If you're using paper charts and oral orders to transfer the care of patients from the OR to the PACU, I'm here to tell you that there's a better way: an instant, electronic patient handoff. As our nurses can attest, it's helped our very large hospital's very busy outpatient surgery department improve patient flow and increase patient safety.

Communication breakdown
As you know, maintaining good patient flow and preventing bottlenecks can be a real challenge. Patients need to enter and exit the PACU and day surgery unit in a manner that is predictable and safe and that makes the best use of the resources available. Many factors can disrupt our best-laid plans:

• when the in-house census is full or the operating room is at capacity;
• when many cases finish within a short period, requiring on-the-fly reorganization of resources; and
• when the needs of patients arriving on the unit change (for example, a patient expected to require minimal resources has a radical change in his surgery and post-operative needs).

This last factor is particularly troublesome. Your PACU/DSU might remain in the dark on these changes until the call comes for a slot in the recovery area. Even then the complete picture might not be clearly understood until the circulating nurse and anesthesia team give recovery the full report.

What we found
Our outpatient surgery department handles 100 to 120 patients each weekday. When we examined the methods we used in our perioperative area to handle the influx of patients more efficiently, it was clear that communication was the key: Nurses in the OR needed to pass information to the PACU/ DSU so we could make patient assignment decisions. The nurse in charge had to be able to communicate where patients were going to the recovery staff person and the OR nurse transporting the patient. The fly in the ointment here was that no information was passed from the OR to the PACU in advance of patients' arrivals on the unit, often necessitating room holds while beds and staff were sorted out. Closer examination of the process revealed that the nurse in the OR was really giving two reports: The first, over the telephone, revealed the acuity of the patient and would let the PACU/ DSU determine the correct staff and bed space; and the second, a verbal handoff report given to the nurse in the receiving unit, contained all the patient specifics.

We wanted to eliminate the first report phone call and still have an informed staff person ready to receive the patient. As luck would have it, this was about the same time the Joint Commission announced its National Patient Safety Goals for 2007, and No. 2 safety goal was to "improve the effectiveness of communication among caregivers," which only gave us more incentive. Suddenly, developing an electronic handoff was part of our quality improvement for accreditation purposes. The result was an intertwined system of computer programs and user inputs that let staff transfer care from the OR to the PACU/DSU efficiently and safely, while surpassing Joint Commission standards.

Onscreen monitoring
So we began to develop a computer program that would let the nurses in charge in both the PACU and the DSU see the big picture. I mean that literally: A major component of the program is an onscreen map of all available beds, the status of each bed and to whom they're currently assigned.

The other component of the program lets us send a sort of instant message from the OR to the PACU/DSU that contains enough information for the receiving unit to determine which nurse and to what slot a patient should be assigned. It all starts in the OR, where the nurse checks various items pertaining to the patient on an electronic list (see the form to the right) and sends it to the receiving unit when the surgical closure is under way. The nurses in charge in the PACU/DSU receives the instant message with the list, reviews it and assigns a nurse and slot to the patient, passing the information back to the OR at the same time it is forwarded to the staff nurse who'll receive the patient.

This gives the staff nurse ample time to review the electronic health record and prepare to receive the patient. When the patient arrives in recovery, the verbal handoff report that the OR nurse gives is guided by a printout of key elements pulled from the patient's EHR, which is in turn organized to reflect the expected flow of the verbal report. This printout remains with the PACU/DSU nurse as a reference tool.

In order to both standardize and customize the verbal handoff report, we created a printed, patient-specific reference tool. PACU staff input was key; they suggested that more information be added to this tool, not because it would aid in their reports, but because it would help them provide care to the patient after the reports. Simple things like knowing who the third-string resident was on the case - as he'd most likely be the one to call for questions that arise post-operatively - were added. The post-op care report (see the form on the preceding page) draws elements from the electronic nursing record as well as from the EHR and displays it in a format that is useful to read from and refer to.

Proof positive
The time it takes to give the report has now de-creased to two minutes or less, and staff are more accurate while reporting more information. Before the electronic handoff, 72 percent of our nurses said they were relying on memory alone to give their reports; this has shrunk to less than 15 percent (and we expect it to continue to shrink). When we drilled down to determine specific items that nurses report on, we found huge improvements there as well; for example, 94 percent of our nurses say they always report patient identification now. We've improved patient care and patient safety because the information communicated by the system is patient specific and leaves fewer unanswered questions at the post-op care report.

I could continue to extol the virtues of digital information transfer, but actual usage tells the tale far better. Six months after we'd instituted the electronic handoff program, we surveyed all perioperative staff about its use and gave them a chance to recommend improvements. An overwhelming majority on both ends - OR and PACU/DSU - indicated it had positively affected patient care in their areas.

A very large majority in the recovery areas also indicated that they wanted more information to be made available electronically; for example, specification of the last dose of antibiotics given in the OR. Another common request was to take the digitization a step further by making the post-op care report an entirely electronic document that both OR and recovery nurses can refer to on bedside computers.

It seems that, overall, we've succeeded at building a system of computer programs that interact with each other, effectively communicate information about our patients, target that information to the appropriate staff members and do it all in a timely fashion.