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APSF Stoelting Conference 2017

September 5, 2017 - September 7, 2017

2017 APSF Stoelting Conference Report

2017 APSF Stoelting Conference

Perioperative Handoffs: Achieving Consensus on How to Get It Right

Convene people interested in perioperative safety
The APSF annual conference (now the Stoelting Annual Conference in honor of past president Robert Stoelting, MD) is an opportunity to foster discussion about key safety issues in perioperative care. This meeting is an opportunity to network and to catalyze collaborative relationships.

Discuss perioperative handoffs
Handoffs represent both a patient safety risk and an opportunity. We aimed to facilitate discussion about the important role that these care transitions play in safe, high quality patient care.

Reach consensus
Our ambitious goal was to reach consensus about key topics relating to perioperative handoffs. In so doing, we hope to provide guidance to clinicians, administrators, researchers, and policymakers in their efforts to advance patient safety.

Using our threshold of 75%, we reached consensus on more than 50 statements related to handoffs in perioperative care!


Large Anesthesia/Practice Management Groups Drug Diversion in the Anesthesia Profession How Can APSF Help Everyone Be Safe?

The Anesthesia Patient Safety Foundation (APSF) is inviting members of large anesthesia groups and representatives of practice management groups to participate in a half day conference with diverse key stakeholders to discuss mutually relevant anesthesia patient safety issues related to drug diversion in the healthcare workplace.

2017 APSF Stoelting Conference Program [PDF]


Why are we here? What’s the problem we are trying to solve? [PDF]

Jeff Cooper
Professor of Anaesthesia
Harvard Medical School
Department of Anesthesia, Critical Care & Pain Medicine
Massachusetts General Hospital
Executive Director Emeritus & Senior Fellow
Center for Medical Simulation
Boston, MA

The consensus process for this meeting

Jay Vogt
Concord, MA

What is a handoff? [PDF]

Meghan Lane-Fall
Assistant Professor of Anesthesiology and Critical Care
Perelman School of Medicine
Co-Director, Center for Perioperative Outcomes Research and Transformation
Leadership team, Center for Healthcare Improvement and Patient Safety
Senior Fellow, Leonard Davis Institute of Health Economics
University of Pennsylvania
Philadelphia, PA

Healthcare handoffs are often characterized as the simple transfer of patient information at times of transition. However, handoffs involve so much more than information transfer; social interaction, the production and reinforcement of norms, and provision of anticipatory guidance are also important components of the handoff. This talk, given in memory of pioneering handoff researcher Robert Wears, MD, PhD, will outline the different functions that a handoff should serve. Conference attendees will be encouraged to keep these functions in mind throughout the day as they consider handoff best practices and consensus statements.

What are the possible perioperative handoffs and how do they differ? [PDF]

Amanda Lorinc
Assistant Professor
Division of Pediatric Anesthesiology
Monroe Carell Jr. Children’s Hospital at Vanderbilt
Nashville, TN

The interactions between anesthesia providers and other medical professionals can be a source of a significant portion of all medical handoffs for a patient during their hospital course. The practice of perioperative care involves frequent transitions of patients between multiple areas. This presentation will discuss the main perioperative transitions of care (Fig 1) and how they differ. First, preoperative handovers often begin in the holding room and take place between nursing and anesthesia staff, but they may also originate in locations such as the emergency room, intensive care unit, or floor and involve various providers at those locations. Next, we will discuss intraoperative handovers which may be provider to provider handoffs (for breaks or shift change) or location/procedure change handoffs (which may involve an entirely new team of providers). Finally, postoperative handoffs from the OR to the PACU and ICU will be presented. We will discuss the similarities and differences between the types of handoffs as well as the barriers to effective communications and communication failure types specific to these locations.

Human Factors – Tools and Teaming [PDF]

Joseph Keebler
Assistant Professor
Department of Human Factors
College of Arts and Sciences
Embry-Riddle Aeronautical University
Daytona Beach, FL

Handoff events and transitions of care are a frequent occurrence in medicine and are associated with up to 80% of medical errors. Further, communication failures have been shown to be the leading cause of preventable error in malpractice claims (Singh, Thomas, Petersen, & Studdert, 2007). Consequently, research regarding handoffs is rapidly increasing (Mardis et al., 2016). To illustrate the recent prevalence and widespread attention to this issue, there were five papers published in 1986 focused on handoffs in the inpatient setting, but in 2016, there were 353 papers published, an increase of over 70 times (Riesenberg, Davis, & O’Hagan, 2016). Given the rise of research in this domain, current theory on teamwork during transitions of care is lacking. Specifically, there is little theoretical grounding for the major input, process, and output variables that must be considered when improvements in handovers are being sought. This talk will focus on one such model which integrates relevant theoretical frameworks with the intent of providing insight from the teamwork lens. This should further advance practice and research on handoffs, and aid providers, stakeholders, and leadership in the medical community in understanding the variables that can affect teamwork prior to, during, and after handover events.

Impact of evidence of association of handoffs with adverse outcomes [PDF]

Aalok Agarwala
Division Chief, General Surgery Anesthesia
Associate Director, Quality and Safety
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, MA

Communication failures are associated with a significant portion of medical errors, however the specific effects of perioperative handoffs on patient outcomes has only recently been studied. This talk will review the current evidence for the association of perioperative handoffs with adverse patient outcomes.

Principles of standardization in perioperative handoffs [PDF]

Amanda Burden
Associate Professor of Anesthesiology
Director Clinical Skills and Simulation
Cooper Medical School of Rowan University
Cooper University Hospital
Camden, NJ

Patient handoffs are more than simply a transfer of information, they are the transfer of professional responsibility. This process is so critical that the Joint Commission recognized its importance and in 2006 designated handoff standardization, both process and content, as a national patient safety goal. Consistent, accurate, structured, scripted communication that allows for reassessment and read-back of information is a critical component of this effort. Handoffs should be a structured, active process that occurs without interruptions; time should be allowed to review clinical events and studies and to assure that the most current patient information is provided. Opportunities for questions and discussions about a patient’s care and anticipated events should be provided and welcomed. While standardization of the process and content is critically important, this should not be an automated process; all parties should be open to verification of the information and to consideration of new information. This is an ideal time to seek advice and insight from colleagues. It is essential that the handoff holds the full attention of both the handoff giver and receiver so questions can be asked and both parties can remain alert for incorrect assumptions.

Handoffs in other fields (athletics, aviation, nuclear power) are practiced repetitively to optimize precision and anticipate and address errors. Similarly, healthcare handoff communication is also a skill that requires training and practice and should be included in curriculum development for students and trainees; practicing physicians and nurses will also benefit from ongoing training. Time and administrative support for handoffs should be included in practitioners’ working hours. Studies comparing handoff models are encouraged to establish a standardized, validated process and outcome metrics. Gaining senior leadership support for these initiatives is a key factor for success. The implementation of changes and ideas must be based on a clear mandate from leadership and other critical stakeholders. The culture, staff experience, and expertise of the organization must be respected.

Principles of implementation science that apply to handoffs [PDF]

Brian Mittman
Senior Research Scientist
Division of Health Service Research and Implementation Science
Kaiser Permanente Southern California Department of Research and Evaluation
Los Angeles, CA

The application of implementation science principles to perioperative handover redesign are critical to scaling and sustaining these vital team-based events. This presentation will address key factors necessary for achieving successful system-wide adoption. These include understanding barriers to change, contextual influences, group heterogeneity, professional norms and influences and organizational commitment. Attendees should be able to use these principles to shape recommendations for implementing handover redesign in this afternoon’s sessions.

Educational strategies and tactics [PDF]
Supplement Handoff Curriculum Resources [PDF]

Lee Ann Riesenberg
Associate Director Education
Professor, Department of Anesthesiology and Perioperative Medicine
The University of Alabama at Birmingham, School of Medicine
Birmingham, AL

There is ample evidence that prior education and preparation is needed to conduct safe and effective handoffs. A complete handoff curriculum should include education geared at improving learner knowledge, skills-based sessions such as simulation, and robust mechanisms for learner evaluation and feedback. This talk will briefly review literature concerning handoff curricula and will present instruction and evaluation options that could be used to achieve handoff educational goals.

Use of EMR to promote HRT [PDF]

Patrick Guffey
Associate CMIO – Children’s Hospital Colorado
Performance Improvement & Informatics Officer
Associate Professor, Department of Anesthesiology
University of Colorado
Aurora, CO

This talk will focus on how to leverage the EHR to promote high reliability. Examples will be provided in the form of protocols and timeouts. Dr. Guffey will also review the results of a project to use the EHR for a checklist prior to providing anesthesia services. Finally, he will review the hierarchy of effectiveness for interventions applied to the EHR.

Successful handoff implementation [PDF]

Raj Srivastava
Assistant Vice President of Research
Intermountain Healthcare
Salt Lake City, UT

This talk will focus on the practical aspects around a series of successful implementation studies, known as IPASS. IPASS studies have been conducted over a variety of hospitals, disciplines, and varying levels of trainees/providers.

Provocative issues in handoffs [PDF]

Philip Greilich
Professor of Anesthesiology & Pain Management
Holder, S.T. “Buddy” Harris Distinguished Chair in Cardiac Anesthesiology
University of Texas Southwestern School of Medicine
Health System Quality Officer, Office of the Executive Vice President of Health Affairs
University of Texas Southwestern Hospitals and Clinics
Dallas, TX

Establishing “best practices” for handover redesign and implementation is in its infancy. Even with so much yet to be discovered with respect to critical elements, education and training, key metrics, patient involvement and implementation, several provocative issues have already begun to surface. Examples include “what do patients really want from handovers and what do we need from them”, “how much (or little) additional structure is really necessary”, “which measures are most likely to demonstrate causality between improvements in handovers and outcome, if it exists” and “how important is it to make the business case for handover redesign to hospital executives”. Based on your responses to the pre-conference Delphi survey, this lecture will address 2-3 of these provocative issues. My objective is to broaden your understanding of these selected topics and hopefully assist you in your deliberations on potential recommendations this afternoon in the breakout sessions.

Breakouts: Each group seeks consensus on statements regarding one handoff question

Group 1: What are critical common process elements for any handoff to be successful? What essential behaviors (and roles) should be present in highly reliable handover teams?
Aalok Agarwala

Group 2: What metrics (process and outcomes) can we use to measure handoff effectiveness?
Meghan Lane-Fall

Group 3: What are the most important unknown questions about handoffs? (What should the research agenda be?)
Atilio Barbeito

Group 4: Is there a single mnemonic that can be used for perioperative handoffs? What are the essential characteristics of durable handover education/training?
Steve Greenberg

Group 5: What are best practices for handoff process implementation?
Philip Greilich

Group 6: How should patients be engaged in/notified of perioperative handoffs? (Not expecting to reach consensus.)
Erin Pukenas


Drug Diversion from the Healthcare Work Place: a Multiple-Victim Crime

Keith Berge, MD
Associate Professor of Anesthesiology
Mayo Clinic
Rochester, MN

While many view addiction as a “victimless crime,” the diversion of drugs from the healthcare workplace is a criminal act that endangers patients, co-workers, healthcare facilities, and the diverter. The purpose of this brief talk is to shine a light on pervasive nature of diversion, and on strategies that have proven helpful in preventing and detecting it.

Catch me if You Can

Rodrigo Garcia APN, MSN, CRNA-C, MBA
CEO, Parkdale Center for Professionals
Chesterton, IN

The effects of the current opioid crisis are continuing to increase and can be felt across the entire spectrum of society. However, the significance of the impaired health care professional continues to remain the “elephant in the room”. While addiction rates in the general population remain near 1:15, rates of addiction amongst health care professionals is even higher at nearly 1:10. The impaired professional is not only a detriment to themselves but also to the hundreds of patients and families they are tasked and trusted to care for.

Addressing addiction through the disease model continues to be challenged on some fronts while public perception of the addict remains non-supportive and often punitive. Recent advancements in the field have yielded crucial information that has redirected the focus from punishment to prevention, education, and early identification. This information includes an identifiable genetic component, the significance of dual diagnosis, and predisposing characteristics of the impaired professional.

Today Rodrigo will share his personal story of his battle with addiction and his efforts to achieve and maintain sobriety while ultimately safely reentering the anesthesia profession. He will also share his experience as the CEO of Parkdale Center, a treatment center for professionals on the front lines of treating the impaired provider. In closing he will discuss identifying characteristics, appropriate intervention actions to be taken by department heads, and proposed solutions to help safeguard your organization.

“Being addicted to pain medication as a health care provider is like an alcoholic working as a bartender”. – Rigo Garcia, CRNA

Securing Narcotics: Standard of Care Evolves in Wake of Hepatitis C Outbreaks

Brian J. Thomas, JD
Vice President – Risk Management, Preferred Physicians Medical

Several recent high profile incidents involving the diversion and tampering of narcotics by hospital employees have driven an evolving standard of care for securing narcotics and other medications. These intentional criminal acts by rogue hospital employees resulted in dozens of patients being infected with hepatitis C and subjected those facilities and anesthesiologists who were involved to significant liability exposure, medical licensing board investigations, negative media coverage and public relations challenges.

Malpractice litigation is an additional perspective from which to evaluate the scope and impact of drug diversion and tampering in the anesthesia workplace. As highlighted by Preferred Physicians Medical’s defense of multiple hepatitis C lawsuits, the legal standard of care for storing and securing narcotics and other medications continues to evolve in response to these significant outbreaks. Insurance industry loss data support risk management strategies to promote the development and implementation of hospital/facility drug storage and security policies and protocols to ensure narcotics are secured or controlled by the anesthesiologist from the time the medication is obtained until it is administered. Anesthesia practice groups should also revisit the role of important workplace drug testing policies.

In light of today’s growing opioid crisis, the increasing prevalence of substance abuse in the patient population, health care providers, and staff in the anesthesia workplace warrants increased awareness and measures to prevent drug diversion and tampering to protect patient safety.

The Silent Epidemic: Drug Diversion in the Health Care Setting

Tricia Meyer, MS, PharmD, FTSHP, FASHP
Regional Director Pharmacy
Scott & White Temple Medical Center
Associate Professor of Anesthesiology

Controlled substance diversion and abuse continue to be a significant problem in health care. There are numerous reports in the press about the disease of addiction in celebrities and athletes. However, the problem of diversion and addiction among health-care workers is not well known outside of the walls of the healthcare environment.

The medication process in the perioperative environment is fundamentally different from that in the patient care unit with medications almost always prescribed, obtained, prepared & administered by the licensed independent practitioner such as anesthesiologists, surgeons and nurse anesthetists. A significant proportion of the medications used are highly potent & addictive substances and are given on a daily basis to provide analgesia (opioids, ketamine), blunt the stress response to intubation (opioids), induce general anesthesia (volatile agents, propofol) and provide sedation, amnesia and anxiolysis (midazolam). There are many steps in the medication use process where diversion can occur and many methods of diversion. Therefore, anesthesia and the operating rooms are considered high risk areas for diversion.

The American Society of Health System Pharmacists published the Guidelines on Preventing Diversion of Controlled Substances in early 2017. The document describes a detailed and comprehensive approach to facilitate organizations in developing their controlled substance diversion prevention program (CSDPP). A diversion program should utilize technology and surveillance to review process compliance and effectiveness, strengthen controls in order to proactively prevent diversion.

Are Opioids Necessary for Surgical Patients?

Ronald S. Litman, D.O.
Medical Director, Institute for Safe Medication Practices
Professor of Anesthesiology and Pediatrics, The Children’s Hospital of Philadelphia
and the Perelman School of Medicine at the University of Pennsylvania
Philadelphia, PA

The only valid way to prevent opioid diversion is to “engineer” it away. In other words, we must create a systems solution that prevents the ability of anesthesia personnel to divert opioids away from the patient. This talk will begin with a discussion on the need for opioids intraoperatively. Evidence will be presented that demonstrates the advantages of intraoperative opioid avoidance. Furthermore, in a recent analysis of medication errors in pediatric anesthesia, opioids topped the list. The concept of the “opioid sommelier” will be introduced. Anesthesiology personnel will not be able to obtain opioids from their hospital pharmacy but rather, if they need to administer it to a patient intraoperatively, an opioid sommelier will be summoned, and he or she will administer it. It’s a creative and daring way to completely eliminate opioid diversion. At first, many groups will be reluctant to prohibit anesthesia personnel from handling opioids but all it will take is one daring group to try it and then publicize their results, and others will follow. We must create a new paradigm, so that opioids are not as casually given as usual.


September 5, 2017
September 7, 2017
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