Implementation of an Electronic Checklist to Improve Patient Handover From Ward to Operating Room.

OBJECTIVE: Research has identified numerous safety risks in perioperative patient handover. In handover from ward to operating room (OR), patients are often transferred by a third person. This adds to the risk of loss of important information and of caregivers in the OR not identifying possible risk factors. The aim of this study was to describe the implementation process and completion rate of a new preoperative, ward-to-OR checklist. Our goal was a 90% fulfillment. METHOD: This study is a prospective, observational study in a Danish University Hospital including all patients undergoing surgery in 2013. The checklist was a screen page with 27 checkboxes of information relevant for a safe handover. The checklist should be completed in the ward before handover to the OR and should be checked in the OR before receiving the patient. The Plan-Do-Study-Act (PDSA) cycle method was used in the implementation process of the checklist. RESULTS: A total of 17.361 patients were included. In wards with only elective surgery (plastic and breast surgery), the checklist was used in 1.419 of 2.286 patients (62.1%). In wards with both elective and emergency surgery (abdominal, orthopedic, urology, gynecology and obstetrics), the checklist was used in 1.963 of 7.460 elective patients (26.3%) and in 812 of 7.615 emergency patients (10.7 %). CONCLUSION: Our goal of a 90% fulfillment was not reached. The electronic checklist seemed to be used most frequently in wards with only elective surgery.

[Thromboelastography-guided transfusion in a patient with amniotic fluid embolism and massive coagulopathic bleeding]. / Tromboelastografivejledt transfusiontil en patient med amnionvæskeemboliog massiv koagulopatisk blødning.

Amniotic fluid embolism is a serious and devastating complication in obstetrics. Despite a low incidence of 1-6:100.000, it remains one of the leading causes of maternal death in developed countries. Several risk factors have been proposed, but studies are conflicting, and to date there are no ways to predict or prevent this condition. Despite early and aggressive treatment, mortality and risk of neurological impairment remain high. We present a classic case of amniotic fluid embolism during labour and briefly discuss the current recommendations for treatment.

Exploring challenges and solutions in the preparation of surgical patients.

INTRODUCTION: Handover of surgical patients from ward to operating room is a sensible point for information and communication failures. Guidelines were developed for preparation of surgical patients. Our aim was to explore if patients are sufficiently prepared for surgery according to local guidelines and to identify challenges and solutions for correct preparation through interactive table simulation-based workshops involving the various professions and specialties. METHODS: Firstly, specific tasks in the hospital guidelines were monitored for all surgical procedures during one week. Secondly, workshops including table simulations involving the various professions and specialties were held. RESULTS: In total, 314 surgical procedures were performed of which 196 were eligible for analysis. Emergency procedures showed the poorest results with non-completed tasks comprising 58% of electronic patient management system tasks, 26% of anaesthesia record tasks, 24% of medication tasks, 14% of blood test tasks and 12% of patient record tasks. In two workshops held for each of four specialties, a total of 21 participants mapped the preoperative patient journey with related responsibilities, tasks and written documentation. Furthermore, challenges and suggestions for solutions were identified. CONCLUSIONS: Completion of mandatory tasks for surgical patient preparation was poor. Workshops with table simulations actively involved the stakeholders from various professions and specialties in describing the patient trajectory and mandatory tasks according to hospital guidelines in addition to identifying challenges and solutions for improvement. FUNDING: none. TRIAL REGISTRATION: not relevant.

[Intubation of a first time parturient with Klippel-Feil syndrome].

We describe a case of a first time parturient with Klippel-Feil syndrome (KFS). KFS is defined by fusion of cervical vertebrae and the clinical triad of low posterior hairline, short wide neck and limited neck movement. KFS represents a complex challenging anaesthesiologic condition due to limited movement of the neck and the risk of irreversible neurologic sequelae if manipulated, as well as unpredictable effect of neuroaxial anaesthesia. We recommend awake fiberoptic intubation for airway management in this rare disorder and stress the necessity of early anaesthesiologic assessment in any cervical spine disorder that might need airway management.

Postoperative handover: characteristics and considerations on improvement: a systematic review.

CONTEXT: Current research has identified numerous safety risks related to patient handovers including postoperative handovers. During the postoperative handover and the recovery period, the patient is at risk of potential complications of surgery or anaesthesia. Furthermore, patients are subject to a downscale in monitoring and observation, which makes them vulnerable to incidents and errors. OBJECTIVES: To describe the characteristics and potential hazards to quality and patient safety during postoperative handover. To identify concrete recommendations for improvement in this process. DESIGN: A systematic review of the literature. DATA SOURCES: Comprehensive search of electronic databases (Medline, Embase, Cochrane Library) in March 2012. Additional studies were obtained from bibliographies of retrieved reports. ELIGIBILITY CRITERIA: Studies analysing the characteristics of the postoperative handover and interventional studies with the aim of improving postoperative handover. Only original research was included. RESULTS: We identified 23 studies including descriptive and interventional studies. Postoperative handovers are described as a complex work process challenged by interruptions, time pressure and a lack of supporting framework. Interventional studies introduced standardised handover tools in combination with environmental changes, resulting in better flow of information in four out of five, better teamwork in two and less technical errors in two out of three studies. CONCLUSION: Postoperative handover is a complex and dynamic situation. It is very important to analyse the challenges in the local setting and that solutions are customised to fit the specific context in which the postoperative handovers takes place. It is also important to acknowledge the role of non-technical skills in the work process with respect to patient safety. Implementation of new handover strategies must be considered carefully. To optimise the motivation for change among staff, the importance of improvement in postoperative handover in all settings must be outlined in future studies with more patient-specific outcomes.

The effect of multi-professional education on the recognition and outcome of patients at risk on general wards.

AIM: The aim of this study was to evaluate the effect of multi-professional full-scale simulation-based education of staff on the mortality and staff awareness of patients at risk on general wards. DESIGN, SETTINGS AND PATIENTS: A prospective before-and-after study conducted on four general wards at Herlev Hospital, Denmark. In the pre-intervention period (June-July 2006) and post-intervention period (November-December 2007), all patients on the wards had vital signs measured in the evening by study personnel, who also asked nursing staff questions about patients with abnormal vital signs. The mortality of patients with abnormal vital signs was registered from the hospital database. Simplified medical emergency team calling criteria were used to define abnormal vital signs. INTERVENTION: In the intervention period (February-June 2007), 50% of medical and 70% of nursing staff on the wards (app. 220 members of staff) were trained in a 1-day multi-professional full-scale simulation-based course. RESULTS: In the pre- and post-intervention periods, 690 and 873 patients were included and of these 129 and 155, respectively, had abnormal vital signs. No significant differences were observed between the pre- and post-intervention periods concerning the incidence of patients with abnormal vital signs (p=0.64), staff awareness of patients at risk (p=0.80), 30-day mortality (p=1.00), 180-day mortality (p=1.00) or length of hospital stay (p=0.11) among patients at risk. CONCLUSIONS: This multi-professional education of staff did not affect the rate of mortality or staff awareness of patients at risk on the wards.

A multi-professional full-scale simulation course in the recognition and management of deteriorating hospital patients.

INTRODUCTION: Recognition and management of deteriorating patients is often suboptimal, resulting in adverse events that may be avoided if a unified understanding of the signs and needs of deteriorating patients is secured through the education of staff. This paper describes the planning and evaluation of a multi-professional, full-scale simulation-based course for hospital professionals. METHODS: A systematic approach to course development was used and the programme was introduced on four general wards in a university hospital. Experts from the wards were trained as educators and participated in the course development. A needs assessment consisting of an observational study, questionnaires and interviews resulted in the creation of learning objectives to provide the road map for content and teaching methods. A 1-day multi-professional ward-specific educational programme with full-scale simulations, mini-lectures, case discussions and practical training was planned. Course material, a manual for educators and questionnaires for evaluation of the course were developed. RESULTS: A 1-day full-scale simulation-based educational programme was developed and 50% of the medical staff and 70% of the nursing staff on four wards were trained in a 5-month period. The course was highly rated in terms of content and teaching methods. DISCUSSION: The systematic approach for developing the course resulted in a relevant, highly rated course, deeply rooted in the wards, implying the opportunity to facilitate local improvements and adjust the content to local needs. CONCLUSION: The use of a systematic approach was successful in the development of this multi-professional full-scale simulation-based educational programme, which has proven to be easily applicable and usable.

[Observation of critically ill patients]. / Observation af kritisk syge patienter.

INTRODUCTION: The aim of this study was to estimate to which extent patients with abnormal vital signs on general wards had their vital signs monitored and documented and to establish if staff concern for patients influenced the level of monitoring and was predictive of increased mortality. MATERIAL AND METHODS: Prospective observational study at Herlev Hospital, Copenhagen, Denmark. Study personnel measured vital signs on all patients present on five wards during the evening and night and interviewed nursing staff about patients with abnormal vital signs. Subsequently, patient records were studied. RESULTS: A total of 155 patients with abnormal vital signs were identified, and staff was interviewed about 139 patients. In 61 of these 139 patients, some vital signs were measured by staff, but the respiratory rate was not measured. In 86 cases staff decided to intervene because of abnormal vital signs measured by study personnel. A total of 77% of patients had vital signs documented in their records on the day of the observation. The previous day, vital signs were documented in 70% of records and on the day after in 66%. The documentation of vital signs was significantly higher when staff expressed concern for a patient in the patient record (95% vs. 65%, chi(2): p < 0.001), but 30-day mortality did not differ significantly (15% vs. 10%, chi(2): p = 0.40). CONCLUSION: In more than half of the patients, the abnormal vital signs were not identified by staff because the vital signs were not measured. In two out of three patients, staff decided to intervene because of abnormal vital signs measured by study personnel, indicating a need to reevaluate monitoring routines at general wards.

Incidence, staff awareness and mortality of patients at risk on general wards.

UNLABELLED: The aim of this study was to estimate the incidence, staff awareness and subsequent mortality of patients with abnormal vital signs on general wards in a Danish university hospital. DESIGN AND SETTINGS: Prospective data collection in two surgical and three medical wards at Herlev University Hospital, Copenhagen. Study personnel measured vital signs of all patients present on the wards at random points during the evening and interviewed nursing staff about patients with abnormal vital signs. Simplified medical emergency team (MET) calling criteria were used to define abnormal vital signs. INTERVENTIONS: None. RESULTS: During the 2-month data collection period, 877 patients were included in the study and 155 (18%) had abnormal vital signs. The 30-day mortality in this group was 13% compared to 5% among patients with normal vital signs (p<0.0001). Of the 155 patients with abnormal signs, nursing staff were not aware of all of the patient's abnormalities in 67 (43%) cases. For 20 patients (13%), staff were aware of some of their abnormalities, while for 52 patients (34%), staff were aware of all their abnormalities. CONCLUSIONS: One out of five patients in the general wards developed abnormal vital signs during the 2-month study period and these patients had a 3-fold increased 30-day mortality. For almost half of the patients, nursing staff were unaware of their abnormal vital signs. Strategies to improve identification of patients at risk should be an initial step in preventing serious adverse events on the general wards.