Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member
Lack of communication or miscommunication between anesthesia providers and perioperative nurses can lead to patient harm. Anesthesia providers routinely transfer patients from the operating room (OR) to the ICU, and are responsible for communicating important information regarding the patient’s history, intraoperative course, and plans for pain management during the recovery period. Literature suggests that the handover process is more effective in relaying this important information when supported by the use of a standardized checklist.1-2
The Agency for Healthcare Research and Quality found that “current signout mechanisms are generally ad-hoc, varying from hospital to hospital and unit to unit.” (Link to Patient Safety Network - Handoffs and Signouts Article [accessed June 30, 2015]). According to data published by the Joint Commission, communication errors were indicated in 59% of reported sentinel events in 2012 and in 54% of operative/post-operative complications between 2004 and 2012. A 2006 survey among residents at Massachusetts General Hospital found that 59% of respondents reported one or more patients experiencing harm as a result of ineffective patient handoff practices during their most recent clinical rotation.
Therefore, a standardized transfer of care protocol or handoff tool/checklist that is utilized for all patients directly admitted to the ICU after undergoing a procedure under the care of an anesthesia practitioner will facilitate effective communications between the medical practitioner who provided anesthesia during the procedure and the care practitioner in the ICU who is responsible for post-procedural care. This should minimize errors and oversights in medical care of ICU patients after procedures.
Anesthesia Start to Anesthesia End
A transfer of care protocol or handoff tool/checklist that includes the key handoff elements is used.
The percentage of handoffs will be calculated as number of handoffs documented as “yes” in the electronic anesthesia record where the denominator equals the number of direct transfer to ICU events.
Note: Postoperative destination is determined using the MPOG Postoperative Destination phenotype. Only cases determined to be transferred to ICU by the phenotype will be included for this measure.
The key handoff elements that must be included in the transfer of care protocol or checklist include:
Identification of patient- In the instance the identity of the patient is unable to be confirmed, identification provided by the clinical faculty would suffice toward meeting performance of the measure.
Not applicable
Anesthesia provider in the room providing care at Anesthesia End.
Method for determining Responsible Provider:
Date Reviewed | Reviewer | Institution | Summary | QC Vote |
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NA |
NA |
NA |
NA |
NA |
Date | Criteria | Revision |
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None |