Implementation of a Pediatric Post-Operative Hand-Off Tool: A Patient Safety Project

Abstract Problem: The clinical nurse leader (CNL) performed a microsystem assessment using the Dartmouth assessment tool to evaluate the microsystem’s readiness to provide safe care for pediatric post-operative cardiovascular patients. The microsystem is a 12-bed unit caring for critically ill pediatric patients requiring intensive monitoring and therapy. The microsystem’s interdisciplinary team is comprised of medical doctors, nurses, respiratory therapists, social workers, nutritionists, child life specialists, and pharmacists. During assessment and gap analysis, the CNL identified gaps in nursing knowledge and skills to deliver safe care for this patient population during the immediate post-operative phase of recovery. There is a concern for patient safety and poor quality outcomes due to these gaps. Since it is a new patient population for the microsystem, there are no protocols nor tools in place for nurses to feel confident in their ability to safely and effectively care for these patients. Context: As part of the organization’s integration efforts, the pediatric cardiovascular surgical service will be offered to its members beginning August 2018. This service will be piloted in a 12-bed microsystem, where the care of the patients post-operatively will occur. The microsystem interdisciplinary team has never cared for these patients in their immediate post-operative phase of recovery. Approximately 40% of the nurses in the microsystem are master’s prepared, and 85% of the nurses in the microsystem have over 5 years of experience in the pediatric intensive care unit (PICU). Because this is a new patient population for the microsystem, a nursing knowledge and skills gap was identified. Nurses are not confident and competent to care for these patients in the current state. To address this, prior to the first surgical date of August 15, 2018, the organization partnered with a neighboring organization with extensive experience in caring for congenital heart disease patients for training and education. Thirty-five out of 70 nurses in the microsystem, who volunteered to be part of the core group of cardiothoracic (CT) surgery trained nurses, were sent to that organization for training and education. Each nurse received 32 hours of didactic classes and 36 hours of hands-on precepted training in the other organization. The microsystem also provided 8 hours of further education and training of equipment and simulation. After training and education, the CNL collaborated with the nurse manager and frontline interdisciplinary team to create a hand-off tool and to define nurse roles during post-operative take back to ensure safety and quality outcomes during the most critical phase of the patient’s recovery. Intervention: The interdisciplinary team created a post-operative hand-off tool for a safe hand off at the PICU. The tool includes basic patient information, weight, diagnosis, surgical procedure, intraoperative information such as anesthesia and sedation used, blood products and medications administered during the procedure, and events such as arrhythmia and bleeding. The tool also has information pertinent to post-operative care, such as vital signs parameters, pain and sedation plan, medications, laboratory monitoring, and other details important for the nurse to monitor. The frontline nurses also created defined nursing roles during the post-operative take back to help ensure that all necessary care and tasks are safely accomplished in a timely and effective manner. Measures: Direct observation was done during the hand-off process to evaluate completion of all items in the hand-off tool at the PICU during hand off. Direct observation was done on the execution of the RN1 and RN2 roles. The goal is 100% utilization of the tool and the defined RN roles every post-operative take back. Results: Four surgical cases were performed since August 15, 2018. The hand-off tool and RN1 and RN2 roles have been utilized 100%, with no variances and barriers. Conclusion: The immediate post-operative phase of recovery for a pediatric cardiovascular patient is the most critical and intense period. Attention to detail and timely delivery of care are very important; hence, clear communication is vital during the hand-off process. In an effort to achieve a safe hand-off process and meet the patient’s care demands, the interdisciplinary team created the tool and the roles. Based on the results to date, these tools are effective interventions to ensure delivery of safe quality care to acutely ill pediatric patients after CT surgery in the immediate post-operative period