A Standardized Handover and Transport Process for Critically Ill Pediatric Patients: An Interdisciplinary Collaboration

Friday, 28 July 2017

Brigit VanGraafeiland, DNP, MSN1
Cynthia Foronda, PhD2
Sarah Vanderwagen, BSN3
Laura Allan, BSN4
Meghan Bernier, MD5
Jennifer Fishe, MD3
Elizabeth Hunt, MD6
Justin Jeffers, MD3
(1)School of Nursing, Johns Hopkins University, Baltimore, MD, USA
(2)School of Nursing Health Studies, University of Miami, Coral Gables, FL, USA
(3)Pediatric Emergency Department, Johns Hopkins Hospital, Baltimore, MD, USA
(4)PICU, Johns Hopkins Hospital Children's Center, Baltimore, MD, USA
(5)Department: Anesthesiology-Pediatric Critical Care, Johns Hopkins Hospital, Baltimore, MD, USA
(6)SOM Pediatric Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA


Background:The transfer and handover of critically ill pediatric patients from the pediatric emergency department (PED) to the pediatric intensive care unit (PICU) is a period of vulnerability associated with adverse events. The Institute of Medicine (IOM) has emphasized that multiple threats to patient safety exist during the transfer of patients due to the potential for delayed, incorrect, interrupted, or incomplete communications. Furthermore, delays in transfer and handover impact the time for the patient to receive definitive treatment.

Aims: Using a Systems Engineering Initiative for Patient Safety framework, the aims of this project were to 1) examine staff members’ satisfaction with the current handover and transport process, 2) develop a new protocol and process for handover, and 3) evaluate staff satisfaction with the standardized, interdisciplinary, handover and transport process.

Methods:Focus groups were conducted to determine barriers and facilitators to the current handover and transport process. Using these data, a multi-disciplinary team convened to establish seven patient criteria for specialized transport as well as a standardized, interdisciplinary handover tool. The seven patient criteria were; 1.) Out of hospital witnessed arrest with return of spontaneous circulation, 2.) Status epilepticus, 3.) Complex cardiac patients with unstable vital signs, 4.) Intubation or ventilation requirements in the form of new BiPAP or CPaP, 5.) Shock physiology with vasopressor requirement, 6.) New Glasgow Coma Scale less than 10, 7.) High risk for acute compensation at the discretion of the attending physician. When patients met the established criteria, the PICU nurse and physician would come directly to the ED for team-to-team (the Pediatric Expedited Team) handover and physically assist with the transport to the PICU. The new process was piloted over a 6-month period, from September 2015 to March 2016. Staff satisfaction regarding the new process was examined pre and post-intervention using mixed methods.

Findings: Focus groups revealed five themes: need for improved communication, cultural dissonance among units, defects in system and processes, need for standardization, and ambiguity between providers regarding acuity. During the 6- month pilot period there were 370 PED to PICU transfers, 45 of which activated the PET Team (12.1%). Quantitative data were analyzed using cross-tabulations and descriptive statistics. Staff members reported improvements in their perceptions of satisfaction, safety, communication, and role understanding with the new process.