Handoffs and Transitions in Critical Care - Understanding Scalability

Surgical patients who require post-surgical critical care are usually transferred from the operating room (OR) to the intensive care unit (ICU) for ongoing care. The process of transferring the patient from the OR to the ICU is called a "handoff." Handoffs involve the transfer of patient information and transfer of patient care responsibilities from the OR team to the ICU team. Multiple studies suggest that these handoffs can expose patients to preventable harm, which can be avoided with standardization of the handoff. The Handoffs and Transitions in Critical Care (HATRICC; IRB #819726) study, started in 2014, developed and implemented a standardized OR to ICU handoff process in two Penn surgical ICUs (SICUs) that did not have a standardized handoff process.

Four clinicians (surgeon, anesthetist, ICU provider, and ICU nurse) from two teams (surgical and intensive care) usually take part in handoff communication. During the HATRICC study, the investigators evaluated handoff communication between the OR and ICU teams before and after implementation of the new standardized handoff process (the "HATRICC process") in multiple ways, using observations, interviews, focus groups, and surveys. The investigators demonstrated a 20% improvement in information exchange after implementation of the HATRICC standardized handoff process, a process tailored to meet the needs of the different clinicians participating in OR to ICU handoffs.

Prior studies have indicated short-term success in standardizing OR to ICU handoffs, but sustainability of these improvement interventions has been less well studied. Two studies have demonstrated sustained or improved information exchange following the institution of structured OR to ICU handoff processes, but the factors influencing sustainability remain to be elucidated.

The aims of this study are to:

1. Ascertain determinants of OR-to-ICU handoff protocol adoption and use in 12 adult and pediatric ICUs in five health systems. 2. Adapt handoff protocols using engineering approaches and select tailored implementation strategies with implementation mapping. 3. Test the effectiveness of tailored, multifaceted, multilevel implementation strategies. 4. Design and create a digital toolkit for other ICUs to identify implementation determinants, customize OR-to-ICU handoff protocol, and select appropriate implementation strategies.

• Perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory (Acceptability) [Time frame: Baseline (Year 1); within 2months of implementation; within 2 months of beginning sustainment]
• Perceived fit, relevance, or compatibility of the innovation in a practice setting or to address a particular issue (Appropriateness), measured by the Intervention Appropriateness Measure [Time frame: Baseline (Year 1); within 2months of implementation; within 2 months of beginning sustainment]
• Feasibility of treatment or innovation to be carried out in a practice setting, measured using the Feasibility of Intervention Measure. [Time frame: Baseline (Year 1); within 2months of implementation; within 2 months of beginning sustainment]
• Fidelity over time (Sustainment) [Time frame: This outcome will be measured at monthly intervals starting 2 years after implementation, up to 5 years.]
• Monetary and non-monetary costs measured using the line item classification system [Time frame: This outcome will be measured within 2 months of implementation; within2 months of beginning sustainment]
• Teamwork (effectiveness) measured using the Team Emergency Assessment Measure. [Time frame: This outcome will be measured at quarterly intervals starting Year 1, Quarter 2 and continuing until the end of Year 5]
• Clinician satisfaction measured at the individual level. [Time frame: This outcome will be measured annually from Years 1 to 5.]
• Workload measured using the NASA Task Load Index. [Time frame: This outcome will be measured at quarterly intervals starting Year 1, Quarter 2 and continuing until the end of Year 5.]
• Completeness of information exchange (Information Omissions) measured using a structured observation form. [Time frame: This outcome will be measured at monthly intervals starting Year 1, Quarter 2 and continuing until the end of Year5]
• Weighted average of the reliability-adjusted observed-to-expected ratios for component indicators of adverse events [Time frame: This outcome will be measured at quarterly intervals starting Year 1, Quarter 2 and continuing until the end of Year 5.]
• AHRQ PSI 9: Perioperative hemorrhage or hematoma rate(effectiveness) [Time frame: This outcome will be measured at monthly intervals starting Year 1, Quarter 2 and continuing until the end of Year 5]
• AHRQ PSI 10: Postoperative physiologic or metabolic derangement rate (effectiveness) [Time frame: This outcome will be measured at monthly intervals starting Year 1, Quarter 2 and continuing until the end of Year 5.]