Handoffs and transitions in critical care-understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial.

BACKGROUND: The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings. METHODS: The Handoffs and Transitions in Critical Care-Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU). DISCUSSION: The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04571749 . Date of registration: October 1, 2020.

Use of Simulation in Performance Improvement.

Human error and system failures continue to play a substantial role in preventable errors that lead to adverse patient outcomes or death. Many of these deaths are not the result of inadequate medical knowledge and skill, but occur because of problems involving communication and team management. Anesthesiologists pioneered the use of simulation for medical education in an effort to improve physician performance and patient safety. This article explores the use of simulation for performance improvement. Educational theories that underlie effective simulation programs are described as driving forces behind the advancement of simulation in performance improvement.

Continuous Non-invasive finger cuff CareTaker® comparable to invasive intra-arterial pressure in patients undergoing major intra-abdominal surgery.

BACKGROUND: Despite increased interest in non-invasive arterial pressure monitoring, the majority of commercially available technologies have failed to satisfy the limits established for the validation of automatic arterial pressure monitoring by the Association for the Advancement of Medical Instrumentation (AAMI). According to the ANSI/AAMI/ISO 81060-2:2013 standards, the group-average accuracy and precision are defined as acceptable if bias is not greater than 5 mmHg and standard deviation is not greater than 8 mmHg. In this study, these standards are used to evaluate the CareTaker® (CT) device, a device measuring continuous non-invasive blood pressure via a pulse contour algorithm called Pulse Decomposition Analysis. METHODS: A convenience sample of 24 patients scheduled for major abdominal surgery were consented to participate in this IRB approved pilot study. Each patient was monitored with a radial arterial catheter and CT using a finger cuff applied to the contralateral thumb. Hemodynamic variables were measured and analyzed from both devices for the first thirty minutes of the surgical procedure including the induction of anesthesia. The mean arterial pressure (MAP), systolic and diastolic blood pressures continuously collected from the arterial catheter and CT were compared. Pearson correlation coefficients were calculated between arterial catheter and CT blood pressure measurements, a Bland-Altman analysis, and polar and 4Q plots were created. RESULTS: The correlation of systolic, diastolic, and mean arterial pressures were 0.92, 0.86, 0.91, respectively (p < 0.0001 for all the comparisons). The Bland-Altman comparison yielded a bias (as measured by overall mean difference) of -0.57, -2.52, 1.01 mmHg for systolic, diastolic, and mean arterial pressures, respectively with a standard deviation of 7.34, 6.47, 5.33 mmHg for systolic, diastolic, and mean arterial pressures, respectively (p < 0.001 for all comparisons). The polar plot indicates little bias between the two methods (90%/95% CI at 31.5°/52°, respectively, overall bias = 1.5°) with only a small percentage of points outside these lines. The 4Q plot indicates good concordance and no bias between the methods. CONCLUSIONS: In this study, blood pressure measured using the non-invasive CT device was shown to correlate well with the arterial catheter measurements. Larger studies are needed to confirm these results in more varied settings. Most patients exhibited very good agreement between methods. Results were well within the limits established for the validation of automatic arterial pressure monitoring by the AAMI.

Efficacy of surgical safety checklist: Assessing orthopaedic surgical implant readiness.

INTRODUCTION: Our institution employs a Surgical Universal Protocol Preoperative Checklist in accordance with World Health Organization guidelines to promote patient safety. It is used in part to evaluate orthopaedic surgical equipment and implant readiness prior to the initiation of each surgical case. Our goal is to measure the preoperative checklist's efficacy in assessing orthopaedic equipment readiness preoperatively and its ability to prevent orthopaedic equipment failures (OEF). Our study focused on orthopaedic surgery cases as they require a large volume of equipment and implants for successful completion. These cases therefore present an appropriate medium to identify potential weakness in our institution's current surgical safety checklist (SSC). METHODS: Data was collected over a 6 month period of time, broken into 2 distinct periods. The goal during the first 3 months was to observe compliance with the SSC. And during this time, we observed how often the SSC identified an implant or equipment deficiency at the outset of the case. The goal during the second 3 months was to record if orthopaedic surgical equipment issues were occurring that should have been identified by the SSC. During the second 3 months, we continued to utilize the SSC but also added a postsurgical review at the end of each surgical case. The postsurgical review was a one page questionnaire aimed at identifying any orthopaedic equipment failures that had occurred during the surgical case. For the purposes of this study, we defined an intraoperative orthopaedic equipment failure (OEF) as any one of the 6 following categories: (1) surgery delayed due to missing equipment, (2) lack of sterility of equipment, (3) equipment not available, (4) equipment malfunction, and (5) equipment sets incomplete, or (6) additional equipment brought into room necessary for completion of case. The data was collected at a postsurgical review that was performed by the physicians, nurses, and technicians from the surgical team in a nonthreatening manner. We also attempted to quantify the impact that the OEF had upon the surgical case. RESULTS: During the first 3 months of the study (phase 1), we confirmed that our institutional SSCs were completed for all orthopaedic cases, including the specific questions related to implants and equipment. During phase 1, using the SSC alone, no orthopaedic equipment failures were identified. During phase 2, 33% of the reported surgical cases were identified as having started without essential equipment available or operational (defined as an orthopaedic equipment failure) in the operating room. The most common negative impact upon the surgical case was additional time requirement. CONCLUSION: Our institution's current SSC fails to prevent OEF in our operating rooms. These checklist failures and intraoperative equipment deficiencies have measureable negative patient safety and institutional cost implications. IMPLICATIONS: While the SSC is an effective tool it cannot be used alone to prepare for orthopaedic surgical cases. In order to improve patient safety and decrease hospital losses, further research is necessary to implement an effective communication network between surgeons, administrators, operating room nursing and sterile processing to eliminate OEF. LEVEL OF EVIDENCE: Level IV.

Simulation-based education with deliberate practice may improve intraoperative handoff skills: a pilot study.

STUDY OBJECTIVE: To examine the results of simulation-based education with deliberate practice on the acquisition of handoff skills by studying resident intraoperative handoff communication performances. DESIGN: Preinvention and postintervention pilot study. SETTING: Simulated operating room of a university-affiliated hospital. MEASUREMENTS: Resident handoff performances during 27 encounters simulating elective surgery were studied. Ten residents (CA-1, CA-2, and CA-3) participated in a one-day simulation-based handoff course. Each resident repeated simulated handoffs to deliberately practice with an intraoperative handoff checklist. One year later, 7 of the 10 residents participated in simulated intraoperative handoffs. All handoffs were videotaped and later scored for accuracy by trained raters. A handoff assessment tool was used to characterize the type and frequency of communication failures. The percentage of handoff errors and omissions were compared before simulation and postsimulation-based education with deliberate practice and at one year following the course. MAIN RESULTS: Initially, the overall communication failure rate, defined as the percentage of handoff omissions plus errors, was 29.7%. After deliberate practice with the intraoperative handoff checklist, the communication failure rate decreased to 16.8%, and decreased further to 13.2% one year after the course. CONCLUSIONS: Simulation-based education using deliberate practice may result in improved intraoperative handoff communication and retention of skills at one year.

Using Simulation Education With Deliberate Practice to Teach Leadership and Resource Management Skills to Senior Resident Code Leaders.

BACKGROUND: Cardiopulmonary arrests are rare, high-stakes events that benefit from using crisis resource management (CRM). Simulation-based education with deliberate practice can promote skill acquisition. OBJECTIVE: We assessed whether using simulation-based education to teach CRM would lead to improved performance, compared to a lecture format. METHODS: We tested third-year internal medicine residents in simulated code scenarios. Participants were randomly assigned to simulation-based education with deliberate practice (SIM) group or lecture (LEC) group. We created a checklist of CRM critical actions (which includes announcing the diagnosis, asking for help/suggestions, and assigning tasks), and reviewed videotaped performances, using a checklist of skills and communications patterns to identify CRM skills and communication efforts. Subjects were tested in simulated code scenarios 6 months after the initial assessment. RESULTS: At baseline, all 52 subjects recognized distress, and 92% (48 of 52) called for help. Seventy-eight percent (41 of 52) did not succeed in resuscitating the simulated patient or demonstrate the CRM skills. After intervention, both groups (n  =  26 per group) improved. All SIM subjects announced the diagnosis compared to 65% LEC subjects (17 of 26, P  =  .01); 77% (20 of 26) SIM and 19% (5 of 26) LEC subjects asked for suggestions (P < .001); and 100% (26 of 26) SIM and 27% (7 of 26) LEC subjects assigned tasks (P < .001). CONCLUSIONS: The SIM intervention resulted in significantly improved team communication and cardiopulmonary arrest management. During debriefing, participants acknowledged the benefit of the SIM sessions.