Essay 4: Anaesthetists and post-anaesthetic care
Essay 4: Anaesthetists and post-anaesthetic care
Handover between anaesthetists and post-anaesthetic care unit nursing staff using ISBAR principles: A quality improvement study
Authors Patricia Kitney RN, BAppSc-Nsg, DAppSc-Nsg Ed, MEd (Research), GradCert LdrshipEdTrng, GradCertPeriop Western Health, Sunshine, Vic
Raymond Tam MBBS FANZCA Western Health, Sunshine, Vic
Paul Bennett RN BN GradCertSc (App Stats) MHSM PhD Deakin University, Geelong, Victoria, Western Health – Nursing Research Centre, Sunshine, Vic
Dianne Buttigieg RN, BHSc (Nursing), Grad Cert Periop Nsg, DipMgt Western Health, Sunshine, Vic
David Bramley MBBS MPH FANZCA Western Health, Sunshine, Vic
Wei Wang Msc (Stats) GdipSci (Stats) MD PhD Deakin University, Geelong, Vic

Corresponding author
Patricia Kitney Clinical Nurse Educator – Perioperative Services Western Health, Gordon Street, Footscray VIC 3011 Tel. 03 8345 0506 [email protected]
Abstract A structured approach to communication between health care professionals contains introduction/identification; situation; background; assessment and request/recommendation (ISBAR). ISBAR was introduced into the post-anaesthetic care unit (PACU) of a large Victorian health service in 2013. The aim of this study was to measure the effect of an education program on ISBAR compliance. Method: A pre/post-test design using a 14-item audit tool was used to measure compliance to ISBAR before and after an education intervention in two acute hospitals in Melbourne, Victoria. The intervention consisted of one 30-minute education session to anaesthetists, and two 30-minute education sessions to PACU nurses, combined with visual cues using ISBAR wall posters.
Results: In Hospital A, significant improvement from pre- to post-audit was found in the items of cardiovascular assessment (χ2 (1) = 4.06, p < .05), respiratory assessment (χ2 (1) = 12.85, p < .01), analgesia assessment and actions (Fisher’s exact test p < .05) and responsibility + referral (χ2 (1) = 4.44, p < .05). For Hospital B significant improvement was found in communication difficulties (χ2 (2) = 13.55, p < .01) and significant decreased performance was found in respiratory assessment (χ2 (1) = 8.98, p < .01) and responsibility + referral (χ2 (1) = 13.26, p < .01).
Implication for practice: The results from this study cohort suggest an augmented education program may produce mixed results for ISBAR compliance. More than education and visual tools may be required to improve PACU ISBAR compliance.
Keywords Handover, anaesthetist, post-anaesthetic care, post-anaesthetic nurse.
Journal of Perioperative Nursing in Australia Volume 29 Number 1 Autumn 2016 31
Background In 2012 the Australian Commission on Safety and Quality in Healthcare (ACSQHC) identified clinical handover as a key standard in the national quality and safety framework1. With over seven million clinical handovers occurring annually in Australian hospitals, it was concerning that global handover processes have been highly variable and unreliable, and associated with patient risk and patient safety2. A recent review of 31 postoperative handover primary research studies confirmed the positive association between handovers and adverse events and recommended the standardisation of handover processes3. Standardisation of clinical handover is likely to improve the safety of patient care as critical information is more likely to be transferred and acted upon1. Essay 4: Anaesthetists and post-anaesthetic care
In the perioperative environment surgeons, scrub nurses, anaesthetists, anaesthetic nurses and scout nurses are all involved in the care of the patient during
a surgical procedure. Each team member is accountable for the information they transfer from one part of the patient journey to the next; however, in Australia, it is most commonly the anaesthetist who performs the post-operative handover4. The post-operative handover consists of the transfer of information of the patient’s state and care by the anaesthetist to the post-anaesthetic care unit (PACU) staff with appropriate briefing on relevant aspects of the surgery and anaesthetic technique5.
ISBAR is a structured approach to communication between health care providers. ISBAR refers to: Introduction/Identification; Situation; Background; Assessment; and Request/Recommendation6. The introduction of ISBAR to Western Health, a large metropolitan health service in Melbourne, Victoria, was undertaken to provide a standardised organisation-wide approach7. The introduction of ISBAR identified issues of non-compliance, resulting in an education strategy being
implemented. The aim of the quality improvement project reported here was to measure the effect the education program had on ISBAR compliance.
Design A pre/post-test design using audit tools to measure compliance before and after a quality improvement intervention.
Sample A convenience sample of anaesthetists were observed over a one-week period in two PACU units from two participating hospitals within the same health service. Handovers were performed by anaesthetists providing a clinical handover of their patients to PACU nursing staff were included in the audit. There were no data in the literature to guide detailed sample size calculations for comparison of before and after compliance with the ISBAR handover tool in PACU. Assuming normally distributed population data in the independent samples, a proposed sample size of 100 observations in each group would give 83% power to detect a difference in proportion of handover compliance from 50% to 70% at a significance level of 0.05 in a post- hoc analysis of entire cohort. An historical case load suggested that this would result in a sample of approximately 200 events (clinical handovers).
Intervention The intervention consisted of two strategies. Firstly, in-service education session to anaesthetists and PACU nurses on current handover performance was undertaken. The education sessions were mainly of a didactic nature, presenting evidence supporting the introduction
Identification Patient Staff members
Situation Procedure Anaesthetic type
Background Allergies Co-morbidities Communication difficulties (including non-English speaking)
Assessment & Actions
Intra-operative issues: • surgery and anaesthesia Current issues: • cardiovascular observations, limits, therapy • respiratory observations, limits, therapy • analgesia interventions to date, orders • additional needs, e.g. anti-emetics, BSL.
Responsibility & Referral
Name and contact details
ICU/HDU/ward/discharge home
Figure 1: ISBAR cue card
Journal of Perioperative Nursing in Australia Volume 29 Number 1 Autumn 2016
of structured clinical handover. The model of ISBAR handover was presented and reinforced. Secondly, ISBAR poster-sized cue cards (Figure 1) were fixed to the walls of all PACU patient bays.
Tool The audit tool was developed measuring the adherence to ISBAR principles during the handover from anaesthetist to PACU nurses (Figure 2). This was designed to encompass guidelines from the Australian and New Zealand College of Anaesthetists (ANZCA) and the health care organisation. To assist with face and content validity the tool was disseminated to expert clinicians where minor modifications Essay 4: Anaesthetists and post-anaesthetic care
were made. The tool was then piloted before the study where further minor modifications were undertaken.
Data collection The pre-audit was undertaken immediately following the introduction of ISBAR. The education and poster strategy was implemented in the succeeding two weeks immediately following the audit. The post-audit was undertaken four months after the education and poster strategy. The audit tool (Figure 2) was completed by Sunshine and Footscray PACU nursing staff during the clinical handover by the anaesthetist once the patient had been connected to monitoring equipment and the patient was
deemed stable by the PACU nurse. The audit tool was piloted in 10 handovers by two PACU nurse educators and found to be practical, timely and demonstrated high inter-rater agreement. Audits were undertaken by PACU nurses who had been trained to complete the audits during the two education sessions. Completed audits were placed into a secure box, which were collected from the box at the end of the one- week period by the project team leader (PK).
Ethics Quality assurance was reviewed by the Western Health Low Risk Research and Ethics Panel. Approval was granted on 13 October 2014. Low-
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