handover settings can clarify its potential for decreasing adverse communication-related events.

Respiratory and Swallowing Outcomes Based on Aneurysm Location in 360 Patients with Subarachnoid Hemorrhage.

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (aSAH) may result in abnormal respiratory and swallowing function. We analyzed factors that may influence long-term respiratory and swallowing function in aSAH patients and compared patients with anterior and posterior aneurysm locations. METHODS: We retrospectively reviewed 360 consecutive aSAH patients. We recorded location of the aneurysm and respiratory indices on admission, in-hospital adverse respiratory events, and the need for tracheostomy (for respiratory failure) or percutaneous endoscopic gastrostomy (PEG) tube (for prolonged dysphagia). Respiratory and swallowing function was also reviewed at 1 year and at most recent clinical follow-up. RESULTS: Aneurysms consisted of 293 described as anterior circulation (81.4%) and 67 described as posterior circulation (18.6%), including 31 patients with basilar artery aneurysms and 16 with posterior inferior cerebellar artery (PICA) aneurysms. There were no differences in oxygen saturation or PaO2:FiO2 ratio on admission, though patients with PICA aneurysms presented significantly more commonly with endotracheal intubation. PICA aneurysm patients had higher rates of tracheostomy and PEG tube dependence at 1 year in univariate analysis. Higher Hunt-Hess grade was a predictor of pneumonia and prolonged intubation, whereas older age and prolonged hospitalization were predictors of PEG placement in multivariate analysis. CONCLUSIONS: Ruptured anterior and posterior circulation aneurysms have similar rates of in-hospital respiratory and swallowing dysfunction. There was a higher rate of swallowing dysfunction in the posterior circulation aneurysm group compared with the anterior group at most recent follow-up (12% vs. 2%, P = 0.035). Patients with PICA aneurysms demonstrated higher rates of tracheostomy and PEG, though the latter did not achieve statistical significance.