While driving home after a long day in the sedation unit, a nurse’s cell phone rings. She ignores it and keeps driving, but it rings again. And again. So, she pulls over to see what the call is about. The number is for the observation unit, where the last MRI sedation patient of the day was transferred to finish his recovery and be discharged back to his care home. When the observation unit nurse answers, she is frantic – “The patient you signed out to us is awake, but he can’t move his legs!!! We think there is something very wrong with him!” The care home nurse who came to pick him up is someone who is not familiar with him. The sedation nurse asks a few more questions, but quickly figures out what the problem is. So what’s the answer? The nonverbal, significantly developmentally different child also has known myelomeningocele with very limited movement of his lower extremities at baseline. But, in looking back through the sedation nurse intake documentation and the provider documentation, altered neurologic function checkboxes have been checked due to his baseline developmental delay and seizure disorder, but no mention is made of his significant lower extremity paresis.
Although this is a somewhat dark/humorous example of the importance of handoff communication, I’m sure we all have more serious instances we could relate, some of which may have led to unfortunate or even disastrous complications for patients. I certainly have seen antibiotic doses missed because one person thought the other had given the medication, ongoing NPO instructions confused, latest EMR orders not refreshed, and on and on. A review of handoff related care failures in children’s hospitals from 2014 also identified interpreter needs, custody issues, breast milk/formula issues, and incomplete or incorrect infection prevention precautions as some other potentially relevant transition issues (1). Although it would be fantastic if all of these details were kept perfectly sorted in real time by our EMRs – and they do a good job of that for the most part – no system is perfect, especially during handoffs and transitions of care.
Improving patient safety through robust handoff processes has been a major focus of children’s hospitals’ recent quality and safety initiatives. Many of you are familiar with I-PASS, the tool designed to standardize verbal handoffs between pediatric providers (2). There are a number of other similar tools and processes – SBAR (situation, background, assessment, recommendation), for example, is the model recommended by The Joint Commission (3). There are also handoff tools which are more situation-specific, such as those for pediatric cardiac surgical patients returning postoperatively to the PICU.
In terms of post sedation care, many organizations use a similar handoff process to that used in many pediatric PACUs. There are likely as many different checklists/tools for this process as there are institutions, though, and even a review of the anesthesia literature shows that there is no single/universal tool utilized for this process. The Anesthesia Patient Safety Foundation recently posted two checklists in their newsletter, one from Medstar Georgetown (figure 1, reference 4) and one from MD Anderson Cancer Center (figure 2, reference 5).
Potestio et al 2015
Tan et al 2015
Not surprisingly, there are no references in the literature of a handoff of care process specific to procedural sedation in children. Many units try and minimize these transitions by caring for patients from arrival to discharge with the same team, but handoffs of care to another caregiver, to another procedural area, and back to the inpatient ward are inevitable. So, to get a better sense of what everyone is doing, I queried the pediatric sedation list serve. I got 3 replies (thank you!) which I will summarize here. Dr. Landrigan-Ossar from Boston Children’s replied that they utilize the I-PASS system, and they customize the report process to area of care. She wisely noted that, “one of the most important parts of any handoff of a complex patient is the readback part, as it’s not uncommon to have to make clarifications at that point.” The I-PASS tool utilized by their IR team is shown below:
Lorie Reilly from CHOP forwarded me their radiology nursing patient handoff checklist here.
And, Drs. Elizabeth Mack and Ben Jackson from MUSC sent me the safety checklist from their procedural sedation unit that includes debriefing at the end of the case:
Each of these provides some great ideas of where to start if you are looking to design your own pediatric sedation handoff tool/checklist. This could also be a great collaborative project (perhaps even grant funded!) for a group of folks within the SPS – designing and then pilot testing a standardized, pediatric sedation-specific handoff tool. Anyone interested? Also, please feel free to send me other examples of handoff tools and checklists and we’ll post either in the next edition of the newsletter or on the SPS website.
- Bigham MT et al. Decreasing handoff-related care failures in children’s hospitals. Pediatrics 2014; 134:e572-e579.
- Starmer AJ et al. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics 2012; 129:201-204.
- Haig KM et al. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006; 32:167-175.
- Potestio C et al. Improving post anesthesia care unit (PACU) handoff by implementing a succinct checklist. APSF Newsletter 2015; 30:13-15.
- Tan J et al. An alternative succinct checklist offered for PACU handoff communication. APSF Newsletter 2015; 30:37-38.