OR TO ICU HANDOFFS

EVIDENCE-BASED PROTOCOLS IN ICU CARE IMPROVE PATIENT OUTCOMES, BUT THEY ARE INCOMPLETELY ADOPTED, LEADING TO PERFORMANCE GAPS. ICU care protocols include (1) participation in multidisciplinary rounds, (2) use of care bundles to promote wakefulness, breathing, and mobility, and (3) central line insertion checklists. These protocols have been proven effective in rigorous multicenter research, but they have been variably adopted with modest protocol fidelity. These findings track with others demonstrating poor-to-moderate protocol fidelity in acute care.

EFFECTIVE ACUTE-CARE IMPLEMENTATION STRATEGIES ARE URGENTLY NEEDED TO NARROW THE PERFORMANCE GAP IN THE CARE OF PATIENTS WITH CARDIOPULMONARY FAILURE. There is a critical knowledge gap about effective implementation strategies in acute care settings. Dixon-Woods et al examined implementation determinants in an ethnographic study of central line insertion protocol use in the ICU, finding that both outer and inner contexts influenced whether ICUs would take up an evidence-based practice (EBP). However, we do not know whether targeting these determinants with theory-based implementation strategies can overcome barriers to ICU EBP adaptation and use.

STANDARDIZED HANDOFF PROTOCOLS ARE AN IDEAL USE CASE FOR THE STUDY OF IMPLEMENTING ACUTE CARE EBPS. OR-to-ICU handoffs are sociotechnical interactions meant to explicitly transfer patient care and accountability between care teams, and thus require effective communication. The handoff team is composed of four key roles: the surgeon, the anesthesia provider, the ICU nurse, and the ICU ordering provider. Published standardized handoff protocols include two core elements: (1) a face-to-face group conversation at the patient’s bedside, and (2) use of a template or checklist to structure that conversation. Since 1990, at least 65 published studies have reported on and demonstrated that standardizing these handoffs improved information exchange and patient outcomes. As such, the American Heart Association has endorsed the use of structured protocols to guide perioperative clinician communication. However, adoption and adherence to such protocols encounter challenges in clinical practice. From a scientific perspective, this EBP is an ideal target for study given its high frequency (>500 events per ICU per year) and predictable location (at or near the patient’s bedside).

STANDARDIZED HANDOFF PROTOCOLS NEED TO BE CUSTOMIZED TO FIT INDIVIDUAL PRACTICE SETTINGS. Complex multi-step interventions are not “one size fits all” innovations; rather, they must fit the system and the organization into which they are deployed. The roles of the clinicians involved in the handoff and the nature of the scripting should conform to local expectations and resources. The individual studies comprising the evidence base on protocolized OR-to-ICU handoffs bolsters this argument. These studies show improvements in process and patient outcomes by maintaining the same two handoff protocol functions with different protocol details.

TAILORING IMPLEMENTATION STRATEGIES IS A PROMISING APPROACH TO FACILITATING EBP UPTAKE. The relative importance of implementation determinants varies across settings, necessitating different approaches to implementation. As explained by Lewis et al, tailoring allows the most important drivers of implementation for a particular setting to take precedence, which increases the likelihood of a successful implementation effort.