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Abstract

Miscommunication or non-transfer of pertinent patient information during intraoperative handoffs between anesthesia providers creates patient safety risks. An evidence-based facility-specific cognitive aid was developed and introduced to nurse anesthetists in an anesthesiology department of a large academic hospital with the aim of improving the intraoperative patient handoff process. The program used a handoff cognitive aid that addressed five pertinent patient information points. A secondary measure was evaluation of provider satisfaction. Twenty-four nurse anesthetists utilized the handoff cognitive aid during handoffs in the course of a 4-week pilot program. Eighty-eight nurse anesthetist handoffs were observed (23 with and 65 without the cognitive aid). Statistically significant improvement in the transmission of 3 of the 5 measured elements occurred when the cognitive aid was used. These areas included: intake and output (95.6% vs. 70.7%, p = 0.018); antibiotic administration (95.6% vs. 73.8%, p= 0.033); and intravenous access (100% vs. 76.9%, p = 0.009). An additional area that reached statistical significance (78.2% vs. 41.5%, p = 0.003) was the transmission of all 5 elements when the handoff cognitive aid was utilized in the handoff. In a post-implementation survey, nurse anesthetists utilizing the cognitive aid overwhelmingly agreed that the handoff cognitive aid was easy to use, contained appropriate content, and minimized risks to patient safety. Incorporation of a cognitive aid to standardize intraoperative handoffs was well received and improved communication of pertinent patient information during handoffs between nurse anesthetists.

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