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Perioperative Handoff Education Resources

July 31, 2024

Christopher P. Potestio MD; Desteni Barnes, OMS-IV, PA-C; Kunal Karamchandani MD, FCCP, FCCM; Meghan Michael, MD; Lee Ann Riesenberg, PhD, MS, RN, CMQ

Doctors Engaged in a Perioperative HandoffTransitions of care between healthcare providers, often referred to as “handoffs,”, “handovers” or “signouts” have generated much discussion in recent years due to the association between poor quality of these transitions and patient harm.1 Communication failures are a leading contributor to sentinel events,2 and those occurring during transitions of care consistently yield some of the lowest scored domains on the Agency for Healthcare Research and Quality (AHRQ) safety culture survey.3 Perioperative handoffs, which occur before, during, and after surgery, present unique challenges. Perioperative handoffs occur among medical disciplines, as well as across professions from physicians to nurses. These structural and communication challenges occur in the setting of variable locations and monitoring capabilities and potentially during a time when a patient’s clinical condition can rapidly change.

The importance of perioperative handoffs and a lack of consensus regarding handoff form and content leads to a conundrum for medical educators: how best to design and implement handoff education. Handoff education tools vary in form and content and are often institution specific. This article aims to aggregate and describe many of the high-quality studies, tools, and resources available in perioperative handoff education.

HANDOFF RESOURCES IN THE LITERATURE

A recently published systematic review of anesthesiology handoff education interventions identified 26 relevant studies that included education as an interventional component.1 For each of these studies, they provide a brief description of the education provided, curriculum development components and the outcomes assessed. Based on their review, the authors recommend that future education interventions should follow curriculum development best practices, including using educational theoretical concepts and conducting a needs assessment prior to intervention and evaluation of meaningful educational outcomes. The authors conclude that multimodal education interventions, periodic reinforcement, memory aids, direct observation, and feedback are beneficial strategies.

The first publication conducted a study incorporating learning theory, simulation, and practical training methods to improve the Operating Room (OR) to PACU handoffs within their institution.4 Participants included 160 PACU registered nurses and 151 anesthesia professionals (certified registered nurse anesthetists and anesthesiology residents). The authors provide a detailed description of their curriculum development process, handoff evaluation tool development, and the handoff evaluation tool itself. In addition, they include a scenario storyboard for initial simulation training sessions and a representative simulation scenario within the supplemental material. Evaluation of their handoff training intervention led to a significant improvement in global handoff as measured by grading six categories including Introduction, Situation, Background, Assessment, Recommendation (SBAR) handoff mnemonic components, organization and clarity, and engagement. The authors demonstrated long-term skill retention of the handover education with reevaluation after three years.

The second publication utilized simulation and deliberate practice during intraoperative handoff by anesthesia residents.5 They designed 27 scenarios to test knowledge and clinical skill acquisition. The ten resident participants were videotaped during simulation and provided individual and group feedback. A predesigned checklist was used to measure errors and omitted information. Evaluation of the educational intervention demonstrated significant improvement immediately post intervention and at follow-up one-year later. Post-intervention surveys showed that residents felt more confident in handoff skills with improved attitudes toward patient safety.

The third publication studied the effect of shift-to-shift handoffs in a variety of settings using the I-PASS system.6 The authors employed 13 specific tactics to improve handoff behaviors, including specific written or electronic handoff document and standardized structure and content with the use of the I-PASS mnemonic. Many of their teaching modalities are available via the I-PASS developers at https://www.ipassinstitute.com/, and their handoff observation tool and post-training survey are available in the supplemental file of the publication. In addition, their use of the validated Kirkpatrick model of education evaluation provides an excellent example of education effectiveness assessment. The Kirkpatrick model is a robust four level model that assesses training against four levels of criteria: reaction, learning, behavior, and results. Each of the four levels is reported by the study team with their training showing improvement at each level.7

EDUCATIONAL RESOURCES AVAILABLE ONLINE

MedEdPORTAL (www.mededportal.org) is an excellent resource for medical educators providing high-quality medical education tools that include workshops, simulation cases, and other handoff educational material. A search in MedEdPORTAL conducted by the authors on February 25, 2024, yielded 44 articles containing the keywords handoffs, handovers, signouts, or transitions of care. While only 6 of the articles are specific to perioperative handoffs, many contain valuable elements that can be incorporated into perioperative handoff training.

One representative example is an anesthesia provider-specific simulation curriculum designed to improve the handoff process for new residents assuming care of patients in the ICU going to the OR.8 Their 1-hour educational intervention session starts with a 10-minute didactic session during which the participant learns how to collect and organize a patient’s relevant history and ICU course, and then how to provide a verbal handoff to an anesthesia professional who will be caring for the patient during an urgent procedure. The didactic session is followed by a simulation which allows the participant to practice the handoff. The simulation curriculum provides a variety of materials which can be used by others including a resource tool that can be referenced by the learner as they move through the simulation, teaching points, a learner evaluation tool and a scoring key. The authors reported that 27 learners at their institution participated in this handoff simulation. Senior participants (CA-3 residents) performed significantly better than junior participants (CA-1, medical students, SRNAs), suggesting that the evaluation tool accurately reflects skills that are acquired during anesthesia training. Feedback from the learners, both verbal and written, indicated that participants found the experience authentic, useful, enjoyable, and enriching.

Another relevant simulation scenario published in 2017 focuses on perioperative care of a septic patient and includes the OR-to-PACU handoff as major part of the scenario. The simulation is complicated by patient deterioration during the handoff and is designed to capture the difficulty of diagnosing and managing sepsis in real time.9 Supplementary materials provided include a detailed case description, debriefing material, a critical action checklist and a post-course survey. The simulation highlights the importance of communication in the perioperative period and how a patient changing locations and phases of perioperative care can make diagnosis and management more challenging.

Many other resources exist on MedEdPORTAL that contain relevant elements of handoff education but are geared toward other specialties or other clinical scenarios. For example, an interprofessional team training scenario in 2009 focuses on the handoff of an orthopedic trauma patient from emergency department (ED) to OR.10 In this high-fidelity simulation scenario, hemodynamics change in response to the participant’s clinical decision making. Successful management hinges on the participant’s ability to communicate with their colleagues, who are other learners participating in the scenario. This scenario provides an opportunity to learn important communication skills and reinforces the link between communication and clinical decision making. A 4-hour joint training session incorporate the TeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety) evidence-based teamwork program.11 The scenario was designed for third-year medical students and fourth-year nursing students, but could be readily adapted to other perioperative providers.

Perioperative handoff skills are important in specialties like obstetrics and pediatrics, and specific education tools for enhancing handoffs in these specialized practice environments are also available on MedEdPORTAL. For example, there is a validated handoff checklist for clinicians to use in the delivery room. 12 The checklist was shown to enhance team communication during simulated deliveries over a 3-year assessment period. Improvements were also seen in checklist fidelity during high-risk deliveries. Another simulation program directed toward communication and the team practice of pediatric critical care members was developed. It utilized high-acuity cardiopulmonary scenarios involving common congenital and acquired heart diseases.13 Each simulated case begins with a handoff of the patient to the primary nurse, who asks for the assistance of resident physicians, with escalation to a pediatric critical care medicine fellow. These simulation scenarios are followed by a structured, interactive, debriefing session. This series may help to advance self-reported learner knowledge and skills surrounding management of cardiopulmonary events in a high stress situation, while providing opportunities to enhance teamwork and communication skills.

CONCLUSION

A recent literature review and search of MedEdPORTAL provides educators with a variety of education resources and evidence-based teaching tools for improving perioperative handovers. These resources often incorporate simulation scenarios, handoff templates, debriefing materials, as well as evaluation tools to assess learning the resources vary in a targeted learner group and practice domain, but are often readily adaptable to perioperative practice. Through the use of such educational curriculum, perioperative providers can improve handoff quality which should have a positive effect on patient safety and outcome.

 

Christopher P. Potestio, MD is an Assistant Professor of Anesthesiology in the Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ, USA.

Desteni Barnes is a medical student at Lake Erie College of Osteopathic Medicine, Erie, PA, USA.

Kunal Karamchandani, MD is an Associate Professor in the Department of Anesthesiology and Pain Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Meghan Michael, MD is an Associate Professor in the Department of Anesthesiology and Pain Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Lee Ann Riesenberg, PhD, MS, RN, CMQ is a Professor and Associate Director of Education in the Department of Anesthesiology and Perioperative Medicine Heersink School of Medicine, The University of Alabama at Birmingham.

The authors have no conflicts of interest.

REFERENCES

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