Abstract
Objective
Transitions of care are critical periods when NICU patients are at risk for miscommunication leading to patient harm. This quality improvement project aimed to decrease post-operative hand-off-related failures and improve communication in a level IV NICU.
Project design
The Vermont Oxford Network transitions of care framework was used to develop a safe surgical hand-off definition; (1) all team members present, (2) a structured hand-off format utilized, and (3) an environment conducive for hand-off. Interventions included using standardization for process improvement, scripting ideal communication, and simulation to establish behavioral norms of effective communication.
Results
Post-surgical hand-off-related care failures decreased from 75% pre-implementation to 6% post-implementation (p < 0.00001) by increasing the percentage of hand-offs meeting pre-defined criteria.
Conclusion
Using quality improvement methods to implement process and behavioral changes to improve communication, our team reached our goal of decreasing post-operative hand-off-related care failures.
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References
Inadequate hand-off communication. Sentinel Event Alert. 2017:1–6.
Piazza AJ, Brozanski B, Grover T, Chuo J, Mingrone T, Rao R, et al. STEPP IN: A Multicenter Quality Improvement Collaborative Standardizing Postoperative Handoffs. Pediatrics. 2021;148:75–84.
Humphrey KE, Sundberg M, Milliren CE, Graham DA, Landrigan CP. Frequency and Nature of Communication and Handoff Failures in Medical Malpractice Claims. J Patient Saf. 2022;18:130–7.
Bigham MT, Logsdon TR, Manicone PE, Landrigan CP, Hayes LW, Randall KH, et al. Decreasing handoff-related care failures in children’s hospitals. Pediatrics. 2014;134:e572–9.
Dalal PG, Cios TJ, DeMartini TKM, Prasad AA, Whitley MC, Clark JB, et al. A Model for a Standardized and Sustainable Pediatric Anesthesia-Intensive Care Unit Hand-Off Process. Children (Basel). 2020;7:1–12.
Kaplan HC, Edwards EM, Soll RF, Morrow KA, Meyers J, Timpson W, et al. Variability in the systems of care supporting critical neonatal intensive care unit transitions. J Perinatol. 2020;40:1546–53.
Reine E, Rustøen T, Raeder J, Aase K. Postoperative patient handovers-Variability in perceptions of quality: A qualitative focus group study. J Clin Nurs. 2019;28:663–76.
Barbeito A, Agarwala AV, Lorinc A. Handovers in Perioperative Care. Anesthesiol Clin. 2018;36:87–98.
Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP The improvement guide: a practical approach to enhancing organizational performance: John Wiley & Sons; 2009.
ACGME Core Program Requirements (Fellowship) 2023 [Available from: https://www.acgme.org/globalassets/pfassets/programrequirements/cprfellowship_2023.pdf.
Children’s Surgery Verification [cited 2024. Available from: https://www.facs.org/quality-programs/accreditation-and-verification/childrens-surgery-verification/.
Guttman OT, Lazzara EH, Keebler JR, Webster KLW, Gisick LM, Baker AL. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resiliency, Reliability, and Patient Safety. J Patient Saf. 2021;17:e1465–e71.
Abraham J, Meng A, Tripathy S, Avidan MS, Kannampallil T. Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs. BMJ Quality Safety. 2021;30:513–24.
Provost LP, Murray SK The health care data guide: learning from data for improvement: John Wiley & Sons; 2022.
Bower KM, editor When to use Fisher’s exact test.
Picarillo AP. Introduction to quality improvement tools for the clinician. J Perinatology. 2018;38:929–35.
Mesa AK, Wiseman SM. Sterile cockpit: Reducing Distractions Operating Room. Am J Surg. 2023;S0002-9610:00627–X.
Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Quarterly. 1999;44:350–83.
Schwappach DL, Gehring K. Trade-offs between voice and silence: a qualitative exploration of oncology staff’s decisions to speak up about safety concerns. BMC Health Services Research. 2014;14:1–10.
Kolbe M, Burtscher MJ, Wacker J, Grande B, Nohynkova R, Manser T, et al. Speaking up is related to better team performance in simulated anesthesia inductions: an observational study. Anesthesia Analgesia. 2012;115:1099–108.
Kaplan HC, Provost LP, Froehle CM, Margolis PA. The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ Qual Saf. 2012;21:13–20.
Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf. 2010;36:52–61.
Acknowledgements
We would like to acknowledge Dr. Tiffany Wright and Dr. Tyler McCambridge for their contributions to this improvement project.
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DB contributed to the study design, implementation of interventions, data collection, evaluation of outcomes, manuscript review and final approval. JF contributed to the study design, implementation of interventions, data collection, evaluation of outcomes, manuscript review and final approval. DK contributed to the study design, implementation of interventions, data collection, evaluation of outcomes, manuscript review and final approval. CM contributed to the study design, implementation of interventions, data collection, evaluation of outcomes, manuscript review and final approval. JS contributed to the study design, implementation of interventions, data collection, evaluation of outcomes, manuscript review and final approval. TS contributed to the study design, implementation of interventions, data collection, evaluation of outcomes, manuscript review and final approval. HF contributed to the study design, implementation of interventions, data collection evaluation of outcomes, drafted the manuscript and finalized the submission.
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The authors declare no competing interests.
Ethical approval
The University of Louisville IRB determined this project to be non-human subject research. Interventions were considered best practice and applied to all patients requiring a surgical hand-off in the NICU.
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Fischer, H., Buckley, D., Ford, J. et al. A quality improvement project improving post-operative transitions of care in a level IV NICU. J Perinatol (2025). https://doi.org/10.1038/s41372-025-02228-x
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DOI: https://doi.org/10.1038/s41372-025-02228-x
