Photo by Photographer’s Mate 2nd Class Johansen Laurel, U.S. Navy.

Patient transfers between units can be less than orderly, resulting in miscommunication and frustration. Most ICU nurses have a war story (or two) that quickly comes to mind if asked about a memorable admission to their unit from the OR or recovery unit. I recall one instance, when I was a clinical nurse specialist covering critical care, in which I received a frantic call at 11:30 am from the ICU nurse manager.

Apparently, the ICU had been told they would receive a patient from recovery at about 2 pm. With this in mind, the ICU had arranged to transfer a patient out to a med-surg unit just after noon. The ICU manager had worked out the transfer time with the med-surg nurse manager to allow the med-surg RN to return from lunch before the transfer, and also to give the ICU nurse a chance to have lunch and prepare the equipment in the ICU slot for the new patient after it was cleaned by housekeeping.

But as it happened, the recovery nurse manager called the ICU at 11:30 am to say her unit needed the bed and the new patient would be transferred to the ICU in 15 minutes instead of at 2 pm as planned. This meant the ICU patient had to be moved to the med-surg unit ahead of time by a nurse who was not the patient’s primary nurse but would be giving the report to the med-surg unit nurse. It also meant that the ICU nurse who would be caring for the new post-op patient was not going to be available to admit him and take the report.

Moreover, the equipment was not ready when the patient arrived. General bedlam prevailed for about an hour. This disruption caused stress and hostile exchanges among staff, created an unsafe situation, disrupted care for the patients involved as well as other patients, and caused the two patients undue stress as they waited on stretchers in hallways until arrangements were completed.

This incident became the impetus for this small community hospital to examine and overhaul transfer policies (the root cause analysis revealed that the solution was to be found in better OR scheduling).

A QI project to improve information sharing during handoffs.

In the February issue, author Dawn Krimminger and colleagues at Barnes-Jewish Hospital in St. Louis report on their quality improvement initiative in “A Multidisciplinary QI Inititiative to Improve OR-ICU Handovers.” (The article is the winner of the 2017 Nurse Faculty Scholars/AJN Mentored Writing Award.)

It’s a well-done report on a successful attempt to address a significant issue. Their standardized handover process “decreased handover process and information-sharing errors and increased provider satisfaction, with no significant increase in handover time.” The article includes the handoff tools. I highly recommend it.

Let us know your thoughts on this project or on related issues from your own practice.