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Nabil El-Askalany MD Professor of Anaesthesia, Military Medical Academy Secretary General of the EgSA

Lecture objectives  The risks and guidelines of handover shall be

highlighted in this lecture.  The target is:  to avoid the gaps of inter-professional handover,  avoiding the adverse effects of handover,  improve patient’s safety.

Definition ď‚— The transfer of professional responsibility

and accountability for some or all aspects of care for a patient or group of patient to

another person or professional group on a temporary or permanent basis.

Handover: The debate  It might be quite advantageous in situations of:  prolonged anaesthesia,  preventing undue fatigue of the primary

anaesthetist,  Handover is required for:  temporary relief,  permanent relief.

Nature of handover ď‚— Temporary ď‚— the relieving anaesthetist should not change

anaesthetic management without conferring with the primary anaesthetist except in emergency, ď‚— the primary anaesthetist must be available to return at short notice.

Nature of handover…cont’d  Permanent:  primary anaesthetist must leave the patient

under the care of another anaesthetist for the remainder of an anaesthetic,  At the completion of anaesthesia care of the patient will be transferred to another person either in, PACU, ICU or HDU.

Effective patient handover  Effective patient handover is critical to ensure:  appropriate coordination among healthcare

providers and continuity of care,  Patient handover has become a research priority in order to improve patient’s safety,  Anaesthesia is one of the leading specialties in patient safety research and improvement.

Handover protocol  Improving handover quality and safety involve the

implementation of standardized handover protocol,  The new handover protocol led to:  improvements in the quality of handover and,  in team work,  without increasing the time needed to perform the handover.

Handover protocol…cont’d  Research of standardization shows that setting specific adaptations that are negotiated among all parties involved are necessary,  Patient handover will always involve balancing competing goals and will depend on:  the changing state of the patients,  care providers and,  work environment,  The question what makes a good handover may over lap with the question what makes team work effective.

The importance of interdisciplinary communication during handover  Interdisciplinary communication during handover

in a climate providing the opportunity to  ask questions,  share information, and  provide comments among different professionals,  for developing negotiated shared goals,  will have a positive impact by reducing the length and cost in ICU.

Responsibilities of the anaesthetist ď‚— The major responsibility is to: ď‚— provide care for the patient, ď‚— to be continually present throughout the

procedure during anaesthesia, sedation or major regional analgesia.

Responsibilities of the anaesthetist…cont’d  Formal handover to another suitably qualified and

available medical practitioner,  Ensures that the patient recovers safely from anaesthesia in an area appropriate for that purpose,  Retains accountability for the management of the patient recovering from anaesthesia particularly while in the recovery room.

The primary anaesthetist  Must be satisfied as to the competence of the

relieving anaesthetist,  Handover responsibility should occur when the

clinical status of the patient is stable,  No foreseen adverse events.

The relieving anaesthetist ď‚— Must be willing to accept responsibility for the

patients, ď‚— Must have had all the facts relevant to the safe

management of the patient adequately explained.

Matters to be communicated  Patient health status  past & present history,

 Anaesthetic technique  drugs, intravascular lines, airway security,  fluid management, untoward events,

 any foreseeable problems,  plans for further intraoperative and

postoperative management.

Matters to be communicated  Surgical procedure:  current state,  implications for management of anaesthesia,

 Monitoring during anaesthesia:  documented in the anaesthetic record,

 Notification of handover to:  

operating surgeon, consultant anaesthetist.

Principles for handover at completion of anaesthesia.  Safe recovery of the patient from surgery and anaesthesia in the appropriate area:  PACU, ICU, HDU,  Effective communication between all health professionals sharing care of the patient,  Adverse effects related to anaesthetic technique,  anaesthetist is responsible for 

recognizing, managing, documenting and informing patient and or caregivers.

Specific responsibilities  Formal handover to suitably qualified staff in recovery room, PACU, ICU, HDU. with appropriate briefing on surgery and anaesthetic technique  Handover should occur when:  the patient’s condition is stable,  Handover should include instructions relating to specific relevant such as:  airways , intravenous and intra-arterial devices,  throat packs, epidurals and drug infusions.

Specific responsibilities  Anaesthetist availability:  anaesthetist must be readily available to deal

with unexpected problems,  ensure that another nominated anaesthetist or

suitably qualified medical practitioner is available,

Specific responsibilities…cont’d  Other responsibilities  discharge criteria are satisfied,  plans for adequate post-operative care after

discharge of patient from PACU,  Advice to the primary care team after discharge

of patient from PACU.

Specific advice  The anaesthestist will provide specific advice regarding:  clinical observations and monitoring,  pain relief,  management of complications (PONV),  fluid therapy, respiratory therapy,  residual regional anaesthesia block,  discharge expectations from PACU,  ongoing care related to anaesthesia matters.

Research on handover  Research on handover between anaesthesia and

recovery room or anaesthesia & ICU is particularly important because these transitions of care take place in an environment that is:  time pressured,  prone to concurrent distractions.  while the patient is in at risk state.

Research on handover…cont’d  Gaps should be taken into consideration in moving the field of handover research and improvement forward,  Systematic studies linking detailed analysis of handover processes with measures of handover quality and outcome data are urgently needed,

 A team based view of patient handover seems to be a promising approach to complement current trends in the development of best practices and interventions.

Incident reports during handover  In a study on 334 reported handover incidents by

The Europian Society of Anaesthisiology,  intra-specialty transfer of care accounted for 51% of incidents,  inter-specialty accounted for 29% of incidents,  The most frequent type of incident apart from incomplete handover, was no handover at all.

Recommendations for good handover practice  The necessity of standardization in the handover process to:  optimize communication,  reducing medical errors to improve patient outcomes,  Documentation of any handover,  The handover should take place in the recovery room after  the monitoring has been reconnected to the patient,  nurse’s full attention can be given to the anaesthetist .

Recommendations for good handover practice…cont’d  Important information should be orally communicated to the recovery nurse such as:  surgery (drains , catheters , packs),  anaesthetic technique used,  drugs especially analgesics and anti-emetics,  Intravenous fluids given,  The anaesthetist should stay in the recovery room to see the first recording of the vital signs and should not leave until the patient is in a stable and satisfactory condition.

Recommendations for good handover practice…cont’d  Post-operative instructions:  monitoring required,  Positioning,  drugs and fluids prescribed,  when to inform the anaesthetist should the patient’s condition depart from normal,  The anaesthetist should review the patient before transfer to the ward.

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