An evidence synthesis on perioperative Handoffs: A call for balanced sociotechnical solutions.

SIGNIFICANCE: Perioperative handoffs interconnect the preoperative, intraoperative, and postoperative phases underlying surgical care to maintain care continuity -yet are prone to coordination and communication failures. OBJECTIVE: To synthesize evidence on factors affecting the safety and quality of perioperative handoff conduct and process. MATERIALS AND METHODS: A search of PubMed, EMBASE, and CINAHL was conducted to include observational, descriptive studies of preoperative, intraoperative, and postoperative handoffs published in English language, peer-reviewed journals. Data analysis was informed by the Systems Engineering Initiative for Patient Safety (SEIPS) framework describing the relationship between the work-system, work processes, and outcomes. Study quality was assessed using the Quality Scoring System. RESULTS: Twenty-three studies were included. Eighteen studies focused on postoperative handoffs, with one on preoperative, three on intraoperative and only one that looked at preoperative/postoperative handoffs combined. The SEIPS framework elucidated the complex inter-related factors (enablers and barriers) related to perioperative handoff safety. While some studies found that the use of standardized handoff tools and protocols and interdisciplinary teamwork were frequently-reported enablers, other studies identified the lack of structured handoff tools and protocols, poor teamwork and communication, and improper use of documentation tools were top-cited barriers affecting handoff quality. Suggestions to ensure handoff safety and quality included implementing structured handoff checklists and protocols and building interprofessional teamwork competencies for effective communication. DISCUSSION AND CONCLUSION: Our review highlights an urgency to develop more holistic sociotechnical solutions that can create and sustain a balance between technical innovations in tools and technologies and the non-technical interventions/training needed to improve interpersonal relations and teamwork competencies - taken together, can improve the quality and safety of perioperative handoff practice.

Development and Validation of a Model to Predict Postdischarge Opioid Use After Cesarean Birth.

OBJECTIVE: To develop and validate a prediction model for postdischarge opioid use in patients undergoing cesarean birth. METHODS: We conducted a prospective cohort study of patients undergoing cesarean birth. Patients were enrolled postoperatively, and they completed pain and opioid use questionnaires 14 days after cesarean birth. Clinical data were abstracted from the electronic health record (EHR). Participants were prescribed 30 tablets of hydrocodone 5 mg-acetaminophen 325 mg at discharge and were queried about postdischarge opioid use. The primary outcome was total morphine milligram equivalents used. We constructed three proportional odds predictive models of postdischarge opioid use: a full model with 34 predictors available before hospital discharge, an EHR model that excluded questionnaire data, and a reduced model. The reduced model used forward selection to sequentially add predictors until 90% of the full model performance was achieved. Predictors were ranked a priori based on data from the literature and prior research. Predictive accuracy was estimated using discrimination (concordance index). RESULTS: Between 2019 and 2020, 459 participants were enrolled and 279 filled the standardized study prescription. Of the 398 with outcome measurements, participants used a median of eight tablets (interquartile range 1-18 tablets) after discharge, 23.5% used no opioids, and 23.0% used all opioids. Each of the models demonstrated high accuracy predicting postdischarge opioid use (concordance index range 0.74-0.76 for all models). We selected the reduced model as our final model given its similar model performance with the fewest number of predictors, all obtained from the EHR (inpatient opioid use, tobacco use, and depression or anxiety). CONCLUSION: A model with three predictors readily found in the EHR-inpatient opioid use, tobacco use, and depression or anxiety-accurately estimated postdischarge opioid use. This represents an opportunity for individualizing opioid prescriptions after cesarean birth.

A Multicomponent Fall Prevention Strategy Reduces Falls at an Academic Medical Center.

BACKGROUND: While the reduction in fall rates has not kept pace with the reduction of other hospital-acquired conditions, patient safety research and quality improvement (QI) initiatives at the system and hospital levels have achieved positive results and provide insights into potentially effective risk reduction strategies. An academic medical center developed a QI-based multicomponent strategy for fall prevention and pilot tested it for six months in three high-risk units-the Neuroscience Acute Care Unit, the Myelosuppression/Stem Cell Transplant Unit, and the Acute Care for the Elderly Unit-before implementing and evaluating the strategy hospitalwide. METHODS: The multicomponent fall strategy was evaluated using a pre-post study design. The main outcome measures were falls and falls with harm measured in events per 1,000 patient-days. Fall rates were monitored and compared for three classes of falls: (1) accidental, (2) anticipated physiologic, and (3) unanticipated physiologic. RESULTS: Statistical process control charts showed that the pilot units had achieved significant reductions in falls with harm during the last five months of data collection. Wald test and segmented regression analyses revealed significant improvements in pooled postintervention fall rates, stratified by fall type. The hospitalwide implementation of the program resulted in a 47% overall reduction in falls in the postintervention period. CONCLUSION: A fall prevention strategy that targeted the spectrum of risk factors produced measurable improvement in fall rates and rates of patient harm. Hospitals must continue developing, rigorously testing, and sharing their results and experiences in implementing and sustaining multicomponent fall prevention strategies.

Blood ordering from the operating room: turnaround time as a quality indicator.

BACKGROUND: Quality indicators in transfusion medicine are necessary for patient safety and customer satisfaction. The turnaround time (TAT) of issuing red blood cells (RBCs) has emerged as a quality indicator but is not an established benchmark. We examined the TAT for issuing RBCs from the blood bank to the operating rooms (ORs) at Vanderbilt University Medical Center (VUMC) and Stanford University Medical Center (SUMC). STUDY DESIGN AND METHODS: TAT was defined from time of request to when RBCs exited the blood bank. Cases eligible for analysis had completed type-and-screen results with requests for four or fewer RBC units. Patients with a positive antibody screen had serologically crossmatched units prepared and reserved for intraoperative use. We also e-mailed surveys to academic institutions to establish the current state of TAT monitoring and to anesthesiologists at VUMC to gauge the TAT expectations of the OR. RESULTS: The mean TATs at the two institutions were comparable (VUMC, 10 ± 3.8 min; SUMC, 14 ± 7.2 min) for orders of RBCs. The most common reasons for delayed TAT were overlapping orders, medical technologists occupied by phone calls, and oversaturation of pneumatic tube stations. Only 3 of 24 surveyed institutions actively monitored RBC TAT. Surveyed anesthesiologists (n = 7) reported an expectation for RBC TAT of 5 to 15 minutes for urgent cases. Established internal TAT policies were 15 and 20 minutes at VUMC and SUMC, respectively, for crossmatched RBC requests for patients with complete diagnostic testing. CONCLUSION: Many of the surveyed institutions do not monitor stat RBC issue TAT as a quality indicator. This study serves as a starting point for establishing a benchmark for TAT for issuing RBCs from the blood bank to ORs.

Circumstances surrounding the deaths of hospitalized children: opportunities for pediatric palliative care.

OBJECTIVES: Little is known regarding the assessment and treatment of symptoms during end-of-life (EOL) care for children. This study was conducted to describe the circumstances surrounding the deaths of hospitalized terminally ill children, especially pain and symptom management by the multidisciplinary pediatric care team. DESIGN: Patients in the neonatal intensive care unit, pediatric critical care unit, or general pediatric units of Vanderbilt Children's Hospital who were hospitalized at the time of death, between July 1, 2000, and June 30, 2001, were identified. Children eligible for the survey had received inpatient EOL care at the hospital for at least 24 hours before death. A retrospective medical record review was completed to describe documentation of care for these children and their families during the last 72 hours of life. RESULTS: Records of children who had received inpatient EOL care were identified (n = 105). A majority (87%) of children were in an intensive care setting at the time of death. Most deaths occurred in the pediatric critical care unit (56%), followed by the neonatal intensive care unit (31%). Pain medication was received by 90% of the children in the last 72 hours of life, and 55% received additional comfort care measures. The presence of symptoms other than pain was infrequently documented. CONCLUSIONS: The duration of hospitalization for most children dying in this inpatient setting was sufficient for provision of interdisciplinary pediatric palliative care. Management of pain and other symptoms was accomplished for many children. The documentation of pain and symptom assessment and management can be improved but requires new tools.