Handoffs have become a real hot topic in medicine. With the increase in resident work hours restrictions, handoffs have been identified as one of the more hazardous times in patient care.
This study was an interesting prospective intervention looking at performance change before and after the introduction of a standard handoff protocol. The specific protocol was designed to look at the transfer of a child after surgery for congenital heart disease to the ICU. Before the researchers began their protocol design, they spent a day with the Ferrari F1 racing team at the team headquarters in Maranello, Italy. (How can I sign up for this?)
Why Formula One? The pitstop in Formula One racing is a great example of how a multiprofessional team functions together under high stakes conditions to perform a complex task with minimal error. Think about it: stop car, jack it up, change 4 tires, fully fuel it, clean the drivers visor, drop the jacks, and back to the races, all in about. . .7 SECONDS! Needless to say, the lessons to be gleaned were many and became the basis for the new protocol.
To be truthful, the actual results of this study are not nearly as interesting as the lessons that they learned. Their protocol did result in a decrease in errors to be sure: technical errors went from 5.42 to 3.15, information omissions dropped from 2.09 to 1.07, multiple errors dropped from 39% to 11.5% and so on, but I digress.
So what did they learn that is useful to us?
Leadership: In F1 racing, there is a "lollipop" man who coordinates the entire procedure. How many of you walk into a trauma resuscitation and know who will lead the team, what resident is doing what, which nurse is on monitor duty, drug administration duty, or documentation duty? In this particular study, these roles became defined.
Task Sequence: In racing as well as aviation, the order of events is known. In handovers we are terribly inconsistent with our information. We often have no set sequence to follow leading to omission of critical information. This study broke a critically ill patients transfer into 3 phases: equipment and technology handover, information handover, discussion and plan. This allowed the team to focus on specific transfer issues and markedly decreased technical handoff errors.
Task Allocation: In racing, each team member does only 1 or 2 tasks. Need I make a reference to medicine? In the study protocol, when a transfer took place, people were assigned a specific task who were identified to receive the critical information about their task, ie ventilator, pumps, drains, monitor, etc.
Predicting and Planning: In racing, there is a method used called Failure Modes and Effects Analysis which allows breakdown of tasks and risks to predict problems. Use of a similar tool allowed these researchers to identify and refine safety checks and develop tools such as a ventilator transfer sheet to streamline the transfer of care.
Discipline and Composure: In racing, there is little to no verbal communication; the whole stop only takes 7 seconds. In medicine, handovers can be chaotic, with multiple people trying to give information to others at the same time. The nurses rarely know what the docs say to each other and vice versa. Having the discipline to allow one practitioner to talk uninterrupted can minimize the loss of information during a handoff.
Checklists: Well established in racing and aviation. I'll be posting more on this later, lots more. . .
Involvement: More of an aviation trait, but all team members are trained to speak up with concerns. In medicine, we have a long way to go to improve this area. Simply encouraging the behavior as part of the protocol was how this particular study addressed the issue.
Briefing: Again, well established in racing and aviation. In the emergency department, I rarely see this employed. Multidisciplinary handoffs are far from the norm and are potentially a rich area for improvement.
Situational Awareness: The previously mentioned lollipop man has this responsibilty in racing. Being at the front of the car, the driver doesn't go until he or she gives the okay. Identifying one person to stand back and make safety checks when handoffs occur or other chaotic processes such as codes can improve the overall situational awareness.
Training: Racing and aviation are fanatical about training and repetition. Despite being experts, the pit crew practices time and time and time again to improve their skills. Pilots routinely make trips to the simulator to practice the usual and unusual situations they may face. In the study, they found that staff turnover limited the ability to train. This situation is so common in emergency medicine as well. Instead of long and grueling training, this study focused on a simple process that could be learned in 30 minutes and made helpful training sheets available at EVERY bedside as a memory prompt.
Review Meetings: In racing and aviation, review of past actions is a way of life. Creating an open forum to frequently review problems and suggest solutions will promote lasting change in medicine. Everyone from residents, nurses, docs, and ancillary staff should be encouraged to attend and provide input.
Handoffs are a way of life in emergency medicine. It's pretty easy to look at this study and see parallels that would make our practice safer for patients. Simply focusing on improving the culture in one or two of the themes above will yield exciting dividends in the long run. Are you in?