Implementing AORN Recommended Practices for Transfer of Patient ...

November 2012 Vol 96 No 5 SEIFERTsupport the need for evidence-based practices toreduce communication errors.AORN and The Joint Commission both recommenda standardized and comprehensive approachto patient transfers. Some commonly recognizedareas involving patient transfers include from anursing unit to the OR; from a cardiac catheterizationlaboratory, interventional radiology suite,or other interventional suite to the OR; from anambulatory surgery center to a nursing home ora nursing home to an ambulatory surgery center;and from the OR to the postanesthesia care unit(PACU) or intensive care unit (ICU). Informationtransfer also takes place in the surgical schedulingdepartment or the preanesthesia testing unit wheninstructions are given to the patient. Through its“Hand Off Communications Project,” The JointCommission suggests a program known by theacronym SHARE. 5 The program demonstrateswhich elements the accrediting agency will auditand score. Recommended behaviors and someexamples from the SHARE project includethe following:nnnnS e Standardize critical content.n Provide details about the patient’s history tothe receiver.n Synthesize information received fromseparate sources before passing it on to thereceiver.H e Hardwire behaviors within your system.n Develop standardized forms, checklists, andother tools.n State expectations for a successful hand off.A e Allow the opportunity to ask questions.n Share and receive information as an interdisciplinaryteam.n Scrutinize and question the data and exchangecontact information with the senders in casefollow-up is needed.R e Reinforce quality and measurement.n Monitor compliance with the use of standardizedforms.n Use data to drive process improvement.nE e Educate and coach.n Standardize the training for successful handoffs.n Make successful hand offs an organizationalpriority.Other transfer periods also exist wherein communicationbetween patients and health care representativesmay be insufficient or patients maynot understand or may fail to comply with preoperativeorders. It is not uncommon, for example, tohave patients arrive at the site of surgery later thanthe recommended time without having taken theprescribed antiseptic shower or after having eatenbreakfast. The consequences of not adhering to (orfailing to understanding) the preoperative instructionsmay be as relatively inconsequential as adelay in the start of the surgery or as serious ascancellation of the surgery. A patient’s failure tounderstand or to adhere to the instructions fromstaff members at the surgeon’s office or frompersonnel in the preanesthesia testing unit, wherelaboratory tests may have been performed withina few days before surgery, represents an additionaltransfer point that can affect the patient’s outcome.The potential for patients to misunderstand ornot follow recommendations should alert perioperativeclinicians to engage in strategies that educateboth patients and colleagues (eg, surgeon’soffice staff members who provide preoperativeinstructions to patients) to reinforce the importanceof following the prescribed preoperative activities.The solution may be as simple as having a meetingwith office personnel to review not only the instructions(eg, antiseptic shower, leaving valuablesat home, remaining NPO), but also the rationale forthem. Improved communication between perioperativeclinicians and office staff members canimprove working relationships and help patientsachieve optimal outcomes. Consistency and reliabilityare hallmarks that can be improved withimplementation of the AORN practice recommendationsand the use of other AORN resources,notably AORN’s Patient Hand Off Tool Kit. 9478 j AORN Journal

RP IMPLEMENTATION GUIDE: TRANSFER OF CAREwww.aornjournal.orgDISCUSSIONThe following discussion addresses AORN’s practicerecommendations for the transfer of care andillustrates how the components of the RP documentcan be implemented. Readers should use theirjudgment to determine whether their clinical situationallows adaptation of the examples describedhere or whether other methods of implementationwould be more suitable. One of the key recommendationsis to engage in open, multidisciplinarydiscussions to arrive at procedures and activitiesthat fit the reader’s situation. AORN’s Patient HandOff Tool Kit 9 can be especially valuable becauseit includes a broad array of information, sampleforms and policies, and references for further study.Recommendation I“A transfer of patient information process shouldbe developed, standardized, and based upon thebest available and most current evidence.” 1(p465) Amultidisciplinary team should develop standardizedcommunication protocols that can be applied acrossthe preoperative, intraoperative, and postoperativephases of care to reduce communication errors.AORN’s “Recommended practices for transferof patient care information” 1 addresses strategiesto promote effective communication, which is thebasis for successful information transfers. Thepractice recommendations affect patients and theirfamily members as well as professional caregivers.For example, perioperative nurses can use writteninformation and individualized education relatedto transfers to reduce patient and family memberanxiety. Perioperative personnel can enhance theeffectiveness and accuracy of information transferby communicating directly with one another, encouragingquestions or clarifying instructions thatare unclear, and using all forms of communication(eg, facial expressions, eye contact, body language). 1Multidisciplinary team. Just as effective communicationcan influence positive patient outcomes,so too can caregivers from different departments orprofessions working together. 1 Team leaders (eg,nurse, surgeon, anesthesia professional) are valuablerole models when they demonstrate informationsharing, coordination of care, and working togetherto focus on the patient rather than on personal ordepartmental needs. All team members, includingsupport personnel, should be included in the teamand be recognized as bringing important skill sets,special knowledge, and significant experience to thepatient’s care.Standardization. This first recommendationaddresses the importance of standardized transferprotocols as a way to reduce or prevent communicationerrors. 10,11 Research has shown thatinformation transfer failures are common in surgicalcare, but when health care providers use standardizedcommunication techniques, such as checklists, theyfacilitate surgical safety by reducing the number ofcommunication-related errors. 4,12 In a study by Joyet al 12 that involved using a standardized checklist,technical errors were reduced from 6.24 to 1.52 (P

November 2012 Vol 96 No 5 SEIFERTFigure 1. A checklist is a standardized communication tool that can be used before the start of surgery to ensurethe handover of critical information.reflects the patient’s needs. For example, nursesreceiving a patient in the PACU would want informationfrom the OR including the patient’sname, the title of the surgical procedure, the patient’shemodynamic status, the type of anesthesia,and any allergies. 1 When creating the form, nursesfrom the OR and PACU would collaborate tospecify what information is available to the senderand needed by the receiver. The sending nurse inthe OR would complete the form with the requiredinformation before transporting the patient to thePACU, and the receiving nurse in the PACU wouldwrite down the information on a duplicate form.This process reduces the risk of omitting information.It is also easier to notice and correct gapsin the information when both the sending andreceiving nurses use the same form.In addition to The Joint Commission’s SHAREprocess, 5 other communication techniques forperioperative nurses are illustrated in the AORNRP document and the AORN Patient Hand OffTool Kit. 9 These techniques standardize the informationthat should be included in hand-off reports.Standardized communication and documentationtechniques may be used in the written recorditself and also can be used to communicate verballywith a colleague. The RP document liststhe following formats:n SBAR: situation, background, assessment,recommendation 16n I PASS the BATON: introduction, patient,assessment, situation, safety concerns, (the)background, actions, timing, ownership, next 17n SURPASS: SURgical PAtient Safety System 18n SHARED: situation, history, assessment,request, evaluate, document. 19We applied the SBAR technique to a cardiovascularOR transfer report at my facility (Figure 2).Preoperative phase. A preoperative formshould be used and made available both to preoperativeand intraoperative caregivers. Often, it isthe patient’s circulating nurse who reviews theinformation on the preoperative form and discussesits contents with the patient, preoperative nurse,surgeon, anesthesia professional, and other membersof the team who are involved in the patient’s care.For example, site marking should be noted on the480 j AORN Journal

November 2012 Vol 96 No 5 SEIFERTnnnnmonitoring line types (eg, electrocardiogram,arterial blood pressure line) and locations (eg,right radial artery, left upper arm),specimens (eg, type, number, location, testsrequested),whether there are special needs (eg, child withautism), andfamily member or patient concerns or fears (eg,the patient is embarrassed by lack of dentures).At the completion of surgery, but before transportingthe patient to the receiving unit, the surgeonmay perform a debriefing, 22 which could includewhat went well during the procedure, what could beimproved, and other concerns or comments.Postoperative phase. During the postoperativephase, the following information should be includedin the communication to the receiving unit:n patient verification;n procedure performed;n allergies;n hemodynamic status;n ventilator settings;n medications (eg, being given through the IVline);n urine output;n dressings, tubes, and drains (eg, type, location);n surgeon’s orders (eg, drains, diet, medications);n complications; andn standard precautions taken for infectionprevention.Additional transfer reports depend on the clinicalenvironment (eg, ambulatory or hospital setting),the patient’s acuity, any identified safety risks (eg,presence of neurological or physical deficits), andthe clinicians who are involved. 1,18,29 Informationshared on transfer to an inpatient nursing unitwould include the postoperative transfer components,but if the patient were in the ambulatorysetting and scheduled to be discharged, the transferinformation also would include discharge instructions,possible complications, and whom to call forhelp. The numerous possible transfer scenarios thata patient may undergo reinforce the recommendederror-prevention strategies of standardizing informationprocesses, using them within a multidisciplinaryteam, and using active communicationtechniques (Figure 3). 1Recommendation II“Patients, families, and significant others shouldhave an active role in transfer of patient informationprocesses whenever possible.” 1(p468) Reducinganxiety is an important aspect of patient care becausepatients and their significant others andfamily members may be anxious about surgery(Figure 4). Nurses should be actively involved intransfer processes whenever possible. When nursesprovide a structured and individualized transferprocess that engages patients and their familymembers, they can help reduce family members’anxiety. 1,30,31Nurses may employ a variety of communicationmethods that can be used with waiting familymembers. These may include calling the waitingarea and talking with family members, going onrounds (ie, rounding) in the waiting area to talk tofamily members in person, and providing writteninformation. Written, individualized informationabout transfers given to relatives and friends alsohas been shown to decrease anxiety. 32,33 Engagingthe patient and others also can be achieved withindividualized and structured transfer methods,such as providing education a few days beforesurgery. This helps with retention of informationbecause higher anxiety levels, as in the immediatepreoperative period, can reduce retention. Preoperativetours for children and their parents are alsovaluable for promoting information retention andcan enhance the entire perioperative period for thepatient and his or her family members.The Final FourThe final four recommendations in each AORNRP document discuss education/competency, documentation,policies and procedures, and qualityassurance/performance improvement. These four484 j AORN Journal

RP IMPLEMENTATION GUIDE: TRANSFER OF CAREwww.aornjournal.orgpatient advocacy because being proactive and notbeing pushed to rush is consistent with betterpatient outcomes, like minimizing or eliminatingthe risk of surgery on the wrong eye.HOSPITAL PATIENT SCENARIONurse L is in charge of a 10-room OR on a Saturdaymorning. She receives a call from the emergencydepartment (ED) charge nurse that a patient witha traumatic subtotal transection of a thumb isscheduled to arrive in the ED within 30 minutes. TheED charge nurse states that the hand surgeon, Dr N, ison the way to the ED and wants to transport thepatient immediately to the OR for repair and reattachmentof the thumb. Nurse L asks and is told thatthe patient’s right hand is affected. The ED chargenurse gives Nurse L additional available information,including the patient’s name, age, and allergies.Nurse L requests that the ED nurse or her designatepage her immediately when the patient arrives, andshe confirms that there are sufficient ED personnelto transport the patient to the OR.Nurse L pages Dr N and discusses the preliminaryplan using the SBAR format:n the situation is that there is a traumatic injury tothe patient’s right thumb, which requires repair;n the background is that the patient had a caraccident during which he suffered the thumbinjury;n the assessment is that the surgical repair must beperformed as quickly as possible to minimizethe possibility of irreparable harm to theviability of the thumb; andn the recommendation is to perform reparativesurgery as promptly as possible.Nurse L asks about the planned surgical procedureand any special instrumentation that may be needed,and Dr N describes the proposed surgery and liststhe special items that he needs. Nurse L writesdown the surgeon’s cell phone number and lets himknow that she will call him shortly with an update.Nurse L contacts the anesthesia professional andreports the plan.Nurse L calls the sterile processing departmentand requests that a case cart for hand surgery withDr N’s specially requested items be brought to theOR as rapidly as possible. Nurse L assesses thecurrent OR schedule and sees that no staff membersare available. She determines that of the threerunning procedures, the one in OR 6 is nearingcompletion, so the perioperative team will beavailable immediately after their patient is transferredto the PACU.Nurse L considers the trauma patient’s transferfrom the ED to the OR. For the hand surgery, sheselects OR 8 because the right side of the ORbed is parallel to the OR wall and on the oppositeside of the OR patient entrance door. In this way,the “ironing board” positioning device for hand/arm surgery can be attached to the bed before thepatient arrives. This will allow the patient to betransferred to the OR bed, the right hand immediatelyplaced on the positioning device, and the lowerright arm and hand promptly prepped and draped.Nurse L then goes to OR 6 where surgery isbeing completed and notifies the circulating nurse.Nurse L asks the circulating nurse to have thesurgical technologist go to OR 8 and set up theprocedure as soon as the current patient leavesthe room en route to the PACU. Nurse L tells thecirculating nurse that she has ordered the instrumentationand will set the instruments and suppliesaround the OR as soon as they arrive. She asks thecirculating nurse to go to OR 8 after transportingher current patient to the PACU and completing herdocumentation.Nurse L calls the surgeon and gives him anupdate on the situation. The case cart arrives a shorttime later, and Nurse L obtains the arm boardpositioning device and brings it and the case cartto OR 8. She sets up the positioning device and setsaround the instrument and supply packs. The surgicaltechnologist arrives in OR 8, and Nurse Lopens the packs while the surgical technologistscrubs. Nurse L ties up the gown of the surgicaltechnologist, who prepares the instrumentation.The anesthesia professional arrives, followed byAORN Journal j 487

November 2012 Vol 96 No 5 SEIFERTthe circulating nurse from OR 6. Nurse L reportsthe most recent information available to the team.The ED nurse calls to say that the patient hasarrived and that the surgeon is in the ED assessinghim. The ED nurse also informs Nurse L that bothof the patient’s hands were injured in the accidentbut only the right hand requires surgery. Nurse Lreports this to the surgical team. The team is readyto receive the patient, so Nurse L contacts the EDnurse to tell her that the OR is ready. The anesthesiaprofessional arrives and prepares for inductionof general anesthesia. Dr N arrives and relaysadditional information about the planned surgery.The patient arrives and the circulating nursepromptly identifies the patient. The circulatingnurse notes that both hands are bandaged. Sheinitiates a time out, during which all team membersconfirm the patient and the surgical site. Afterinduction of anesthesia, the circulating nurse positionsand preps the affected arm and hand. Thesurgeon succinctly briefs the team and performsa time out before repairing the injured thumb.After surgery, the anesthesia professional and circulatingnurse transport the patient to the PACU.A few days later, the surgeon informs the perioperativeteam that the repaired thumb is movingand seems to be healing appropriately. Dr N tellsthe team that their efficient and timely preparationmade an important difference and resulted in thesuccessful outcome of the surgery.This transfer from ED to OR was facilitated byproactive communication, anticipation, and criticalResources for Implementationn AORN Nurse Consult Line (800) 755-2676 or (303) 755-6300.n ORNurseLink. http://www.aorn.org/ORNurseLink.n Perioperative Job Descriptions and Competency EvaluationTools [CD-ROM]. http://www.aorn.org/JobDescriptions.n Ambulatory Surgery Center Resources [CD-ROM]. http://www.aorn.org/AmbulatorySurgeryCenterResources.Web site access verified August 8, 2012.thinking, and it serves as a positive example ofwhat can happen when nurses are capable of seeinga picture larger than their own unit. The teamfollowed the basic hand-off recommendations fordirect communication using a standardized format(eg, SBAR), collaborated across disciplines anddepartments, and verified critical factors (eg, patientidentity, correct site), which facilitated anoptimal outcome.This scenario highlights some challenges associatedwith trauma patients coming to an OR froma location outside the hospital. In these situations,clinicians cannot always rely on recommended interventionsthat make use of face-to-face exchangesand opportunities for extensive dialogue. Given thetime constraints associated with trauma or emergencyprocedures, perioperative nurses must usethe available resources. Among these are the collaborativerelationships established among andbetween clinicians in various departments of ahealth care organization. Such relationships arethe foundation of good communication, which inturn is the foundation for optimal patient care.CONCLUSIONAORN’s “Recommended practices for transfer ofpatient care information” affects most aspects ofperioperative patient care because the communicationof information underlies so many patientcare activities. Key recommendations includestandardizing communication processes and techniquesto avoid communication failures; workingwith colleagues from all relateddisciplines; using bothverbal and written communication;encouraging allteam members to ask questions;developing patienttransfer protocols; and activelyincluding the patientand his or her family membersand significant othersin the communication processes.Because effective488 j AORN Journal

November 2012 Vol 96 No 5 SEIFERTintensive care unit: the development and evaluationof an information booklet. J Clin Nurs. 2004;13(3):396-405.33. Tel H, Tel H. The effect of individualized educationon the transfer anxiety of patients with myocardial infarctionand their families. Heart Lung. 2006;35(2):101-107.34. Perioperative Job Descriptions and Competency EvaluationTools [CD-ROM]. Denver, CO: AORN, Inc; 2012.35. Policy and Procedure Templates. 2nd ed [CD-ROM].Denver, CO: AORN, Inc; 2010.Patricia C. Seifert, MSN, RN, CNOR, CRNFA,FAAN, is a staff nurse in the CardiovascularOperating Room, Inova Heart and VascularInstitute, Falls Church, VA. Ms Seifert has nodeclared affiliation that could be perceived asposing a potential conflict of interest in thepublication of this article.This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document uponwhich it is based and is not intended to be a replacement for that document. Individuals who are developing andupdating organizational policies and procedures should review and reference the full recommended practicesdocument.490 j AORN Journal

EXAMINATIONCONTINUING EDUCATION PROGRAMImplementing AORN RecommendedPractices for Transfer of Patient CareInformation3.3www.aorn.org/CEPURPOSE/GOALTo educate perioperative nurses about implementing recommended practices fortransfer of patient care information.OBJECTIVES1. Identify risks associated with miscommunication during patient transfers.2. Explain how certain activities may increase the risk of miscommunicationduring the transfer of patient care information.3. Discuss activities and behaviors that may improve the successful transfer ofpatient care information.4. Describe the types of information that should be shared during patient transfers.The Examination and Learner Evaluation are printed here for your convenience.To receive continuing education credit, you must complete the Examinationand Learner Evaluation online at http://www.aorn.org/CE.QUESTIONS1. The Joint Commission has estimated that ___%of serious medical errors are associated withmiscommunication during patient hand offs.a. 50 b. 65c. 80 d. 952. The use of cellular telephones, pagers, and musicare considered interruptions and distractionsduring the transfer of patient care information.a. true b. false3. Examples from The Joint Commission’s SHAREproject of recommended behaviors that can beused during the transfer of patient care informationinclude1. providing details about the patient’s historyto the receiver.2. developing standardized forms and checklistsand monitoring compliance with their use.3. stating expectations for a successful hand off.4. sharing and receiving information as aninterdisciplinary team.5. standardizing training for successful hand offs.a. 1 and 3 b. 1, 2, and 5c. 2, 3, and 4 d. 1,2,3,4,and54. Perioperative personnel can help promote effectivecommunication and accurate informationtransfer bya. communicating only with direct supervisors orsubordinates.Ó AORN, Inc, 2012 November 2012 Vol 96 No 5 AORN Journal j 491

November 2012 Vol 96 No 5 CE EXAMINATIONb. encouraging questions and clarifying instructionsthat are unclear.c. avoiding the use of facial expressions and bodylanguage.d. minimizing eye contact during intenseconversations.5. Research has shown that when health care providersuse _________, they facilitate surgicalsafety by reducing communication-related errors.a. checklistsb. Internet resourcesc. text messagingd. telephonic communications6. Forms used to communicate information fromone area of the health care institution to the othershould be developed by personnel in both thesending and receiving units.a. true b. false7. Information that should be included on a preoperativeform includes1. allergies and medication profile.2. advanced directives.3. cultural and spiritual needs of the patient.4. planned anesthesia type.a. 1 and 2 b. 3 and 4c. 1, 2, and 3 d. 1, 2, 3, and 48. A standardized form used to verify OR-specificinformation before the incision is made shouldinclude1. anticipated blood loss and blood productavailability.2. availability of special equipment, devices,instruments, and implants.3. deep vein thrombosis prophylaxis.4. urine output.a. 1 and 3 b. 2 and 4c. 1, 2, and 3 d. 1, 2, 3, and 49. Before completion of surgery, patient informationthat should be reported to the receiving unitincludes1. laboratory test values.2. patient concerns or fears.3. the medications that were given, includingantibiotics.4. the patient’s hemodynamic status and whatmonitoring devices were used.a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 410. Communication methods that may be useful fora perioperative nurse to use with a patient’sfamily members include1. going on rounds in the waiting area to talk tothe family members in person.2. providing written, individualized informationabout transfers.3. providing education a few days beforesurgery to help with information retention.4. conducting tours of the OR for children andtheir parents.a. 1 and 3 b. 2 and 4c. 1, 2, and 3 d. 1, 2, 3, and 4492 j AORN Journal

LEARNER EVALUATIONCONTINUING EDUCATION PROGRAMImplementing AORN RecommendedPractices for Transfer of Patient CareInformation3.3www.aorn.org/CEThis evaluation is used to determine the extent towhich this continuing education program metyour learning needs. Rate the items as describedbelow.OBJECTIVESTo what extent were the following objectives of thiscontinuing education program achieved?1. Identify risks associated with miscommunicationduring patient transfers.Low 1. 2. 3. 4. 5. High2. Explain how certain activities may increase therisk of miscommunication during the transfer ofpatient care information.Low 1. 2. 3. 4. 5. High3. Discuss activities and behaviors that may improvethe successful transfer of patient care information.Low 1. 2. 3. 4. 5. High4. Describe the types of information that should beshared during patient transfers.Low 1. 2. 3. 4. 5. HighCONTENT5. To what extent did this article increase yourknowledge of the subject matter?Low 1. 2. 3. 4. 5. High6. To what extent were your individual objectives met?Low 1. 2. 3. 4. 5. High7. Will you be able to use the information from thisarticle in your work setting? 1. Yes 2. No8. Will you change your practice as a result of readingthis article? (If yes, answer question #8A. If no,answer question #8B.)8A. How will you change your practice? (Select all thatapply)1. I will provide education to my team regardingwhy change is needed.2. I will work with management to change/implement a policy and procedure.3. I will plan an informational meeting withphysicians to seek their input and acceptanceof the need for change.4. I will implement change and evaluate theeffect of the change at regular intervals untilthe change is incorporated as best practice.5. Other: ________________________________8B. If you will not change your practice as a resultof reading this article, why? (Select all thatapply)1. The content of the article is not relevant to mypractice.2. I do not have enough time to teach othersabout the purpose of the needed change.3. I do not have management support to makea change.4. Other: ________________________________9. Our accrediting body requires that we verifythe time you needed to complete the 3.3 continuingeducation contact hour (198-minute)program: _________________________________Ó AORN, Inc, 2012 November 2012 Vol 96 No 5 AORN Journal j 493