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Using cognitive task analysis to capture how expert anesthesia providers conduct an intraoperative patient care handoff
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Using cognitive task analysis to capture how expert anesthesia providers conduct an intraoperative patient care handoff
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Running head: INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 1
USING COGNITIVE TASK ANALYSIS TO CAPTURE HOW EXPERT ANESTHESIA
PROVIDERS CONDUCT AN INTRAOPERATIVE PATIENT CARE HANDOFF
by
Charlotte Ann Garcia
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
May 2015
Copyright 2015 Charlotte Ann Garcia
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 2
Dedication
This dissertation is dedicated to those closest in my life (especially Alfonso) who have
been my biggest supporters, advocates and cheerleaders throughout this process. As well, this
work is dedicated to the patients seeking safe passage through the surgical home. I hope the
results of this research can help strengthen the building blocks of that home, the safe place of
healing and respite for those individuals we are blessed to take under our care.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 3
Acknowledgements
This dissertation would not be complete without acknowledging the tireless dedication of
Dr. Kenneth Yates, whose depth of knowledge and heartfelt desire to see his students succeed
are unsurpassed. I am so fortunate to have worked with him! I have to thank Dr. Karen Embrey,
who motivated me and sparked my interest in achieving a Doctoral degree. I give a special
thanks to Dr. Maura Sullivan, whose kindness and support were also such great motivating
factors, and whose scholarly work in Cognitive Task Analysis in the health professions is that
which we can all aspire to. Thanks to Dr. Kari Cole and Dr. Judith Franco, colleagues in the
study of perioperative handoff of anesthesia care who shared with me the vision, and undertook
the task.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 4
Table of Contents
Dedication 2
Acknowledgements 3
List of Tables 6
List of Figures 7
List of Abbreviations 8
Abstract 10
Chapter One: Overview of the Study 11
Statement of the Problem 11
Purpose of the Study 14
Methodology of the Study 14
Definition of Terms 15
Definitions Specific to Intraoperative Patient Care 17
Organization of the Study 17
Chapter Two: Literature Review 19
Inadequate Communication and Patient Harm 19
Handoff Definition and Purpose 20
Definition of Patient Care Handoff 20
Intraoperative Handoff between Anesthesia Personnel 20
Purpose of Handoff 21
Perioperative Factors that Affect Handoff Quality 22
Communication 22
Handoff Tools 23
Lack of Handoff Education and Training 26
Current Methods of Handoff Training 27
Summary 28
Knowledge Types 28
Declarative Knowledge 29
Procedural Knowledge 29
Expertise 30
Characteristics of Experts 30
Building Expertise 31
Consequences of Expertise and Expert Omissions 32
Automaticity 32
The 70% Rule 34
Cognitive Task Analysis (CTA) 35
Definition of CTA 35
CTA History 36
Cognitive Task Analysis Methodology 37
Effectiveness of CTA for Capturing Expert Knowledge 39
Effectiveness of CTA-Based Training 40
Summary 42
Chapter Three: Methods 43
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 5
Task 43
Participants 44
Data Collection for Research Question 1: What are the action and decision steps that expert
anesthesia providers recall when they describe how they conduct an intraoperative handoff
of anesthesia care? 44
Phase 1: Collection of Preliminary Knowledge 45
Phase 2: Identification of Knowledge Types 45
Phase 3: Application of Knowledge Elicitation Techniques 45
Phase 4: Data Analysis 48
Phase 5: Formatting the Results 48
Summary 49
Data Analysis for Question 2: What percentage of actions and/or decision steps, when
compared to a gold standard, do expert anesthesia providers omit when they describe how
to conduct the intraoperative handoff of anesthesia care? 50
Spreadsheet Analysis 50
Chapter Four: Results 51
Overview of the Results 51
Research Questions 51
Question 1 51
Question 2 58
Chapter Five: Discussion 61
Overview of the Study 61
Process of Conducting Cognitive Task Analysis 61
Selection of Experts 61
Collection of Data 62
Discussion of Findings 65
Question 1 65
Question 2 70
Limitations 72
Confirmation Bias 72
Internal Validity 72
Implications 74
Future Research 74
Conclusion 75
Appendix A: Cognitive Task Analysis Interview Protocol 98
Appendix B: Inter-rater Reliability Code Sheet for SME A 101
Appendix C: Job Aid for Developing a Gold Standard Protocol 102
Appendix D: SME A Individual Protocol Flowchart 104
Appendix E: Gold Standard Protocol 111
Appendix F: Incremental Coding Spreadsheets 120
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 6
List of Tables
Table 1: Cumulative Action and Decision Steps Captured for Each SME in the Initial Individual
Protocols 55
Table 2: Additional Expert Knowledge Captured, in Action and Decision Steps, During Follow-
up Interviews 57
Table 3: Number and Percentage of Action and Decision Steps that are Highly Aligned, Partially
Aligned, and Slightly Aligned 58
Table 4: Total Action and Decision Steps, or Expert Knowledge, Omissions by SME when
Compared to the Gold Standard Protocol 59
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 7
List of Figures
Figure 1: Five Stages of the CTA 50
Figure 2. Progression of an Action Step as Data Described by each SME from 53
Individual Protocols is Aggregated to Create an Action Step Found in the GSP
Figure 3:Total Non-Repeating Action and Decision Steps from The CTA Process
Represented in the Gold Standard Protocol: Action and Decision Steps – 158;
Action Steps –103; Decision Steps 55 56
Figure 4: Total Non-Repeating Action and Decision Steps from the CTA Process
Represented in the Gold Standard Protocol: Action and Decision Steps – 158;
Action Steps – 103; Decision Steps 55 60
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 8
List of Abbreviations
ACGME: Accreditation Council for Graduate Medical Education
AHRQ: Agency for Healthcare Research and Quality
CDM: Critical Decision Method
CLT: Cognitive Load Theory
CPP: Concepts, Processes and Principles
CRNA: Certified Registered Nurse Anesthetist
CTA: Cognitive Task Analysis
CVC: Central Venous Catheter
EMR: Electronic Medical Record
GS: Gold Standard
GSP: Gold Standard Protocol
HMS: Human Machine System
HRO: High Reliability Organization
IOM: Institute of Medicine
IRR: Inter-rater Reliability
JCAHO: Joint Commission on Accreditation of Healthcare Organizations
OC: Open Cricothyrotomy
OR: Operating Room
PACU: Post Anesthesia Care Unit
PARI: Precursors, Action, Result and Interpretation
PSG: Patient Safety Goal
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 9
PGSP: Preliminary Gold Standard Protocol
QSEN: Quality Safety Education in Nursing
SCE: Simulated Clinical Experience
SME: Subject Matter Expert
WHO: World Health Organization
3i + 3r: Three Independent Interviews + Three Reviews
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 10
Abstract
The purpose of this study was to use Cognitive Task Analysis (CTA) methods to capture the
critical action and decision steps from experts when they describe how to deliver an
intraoperative patient handoff of anesthesia care. This study also sought to identify the
percentage of action and decision steps experts omit, as compared to a gold standard, when they
recall those action and decision steps they use during that high stakes handoff. Three subject
matter experts participated in semi-structured interviews, and protocols were developed and
reviewed by the experts. A gold standard protocol was generated from the individual interview
protocols and reviewed by a fourth subject matter expert. The resulting gold standard protocol
was analyzed for knowledge omissions in the form of action and decision steps, which were
quantified. Results indicate that experts omitted 44.73% of the action and decision steps
necessary to inform the process of intraoperative handoff of anesthesia care. Although these
results do not meet the “70%” omissions findings from previous studies, they support the work
of other CTA studies showing that experts have more difficulty recalling decisions they make
than the actions they take. The importance of this study is twofold – intraoperative handoff of
anesthesia care has not been widely studied and, regulatory bodies mandate standardization of
handoff procedures due to the widespread problem of patient complications related to inadequate
handoff communication. Recent efforts at handoff standardizations have provided minimal
evidence in process improvement. The results of this study are timely and enabled a fuller
explication of the task.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 11
CHAPTER ONE: OVERVIEW OF THE STUDY
Statement of the Problem
Within the hospital setting inadequate exchange of critical patient care information
through poor communication between health care providers results in patient morbidity and
mortality. In 2001 the Institute of Medicine (IOM) published the seminal report “To Err is
Human” indicating that between 44,000 and 98,000 patients die each year due to preventable
medical errors related to ineffective communication between health care providers (National
Research Council, 2000). “To Err is Human” was a springboard for health care leaders and
policy makers to improve the quality of care patients receive. In 2006 the Joint Commission,
formerly known as Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
instituted a national patient safety goal meant to improve communication effectiveness among
health care providers, with a major impetus toward improved handoff practices. A handoff is
defined as an episode in which control of, or responsibility for, a hospital patient passes from one
health professional to another, and in which important information about the patient is also
exchanged (Cohen & Hilligoss, 2010). The Joint Commission patient safety goal (PSG) required
hospitals to implement standardized patient handoff procedures in a sweeping attempt at
reducing patient harm. Goal implementation included a three year initiative to define methods for
improving the effectiveness of handoff procedures. The mandate proved problematic, and ridden
with barriers related to the range and complexity of the handoff process that was slowly revealed,
as a body of handoff research has taken shape.
Handoff within the perioperative environment is complex (Bonifacio et al., 2013; Smith,
Pope, Goodwin & Mort, 2008). Although communication and handoff practices have been
studied here and abroad, system wide barriers and deficiencies hinder process improvement
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 12
(Berger, May-Britt, & Stockwell, 2012; Boat & Spaeth, 2013; Prabhakar et al., 2012; Riesenberg
et al., 2010; Smith, Goodwin & Mort, 2008; Tan & Helsten 2013). The operating room is a
highly complex and dynamic environment at which time the patient may be at a most vulnerable
point, however the evidence is weak in the study of handoff within the perioperative arena, and
there is a dearth of evidence related to the intraoperative handoff of patient care between
anesthesia providers (Lane-Fall, Brooks, Wilkins, Davis & Riesenberg, 2014). Intraoperative
handoff occurs when an anesthesia provider, (anesthesiologist or nurse anesthetist) hands off
care to another provider at the end of shift, while the patient is anesthetized and undergoing
surgery. The few studies identified have included surveys, a malpractice claims review, and
protocol proposals (Cooper et al., 1982; Horn, Bell & Moss 2004; Jayaswal et al., 2011) however
no best practices in the handoff process or teaching therein, have been shown. A safe and
effective intraoperative patient care handoff procedure between anesthesia providers has yet to
be defined.
The effectiveness of educational interventions meant to improve patient care handoff
remains unclear (Arora, 2008; Gordon & Findley, 2011; Lane-Fall et al., 2014; Airan-Javia et al.,
2012). Although the Joint Commission and the Accreditation Council for Graduate Medical
Education (ACGME) have mandated education for handoff procedures, best practices have not
yet been established; the effect on patient outcomes remains unknown, and a curriculum for
handoff education has not been clearly identified. Currently the apprenticeship model of
knowledge transfer remains a factor in handoff education. Historically the apprenticeship model
(Halsted, 1904) has been the mainstay of medical education, but the method limits learning
opportunities, demands maximum speed and minimal efficiency, and does not follow best
practices in teaching (Grantcharov & Reznick, 2008). The lack of a standardized methodology of
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 13
teaching and the numerous tools, checklists, and procedures that lack empirical evidence of
efficacy in complex task-training continue as barriers to improved handoff communication and
patient safety. A cognitive task analysis (CTA) could identify the “gold standard” whereby the
intraoperative handoff procedure can be taught.
Cognitive task analysis is a methodology whereby a set of tasks are analyzed in order to
elucidate the knowledge, thought processes, and goal structures that underlie expert performance
(Chipman,2000). Ericsson and Charness (1994) identified that expertise encompasses extreme
adaptations through life-long effort, leading to superior performance after years of continued
skill acquisition. However, the research indicates that experts may leave out 70% of critical
actions and decisions when describing complex tasks (Feldon & Clark, 2006). Cognitive Task
Analysis enables capture of the specific knowledge, skills and decision steps experts use when
performing a complex task. Through the use of CTA the methods and techniques specified by
experts, can be clearly elucidated to develop a “gold standard” whereby complex task
performance can be taught, rendering the Halstedean approach of “see one, do one, teach one”
ineffective. Results of previous studies in CTA based instruction show improved performance of
complex skills in many domains (Clark et al., 2008). CTA based instruction was shown to
improve surgical decision making (Luker et al., 2008), performance and cognitive strategies used
by learners in bedside surgical procedures (Sullivan et al., 2008), and instructional descriptions
of procedures by surgeons (Clark et al., 2012). Currently, there is no standardized process or
gold standard for performance of the intraoperative anesthetic handoff procedure. A cognitive
task analysis in this area would help define the knowledge, skills, procedures, tools and use of
senses necessary to perform a safe patient care handoff.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 14
Purpose of the Study
The purpose of this study is to conduct a CTA with anesthetists who have been identified
as experts, to capture the knowledge and skills, primarily represented by the action and decision
steps they use when conducting the intraoperative handoff of anesthesia care.
The research questions that guide this study are:
1: What are the action and decision steps that expert anesthesia providers recall when
they describe how they conduct an intraoperative handoff of anesthesia care?
2: What percentage of actions and/or decision steps, when compared to a gold standard,
do expert anesthesia providers omit when they describe how to conduct the intraoperative
handoff of anesthesia care?
Methodology of the Study
The methodology of this study was to conduct a Cognitive Task Analysis in the area of
intraoperative patient care handoff between anesthesia providers at a large teaching hospital in
Los Angeles California. The CTA was conducted to determine the knowledge, skills,
procedures, tools and senses that anesthesia providers need in order to conduct a safe
intraoperative patient care handoff. Four subject matter experts (SMEs) were selected, three to
participate in interviews and a fourth to verify the data collected from the three SMEs on
intraoperative patient care handoff. The CTA followed a five-step process identified by Clark,
Feldon, van Merriënboer, Yates and Early (2008):
1. Collection of preliminary knowledge, sometimes called “bootstrapping” for those
without specific familiarity of the task.
2. Identification of knowledge representations, or types of knowledge necessary to
perform the task.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 15
3. Application of focused knowledge elicitation methods in order to capture the
conditions and complex problem solving related to the task.
4. Analysis and verification of the acquired data.
5. Formatting of the results which provides a basis for the development of an expert
gold standard protocol (GSP).
Definition of Terms
The following are definitions of terms related to CTA compiled by Zepeda-McZeal
(2014).
Adaptive expertise: When experts can rapidly retrieve and accurately apply appropriate
knowledge and skills to solve problems in their fields of expertise; to possess cognitive
flexibility in evaluating and solving problems (Gott, Glaser, Hall, Dibble, & Pokorny, 1996;
Hatano & Inagaki, 2000).
Automaticity: An unconscious fluidity of task performance following sustained and
repeated execution; results in an automated mode of functioning (Anderson, 1996; Ericsson,
2004).
Automated knowledge: Knowledge about how to do something: operates outside of
conscious awareness due to repetition of task (Wheatley & Wegner, 2001).
Cognitive load: Simultaneous demands placed on working memory during information
processing that can present challenges to learners (Sweller, 1988).
Cognitive tasks: Tasks that require mental effort and engagement to perform (Clark &
Estes, 1996).
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 16
Cognitive task analysis: Knowledge elicitation techniques for extracting implicit and
explicit knowledge from multiple experts for use in instruction and instructional design (Clark et
al., 2008; Schraagen, Chipman, & Shalin, 2000).
Conditional knowledge: Knowledge about why and when to do something; a type of
procedural knowledge to facilitate the strategic application of declarative and procedural
knowledge to problem solve (Paris, Lipson, & Wixson, 1983).
Declarative knowledge: Knowledge about why or what something is; information that is
accessible in long-term memory and consciously observable in working memory (Anderson,
1996a; Clark & Elen, 2006).
Expertise: The point at which an expert acquires knowledge and skills essential for
consistently superior performance and complex problem solving in a domain; typically develops
after a minimum of 10 years of deliberate practice or repeated engagement in domain-specific
tasks (Ericsson, 2004).
Procedural knowledge: Knowledge about how and when something occurs; acquired
through instruction or generated through repeated practice (Anderson, 1982; Clark & Estes,
1996).
Subject matter expert: An individual with extensive experience in a domain who can
perform tasks rapidly and successfully; demonstrates consistent superior performance or ability
to solve complex problems (Clark et al., 2008).
Tacit knowledge: Knowledge that is difficult to articulate, but supportive of knowledge
needed for task performance, and subsidiary to skill acquisition (Polyani, 1962).
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 17
Definitions Specific to Intraoperative Patient Care
Anesthesiologist: A physician specializing in anesthesiology
Anesthesiology: A branch of medical science dealing with anesthesia and anesthetics
(Merriam-Webster’s Collegiate Dictionary, 2014).
Intraoperative: Describes an event occurring during, or at the time of the operation or
surgery, within the surgical suite.
Intraoperative Handoff of Anesthesia Care: An episode in which control of, or
responsibility for the care of a patient undergoing anesthesia within the operating room, is passed
from one anesthesia provider to another, and in which important information about the patient is
exchanged.
Nurse Anesthetist: An advanced practice Registered Nurse who specializes in the
administration of anesthesia.
Patient Care Handoff: An episode in which control of, or responsibility for, a hospital
patient passes from one health professional to another, and in which important information about
the patient is also exchanged (Cohen & Hilligoss, 2010).
Perioperative: Describes an event occurring before, during or just after the operation or
surgery (Merriam-Webster’s Collegiate Dictionary, 2014).
Sentinel Event: A serious adverse event that results in death, permanent harm, or severe
temporary harm and intervention required to sustain life (Joint Commission, 2014).
Organization of the Study
Chapter Two consists of two parts. First, it reviews the literature related to handoff
definition, range and complexity, barriers to intraoperative handoff, and the state of current
efforts at improvement and education. The second part addresses Cognitive Task Analysis and its
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 18
effectiveness for training. Chapter Three addresses the methodology of the study and how the
approach taken in this research addresses the research questions. Chapter Four reviews the study
results and compares findings to each of the research questions. Chapter Five is a discussion of
the findings and their relevance to current handoff practices and research.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 19
o
CHAPTER TWO: LITERATURE REVIEW
Inadequate Communication and Patient Harm
Inadequate intercommunication of critical information between health professionals is a
principal source of patient harm globally (World Health Organization, 2006). The major impetus
for improvement in communication between health care providers began when the Institute of
Medicine (IOM) published a seminal report “To Err is Human” in 1999 which identified that
between 44,000 and 98,000 people die annually in U.S. hospitals due to medical error (IOM,
2000). As identified by the Joint Commission in 2005 (formerly known as the Joint
Commission on Accreditation of Healthcare Organizations), communication failure during
patient care handover was a major source of error, resulting in the institution of a National
Patient Safety Goal (Joint Commission, 2006) designed to mandate a standardized approach to
“hand off “communications among caregivers, including anesthesia providers. The World Health
Organization (WHO) in conjunction with the Joint Commission International launched the “High
5s Project” to bring international attention to and increase global collaboration in developing and
instituting standardized interventions meant to combat five challenging patient safety problems
around the world including errors resulting from miscommunication (WHO, 2006). In spite of
national and international awareness of the need for improved handoff practices, patient harm,
and system wide barriers and deficiencies still remain (Berger, May-Britt, & Stockwell, 2012;
Tan & Helsten 2013). A large body of literature has been generated related to handoff and its
many aspects. This review will attempt to bring into perspective key aspects that inform the
topic of intraoperative patient care handoff.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 20
Handoff Definition and Purpose
Medical researchers look to other domains, including airline, automobile and nuclear
power industries, as points of reference in order to improve their own practices (Gawande, 2010;
Gogan, Baxter, Boss & Chircu, 2013). High Reliability Organizations (HROs) within those
domains perform high risk work without catastrophic events (Agency for Healthcare Research
and Quality, 2008). However, many healthcare organizations including hospitals and hospital
settings do not qualify as HROs. Hospitalized patients continue to suffer catastrophic events
related to the point of intercommunication between health care providers, including the point of
patient care handoff.
Definition of Patient Care Handoff
There are many definitions of patient care handoff throughout the literature resulting in a
lack of clarity about a true definition and scope (Cohen & Hilligoss, 2010). One commonly used
definition encompasses handoff as an episode in which control of, or responsibility for, a hospital
patient passes from one health professional to another, and in which important information about
the patient is also exchanged (Lane-Fall, Brooks, Wilkins, Davis & Riesenberg, 2014;
Riesenberg, 2012). There are many types of patient handoffs including those at nursing shift
changes, physician sign-outs, physician-to-physician transfers, and nurse-to-nurse transfers
(Patterson & Wears, 2010). The focus of this CTA is the handoff that occurs within the
operating room, between anesthesia providers.
Intraoperative Handoff between Anesthesia Personnel
The handoff of anesthesia care within the operating room environment has many
important features that distinguish it from other types of care transitions (Lane-Fall et al., 2014).
There may be varying levels of practitioner training and expertise, and handoff may occur over
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 21
differing time frames and for differing reasons, or even at times of procedural milestones during
the surgical case. For instance, a handoff between anesthesia attending staff may occur outside
of the operating room without involvement of the person actually delivering the anesthetic within
the operating room (Boat & Spaeth, 2013; Lane-Fall et al., 2014). The anesthesia handoff may
occur between individuals with different professional backgrounds, such as between
anesthesiologists and nurse anesthetists, or between students within those perspective
professions. The interdisciplinary aspect of the anesthesia handoff is a distinguishing feature that
necessitates a care team approach on behalf of anesthesiologists and nurse anesthetists (O’Daniel
& Rosenstein, 2008).
Smith, Pope, Goodwin and Mort (2008) studied the interprofessional process of
anesthesia handover from the operating room (OR) to the post anesthesia recovery room
(PACU). Their research found the informal process of interdisciplinary transfer of patient
information posed safety concerns through insufficient data transfer, and poor communication.
There is a substantial amount of research related to OR to PACU patient handoff (Segall, et al.,
2012), however intraoperative handoff between anesthesia providers has been rarely studied.
Intraoperative handoff of anesthesia care remains a point of vulnerability in patient safety, and a
root cause of sentinel events resulting in death, and severe or temporary harm (Joint
Commission, 2013).
Purpose of Handoff
The Joint Commission has identified the primary purposes of the handoff in order to
provide a conceptual framework whereby health care personnel can measure outcomes and
improve patient safety procedures (Cheung et al., 2010; Patterson & Wears, 2010;). The
framework emphasizes handoff as a complex cognitive process, requiring a number of skills in
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 22
order to be performed safely. A key component of the framework involves development of a
shared mental model with clear co-construction of meaning. In other words, the hunches,
predictions and uncertainties, otherwise known as tacit knowledge (Polyani, 1962) must be
brought forward and verbalized within the handover. Tacit knowledge was identified by Manser,
Foster, Flin and Patey (2013) as that which is rarely shared in the handover process within the
operating room, and has been identified in other handoff research as that which is difficult to
capture (Cooper, 2010; Gogan, Baxter, Boss & Chircu, 2013; Smith, Pope, Goodwin & Mort,
2008). Although tacit knowledge is rarely articulated, it is an important component of the
cognitive processes involved in proficient task performance (Klein, 1995; 1989). To date,
handoff researchers have studied the need for, but have not been able to successfully capture
proficient task performance of the intraoperative handoff of anesthesia care. As will be shown,
this Cognitive Task Analysis has been able to do so.
Perioperative Factors that Affect Handoff Quality
The following section will explore communication, lack of effective intraoperative
handoff tools, and will summate with the move toward best practices in handoff education.
Communication
Research shows that poor communication causes disorder in an already complex
operating room environment. The OR is characterized as a complex human-machine-system
(HMS) that fluctuates with varying complexity, interspersed with critical events (Pfeffer, Maier,
Stricker, Rall & Trick, 2012). Multiple checkpoints, transitions and handoffs the surgical patient
undergoes can be distracting to even an expert practitioner (Wheeler, 2014). Within a dynamic
operating room, a surgical patient is subject to approximately five to seven handoffs per case
between nursing staff (Christian et al., 2006), and numerous handoffs of anesthesia care related
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 23
to breaks, meals, and shift relief. A summary of intraoperative handoff studies indicates
numerous anesthesia-related preventable patient care errors result from miscommunication,
leading to provider dissatisfaction with current handoff processes, and non-compliance with
attempts at process standardization (Lane-Fall, Brooks, Wilkins, Davis & Riesenberg, 2014;
Pham et al., 2012).
In the OR communication breakdowns and failures are well documented (Christian et al.,
2006; Greenberg et al., 2007; Kitch et al., 2008; Mazzocco et al., 2009; Tan & Helsten, 2013).
Greenberg et al. (2007) identified hundreds of cases of medical malpractice involving
intraoperative handoff communication breakdowns. Ong, BiomedE, and Coiera (2011)
conducted a systematic reviewed handoff communication during in hospital transfers, identifying
an urgent need for improvement in intraoperative communication related to patient transitions
throughout the surgical period. Data collected by the Joint Commission indicates the continued
prevalence of perioperative communication errors result in patient death, or severe injury (Joint
Commission, 2013). In a comprehensive review of the literature specific to intraoperative
patient care handoff by anesthesia providers, Lane-Fall et al. (2014) identified that there have
been only a handful of studies over the past 40 years addressing the intraoperative handoff, and
those studies have not offered significant guidance on handoff communication improvement, as
will be discussed in the following section on handoff tools.
Handoff Tools
Within complex settings such as the OR, decision making, sense making, situation
assessment, planning, adapting, problem detection and coordination all comprise the shared
mental model that must be developed in a handoff of anesthesia care. The small body of
literature related to intraoperative handoff has demonstrated attempts at managing that
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 24
complexity through handoff process standardization, as mandated by the Joint Commission.
Cooper, Long, Newbower and Philip (1982) conducted the first review of incidents related to
intraoperative relief practices of anesthesia providers in an attempt at process standardization.
The researchers utilized the critical incident technique (Flanagan, 1954) whereby practitioners
were asked to retrospectively analyze critical incidents relating to anesthesia handoff. Those
interview results were used to standardize that handoff procedure, however the critical incident
technique relies upon retrospection, and may be subject to memory loss, distortion and omission
(Crandall, Klein & Hoffman, 2006). Tan and Helsten (2013) introduced the first computerized
handoff checklist for utilization in break and shift relief in the OR. The checklist prompts
interactive discussion and documentation of key patient information, including the pre-operative
assessment, anesthetic plan, intraoperative management and course, as well as space for
discussion and prospective planning. Although the checklist meets the Joint Commission
mandate for standardization, as with many handoff implementation practices, there is no solid
evidence of improved process or patient outcomes, and the researchers did not identify the
methodology of tool development.
In a quality improvement project aimed at improving poor handoff practices at their
institution, Boat and Spaeth (2013) also developed and implemented a standardized checklist for
intraoperative patient handoff. The study was based upon identification of key components of a
handoff tool, and those components were specified by various members of the anesthesia team.
The metrics agreed upon were based on “input” but there was no discussion as to the
qualifications or expertise of those involved, or of the process that developed those knowledge
representations. Thus, the value of the content remains questionable. To date, practice surveys
both in the U.S. and abroad have identified lack of formalization, inadequate knowledge transfer
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 25
and adverse outcomes related to handoff of anesthesia care remain problematic (Jayaswal et al.,
2011; Horn, Bell & Moss, 2004).
In medical education there has been a shift in emphasis from a biomedical model to a
psychosocial one that attends to human factors that influence patient safety (Glavin & Flin, 2012;
The Joint Commission, 2012, World Health Organization, 2009). Attention to worker fatigue,
memory limitations, and environmental distractions have been increasingly incorporated into
handoff research efforts and show a continued evolution and improved methodological rigor
(Arora & Johnson 2006; Eldridge & Revere, 2005; Horwitz et al., 2012; Manser et al., 2013;
Manser et al., 2010). Cohen, Hilligoss, and Kajdacsy-Balla Amaral (2012) addressed the
importance of more fully incorporating what has been learned from cognitive science into
handoff research. Acknowledging the cognitive complexity of the handoff, the authors
emphasize the importance of the shared mental model in the development of a superior handoff
tool that would improve upon simple mnemonics that lack empirical evidence as to efficacy in
continuity of care. That tool has not yet been developed. Gawande (2010) suggests that the
breadth, quantity of knowledge and skill which is required to provide safe care in complex health
care environments is formidable, however can be assuaged with the use of checklist type tools,
when developed and utilized properly.
Indeed studies indicate some positive results of checklist type tools that show strong
evidence of improved patient outcomes in the perioperative setting (Abraham, Kannampallil,
Amloosa, Patel, & Patel, 2014; Mustafa, Samaraee, & Bhattacharya, 2012; Thomason,
Storesund, Softeland, & Brattebo, 2014), but there still exists an inadequate understanding of the
cognitive processes that experts use during the handoff process (Manser et al., 2013). This
review of the literature identifies a fundamental flaw in the knowledge elicitation techniques
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 26
used in the aforementioned studies. Experts may omit approximately 70% of information critical
to train the task, thus leaving the method used to develop the previously discussed tools
somewhat foolhardy. Another key point identified in this review indicates a lack of educational
interventions regarding their use.
Lack of Handoff Education and Training
This section will explore how handoff is currently taught to trainees and the gaps therein.
Educational interventions can improve patient handoff quality and subsequent patient care
outcomes. It has been shown that critical information decays in subsequent handoffs in
practitioners that lack formalized handoff teaching (Jensen et al., 2013). This evidence shows
that the current state of handoff education is problematic. The literature consistently cites a lack
of a handoff education as a barrier to improved communication and patient care (Arora &
Johnson, 2006; Arora, Johnson, Lovinger, Humphrey, & Meltzer, 2005; Cohen & Hilligoss,
2010; Lane-Fall et al., 2014; Riesenberg, Leitzsh & Cunningham, 2010; Segall et al., 2012;
Sutcliffe, Lewton, & Rosenthal, 2004).This gap appears a natural result of the lack of evidence to
support the efficacy of many of the strategies previously discussed. Educational mandates have
resulted in a flurry of educational interventions, but a lack of consistent learning outcomes.
The Accreditation Council for Graduate Medical Education (ACGME) has implemented
the requirement that all accredited programs ensure that their resident physicians are competent
at performing effective handoffs (ACGME, 2013; Kitsch et al., 2008; Nasca, Day, & Amis,
2010), however there is no evidence that educational interventions occur in a consistent manner,
and there is no common method of teaching handoff skills (Gordon & Findley, 2011; Wohlauer
et al., 2012; Woodward et al., 2010). Little is known about educational interventions in
intraoperative handoff, except that the educational process is lacking (Lane-Fall et al., 2014; Lin,
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 27
Chase, & Merkel, 2014; Wright 2013). The effectiveness of educational interventions meant to
improve patient care handoff continues to remain unclear (Arora, 2008; Gordon & Findley,
2011; Lane-Fall et al., 2014; Subha et al., 2012).
Current Methods of Handoff Training
Within medical education, a variety of handoff curricula have been suggested and
implemented, but there are no formal curricula, nor a comprehensive approach that would meet
the ACGME requirements for physician training (Wohlauer et al., 2012). It appears there is no
evidence that ACGME recommendations have become widely undertaken or accepted. The
same lack of formal curricula holds true in nursing education, and within the practice of
anesthesiology (AANA, 2014; Lin, Chase, & Merkel, 2014; QSEN, 2012). Traditional teaching
methods such as the apprenticeship model are still common to medical education (Didwania et
al., 2013; Wohlauer et al., 2012). As such, there are many ways educators have tried to meet the
general mandate for handoff education, and inconsistencies in performance outcomes have
resulted (Airan-Javia et al., 2012; Didwania, Kriss, Cohen, McGaghie, & Wayne, 2013; Gordon
& Findley, 2011). Simulation education is utilized in a structured manner to deliver handoff
teaching, but there is still no common curriculum.
Technology-enhanced simulation education had been shown to improve learning in
healthcare education (Cook et al., 2013; Gaba, Howard, Fish, Smith & Sowb, 2001) and is now a
key component to hand-off curriculum delivery (Berkenstadt et al., 2008; Bonnell, Macauley &
Nolan, 2013; Chen, Mistry, Wright & Turner, 2010; Farnan et al.2010; Lane-Fall, et al., 2014;
McQueen-Shadfar & Taekman, 2010; Senette, O'Malley & Hendrix, 2013; Shbeeb, Nelson,
Strom, & Mecca, 2013). A simulated clinical experience for intraoperative handoff has been
published with recommendations as to the structure of the experience as well as recommended
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 28
debriefing points (McQueen-Shadfar & Taekman, 2010). Again, as with previous educational
interventions, the choice of mnemonic to be used in the simulation was not based upon evidence
but rather opinion and practicality. Further efforts to develop and utilize simulation for
intraoperative handoff education must be based upon evidence that up until this point has been
lacking.
Summary
In sum, handoff process standardization has been mandated by regulatory bodies and as a
strategy in the development of best practices, but there is a lack of empirical evidence as to the
efficacy of the mandate approach. Many gaps have opened as a result of the rush to meet the
mandate, including gaps in research and education that effect handoff quality. Although there
has been a shift away from handoff as an information processor toward a process that elicits tacit
knowledge, the tools developed in order to facilitate the process have been based upon flawed
knowledge elicitation techniques. Attention to expert omissions has not been explored in the
handoff research, even though most of the processes, methods, tools and training are based upon
expert knowledge. This is important because research in CTA has shown that experts may leave
out 70% of the actions and decision steps when they describe their performance of complex
tasks. Given the complexity and high stakes involved in the task of intraoperative handoff of
anesthesia care, it is critical to capture expert omissions.
Knowledge Types
Understanding the types of knowledge, structures and processes used by experts in the
performance of the complex task of the intraoperative handoff of anesthesia care is necessary to
effectively elicit that knowledge for process improvement. Eliciting expert knowledge through
CTA enables a deep understanding as to what the practitioner knows, what concepts, processes
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 29
and principles comprise their domain knowledge, which in turn, can be understood through the
types of knowledge they implement (Crandall, Klein & Hoffman, 2006). Both declarative and
procedural knowledge are acquired and utilized by most individuals in order for the successful
execution of most cognitive tasks (Clark & Estes, 1996). Types of knowledge, including
declarative and procedural, enable different task related performance, through decision-making,
reasoning, critical thinking and problem solving. Traditional methods of training, such as those
used by Halsted (1904), did not capture these knowledge types or cognitive processes, and
resulted in incomplete instruction and misconceptions on the part of the learner (Clark et al.,
2008). Herein lies the success of CTA in knowledge elicitation.
Declarative Knowledge
Declarative knowledge is conscious, overt and controllable, and used to answer questions
such as what, where and why, and is sometimes described as “knowledge that” (Clark,
2008).Declarative knowledge consists of knowledge of facts, concepts, processes and principles
used in order to create and individuals mental model, and is goal independent (Anderson &
Schunn, 2000; Clark & Estes, 1996; Corbett, & Anderson, 1995; Schraw & Moshman, 1995).
Over time, through repetition and practice, tasks become familiar, and declarative knowledge is
transformed to largely unconscious thought, efficiently freeing up working memory (Anderson,
1982; Anderson and Schunn, 2000). Procedural knowledge on the other hand, is information
about the “how and when’ of a task.
Procedural Knowledge
Procedural knowledge can be described as the current set of production rules related to a
task presented in a set of if/then statements that specify how a particular goal can be achieved
when the specified pre-condition is met (Anderson & Krathwohl, 2001). The logical
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 30
propositions within the if/then statements define a subset of procedural knowledge, known as
conditional knowledge (Anderson & Krathwohl, 2001; Paris et al., 1983). Conditional
knowledge as a higher order cognitive process, coordinates or modulates the knowledge of
“what, where and why” within declarative memory, thus enabling decisions to be made, and a
decision steps to be taken (Anderson, 1993; Clark & Estes, 1996; Whitehill, 2013). In complex
skill acquisition, declarative knowledge is transformed to procedural knowledge once the skill is
repeated and practiced (Anderson, 1982). Repetition and practice are key to this transformation,
and procedural knowledge has been characterized as difficult to learn but fast to execute (Clark
& Estes, 1996). At this point, the motivated individual can be considered highly skillful, if not
an expert. The following section discusses expertise and the automation of knowledge that comes
from the transformation of declarative knowledge to procedural, the superior performance of
working memory, and the automated knowledge which would otherwise elude capture without
CTA.
Expertise
The following section explores characteristics of experts, how expertise is built, and its
consequences.
Characteristics of Experts
In 1869 Sir Francis Galton introduced the concept of hereditary genius, whereby
individuals’ advanced cognitive abilities were seemingly a result of genetic descent, a concept
that marked the beginning of advanced study of expert knowledge (Germain, 2011). Sir Galton’s
investigation as to whether experts are born or become that way through deliberate practice was
scrutinized in subsequent scientific inquiry. In spite of a generally held belief that expert
performance is innate or comes naturally, empirical evidence shows otherwise. An expert is
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 31
defined as someone who has gained special skills or knowledge representing mastery of a
particular subject through experience and instruction (Ericsson, 2014). Ericsson and Charness’
(1994) seminal study of the structure and acquisition of expertise provided the strongest evidence
to support this definition, and the evidence shows that expertise is not innate or hereditary but is
rather a capacity to learn material specific to a domain. This is evident in the acquisition of
musical skills at a young age secondary to the effect of training on performance (Gardner 1983;
Suzuki 1963/1981). Child prodigies’ acquisition of skill depends upon practice and a conducive
environment, although they may attain higher levels of performance faster and at younger ages
(Feldman, 1986). Glaser and Chi ((1988) found that experts perceive meaningful connected
patterns within their domain, are faster and more accurate than novices, spend extensive time in
problem analysis, and are self-regulated, enabling them to master their own learning (Bransford,
Brown & Cocking,1999, Ericsson &Lehmann, 1996). The ability of experts to structure domain
specific knowledge into schemas enables them to categorize information that can be rapidly
stored, retrieved and manipulated (Bedard & Chi, 1992).
Building Expertise
High levels of performance in a specific domain results from instruction and interaction
within that domain, however studies of superior performance over the short term do not
generalize to superior performance acquired over years to decades in a specific domain (Ericsson
& Charness, 1994). Time and a deliberate effort to improve, or deliberate practice, is necessary
for domain specific expertise (Ericsson, Krampe & Tesch-Romer, 1993). Knowledge acquired
from deliberate practice becomes automated, enabling a superior state of working memory, in
which space is freed up so that experts can attend to and process much more domain relevant
information (Feldon, 2007). The facile way in which experts attend to and process information
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 32
with little effort enables them a quality of adaptivity (Bransford, Brown & Cocking, 1999;
Feldon 2007a; Hatano & Inagaki, 1986). Adaptation to the demands of naturally occurring
situations hallmark expert performance, as de Groot (1946/1978) also identified when studying
master chess players. He found that when players with different levels of skill and expertise
were brought into the middle of a chess match a differentiation of level of skill and mastery
through adaptation could be identified in the expert versus the novice. Adaptive experts
approach new situations with flexibility, and think about how they can improve their thinking to
be more effective problem solvers in new situations. Thus self-reflection and metacognition are
key skills of experts, who spend increased time in qualitative analysis of problems and
subsequent development of knowledge representations of those problems (Simon & Simon,
1978), and the successful implementation of problem solving strategies (Chi, 2006).
These abilities are concomitant with problem solving under the pressure of time constraints (Chi,
2006; Klein, 1993), as experts exhibit quick, accurate responses to visual cues and patterns.
Consequences of Expertise and Expert Omissions
There are burdens that accompany these qualities of experts that clearly result from the
domain specificity of their expertise.
Automaticity
The basic lack of flexibility related to the domain specificity of expert knowledge
presents a barrier in that the automation of the expert’s skill precludes modification of their
behaviors and cognitive processes (Feldon, 2007).Functional fixedness, a form of cognitive bias,
was identified by Chi, (2006) as perhaps one of the most serious handicaps of experts, whereby
they tend to generate treatment hypothesis specific only to their domain, without exploration of
alternatives that could lead to success (Hashem, Chi & Friedman, 2003). This concept is evident
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 33
when an expert teaches a new concept to a novice. They may perform the process, such as
peeling a banana, in a quick and efficient way they are used to, however, if teaching a novice
how to peel a banana, it is difficult for the expert to problem solve teaching of banana peeling.
The expert’s automated, unconscious knowledge limit their teaching performance. They
may be unable to completely recall or verbalize all of the knowledge and skills that comprise
their expertise, posing teaching difficulty (Chi, 2006; Feldon 2007a; Sullivan, Ortega,
Wasserberg, Nyquist & Clark, 2008). Omissions confound the accuracy of the expert’s self-
report as critical information such as the “when, how and why” of a task is lost and may never be
transferred to the learner, forcing them to fill in the blanks of information omitted by experts
who have automated their knowledge (Clark, et al., 2012). When critical steps are omitted in
teaching, the expert often does not recognize that they have done so (Clark & Elen, 2006;
Wheatley & Wegner, 2001). These cognitive limitations are related to the different types of
expert knowledge. Feldon (2007) indicates that declarative knowledge is controllable through
adaptive behavior such as metacognition, whereby thinking can be reflected upon and modified.
Procedural knowledge on the other hand, becomes automated, unconscious, and enables the
circumvention of the limitations of working memory, especially those limitations that occur
when processing novel information (Kirschner, Sweller & Clark, 2006). As a result, experts
perform well, are speedy and efficient, however their automated knowledge is domain specific
making the expert somewhat inflexible and constrained (Clark et al., 2008; Hatano & Inagaki,
1986). They may lack fully informed decision making, leading to inaccurate judgment and
predictions necessitating “bootstrapping,” or the provision of supplemental resources to fill in the
gaps (Dawes, 1971).
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 34
Another consequence of expertise is that the unconscious automated knowledge they
possess makes them poor teachers. They do not easily retrieve critical material the novice needs
to know for success in learning because automated knowledge may be omitted during procedural
explanations (Clark, Pugh, Yates, Inaba, Green & Sullivan, 2011; Sullivan, Yates, Inaba, Lam &
Clark, 2014). The application of expert appropriate information during instruction must be
modified for utilization by a novice through techniques such as those utilized in the current
study. Capturing expert knowledge and enabling the study of it, facilitates the movement toward
a level of increased proficiency that novices can achieve, and possibly reach expert status (Chi,
2006).
The 70% Rule
Empirical evidence shows that experts do not recall approximately 70% of the actions
and decisions they make in explaining how to perform a complex task (Canillas, 2010; Clark,
2014; Clark, Pugh, Yates, Early & Sullivan, 2008; Crandall & Getchell-Reiter, 1993). This gap
is called the 70% rule (Clark, 2014; Clark et al., 2008), and has become a pivotal point in the
study of knowledge elicitation and expertise. The replication of the 70% rule stands with one
exception; when the task is controversial, meaning there has been much recent discussion or
quality improvement activity related to the task within the domain environment. In such a case,
the expert has been shown to omit much less than 70% amount of action and decision steps upon
free recall, versus tasks which are uncontroversial. This exception is evidenced in a healthcare
study of expert recall of the relatively common and uncontroversial open cricothyrotomy
procedure, versus central venous catheter insertion which is highly controversial related to
patient complications (Yates, Sullivan & Clark, 2011). In this instance, expert free recall of the
open cricothyrotomy (uncontroversial) procedure indicated omission of 72% of the decision
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 35
steps, however expert free recall of the central venous catheter (controversial) procedure
indicated only a 35% omission of decision steps. Thus, utilizing experts in any process
standardization efforts, such as those compulsory to patient care handoff, must account for the
70% rule. Cognitive Task Analysis enables the capture of expert knowledge that is key to the
provision of safe patient handoff.
Cognitive Task Analysis (CTA)
Definition of CTA
Cognitive task analysis (CTA) is defined as a variety of methodologies used to capture
the knowledge, thought processes and decision steps experts use to perform complex tasks within
their specific domains (Clark et al., 2008). In short, CTA is a method of capturing human
cognition. As such, the explication of human cognition, of how humans think, is an important
component of process improvement in this modern era where smart systems and advanced
technology are the norm, and as the human interface with these systems becomes more complex.
The result of CTA describes how people perform tasks rather than what steps they use in
carrying them out (Klein, 1995). CTA enables the methods and techniques specified by experts
to be clearly elucidated as a “gold standard” whereby complex task performance can be taught,
rendering the approach of “see one, do one, teach one” (Halsted, 1904) less effective. Ericsson
and Charness (1994) identified that expertise encompasses extreme adaptations through life-long
effort, leading to superior performance after years of continued skill acquisition. However,
research indicates that experts may leave out 70% of critical actions and decisions when
describing complex tasks (Feldon & Clark, 2006). Cognitive task analysis enables capture of
the specific knowledge, skills and decision steps experts use when performing a complex task,
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 36
and differs from traditional methods of task analysis such as time and motion studies, in which
human behavior was the main study focus.
CTA History
Cognitive task analysis evolved from studies of cognitive engineering, applied
psychology, industrial engineering and human factors, with origins as far back as the 1800s when
traditional methods of task analysis emerged (Militello & Hoffman, 2008). In the 1900s husband
and wife researcher team Frank and Lillian Gilbreth explored classical methods of analysis such
as the cognition and movements of bricklayers through time and motion studies. Work in task
analysis is firmly rooted in these historical time and motion studies (Taylor, 1911) whereby the
cognitive elements of work were studied in order to improve human performance. These studies
were used to analyze work movements and how to reduce the number of them to increase
productivity (Annett, 2000). Human factors related to the operation of complex machinery
became obvious in the 1900s, and even more pronounced after World War II (Militello &
Hoffman, 2008).
In the 1950s the foundations for cognitive psychology began to take hold. As the concept
of mental workload and information processing became more important it was realized that
behaviorist learning theory was not sufficient to fully analyze the skills and knowledge necessary
to teach and structure material in a more technologically sophisticated world (Annett, 2000). In
the 1960s the study of social, psychological, and cognitive activities in the workplace emerged in
response to social and political changes (Hoffman & Woods, 2000). The term cognitive task
analysis came into being as early as the 1970s (Annett, 2000; Woods & Roth, 1988). Then, in
the 1980s, expert systems, artificial intelligence and technology further fueled the need for the
study of cognitive systems. Knowledge elicitation techniques have been central to the study of
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 37
knowledge acquisition and engineering (Cooke, 1994), and at this time continue to be integral to
the development and formalization of expert or knowledge based systems. CTA studies
commonly involve settings of high consequence and technology such as air traffic control, the
military and medicine (Annett, 2000), where there is interest in capturing human expertise that
was not possible with historical time and motion studies. CTA enables the mental models used
by experts to be captured and taught to others, and is one of the most successful training
interventions of the last century (Clarke & Estes, 1996).The effectiveness of CTA in capturing
expertise and the delivery of instructional content has been proven more effective than traditional
strategies (Crandall, Klein & Hoffman 2006; Means & Gott 1988) and is now regarded as a
necessary component of research in complex cognitive work, as it addresses the interaction of
people and technology at their work (Hoffman & Militello, 2009).
Cognitive Task Analysis Methodology
The conduct of CTA consists of a set of tasks analyzed in order to elucidate the
knowledge, thought processes, and goal structures that underlie expert performance (Chipman,
Schraagen & Shalin, 2000). Through differing data collection methods including interviews and
observations, CTA yields solid evidence of a true “gold standard” for performance of complex
tasks within a specific domain. The gold standard that results can then be used to efficiently
train novices through an instructional design model that involves scaffolding and provision of
learning tasks, supportive information, just-in-time information, and part-task practice (Clark et
al., 2008). Meta-analytic reviews indicate CTA is highly effective when used for training, as
compared to traditional strategies (Clark, 2014; Lee, 2004; Tofel-Grehl & Feldon, 2013) with the
largest effect size for the Precursor, Action, Result and Interpretation method (PARI). Although
there are over 100 different varieties of CTA found in the literature, most follow a discreet
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 38
process, and only 6 are evidence based (Clark 2014; Clark et al., 2008; Yates & Feldon, 2011).
Frequently used evidence based methods include the concepts, processes and principles (CPP)
method (Clark 2004; 2006), the critical decision method (CDM) and the precursor, action, result,
interpretation (PARI) methods (Tofel-Grehl &Feldon, 2013).
The CPP is a multi-stage interview technique that captures the automated and
unconscious knowledge acquired by experts through experience and practice by using multiple
SMEs to describe the same procedure, followed by cycles of expert-self and peer-review. The
CDM is based on the concept of expert decision making, and uses semi-structured interviews and
cognitive probes to elicit knowledge related to prior knowledge, cues, goals, decision and
assessment factors as well as alternatives (Klein, Calderwood & McGregor, 1989). The PARI
method is a structured, think aloud technique that examines how experts come to problem
solutions and the reason for the decisions made in order to solve those problems (Hall, Gott &
Pokorny, 1995). Components include the precursor, or reason for the action, the action itself,
result, and interpretation of the result. The discreet, evidence based process of CTA chosen for
this study follows a five-stage process identified by Clark et al., (2008). The stages include:
1. Collection preliminary knowledge
2. Identification of knowledge representations
3. Application of knowledge elicitation techniques
4. Analysis and verification of the data acquired
5. Formatting of those results for the intended application
Clark et al. (2008) indicate that in spite of the numerous methods of CTA currently in use, most
knowledge analysts follow the above sequence, and use semi-structured interviews that enable
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 39
capture of both declarative and procedural knowledge which elucidates the “why” the “what”
and the “how” of the process being identified effectively.
Effectiveness of CTA for Capturing Expert Knowledge
There are many definitions of expertise, but most delineate a relationship between time of
practice, effort and how experts automate their knowledge. An example of a seminal study of
expertise is that of Simon and Chase (1974), who looked at the complex memory representations
of experts. In studying chess player’s cognitive processes, they found that expert players were
able to “chunk” information, thus recall more and larger configurations from long-term memory
than novice players. Although “chunking” is part of expert performance, the theory did not
account for an expert’s ability to anticipate, plan, evaluate and reason. The advanced study of
cognitive psychology now attends to knowledge content, and contexts involved in complex
knowledge structures such as decision making, reasoning, problem solving and thinking (Cooke,
1992). CTA is successful because the mental models used by experts can be captured and taught
to others.
Having an organized body of knowledge and schemas upon which to draw, experts have
more domain knowledge than the novice, however may not be able to fully express it. When
teaching or explaining a task, experts may often omit up to 70% of the critical information a
novice needs to know in order to learn and complete that complex task (Clark, 2014; Clark et al.,
2008). As a result, previous methods experts have used to teach complex skills may have
hindered the learner’s success (Feldon, 2007; Tofel-Grehl & Feldon, 2013). Traditional teaching
methods such as apprenticeships have not taken expert omissions into account. Through the
study of cognitive psychology, it has become evident that relying upon expert teaching without
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 40
some sound methodology to capture their knowledge may be sub-optimal. CTA offers that
sound methodology.
The success of CTA lies in a robust methodology which enables capture of both the
declarative and procedural knowledge that experts utilize in order to complete a complex task.
Understanding knowledge types and how experts use them is critical to elicitation of expert
knowledge and the success of CTA methods, which have been proven more effective than
traditional training methods when applied to instruction (Clark 2014). The expert’s ability to
process incoming information facilitates their ease of task execution, and it is the desire to
capture what experts know, rather than gaining the expertise on one’s own through years of
deliberate practice that has spawned improved methods of task analysis, particularly CTA
(Ericsson, 2005).
Effectiveness of CTA-Based Training
Results of studies comparing CTA based instruction with current or “status quo” methods
show improved performance of complex skills in many domains (Clark, Feldon, van
Merrienboer, Yates & Early, 2008). CTA supports effective and efficient training of complex
procedures in medical, nursing, and military education. CTA based instruction was shown to
improve surgical decision making (Luker et al., 2008), performance and cognitive strategies used
by learners in performance of surgical procedures (Sullivan et al., 2007), and instructional
descriptions of procedures by surgeons (Clark et al., 2011). CTA has been used to teach
physician resident learners through a multimedia based curriculum on surgical repair of the
flexor tendon, resulting in improved performance and problem solving (Luker et al., 2008).
CTA based instruction improved surgeons’ performance of colonoscopy procedures, versus the
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 41
traditional training methods (Sullivan et al., 2008), and was shown to help improve decision-
making skills of surgeons performing laparoscopic procedures (Craig et al., 2012).
CTA based instruction improved the acquisition of procedural knowledge in student
nurse anesthetists trained in post-operative endotracheal extubation (Embrey & Yates, 2013).
Crandall and Getchell-Reiter (1993) utilized the CDM method to guide the identification and
treatment of early sepsis in the neonatal intensive care unit. In the military domain Schaafstal,
Schraagen and Marcel (2000) utilized CTA based training in Naval Weapon Engineering
students, and found that system processing, troubleshooting, problem identification were
improved with the CTA study group.
Meta-analysis of studies. Tofel-Grehl and Feldon (2013) performed a meta-analysis of
CTA based training studies to date with the purpose of identifying the value of CTA as a
foundation for training (based upon controlled studies), observing and reporting the magnitude of
observed effects across a range of individualized CTA study methods, and to provide evidence
the CTA is a highly effective instructional methodology. The researchers found that measured
gains robustly support CTA based instruction as more effective than non-CTA based instruction,
yielding highly effective results. The largest effect sizes were noted from the PARI method
versus the CDM method. The PARI method showed an effect size of 1.598 resulting in a 45%
increase in learning for that method versus the CDM method which had an effects size of .329,
resulting in a 13% increase in learning. The overall effect for CTA-based instruction is large at
0.871 based upon Hedges’g value, whereby 0.8 or greater is a large effect with an overall post-
training performance gain of 31% (Clark, 2014). It is clear that the PARI method is much more
effective than the CDM method when applied to instruction. For either method, the effectiveness
of CTA for improved learning and training is evidentiary, and it has been suggested that CTA-
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 42
based curricula affords increased educational value to students of universities which employ a
CTA-based curriculum (Clark, 2014).
Summary
The knowledge required for the performance of complex tasks, such as how experts
deliver a handoff of anesthesia care, has up until this point in history been poorly elucidated.
Cognitive Task Analysis has been empirically proven as an effective mechanism to capture
expert knowledge. The importance of human factors related to difficulty in sharing of tacit
information has recently been identified in the handoff literature. The potential omission of 70%
of critical information that experts may omit during a handoff, remains unexplored. Thus, the
evidence upon which the handoff standardization process is built may be lacking. The
effectiveness of cognitive task analysis as a methodology to help improve the description of the
intraoperative handoff of anesthesia care is therefore examined in this study.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 43
CHAPTER THREE: METHODS
The following chapter will describe the research methods used in this study. The study
employed CTA guided interviews for knowledge elicitation from three subject matter experts in
order to generate a preliminary gold standard for teaching intraoperative handoff to novice
learners. A fourth expert reviewed the protocol and a final gold standard protocol was
developed. Details on the study design, handoff task, CTA, as well as the instruments used for
the study protocol and the statistical evaluation will be presented in this section.
The purpose of this study is to capture the knowledge and skills, operationalized as the
action steps and decision steps, and the equipment, conditions, and sensory experiences experts
use during intraoperative handoff between anesthesia providers. The research questions that
guided the study were:
1. What are the action and decision steps that expert anesthesia providers recall when
they describe how they conduct an intraoperative handoff of anesthesia care?
2. What percentage of actions and/or decision steps, when compared to a gold standard,
do expert anesthesia providers omit when they describe how to conduct the intraoperative
handoff of anesthesia care?
Task
Cognitive Task Analysis methods were used in this study to capture descriptions of
intraoperative patient handoff between anesthesia providers. Intraoperative patient care handoff
occurs when an anesthesia provider, whether an anesthesiologist or nurse anesthetist hands off
care to another provider for a break, or at the end of shift, while the patient is anesthetized and
undergoing surgery. The literature shows that current methods of teaching intraoperative handoff
involve the apprenticeship model, or use various tools, mnemonics, or checklists, that have been
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 44
developed without apparent considerations of expert omissions, and have a documented lack
efficacy in complex task training.
Participants
Ericsson, Krampe, and Tesch-Romer (1993) indicate that 10 years of deliberate practice
(with a few exceptions) identifies a domain expert. That criterion was used in eliciting domain
experts for this study. The experts were selected based upon years of practice in a variety of
settings within the domain of anesthesiology, good departmental standing, reputation, and peer
nomination. At the time of their selection, the experts not only agreed to participate in the
extensive process of Cognitive Task Analysis, but verbalized a desire and motivation to improve
the process of intraoperative handoff within their practice location. The practice location of the
SMEs was a large health science teaching institution on a university campus.
Data Collection for Research Question 1: What are the action and decision steps that
expert anesthesia providers recall when they describe how they conduct an intraoperative
handoff of anesthesia care?
The process for data collection was based on Clark et al. (2008) five-stage process for
conducting Cognitive Task Analysis. The five stages included:
1. Preliminary phase in which information is collected which builds general knowledge
about the task terms and processes, through document analysis, observations, and
informal interviews.
2. Identification of knowledge types including declarative and procedural knowledge
and any knowledge hierarchies in the application of that knowledge.
3. Use of knowledge elicitation techniques specific to the needs of the study.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 45
4. Review and analysis of the elicited knowledge through qualitative data analysis
techniques.
5. Results of the analysis become the basis for an expert system or expert cognitive
model and are formatted into a tool that may be used for training (Chipman,
Schraagen & Shalin, 2000; Clark et al., 2008).
Phase 1: Collection of Preliminary Knowledge
The researcher is an expert in anesthesia provision and well versed in the process of
handoff of anesthesia care. A thorough review of the literature related to handoff, and
intraoperative handoff of anesthesia care was conducted as a method of “bootstrapping” for the
study.
Phase 2: Identification of Knowledge Types
As a result of phase 1, the researcher developed a firm grasp of knowledge types,
including the declarative and procedural knowledge that experts use in complex task
performance of patient handoff, including pre-operative processes and procedures and
declarative knowledge of terms, such IV, fluids, and medications.
Phase 3: Application of Knowledge Elicitation Techniques
Instrument. The semi-structured interview protocol is based upon and modeled after that
created by Clark, Pugh, Yates & Sullivan (2008).The protocol (Appendix A) was developed for
use in data collection, and served as a guide for the researcher.
Clark (2004, 2006) described the CPP method as one whereby the researcher performs a
series of interview “stages” through elicitation of a “think aloud” verbal report. A verbal report
is described as the problem solver’s account of his or her own mental processing in problem
solving, which may also be concurrent or retrospective (Ericsson & Simon, 1993; Taylor &
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 46
Dionne, 2000). The think aloud report elicits the capture of major steps of the task (perhaps four
or five). The CPP technique is then succeeded by “probing” (sometimes referred to as a
“layered” technique) that elicits the SMEs description of the subtasks, and the actions and
decisions therein. Action steps explain what an individual would “do” and usually begin with a
verb. An example would be “Identify whether the patient is an inpatient, outpatient or
emergency case.” A decision step contains an alternative to consider before the action occurs,
and generally contains an IF-THEN couple. An example of such is “IF the patient is identified
as an emergency case, THEN immediately proceed to the operating room, however IF the patient
is not identified as an emergency case THEN begin to acquire in depth knowledge of the
patient’s condition.” The CTA interview technique enables elicitation of these tasks and
subtasks, through probing.
The importance of probing or prompted questions as a predominant knowledge elicitation
technique utilized in CTA (versus historical techniques such as described by Flanagan, 1954)
cannot be understated, as it has been shown to increase the number of explicated action and
decision steps elucidated by experts approximately 25% (Sullivan, Yates, Inaba, Lam, & Clark,
2014). The probing technique requires skill and necessitates practice. This preparation occurred
in the novice researcher’s extensive bootstrapping for performance of the knowledge elicitation
techniques. The interview protocol outlines major concepts, processes and principles required for
the expert to explain the task to a novice, including the following:
1. The definition, meaning and objective of the task.
2. Cues and conditions(including prior knowledge) that must be known prior to
performance of the task, including an explanation of what must be in place before the
task occurs, and/or who or what event initiates the task.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 47
3. Equipment and materials necessary to perform the task, and how the novice would
operate, position and use those materials.
4. Sensory experiences required to perform the task efficiently which may include light,
sound, smell, and feel.
5. Performance standards that the novice must be cognizant of beforehand, such as time
constraints or lack of constraint, efficiency and quality assurance standards that are either
tacit or written, or, whether there are no performance standards for the task.
6. A short list of problems that the novice must be able to solve that may occur in routine
performance of the task, described as integral to know via CTA elicited expert judgment,
whereby the novice would be able to demonstrate both declarative and procedural
knowledge as to what, where, why and how to solve the potential problem. In utilizing
CPP, the researcher began by explaining the CTA method to the SME, eliciting
understanding, allowing for questions to be asked and answered. The SME was then
asked to concisely list the major steps necessary to perform the task.
Interviews. Following Institutional Review Board (IRB) approval from the University of
Southern California, three expert anesthesia providers were identified and asked to participate in
semi-structured interviews as described in the previously outlined interview protocol. The
interviews were approximately 2-2.5 hours in length, were audio recorded and utilizing an on-
line transcription service, were transcribed verbatim with prior approval of the SMEs. Each
semi-structured interview protocol was used by the researcher to capture the non-conscious and
non-observable action steps, decisions, judgments, cognitive processes, and knowledge that the
SMEs use when they describe how to conduct an intraoperative handoff of anesthesia care.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 48
Phase 4: Data Analysis
The verbatim audio recordings enabled deep analysis of the interview data.
Coding. Analysis of the data involves breaking it down into smaller chunks and coding
it in a specific manner. The transcriptions of the semi-structured interviews were coded based
upon a coding scheme via the CPP method described by Clark (2006). The coding scheme was
then used to test for inter-rater reliability in order to ensure reliability and consistency in the
coding procedure (Appendix B).
Inter-rater reliability (IRR). One complete interview transcription was coded via the
coding scheme described above, by the researcher as well as a fellow researcher previously
trained in coding by the CPP method. The cross-checked codes were then analyzed for inter-
rater agreement, and a standard IRR was calculated as a percentage of the correspondence
between the two coders. A 97% agreement was calculated, indicating a high reliability in the
performance of coding among the two data analysts. Hoffman, Crandall and Shadbolt (1998)
determined that once there is 85% or higher agreement, the coding process is consistent and
reliable. The results of the IRR are presented in Chapter Four.
Subject matter expert protocol and verification. The step-by-step protocol for each
SME was then created from each transcribed, coded interview. After being generated, individual
step-by-step protocols were then reviewed by each of the respective SMEs for corrections,
revisions, additions or deletions to their own individual protocols.
Phase 5: Formatting the Results
Gold Standard Protocol (GSP). The reviewed, revised and corrected individual SME
protocols were then aggregated into a preliminary gold standard protocol (PGSP). The CTA Job
Aid (Appendix C) provided a representation of the CTA process, and was utilized in
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 49
development of the GSP. The protocol aggregate was accomplished by first identifying which of
the three protocols was the most complete, and accurate with sound language and terminology.
That protocol was identified as the “initial” protocol, and served as a comparison for the other
two. Each action and decision from the other individual protocols was compared in a precise,
step-wise manner to the initial protocol. If the action and decision steps had the same meaning,
then they were attributed to both SMEs. If the language of an action or decision step was much
more accurate or complete from one of the other two individual SME protocols, then that action
or decision step was slightly modified, then attributed to both SMEs. If there was a new step
identified, that was not listed in the initial protocol, that step was then added in build the initial
GSP aggregate, then that step was attributed to the SME who had described it in their individual
protocol. See Appendix C for a description of the complete procedure for creating a GSP. In this
method the PGSP was formulated and given back to each of SMEs for review of their own
protocols. The corrections, revisions, additions or deletions were incorporated into the PGSP,
which was then given to a fourth SME who was selected for review, one who did not participate
in the semi-structured interviews.
Summary
The five phase process of data collection including the three interviews and four reviews
can be represented visually in Figure 1 below.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 50
Figure 1. Five Stages of the CTA
Data Analysis for Question 2: What percentage of actions and/or decision steps, when
compared to a gold standard, do expert anesthesia providers omit when they describe how
to conduct the intraoperative handoff of anesthesia care?
Spreadsheet Analysis
The last stage of data collection was completed by transferring the action and decision
steps identified as the gold standard protocol (GSP) into a spreadsheet. Each SME’s protocol was
reviewed and compared to the GSP. If an individual protocol included an action or decision step
that was in the GSP, then a “1” was placed in the corresponding spreadsheet cell under the action
or decision step column. If the action of decision step in the GSP was not in the individual
SME’s protocol, then a “0” was placed in the cell corresponding to that action or decision step.
The researcher was able to analyze this data and convert the frequency counts into percentages
which represented the total number of agreements and omissions between the subject matter
expert’s individual protocols when compared to the GSP. In this manner, deep analysis of results
enabled the researcher to examine the knowledge types and omissions in order to answer the
research questions.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 51
CHAPTER FOUR: RESULTS
Overview of the Results
This study examines the declarative and procedural knowledge of four anesthesia experts
expressed as objectives, standards, cues, conceptual knowledge, and action and decision steps as
captured by CTA. The results of the data analysis are organized by research question.
Research Questions
Question 1
What are the action and decision steps that experts anesthesia providers recall when they
describe how they conduct an intraoperative handoff of anesthesia care?
Inter-rater reliability. As previously described in Chapter Three, IRR was determined
by tallying the number of coded items in agreement and dividing that number by the total
number of coded items. The results are shown in Appendix B. Inter-rater reliability was
established at 97%. Given the high inter-rater reliability, a single researcher coded the remaining
two SME interview transcripts prior to creation of an initial individual protocol for each SME.
Flowchart analysis. SME A’s initial individual protocol was used to create a flowchart
which is attached as Appendix D. The flowchart was carefully analyzed and reviewed by the
researcher and the senior researcher, in order to ensure that SME A’s knowledge flowed
logically and that there were no decision steps without corresponding appropriate potential
actions. The flowcharting process revealed additional questions regarding the knowledge
captured in SME A’s initial interview. Questions and clarifications occurred in the round 2
interview, which contributed to the final SME A protocol. The process of flowcharting SME A’s
interview protocol enabled the researcher to identify gaps in the steps and flow of information in
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 52
SME A’s protocol, which was the used for capture of additional action and decision steps, and to
provide the researcher a reference for the following semi-structured interviews.
Gold standard protocol. As described in Chapter Three, the researcher reviewed all
protocols and then aggregated the data. The resulting aggregate provided the initial GSP of the
description of the performance of intraoperative handoff of anesthesia care, as identified by the
experts. During the aggregation process, SME B was determined to have the most complete
individual protocol. That protocol was then used as the foundation upon which to build the
preliminary GSP. In turn, SME A’s protocol was determined more complete than SME C, and
was aggregated in a step-wise fashion. Individual action and decision steps identified by SME A
were compared to those of SME C and where similarities in steps were found, descriptions were
attributed to both SMEs. If there was an action and decision step in SME A’s individual protocol
not captured by SME B, it was added to SME B’s foundational protocol but only attributed to
SME A. Following this process, the individual protocol for SME C was also incorporated into
the PSGP. An example of the process is shown in Figure 1.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 53
Figure 2. Progression of an Action Step as Data Described by each SME from Individual Protocols is Aggregated to
Create an Action Step Found in the GSP.
The researcher identified a fourth SME, and after bootstrapping the fourth SME by
discussing the study problem, purpose and methods, the fourth SME (SME D) agreed to
participate, and was provided a copy of the initial gold standard protocol to review. Subject
matter expert D reviewed the PSGP, and was then met with in person to discuss the captured
additional action and decision steps and modification to the initial gold standard protocol. No
deletions were recommended by SME D. It should be noted that SME D had previous
experience with CTA research and was familiar with the steps of creation of the GSP. This prior
knowledge facilitated the process of formulating the GSP.
The answer to Research Question 1 is displayed in the final gold standard protocol
(Appendix E).The GSP represents the action steps and decision steps that expert anesthesia
providers use to describe the performance of an intraoperative handoff of anesthesia care. Six
SME B –Action Step:
Discuss key points of the
anesthetic case, both normal
and deviant, as well as current
status with the oncoming
provider. (B)
SME A – Additions (in Bold)
to SME B’s Action Step:
Discuss key points of the
anesthetic case, both normal
and deviant, as well as current
status with the oncoming
provider including
induction, intubation,
current quantitative
measure of muscle
relaxation, plan for
endotracheal extubation
and oxygenation. (A, C)
SME C – Additions
(underlined) to PGSP (As
Step reads in final GSP):
Discuss key points of the
anesthetic case, both normal
and deviant, as well as current
status with the oncoming
provider including induction,
intubation, current
quantitative measure of
muscle relaxation, plan for
endotracheal extubation and
oxygenation, and anticipated
postoperative needs of the
patient. (A, B, C)
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 54
procedures comprise the performance of the intraoperative anesthesia handoff. These six
procedures are:
1. Acquire knowledge of the patient’s condition (a pre-anesthetic evaluation) through
medical record review the day before surgery.
2. Interview the patient/designee.
3. Obtain an informed consent for anesthesia.
4. In the event of a “red blanket” emergency case, perform a quick survey of the patient
and document the findings (emergency cases are common to the domain of
anesthesiology and require a different approach when gathering information regarding the
patient condition).
5. Proceed to surgery and deliver, monitor and document anesthesia care until a break or
case relief is expected, and prepare for the handoff.
6. Perform the handoff procedure.
These steps are described in the following sections.
Recalled action and decision steps. Application of procedural knowledge takes the form
of step-by step action and decision steps in order to achieve the sub-task goals (Clark & Elen,
2006). An action step is an observable behavior, such as that performed during a procedure.
Decision steps are those cognitive processes that are not observable but are critical to task
performance. Decisions are made that serve as cues or prompts the SME can act upon by
evaluating, interpreting, analyzing, and making decision alternatives. The SME does this by
reasoning with “IF-THEN” couples. For instance, the experts in this study have identified that
the anesthesia handoff may occur “IF” the oncoming provider exhibits readiness cues “THEN”
the handoff may proceed. The action and decision steps captured by these experts comprise the
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 55
critical information novices need to replicate performance of the intraoperative handoff of
anesthesia care. The researcher conducted an analysis of the action and decision steps each SME
recalled in describing how to perform the handoff.
To conduct this analysis, the researcher listed each action and decision step of the final
GSP in its own unique row on the Microsoft Excel spreadsheet. The number of action and
decision steps were determined through frequency counts. In the first column on the
spreadsheet, each step in the GSP was coded with “A” for action step or “D” for decision step.
Each SME was assigned an identification letter A, B or C to maintain confidentiality, this
identifier was based on the order in which the SME was interviewed. As the action and decision
steps were designated to a specific column on the spreadsheet, those steps identified on the
individual SMEs protocol as well as the GSP were marked with a “1.” The number of actions
and decisions for each SME were totaled at the bottom of the SME’s column. The spreadsheet
analysis is attached as Appendix F. Table 1 provides a total of each SME’s action and decision
steps.
Table 1
Cumulative Action and Decision Steps Captured for Each SME in the Initial Individual
Protocols
Steps
Action Steps Decision Steps Total Steps
SME A 57 24 81
SME B 68 27 95
SME C 58 28 86
Action and decision steps contributed by each SME. Figure 2 represents the action and
decision steps recalled by each SME. In this study, each SME identified more action steps than
decision steps. In many cases the SMEs provided the same action or decision steps throughout
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 56
the CTA process. This can be noted in Table 3, “Alignment of SMEs in describing the same
action and decision steps”. As a result of this alignment, the action and decision steps reported
in Table 1 do not equal the total number of action and decision steps in the GSP.
Figure 3.Total Non-Repeating Action and Decision Steps from the CTA Process Represented in
the Gold Standard Protocol: Action and Decision Steps – 158; Action Steps –103; Decision Steps
55
The SMEs collectively described a total of 158 action and decision steps; however no
individual SME described more than 95 action and decision steps. The percentage of total
recalled action and decision steps described (not omitted) across all SMEs was between 51.27%
and 60.13%.
As shown in Figure 2, SME A recalled 57 action steps and 24decision steps, a difference
of 11.7%. SME B recalled 68 action steps and 27 decision steps, a difference of 16.93%; and
SME C recalled 58 action steps and 28 decision steps, a difference of 5.4%. The range of the
percentages of action steps identified between each SME was 10.68 %. The least percentage
identified was 55.34% versus 66.02% for the most number identified; and the range of decision
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 57
steps identified was 7.27%, between 43.64% for the least number identified and 50.91% for the
most.
Action and decision steps captured in the follow-up interviews. The researcher
identified how many additional action and decision steps were identified by the SMEs in the
round 2 follow-up interviews. The results of this analysis are shown below in Table 2.
Table 2
Additional Expert Knowledge Captured, in Action and Decision Steps, During Follow-up
Interviews
Additional Steps Captured
SME Action Decision
A 1 1
B 1 0
C 0 0
D 2 4
Note: SME D did not participate in the CTA semi-structured interviews and only reviewed the initial gold standard
protocol for additions, modifications, and deletions after it was reviewed by the other 3 SMEs.
The initial SMEs reviewed their own individual protocols and participated in a follow-up
in-person interview. The process resulted in increased action steps by 3 of the 4 SMEs, and an
increase in decision steps by 2 of the 4 SMEs. Subject matter expert D contributed 2 action steps
and 4 decision steps, more action and decision steps than SMEs A, B or C combined in the
second round interviews.
Alignment of SMEs in describing the same action and decision steps. The spreadsheet
was analyzed to determine the number and percentage of action and decision steps described by
each SME that were highly aligned, partially aligned, or slightly aligned. This analysis lends to
the percentage of agreement on all action and decision steps in the GSP identified in the
knowledge elicitation. For each action and decision step, if the step was only included by one
SME, it was identified as being “slightly aligned” then the number “1” was ascribed in a separate
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 58
column. If an action or decision step was described by two of the three SMEs, then the number
was “2” was placed in the column indicating that the step was “partially aligned.” An action or
decision step described by all three SMEs was designated by “3”in the column indicating the
step was “highly aligned.” Table 3 shows the results of this analysis.
Table 3
Number and Percentage of Action and Decision Steps that are Highly Aligned, Partially Aligned,
and Slightly Aligned
Number Percentage
Highly Aligned 33 21.43%
Partially Aligned 42 27.27%
Slightly Aligned 79 51.30%
Collectively the SMEs were “highly aligned” on 33 total or 21.43%, “partially aligned”
on 42 total or 27.27%, and “slightly aligned” on 79 or 51.30% of action and decision steps. The
implications of these differences are discussed in Chapter 5.
Question 2
What percentage of actions and/or decision steps, when compared to a gold standard, do
expert anesthesia providers omit when they describe how to conduct the intraoperative handoff
of anesthesia care?
Total knowledge omissions. To answer Question 2, the spreadsheet data was analyzed
to identify both the percentage of action and decision step captured and also omitted by the
individual SMEs when describing how to conduct an intraoperative patient care handoff of
anesthesia care. Action and decision steps included in the gold standard protocol but omitted by
the SME were marked “0.” The total number of action and decision steps omitted were added
together, then divided by the cumulative number of action and decision steps for all SMEs in the
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 59
GSP, resulting in the percentage of knowledge omissions for action and decision steps and total
steps.
As shown in Table 4, SMEs omitted between 45.57% and 48.73% of total action and
decision steps when compared to the aggregated GSP. Table 4 provides this comparison,
including mean omissions.
Table 4
Total Action and Decision Steps, or Expert Knowledge, Omissions by SME when Compared to
the Gold Standard Protocol
Steps Omitted
Total Action &
Decision Steps
Omitted
%
Action
Steps
Omitted
%
Decision
Steps
Omitted
%
SME A 77 48.73% 46 44.66% 31 56.36%
SME B 63 39.87% 35 33.98% 28 50.91%
SME C 72 45.57% 45 43.69% 27 40.09%
Mean
Omissions
70.66
44.73%
42
40.78%
28.66
52.12%
Note. Total non-repeating action and decision steps from the CTA process represented in the gold standard
protocol: action and decision steps – 158; action steps – 103; decision steps 55.
Across all SMEs, total action and decision steps omitted when describing how to perform
an intraoperative handoff of anesthesia care was on average: 70.66 or 44.72%; 42.0 average total
action steps omitted, or 40.77%; and 28.66 average total decision steps omitted, or 52.12%.
The percentage of both action and decision step omissions, or expert knowledge
omissions by SMEs A, B and C, varied moderately when compared to the GSP, from 39.87% to
48.73%. However, the percentage of action and decision steps when individually compared to
the GSP did not show great variation between SMEs. The omission rates ranged from 43.69% to
44.66% for action steps, and 49.09% to 56.36% for decision steps.
Analysis of action and decision step omissions. Figure 3 represents the action and
decision step omissions by experts A, B, and C when compared to the cumulative GSP.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 60
Figure 4. Total Non-Repeating Action and Decision Steps from the CTA Process Represented in
the Gold Standard Protocol: Action and Decision Steps – 158; Action Steps – 103; Decision
Steps 55
The next chapter will include an overview of the study, a discussion of the findings,
limitations, implications, and future research.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 61
CHAPTER FIVE: DISCUSSION
Overview of the Study
The primary purposes of this study are twofold; to capture the knowledge and skills
expert anesthesia providers use to deliver an intraoperative handoff of anesthesia care, and to
capture the percentage of actions and decisions that experts omit, when compared to the GSP,
when they describe how to conduct an intraoperative handoff on anesthesia care. This section
will discuss the study findings, limitations and implications for further research.
Process of Conducting Cognitive Task Analysis
Selection of Experts
The data collected in this Cognitive Task Analysis supplements the solid body of
evidence that experts are not fully aware of their own decisions when analyzing and explicating a
task (Clark et al., 2008; Feldon & Clark, 2006). This study identified that experts omitted
describing approximately 50% of the actions and decisions necessary to conduct a handoff of
anesthesia care. Empirical evidence shows it is integral to use the correct number of experts in
data collection. The use of three to six experts has been shown the correct number before the
point of diminished marginal utility (Chao & Salvendy, 1994; Crispen, 2010). Diminishing
marginal utility is the point at which each additional SME would provide information that would
narrow the 70% SME procedural step omission gap (Crispen, 2010). In a CTA inquiry
Bartholio (2010) found that the first SME provided an average increase in knowledge of 57.44%,
a second SME provided an average increase in knowledge of 13.28%, and a third SME provided
an average increase of 8.59% increase in knowledge. Addition of a fifth and sixth expert
additional knowledge gains were similar to that of a third expert. According to Chao and
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 62
Salvendy (1994), an established standard of 10% marginal utility is recommended. Based upon
these studies, this researcher utilized three SMEs.
Although there is not a uniform criteria in the literature for what defines an expert, the
selection criteria for experts in this study was based upon years of experience, high regard by
peers, and the special skills and knowledge resulting from extensive experience within their
domain (Chi 2006; Hoffman, 1998; Ericson, Krampe & Tech-Romer, 1993). Each expert had
greater than 8 years of experience and consistent practice within anesthesiology, and broad
experience within the domain, and none had served as instructors specific to the task of handoff
(Clark, 2004; Clark et al., 2011; Flynn, 2012). Three of the four experts were Certified
Registered Nurse Anesthetists (CRNAs). Numerous reasons support this selection. As
previously indicated the practice environment is a large teaching institution. Anesthesia
practitioners include attending anesthesiologists, resident anesthesiologists and student registered
nurse anesthetists, the latter two of which are evolving in their practice expertise. CRNAs
comprise the essential non-novices by whom intraoperative handoff is practiced multiple times
daily as a norm. Three CRNAs participated in the semi-structured interviews, and the fourth
SME D who reviewed the GSP, is a Professor of Anesthesiology. The anesthesia care team
consists of an attending anesthesiologist and either a CRNA or an anesthesia resident. This team
approach enables a balanced approach to the provision of optimal care, and as such proved
essential in expert selection.
Collection of Data
Challenges were identified in the data collection process of this study, the foremost
occurring in the process of protocol review by the experts. Enabled with ample protocol review
time, experts were noted to lack dedicated detailed attention to their individual protocol results.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 63
After addition of minimal, and sometimes no additional steps (Table 2) they indicated “I’m
satisfied” on all occasions. Herbert A. Simon (1956) identified this behavior as “satisficing”
which is a decision making strategy whereby individuals adapt well enough to “satisfice” (in that
they are satisfied enough) but generally do not optimize their behavior. The lack of attention and
focus on detail may also be described by looking at how metacognition interacts with human
curiosity.
Litman (2009) studied the psychology of metacognition as related to curiosity, and found
that metacognitive judgments about the extent to which one knows something influences whether
curiosity, and motivation to satisfy that curiosity is aroused or not. In instances where
knowledge discrepancies are identified by the person, three phenomenological states arise
(Loewenstein, 1994). When the individual searches their memory and realizes they do not have
the desired information, they experience the Don’t Know state. When no information is missing,
the individual experiences the I Know state. Both the Don’t Know and I Know states catalyze
quick and fairly accurate judgments about whether the information is not there or there. The
Feeling of Knowing state indicates that the information is in memory, but cannot be successfully
retrieved, as in the “on the tip of my tongue” phenomenon. The Feeling of Knowing states cause
intense and highly motivated need to retrieve the information, the Don’t Know state causes an
intermediate information seeking state, of moderate intensity, however the I Know state causes
the least information seeking, and the least desire for performance feedback. This may be a
reason why the experts in this CTA were “satisficed” and seemingly did not review their
protocols as thoroughly as possible, nor did they add many revisions, if any. As a result of their
expertise, it is assumed they were in the I Know state, and had a low desire for information, for
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 64
feedback. Another manner in which the review of the individual protocol may have been effected
could be through the priming effect.
Priming is identified as an experimental framework in which the processing of initially
encountered materiel or content is shown to influence a response to a subsequently encountered
stimulus (Janiszewski & Whyer, 2014). In other words, the content of the protocol, and the way
in which it was presented to the expert may have affected their judgment of the protocol content.
Thus, the expert’s initial response to the protocol content affected their subsequent review of it.
For instance, each individual protocol is similar in format to the GSP (Appendix E). The
protocols are thorough, highly detail oriented and specific, and the way the content is presented
schematically may not have activated the expert to thoroughly “take it on” so to speak. Indeed
many aspects of the CTA process take the expert out of their comfort zone.
A third challenge with data collection lies in the expert’s desire to describe actions versus
decisions. As previously described in the discussion of automaticity, functional fixedness as
described by Chi (2006) is a form of cognitive bias whereby the expert may be able to perform
quite easily, but when asked to describe why or how to perform the action, the expert will
experience some difficulty. Functional fixedness resulting from highly automated skills may be
evident in the experts in this CTA, in that they perform the intraoperative handoff of anesthesia
care perfunctorily, and as if from a working silo. They appeared more easily able to talk about
the actions involved in care provision rather than how they became familiar with the patient
condition in order to give an accurate handoff. These challenges outline the skill necessary of the
knowledge analyst in data collection for CTA methods.
To review, the data were collected for this study by conducting semi-structured
interviews with three of the four SMEs who participated in this study. The interview method
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 65
was comprised of three independent interviews and three reviews of the data collected. The
method was supplemented with a fourth independent reviewer who did not participate in the
semi-structured interviews.
Discussion of Findings
This study was guided by two main research questions.
Question 1
What are the action and decision steps that experts anesthesia providers recall when they
describe how they conduct an intraoperative handoff of anesthesia care?
Action steps versus decision steps. As noted in Chapter Four: Results, each SME
identified more action steps than decision steps when describing how they conduct an
intraoperative handoff of anesthesia care (Table 1). Description of more action than decision
steps is not uncommon to CTA, and has been evidenced in numerous other studies utilizing the
CTA technique (Canillas, 2010; Crispin, 2010; Hammitt, 2014; Tolano-Leveque, 2010; Zepeda-
McZeal, 2014). This study identified that on average, the experts recalled 59.22% of the action
steps necessary to conduct the handoff, whereas they recalled 47.88% of the decision steps. An
examination of the conscious and non-conscious (sometimes referred to as unconscious) way in
which experts process complex information in order to explicate actions and decisions may
explain this phenomenon (Clark, 2014).
The difficulty in recalling decision steps in this study may be explained by the nature of
the task and by cognitive theory. Anesthesia practice is described as highly complex,
necessitating detailed knowledge of pharmacology and the patient’s physiology whereby astute
and therapeutic decisions must be made to deliver continuous intensive care of the patient
(Modell, 2011). The ability to practice with such high cognitive load may be understood through
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 66
cognitive load theory (CLT; Sweller, 1988), which suggests that working memory is limited, but
long-term memory modulation enables cognitive schema that vary in degree of complexity and
automation (Sweller, van Merrienboer & Paas, 1988; van Merrienboer & Sweller, 2005;).
Experts can hold seemingly unlimited data in long term memory through schema formation and
automation of processes, also known as development of “germane” load. Germane load directly
contrasts with information that is irrelevant, or “extraneous” load. Central to cognitive load
theory is the individual’s ability to modulate the functional dynamic between deliberate
(conscious) and automatic (non-conscious) processing necessary to perform a complex task or
tasks (Feldon, 2007b). The complexity of anesthesia practice holds a high “intrinsic” load, a
third concept integral to the understanding of how the anesthesia practitioner balances high
cognitive load. Intrinsic cognitive load is a direct function of performing the task, as in the
number of elements that must be simultaneously processed in working memory (Kirschner,
Kirschner & Paas, 2009).
The dual-processing model of cognition holds that both controlled and automatic
processes work independently, and yet intersect such that the individual can perform the task
efficiently (Bargh &Chartrand, 1999; Feldon, 2007).The dual process could be simply explained
by Yogi Berra who said “How can you hit and think at the same time?” Beilock, Wierenga and
Carr (2002) used this reference to explain in simple terms, how expertise leads to proceduralized
control that does not require constant attention, thus experts lack extensive episodic memories
for steps or processes involved in deriving plans or for implementing actions in real time (p.
1237). This may be a reason why experts recall more action steps than decision steps, because
the effortless performance (action) of a handoff of anesthesia care is easily reproduced multiple
times daily, but there is rarely an instant where the conceptual knowledge of what, where, when
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 67
and why must be elicited, or become conscious. Thus, too many consciously mediated decision
points would require too much mental effort, and go beyond the limitations of the anesthetists
working memory. Indeed results of this study indicated that at least one of the three SMEs
utilized a standardized cognitive aid in order to mitigate the limitations of her working memory.
In basic terms, explaining “why” we act or do is not easy, and experts who participate in the
CTA method of knowledge elicitation are led into a metacognitive state and coached to remain
there for sometimes hours on end. Perhaps this is why respondents take the path of least
resistance, in that they avoid the challenge of metacognition by focusing on actions, versus the
decisions behind them.
Action and decision steps captured during the review of the initial individual SME
protocols and preliminary gold standard protocol. As discussed in Chapter Four: Results, a
minimal number of additional action and decision steps were contributed by three of the four
SMEs, with SME C contributing no additional action or decision steps. After the first interview
was conducted, the researcher conducted additional interviews in order to limit any potential
increase in cognitive load resulting from interviews of increased length. The intensive method of
knowledge elicitation has been noted as frustrating for interviewees and requires stamina, as
small segments of performance are broken down into even smaller steps (Clark, 2014). In order
to prevent frustration, bootstrapping and time management techniques were employed by the
researcher, which enabled the capture of 158 action and decision steps for the task. Prior to
participation in the interviews, each SME was adequately briefed to the CTA method, meaning
they were provided with a prerequisite information regarding the rigorous CTA methodology,
and research purpose. The interview for SME A, in which the senior researcher participated,
lasted approximately 1.5 hours, however, the interviews with SMEs B and C lasted 2.5 to 3 hours
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 68
in length, and were broken up into two sessions of approximately 1-1.5 hours in length, at the
discretion of the researcher.
It is possible that this technique of time management decreased the cognitive load that
may have been entailed in a long interview, and proved frustrating, leading to less than optimal
returns for experts who had no prior knowledge of the CTA technique. Further, the second
portion of the interview for SME B occurred via Skype technology. The use of technology in
semi-structured interviews has not been examined to the researcher’s knowledge. Environmental
controls and distraction limitations were discussed and agreed to upon the Skype interview, and
subsequently the SME verbalized that utilization of the technology facilitated a comfortable
environment, less distractions and the ability to think. This finding supports the assertion by
Zepeda-McZeal (2014) that face-to-face protocol reviews increase the number of action and
decision steps elicited by knowledge analysts. It may be that, as it was found in this study, that
face-to-face can include the use of technology, as SME B provided the most combined action
and decision steps of all three SMEs (Figure 2).
It should be noted that experts may not always have large chunks of time to dedicate to
CTA, however SMEs A, B and C verbalized motivation to improve the process of intraoperative
handoff and patient outcomes. High interest from the experts may result, in part, from the
environment as a teaching institution as handoffs are often received from individuals learning
how to perfect the process. SME D reviewed the GSP, and did not participate in the semi-
structured interviews. Surprisingly, SME D contributed the most additional steps, including 2
action and 4 decision steps. SME D however, had prior knowledge of the CTA procedure, having
served as a SME on a previous CTA study. Prior knowledge has been shown to lessen the
number of action and decision steps that experts omit when describing a task (Yates et. al.,
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 69
2011), as described previously in the discussion of exceptions to the 70% rule. Prior knowledge
will be discussed in the subsequent section expert knowledge omissions.
Alignment of action and decision steps. SMEs A, B and C described 21.43% of the
same action and decision steps when verbalizing how they conduct an intraoperative handoff of
anesthesia care. Two out of 3 SMEs agreed upon 27.27% of the total action and decision steps
of the process. If only one SME described a step, it was considered partially aligned, and this
partial alignment or lack of agreement on a step constituted 51.30% of the action and decision
steps of the task. This result possibly reflects the fact that the complex task of intraoperative
handoff is not standardized. However, the six main tasks of the procedure elicited in the free-
recall phase were met with 100% alignment by the SMEs, indicating that there are essential steps
each expert employs in the exchange of information, that are perhaps imperative to maintain
basic safety. Those major tasks however, reflect the current state of handoff within the practice
area, as well as that described in the review of literature, as an information processor, with no
exploration of the essential information derived from tacit knowledge elicitation. Institution of
the formal knowledge elicitation technique including probing, enabled the elucidation of tacit
knowledge by the experts. This is in line with a description by Manser et al., (2013) that
described tacit knowledge as that which is rarely shared in the operating room handover, that
which is difficult to capture. The lack of alignment in the action and decision sub-steps described
by the SMEs (Table 3) may indicate the lack of alignment and/or standardization of the process
itself which was described by the SMEs as generally performed haphazardly without use of
cognitive aids or checklists.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 70
Question 2
What percentage of actions and/or decision steps, when compared to a gold standard, do
expert anesthesia providers omit when they describe how to conduct the intraoperative handoff
of anesthesia care?
Expert knowledge omissions. Experts omitted between 45.57% and 48.73% of the
actions and decision steps when describing how to conduct the intraoperative handoff of
anesthesia (mean omissions 44.73%). These results are similar to other CTA study findings.
Tolano-Leveque (2010) hypothesized that expert surgeons would omit approximately 70% of the
action and decision steps when describing how to perform a relatively common and
uncontroversial procedure, the open cricothyrotomy (OC), versus a controversial procedure, the
central venous catheter procedure. The central venous catheter (CVC) insertion procedure was in
the midst of high controversy at that time as a result of patient complications resulting from the
procedure. As a result of the controversy, there had been recent review of performance standards
related to the procedure, perhaps increasing the prior knowledge of the experts. All six SMEs in
that study were able to recall an increased number of action and decision steps compared to the
GSP (68.97%), meaning they omitted only 31.03% of the action and decision steps compared to
the GSP. Thus, the attention focused on the CVC procedure that time may have produced results
that did not meet the 70% omission rule, as a result of recent review of the procedure. In spite of
the increase in prior knowledge that was theorized to result in the lower amount of omissions
versus the OC procedure where fresh prior knowledge was not a factor, the experts still omitted a
greater number of decision steps versus action steps (34.52% vs 29.92%). This point will be
discussed further in this discussion. However, in relation to the OC procedure Tolano-Leveque
found different results.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 71
Tolano-Leveque (2010) found that experts recalling performance of the OC procedure
where there was no fresh prior knowledge, omitted 51.81% of the total action and decision steps
described by the expert surgeons, when compared to the GSP. This result is similar to the results
of the current study, whereby the expert anesthesia providers omitted 44.73% of the total action
and decisions used to describe the intraoperative handoff of anesthesia care, when compared to
the GSP. Again, expert surgeons describing the OC procedure omitted more decision steps than
action steps (76.96% vs 41.92%) a result that was replicated in the current study.
Another CTA study had similar findings in respect to the percentage of action and
decision steps omitted by expert surgeons when describing a procedure. Bartholio conducted a
CTA (2010) of knowledge omissions related to the number of experts that must be interviewed
to acquire the critical information needed to perform and CVC placement. Bartholio examined
how much critical information was gained from each additional expert (from one to six)
compared to the GSP. Results were utilized as evidence of the utility of using three experts, as is
modeled in the current study. That study found that one SME proved an average of 57.44%
average increase in knowledge gains, a second SME 13.28% gains, and a third 8.59%, meeting
the 10% established standard of marginal utility set by Chou and Salvendy (1994) in explaining
CVC insertion. Bartholio’s findings in relation to the total actions and decisions acquired, were
also pertinent to this CTA. The research indicated that the amount of critical information gained
from each additional expert compared to a six SME GSP was 43% to 73% with a mean of total
acquired knowledge of 57%. The amount of critical information omitted from each additional
expert when compared to a six SME GSP was approximately 43% which is similar to the amount
of total action and decision steps omitted when experts describe how to conduct an intraoperative
handoff of anesthesia care. Although the study by Bartholio (2010) was not a study of omissions,
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 72
the data was relevant to this study focusing on omissions. Analysis and comparison with the
results of this CTA indicate that experts omit approximately half of the critical actions and
decisions used to describe controversial procedures.
Limitations
The findings and limitations of this study are discussed below.
Confirmation Bias
The first limitation of the study is related to potential confirmation bias. This type of
researcher bias poses a threat to the validity of the qualitative conclusions, in that the researcher
imposes existing theories, goals, and motives onto their research (Maxwell, 2013). For instance,
as the researcher is an expert in the provision of anesthesia care, the first interview conducted
with the senior researcher (an accomplished novice in the study of handoff practices in
anesthesia), delineated the preoperative evaluation as a major procedure in the task, a component
that would have otherwise not been included in the initial protocol, as a result of possible
conformational bias by the junior researcher. The senior researcher brought to light the
importance of the preoperative evaluation (acquiring prior knowledge of the patient condition)
and that this information should be included in the protocol. Clark et al., (2008) indicate that
unconscious expertise has great implications in the accuracy of task analysis, as was evidenced
in this potential expert omission of a main protocol step. Bransford, Brown and Cocking (1999)
identified that expertise in a particular domain may be more hurtful than helpful, as it is the
accomplished novice that challenges the expert’s main ideas, as was evidenced in this study.
Internal Validity
Threats to validity raise questions about the experimenter’s ability to conclude that their
intervention affected the outcome, versus some other factor (Creswell, 2009). One potential
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 73
threat to internal validity lies in the use of the Skype technology in a portion of the data
collection. A reason this may be a threat results from a lack of study of this particular method of
data collection in any CTA thus far. There has not, at this point, been evidence of whether or not
use of this technology helps or skews the quality of data elicited. As in this study, the use of
Skype is a proverbial “toe in the water” it important point to consider for future study.
Participant selection of a fourth SME that reviewed the GSP, but had previous prior knowledge
of CTA from having participated in one, may have been a threat to internal validity. This has, to
this researcher’s knowledge, not been evidenced in the literature, and is another point to consider
for future study.
External Validity
A threat to the external validity of this study lies in the potential that it may not be
generalizable due to the specificity of the practice environment. Having been conducted in a
large teaching institution, it is important to remember that not all hospitals or anesthesia care
environments are teaching institutions. Institutions that are not educational entail handoff from
practitioners of differing backgrounds including practitioners who are both seasoned, and those
who are learners. Again, this identifies an area of further study, in that an all anesthesiologist
panel of expert SMEs may potentially result in different data, and interpretation of that data. An
area that supports the external validity of this study lies in qualitative case study research. The
mixed methods quality of CTA research entails both quantitative and qualitative aspects. At the
heart of this CTA is the case study of data acquired from four experts, which is aggregated into
the gold standard for intraoperative handoff. Merriam (2009) indicates that although the case
study focuses on a single unit, in this case the aggregated GSP, much can be learned from a
particular case (p. 51). This CTA not only exemplifies a highly refined technique of knowledge
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 74
elicitation based upon years of scholarship within the realm of cognitive psychology, but enables
the real world application of that knowledge based upon evidence. This study may be applied to
the intraoperative handoff of anesthesia care, in order fills in the gap of an ill-defined process,
thus demonstrating generalizability, and external validity.
Implications
Cognitive task analysis as a technique of knowledge elicitation has proven effective in
capturing expert omissions. Once those omissions are captured, the information can be used for
evidence based teaching and education. This study has identified the action and decision steps
that can be used to deliver the handoff of care of patients who are under anesthesia. It is
important to note that other handoffs identified in the literature include the participation of an
awake, coherent patient who many times may correct misinformation shared by the health care
professional. Accurately identifying the handoff information in a process in which the patient
cannot participate, and revise or correct misinformation is clearly an imperative. Getting to the
knowledge omissions with use of the specialized CTA technique has been proven key to
description of the performance of this complex task, and can potentially be used as a model and
springboard for further process improvements in anesthesiology, as well as general handoff
practices.
Future Research
This CTA guided study identifies many areas for future research. As described in the
Literature Review, handoff process standardization is a mandate. In order to take this research
study to the next level, a standardized process, based upon the GSP must be considered. As
previously described, many standardized processes including EMR checklists have been
employed; however none based upon a CTA. Future research should include development of an
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 75
effective intraoperative handoff checklist or cognitive aid, based upon CTA studies such as this
one. Use of this research for handoff education is a next step. Validation of the technical and
non-technical skills delineated in this CTA may be studied through simulation education,
whereby practitioners can practice the complex skill in a safe environment devoid of the
potential for patient harm. With regard to the interview technique, the use of technology to aid in
the interview process, specifically Skype, is an interesting area for further inquiry.
Conclusion
The purpose of this study was to identify the action and decision steps experts use to
deliver an intraoperative handoff of anesthesia care. Also, the study identified the percentage of
action and decision steps they inadvertently omit when describing the performance of that task.
Indeed the experts were able to produce a standard set of tasks representative of the
intraoperative handoff, a task easily reproduced in a think aloud fashion, as it is reproduced
sometimes many times daily. Automation of the task set forth some difficulty in accessing that
tacit knowledge required to perform the handoff, however the CTA method of knowledge
elicitation enabled the explication of that tacit knowledge. This study supports previous research
results that show experts with prior knowledge of a controversial procedure commit less
knowledge omissions versus procedures that are not controversial. As well, experts were again
found to describe more actions than decision steps. This CTA is an important contribution to the
body of literature related to handoff processes, as it fills in the gap of expert knowledge
omissions in the development of improved intraoperative handoff of anesthesia care.
Implications related to patient safety are perhaps the most important contribution of this CTA,
which has provided an evidence based departure point not simply based upon expert opinion.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 76
This study accounts for inherent expert omissions of critical information that are inevitable in
complex, high stakes tasks.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 77
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Appendix A
Cognitive Task Analysis Interview Protocol
Begin the Interview: Meet the Subject Matter Expert (SME) and explain the purpose of the
interview. Ask the SME for permission to record the interview. Explain to the SME the
recording will be only used to ensure that you do not miss any of the information the SME
provides.
Name of task(s): Intraoperative patient care handoff
Performance Objective: To conduct an accurate and complete exchange of patient care
information
between anesthesia providers in the operating room, in order to achieve consistency in
communication and information exchange during the patient care handoff.
Ask: “How would the action term be stated? What action verb should be used?”
Step 1:
Objective: To capture 100% accurate transfer of patient information during the intraoperative
handoff procedure.
Ask the Subject Matter Expert (SME) to list provider outcomes when these tasks are complete.
Ask them to make the list as complete as possible
A. How is the provider assessed on these outcomes?
Step 2:
Objective: Provide practice exercises that are authentic to the job environment in which the
tasks are performed
A. Ask the SME to list all the contexts in which these tasks are performed (operating room,
hospital setting)
B. Ask the SME how the tasks would change for each job setting
Step 3:
Objective: Identify main steps or stages to accomplish the task
C. Ask SME/provider the key steps or stages required to accomplish the task.
D. Ask SME to arrange the list of main steps in the order they are performed, or if there is
no order, from easiest to difficult.
Step 4:
Objective: Capture a list of “step by step” actions and decisions for each task
A. Ask the SME to list the sequence of actions and decisions necessary to complete the task
and/or solve the problem
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 99
Ask: “Please describe how you accomplish this task step-by-step, so a novice provider
could perform it.”
For each step the SME gives you, ask yourself, “Is there a decision being made by the
SME here?” If there is a possible decision, ask the SME.
If SME indicates that a decision must be made…
Ask: “Please describe the most common alternatives (up to a maximum of three) that
must be considered to make the decision and the criteria novice provider should use to
decide between the alternatives”.
Step 5:
Objective: Identify prior knowledge and information required to perform the task.
A. Ask SME about the prerequisite knowledge and other information required to perform the
task.
1. Ask the SME about Cues and Conditions
Ask: “For this task, what must happen before someone starts the task? What prior task,
permission, order, or other initiating event must happen? Who decides?”
2. Ask the SME about New Concepts and Processes
Ask: “Are there any concepts or terms required of this task that may be new to the
novice?”
Concepts – terms mentioned by the SME that may be new to the novice
Ask for a definition and at least one example
Processes - How something works
If the trainee is operating equipment, or working on a team that may or may not
be using equipment, ask the SME to “Please describe how the team and/or the
equipment work - in words that novices will understand. Processes usually consist
of different phases and within each phase, there are different activities – think of
it as a flow chart”
Ask: “Must novices know this process to do the task?” “Will they have to use it
to change the task in unexpected ways?”
IF the answer is NO, do NOT collect information about the process.
3. Ask the SME about Equipment and Materials
Ask: “What equipment and materials are required to succeed at this task in
routine situations? Where are they located? How are they accessed?
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 100
4. Performance Standard
Ask: “How do we know the objective has been met? What are the criteria, such
as time, efficiency, quality indicators (if any)?”
5. Sensory experiences required for task
Ask: “Must trainees see, hear, smell, feel, or taste something in order to learn
any part of the task? For example, are there any parts of this task they could not
perform unless they could smell something?”
Step 6:
Objective: Identify routine or simple problems that they can do with this procedure.
A. Ask the SME to describe at least one routine problem that the novice should be able to
solve if they can perform each of the tasks on the list you just made.
Ask: “Of the task we just discussed, describe at least one routine problem that the
trainee should be able to solve IF they learn to perform the task”.
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 101
Appendix B
Inter-rater Reliability Code Sheet for SME A
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 102
Appendix C
Job Aid for Developing a Gold Standard Protocol
Richard Clark and Kenneth Yates (2010, Proprietary)
The goals of this task are to 1) aggregate CTA protocols from multiple experts to create a “gold
standard protocol” and 2) create a “best sequence” for each of the tasks and steps you have
collected and the best description of each step for the design of training.
Trigger: After having completed interviews with all experts and capturing all goals, settings,
triggers, and all action and decision steps from each expert – and after all experts have edited
their own protocol.
Create a gold standard protocol
STEPS Actions and Decisions
1. For each CTA protocol you are aggregating, ensure that the transcript line number is
present for each action and decision step.
a. If the number is not present, add it before going to Step 2.
2. Compare all the SME’s corrected CTA protocols side-by-side and select one protocol
(marked as P1) that meets all the following criteria:
a. The protocol represents the most complete list of action and decision steps.
b. The action and decision steps are written clearly and succinctly.
c. The action and decision steps are the most accurate language and terminology.
3. Rank and mark the remaining CTA protocols as P2, P3, and so forth, according to the
same criteria.
4. Starting with the first step, compare the action and decision steps of P2 with P1 and
revise P1 as follows:
a. IF the step in P2 has the same meaning as the step in P1, THEN add “(P2)” at the
end of the step.
b. IF the step in P2 is a more accurate or complete statement of the step in P1,
THEN revise the step in P1 and add “(P1, P2)” at the end of the step.
c. IF the step in P2 is missing from P1, THEN review the list of steps by adding the
step to P1 and add “(P2N)”* at the end of the step.
5. Repeat Step 4 by comparing P3 with P1, and so forth for each protocol.
6. Repeat Steps 4 and 5 for the remaining components of the CTA report such as triggers,
main procedures, equipment, standards, and concepts to create a “preliminary gold
standard protocol” (PGSP).
7. Verify the PGSP by either:
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 103
a. Asking a senior SME, who has not been interviewed for a CTA, to review the
PGSP and note any additions, deletions, revisions, and comments.
b. Asking each participating SME to review the PGSP, and either by hand or using
MS Word Track Changes, note any additions, deletions, revisions, or comments.
i. IF there is disagreement among the SMEs, THEN either
1. Attempt to resolve the differences by communicating with the
SMEs, OR
2. Ask a senior SME, who has not been interviewed for a CTA, to
review and resolve the differences.
8. Incorporate the final revisions in the previous Step to create the “gold standard protocol”
(GSP).
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 104
Appendix D
SME A Individual Protocol Flowchart
Begin Procedure 1:
Acquire knowledge
of the patient
condition through
medical record
review
Identify whether the
patient is an inpatient
or an outpatient
Is the
preoperative
form
complete?
If Inpatient
go to
Procedure
2
Legend
Begin and
end
process
Decision
point
Action step
No: go to
Procedure
2
If outpatient locate
completed
preoperative
evaluation on EMR
End Procedure 1
Yes: Use a heightened
degree of caution
when depending upon
another provider’s
assessment
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 105
Physical
assessment
and consent
complete?
Does the
information
align?
Proceed to the
patient location
Identify
patient/designee and
ensure alignment of
identifiers and
surgical consent
Begin Procedure 2:
Greet, interview
and obtain
informed consent
from the patient
No: Collaborate with
surgical and
anesthesia care team
for further
clarification
Yes: Proceed to the
patient physical
assessment and
consent
No: Repeat procedure
2
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 106
Begin Procedure 3:
Discussion of plan
with anesthesia
care team
Is the plan
agreed upon?
No? Review and
discuss until plan is in
place and repeat
procedure 3
Yes: Proceed to
surgery
End Procedure 3
Yes: End procedure
2
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 107
Begin Procedure 4:
Patient is in surgery
and handoff is
anticipated
Is the case
ready for
handover?
No? Continue handoff
preparation including
update anesthesia
record, total fluids
and calculate deficit,
evaluate muscle
relaxation, observe
surgical field for
expected completion
Yes: Continue to the
next decision point
Will surgery
end beyond
the end of
shift?
No? Then maintain
continuity of care and
complete the case
Yes: Finalize handoff
preparation End Procedure 4
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 108
Begin Procedure 5:
Conduct the handoff
No? Wait for
readiness
Does the
oncoming
provider exhibit
readiness for the
handoff?
Yes: Proceed with
the handoff
Make the
preoperative
evaluation form
available
Identify patient and discuss:
Health history, allergies
Diagnosis
Surgical procedure
How the patient has
tolerated anesthesia
Airway management
Medications and patient
response
Time of last antibiotic
Fluid management
Fluid losses
IV access
Status of surgery
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 109
Is the receiver
satisfied with the
information?
No? Then
clarify
information
and repeat
procedure 5
Yes: Then proceed to
the next step
Does the receiver
exhibit cues of
accurate receipt of
information?
Yes: Then get
confirmation and
inform O.R.
personnel of
personnel change
No? Then
clarify the
information
and repeat
procedure 5
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 110
Was handoff
completed with
clarity of
information?
No? Then ensure
clarification of
information
Yes: Then perform
one last survey and
leave the room
End of
perioperative
handoff of
anesthesia care
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 111
Appendix E
Gold Standard Protocol
Intraoperative Handoff of Anesthesia Care
1. Objective
To provide the safe seamless transition of care for shift relief or break, of a patient from one
provider to another such that they may continue a safe and well executed anesthetic (A,B,C)
2. Reasons
To transfer care of the patient from one provider to another provider such that care can be
continued seamlessly to completion, enabling the oncoming practitioner with complete
information including an in depth review of the patient’s health history, surgical procedure,
intraoperative events, and medications, ensuring a good anesthetic outcome (A,B)
Safe anesthetic outcome (C)
Risks of not performing the patient handoff safely:
A partial transfer of care, or missed information poses a risk to patient safety (A)
Benefits of performing the patient handoff safely:
Enough information is passed on to enable a plan of care to be carried out in the absence of
the primary provider (A)
3. Conditions
Indications
A break handoff (note: a break is generally 15-20 minutes in length) is an abbreviated
handoff report as the practitioner will be returning shortly, and will not be responsible
for a complete care handoff or transport (A,B,C)
An end of shift handoff entails a thorough handoff of care (A), similar to a case
presentation (B) and must entail the primary practitioner’s plan for patient care as
applied to the remainder of the case (A)
Any type of handoff close to emergence time it must entail the plan for the safe
emergence of anesthesia, and extubation technique (A)
The patient must be in stable condition (A,C)
When the pre-op has been completed by another person, review all pertinent
information and review the source data originals and come to your own conclusions
and diagnosis (C)
The pre-operative patient will either be an outpatient, an inpatient, or an emergency
case
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 112
The outpatient may not have a preoperative evaluation complete and on the chart if
they are a healthy patient ASA 1 with no co-morbidities and the pre-op can be
completed quickly the morning of surgery (C)
The inpatient will need to be seen prior to surgery so the preoperative evaluation and
consent can be completed, and a plan of care begun (C)
The ICU patient will have a higher acuity and the pre-operative exam will be more
extensive (C)
Contraindications
Both break and case relief handoff are contraindicated if the patient is having a
critical event at the time (A) or, if the patient is unstable (A,B)
4. Standards
Time:
End of shift handoff is a full report (A,B,C)
Break relief may be an abbreviated report (A,B,C)
The beginning of the case is usually not the best time because of hemodynamic
swings, rapid changes in the patient condition, and charting is not up to date (B)
The middle of the case is usually the safest time to take a break (B)
Standards:
Departmental standards for pre-operative evaluation exist on the anesthesia intranet
document and indicate that enough information should be included in order to
perform a safe anesthetic (C)
The pre-operative evaluation is a legal document (B)
There are no specific “standards of performance” related to patient handoff (B)
Complicated reports can take an extended amount of time (C)
ASA classification of anesthetic risk (C)
Interpreter services will be utilized to as necessary to ensure proper communication
and information transfer (C)
The anesthesia record must be up to date at the time of handoff (C)
5. Equipment
Pre-op evaluation blank form (PF)
Electronic medical record (EMR)
Handoff reference blank sheet
Laboratory report slips
6. Procedure List
Note: the handoff procedure begins with acquisition of patient information in the preoperative
evaluation period
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 113
1. Acquire knowledge of the patient’s condition (a pre-anesthetic evaluation) through medical
record review the day before surgery
2. Interview the patient/designee
3. Obtain an informed consent for anesthesia
4. In the event of a “red blanket” emergency case, perform a quick survey of the patient and
document the findings
5. Proceed to surgery and deliver, monitor and document anesthesia care until a break or case
relief is expected and prepare for the handoff
6. Perform the handoff procedure
7. Procedure steps
1. Acquire knowledge of the patient’s condition (a pre-anesthetic evaluation) through medical
record review the day before surgery [Note: the handoff procedure begins with acquisition of
patient information in the preoperative evaluation period] (A,B).
1.1. Check the anesthesia schedule between 1000 and 1300 for the next day’s cases to see
which room/service on your schedule for the next day and print it or make note of it
(B,C)
1.2. Check and print or make note of the surgery schedule later in the day to determine if
your patient is an inpatient or outpatient (note: the anesthesia schedule and surgery
schedule are the two schedules whereby the complete patient assignment is delineated)
(A,B,C)
1.2.1. IF you are unable to complete Steps 1.1 and 1.2 in person, THEN obtain the
information by calling a colleague or the front desk (B)
1.2.2. IF the patient is an inpatient and time permits THEN obtain a blank pre-operative
evaluation form and performStep 2 (A,B)
1.2.3. IF the patient has a previously completed pre-op on the EMR THEN
1.2.3.1. Review it for completeness using a heightened degree of caution (A)
1.2.3.2. Make alterations to it as necessary (C)
1.3. Go to the inpatient care area/ICU to conduct a document evaluation of the EMR and
hardcopy chart (A,B)
1.3.1. IF the patient is an ICU patient and surgery is imminent THEN take a transport
monitor (C)
1.3.2. IF the patient has a PF completed THEN determine alignment between the
completed pre-op, and patient condition (A)
1.4. Conduct chart and/or EMR review of the following and document pertinent findings
from the nursing notes (A,B), physicians notes (A,B,C), consult notes (A,B,C),
paramedic notes if necessary (B),
1.5. Document integral information on the PF:
1.5.1. Age (B,C)
1.5.2. Height (A,B,C)
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 114
1.5.3. Weight (A,B,C)
1.5.4. BMI (A)
1.5.5. Language spoken (B)
1.5.6. Allergies (A,B,C)
1.5.7. Comorbidities (C)
1.5.8. Home and hospital medications (C)
1.5.9. Previous surgeries (C)
1.5.10. Activity (A)
1.5.11. Neurologic status (A)
1.5.12. Nutritional status/NPO length of time/TPN (A)
1.5.13. Pain (A)
1.5.14. Nausea (A)
1.5.15. Compliance with treatment (A)
1.5.16. Other pertinent issues (A,B,C)
1.6. Review and document pertinent study results including:
1.6.1. EKG (A,B)
1.6.2. CXR (A,B)
1.6.3. laboratory (B,C)
1.6.4. radiology (B,C )
1.6.5. CT scans (B,C)
1.6.6. MRI (C)
1.6.7. echocardiography (B)
1.6.8. cardiac stress tests (C)
1.7. For long-term patients, locate their previous medical records, review and note any
significant findings on the pre-op form (C)
2. Interview the patient/designee
2.1. Approach and identify the patient by name and date of birth (A)
2.1.1. IF the patient is obtunded THEN meet or phone the designated family member to
complete the process(A)
2.2. Establish a relationship, identifying yourself as a member of the anesthesia care team
(A,B)
2.3. Conduct the interview
2.3.1. IF the information provided by the patient/designee aligns with the surgical
consent THEN begin to complete the preoperative evaluation by filling in the
preoperative assessment form (A)
2.4. Perform a patient head to toe physical assessment (B,C) including
2.4.1. Neurologic status and level of sedation (A,C)
2.4.2. Spinal precautions (C)
2.4.3. Heart sounds (A,C)
2.4.4. Lung sounds (A,C)
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 115
2.4.5. Peripheral pulses (A)
2.4.6. Airway exam (A,C)
2.4.7. Skin color (C)
2.4.8. Visual inspection of body and extremities (A)
2.4.9. IV access (C)
2.4.10. Presence of inotropic drugs (C)
2.4.11. Other current medications (C)
2.4.12. IF the patient is in ICU THEN locate and obtain a verbal report from the
physician and nurse who has been taking care of the patient to find out recent
history, changes, how the patient has been progressing or not progressing (C)
2.4.13. IF the pre-operative evaluation was previously completed by another provider,
THEN ensure alignment between the consent and scheduled operation (C),
assessment findings and patient history, and reconcile any gross differences with the
perioperative team to clarify next steps (A,B) and document (B)
2.4.14. IF there are specific risks, concerns, or the case will not proceed THEN
communicate with the surgeon, patient or designee and document(B)
2.4.14.1.
3. Obtain an informed consent for anesthesia (A,B,C)
3.1. Discuss the informed consent for anesthesia services with the patient/designee
3.1.1. IF the patient is obtunded THEN meet or phone the designated family member to
complete the process(A), being attentive to privacy issues (C)
3.1.2. IF the patient has a previously obtained consent THEN review the document for
completeness, and make any changes as necessary (A,B,C)
3.1.3. IF the preoperative evaluation and consent are complete THEN proceed to
surgery
4. IF there is a “red blanket” emergency case, THEN acquire knowledge of the patient’s
condition from the desk personnel (B) AND
4.1. Contact the trauma team as time permits (B,C,D)
4.2. Perform quick survey of the patient’s condition (A,B,D) acquiring the following
information:
4.2.1. Diagnosis (B)
4.2.2. Emergency type (B)
4.2.3. Name (B)
4.2.4. Medical record number (B)
4.2.5. Age (B)
4.2.6. Gender (B)
4.2.7. Allergies (B)
4.2.8. Patient stability (B)
4.3. Identify whether the patient can answer questions
4.3.1. IF the patient is able to answer questions THEN gather the following information
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 116
4.3.1.1. Allergies (C)
4.3.1.2. Health history (C)
4.3.1.3. Medications (C)
4.3.1.4. Verbal consent (C)
4.3.2. IF the patient us unable to answer questions THEN
4.3.2.1. Gather information from the EMR and/or chart when patient stability has
occurred (A,C) OR
4.3.2.2. Direct a team member to gather and document information from the EMR
and/or hardcopy chart and read it aloud to guide treatment (B,C)
4.3.2.3. Write information down on the quick reference sheet or pocket card as a
reference for a possible handoff, if and when able (B)
4.4. Perform a head to toe assessment of the patient while proceeding with surgical and
anesthetic care (B)
4.5. Proceed to surgery and deliver, monitor and document anesthesia care until a break or
case relief is expected
5. Prepare for the handoff (A,B,C)
5.1. Monitor the progress of the surgery by looking at the surgical field and when appropriate
ask the surgeon for the anticipated end of surgery (A, B)
5.2. Monitor the time remaining until the end of your shift or a required break whichever is
sooner and prepare for a break or case relief handoff (A,B,C)
5.3. Make the preoperative evaluation form readily available on the anesthesia machine/cart
while anesthesia care is monitored and documented during surgery (A,B)
5.4. Create a handoff reference sheet for the oncoming provider that includes key
information:
5.4.1. Name (C)
5.4.2. ASA status of patient (B)
5.4.3. Age (B)
5.4.4. Gender (B)
5.4.5. Language (B)
5.4.6. Allergies (B)
5.4.7. Comorbidities/significant health history (A,B,C)
5.4.8. Diagnosis (C)
5.4.9. Surgical procedure (B)
5.4.10. Medications (B)
5.4.11. Fluid intake (A,B,C)
5.4.12. Blood Loss (A,B,C)
5.4.13. Antibiotic times (B)
5.4.14. Patient disposition (B)
5.4.15. Blood refusal (C)
5.4.16. Complications (B,C)
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 117
5.4.17. Number and adequacy of IV lines (A,B,C)
5.4.18. Arterial access (A,B)
5.4.19. Presence of regional blocks and time frames (B)
5.4.20. The anesthetic plan (A,B,C)
5.5. IF the following conditions are met as follows, THEN it is safe to handoff the
patient(A,B,C):
5.5.1. The patient is stable (C)
5.5.2. Necessary tasks are completed (B)
5.5.3. The relief person has the prerequisite knowledge based upon their level of training
(C)
5.5.4. The relief person has the prerequisite skill based upon their level of training (C)
5.5.5. The case will end greater than 30 minutes after the change of shift (A,B,C)
5.5.6. The case is not prohibitively complex (C)
5.6. Complete documentation of the anesthesia paper/EMR record (A,B.C)
6. Conduct the Handoff
6.1. Greet, identify, and look for situational awareness and readiness cues in the oncoming
provider (A,B)
6.1.1. IF the oncoming provider lacks readiness or seems preoccupied THEN verbally
determine and acknowledge their readiness for handoff AND begin the handoff
once ready (A,B)
6.2. Begin the handoff process by surveying the surgical and anesthetic environment
6.2.1. Ensure safe conditions such as visualization of the record will provide for safety
of information sharing (C)
6.2.2. Minimize interruptions in the handoff (A)
6.2.3. Mutually survey the surgical field (B,C)
6.3. Visually inspect the patient
6.3.1. Positioning (B,C)
6.3.2. Eyes and face (B,C)
6.4. Mutually review each point in the handoff reference sheet in step 5.4 (B)
6.5. Refer to the anesthetic record whether paper or EMR and inspect vital signs trends
baseline and trends (A,B)
6.6. Discuss key points and current status both normal occurrences and deviations (B)
including
6.6.1. Induction and intubation (A,C)
6.6.2. Current Muscle relaxant quantitative measure of relaxation (A,B)
6.6.3. Emergence plan for endotracheal extubation and oxygenation (A,B)
6.6.4. Anticipated patient postoperative needs (C)
6.7. Clarify any misinformation and elicit discussion of the handoff information, maintaining
patient stability (A,B)
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 118
6.7.1. IF the oncoming provider exhibits lack of attention to the report THEN restate the
information (A, B, C)
6.7.2. IF the oncoming provider has been writing down information make sure it is
correct information and allow them time to complete their notes (A,C)
6.7.3. IF the receiver asks a question THEN ensure that you cover the information and
answer the question (A)
6.7.4. IF handoff is interrupted for a surgical need, or if the patient has an event that
requires immediate intervention THEN interrupt handoff to take care of the need
(A)
6.8. Complete and document that handoff process (C)
6.8.1. IF the handoff reference sheet and key discussion points have been covered
THEN
6.8.1.1. Give the oncoming person time to digest the information
6.8.1.2. Ask if there are any questions (A,B,C)
6.8.1.3. Get confirmation that the information was received (A,C)
6.8.2. IF the information was not properly received THEN stop and address questions
for clarification (A,C)
6.8.3. IF there are no further questions THEN
6.8.3.1. Introduce the new person to the surgeons and ask if they have any
questions or concerns inform them of the handoff of personnel (B,C)
6.8.3.2. Inform the operating room personnel that a new anesthesia provider is on
board (A,C)
6.8.3.3. Make note in the EMR or paper chart that a complete and accurate handoff
has occurred and that the specified provider accepts transfer of the patient (C)
6.9. Perform a last quick check of the operating room environment (A)
6.9.1. IF satisfied THEN give yourself permission to leave and the handoff is complete
(A)
6.10. IF the above steps have been completed THEN look for verbal or nonverbal cues
that they are satisfied (B) AND leave the room
8. Prerequisite Skills/Knowledge
Student Nurse Anesthetists have ICU training, are familiar with critical situations and what
an ICU nurse needs to know for handoff (B)
A first year anesthesia resident in the months of July or August is considered a compete
novice (B)
A novice must to have underlying knowledge of major common patient comorbidities and
their management prior to giving handoff (A)
A novice must have underlying knowledge of medication types and dosages based upon
patient body habitus and needs (A)
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 119
General prior knowledge of the patient can be acquired through the electronic medical record
(EMR) to include the history and physical, medical notes, consults, and the written chart (A)
The person being handed off to must have the appropriate skill set to receive handoff (C)
9. Sensory Information
Situation awareness-there is constant visual scanning throughout the report (A)
Light (C)
Sound (C)
Sounds in the operating room provide subtle cues about the patient condition including
monitor sounds, alarms, and pulsations (C)
10. Safety Factors
The safest place for a patient is the ICU or operating room, the most dangerous is the hallway
in between (C)
A patient handoff will not occur unless the patient has been identified (A,B,C)
A patient handoff will not occur when the patient is unstable (A,B,C)
11. Environmental Factors
Light and sound play an integral role in the exchange of handoff information during a
surgical procedure
12. References
Standards for pre-operative evaluation and consultation on the anesthesia intranet site
(LAC+USC)
ASA risk status classification (American Society of Anesthesiologists)
Paul Marino “The ICU Book”
13. Problems Inadequate report can result in inappropriate care and multiple related problems
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 120
Appendix F
Coding Spreadsheets
Spreadsheet Analysis: Gold Standard Protocol Procedures, Action and Decision Steps
SME Steps
Step Type Final Gold Standard Protocol Analysis A B C D A D
A 1. Acquire knowledge of the patient’s condition (a
pre-anesthetic evaluation) through medical record
review the day before surgery [Note: the handoff
procedure begins with acquisition of patient
information in the preoperative evaluation period]
(A,B).
1 1 0 0 36 6
1 A 1.1. Check the anesthesia schedule between 1000 and
1300 for the next day’s cases to see which
room/service on your schedule for the next day and
print it or make note of it (B,C)
0 1 1 0
2 A 1.2. Check and print or make note of the surgery
schedule later in the day to determine if your patient is
an inpatient or outpatient (note: the anesthesia
schedule and surgery schedule are the two schedules
whereby the complete patient assignment is
delineated) (A,B,C)
1 1 1 0
3 D 1.2.1.IF you are unable to complete Steps 1.1 and 1.2
in person, THEN obtain the information by calling a
colleague or the front desk (B)
0 1 0 0
4 D 1.2.2.IF the patient is an inpatient and time permits
THEN obtain a blank pre-operative evaluation form
and performStep 2 (A,B)
1 1 0 0
1.2.3.IF the patient has a previously completed pre-op
on the EMR THEN
D 1.2.3.1. Review it for completeness using a
heightened degree of caution (A)
1 0 0 0
D 1.2.3.2. Make alterations to it as necessary (C) 0 0 1 0
A 1.3. Go to the inpatient care area/ICU to conduct a
document evaluation of the EMR and hardcopy chart
(A,B)
1 1 0 0
D 1.3.1.IF the patient is an ICU patient and surgery is
imminent THEN take a transport monitor (C)
0 0 1 0
D 1.3.2.IF the patient has a PF completed THEN
determine alignment between the completed pre-
operative evaluation, and patient condition (A)
1 0 0 0
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 121
A 1.4. Conduct chart and/or EMR review of the
following and document pertinent findings from the
nursing notes (A,B)
1 1 0 0
A physicians notes (A,B,C) 1 1 1 0
A consult notes (A,B,C) 1 1 1 0
A paramedic notes if necessary (B) 0 1 0 0
A 1.5. Document integral information on the PF (A,B,C): 1 1 1 0
A 1.5.1.Age (B,C) 0 1 1 0
A 1.5.2.Height (A,B,C) 1 1 1 0
A 1.5.3.Weight (A,B,C) 1 1 1 0
A 1.5.4.BMI (A) 1 0 0 0
A 1.5.5.Language spoken (B) 0 1 0 0
A 1.5.6.Allergies (A,B,C) 1 1 1 0
A 1.5.7.Comorbidities (C) 0 1 0 0
A 1.5.8.Pregnancy test (D) 0 0 0 1
A 1.5.9.Home and hospital medications (C) 0 0 1 0
A 1.5.10. Previous surgeries (C) 0 0 1 0
A 1.5.11. Activity (A) 1 0 0 0
A 1.5.12. Neurologic status (A) 1 0 0 0
A 1.5.13. Nutritional status/NPO length of time/TPN (A) 1 0 0 0
A 1.5.14. Pain (A) 1 0 0 0
A 1.5.15. Nausea (A) 1 0 0 0
A 1.5.16. Compliance with treatment (A) 1 0 0 0
A 1.5.17. Other pertinent issues (A,B,C) 1 1 1 0
A 1.6. Review and document pertinent study results
including (A,B,C):
1 1 1 0
A 1.6.1. EKG (A,B) 1 1 0 0
A 1.6.2. CXR (A,B) 1 1 0 0
A 1.6.3.laboratory (B,C) 0 1 1 0
A 1.6.4.radiology (B,C ) 0 1 1 0
A 1.6.5.CT scans (B,C) 0 1 1 0
A 1.6.6.MRI (C) 0 0 1 0
A 1.6.7.echocardiography (B) 0 1 0 0
A 1.6.8.cardiac stress tests (C) 0 0 1 0
A 1.7. For long-term patients, locate their previous
medical records, review and note any significant
findings on the pre-op form (C)
0 0 1 0
A 2. Interview the patient/designee (A,B,C) 1 1 1 0 16 5
A 2.1. Approach and identify the patient by name and
date of birth (A)
1 0 0 0
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 122
D 2.1.1.IF the patient is obtunded THEN meet or phone
the designated family member to complete the
process(A)
1 0 0 0
A 2.2. Establish a relationship, identifying yourself as a
member of the anesthesia care team (A,B)
1 1 0 0
A 2.3. Conduct the interview (A,B,C) 1 1 1 0
D 2.3.1.IF the information provided by the
patient/designee aligns with the surgical consent THEN
begin to complete the preoperative evaluation by
filling in the preoperative assessment form (A)
1 0 0 0
A 2.4. Perform a patient head to toe physical
assessment (B,C) including
0 1 1 0
A 2.4.1.Neurologic status and level of sedation (A,C) 1 0 1 0
A 2.4.2.Spinal precautions (C) 0 0 1 0
A 2.4.3.Heart sounds (A,C) 1 0 1 0
A 2.4.4.Lung sounds (A,C) 1 0 1 0
A 2.4.5.Peripheral pulses (A) 1 0 0 0
A 2.4.6.Airway exam (A,C) 1 0 1 0
A 2.4.7.Skin color (C) 0 0 1 0
A 2.4.8.Visual inspection of body and extremities (A) 1 0 0 0
A 2.4.9.IV access (C) 0 0 1 0
A 2.4.10. Presence of inotropic drugs (C) 0 0 1 0
A 2.4.11. Other current medications (C) 0 0 1 0
D 2.4.12. IF the patient is in ICU THEN locate and obtain
a verbal report from the physician and nurse who has
been taking care of the patient to find out recent
history, changes, how the patient has been progressing
or not progressing (C)
0 0 1 0
D 2.4.13. IF the pre-operative evaluation was previously
completed by another provider, THEN ensure
alignment between the consent and scheduled
operation, assessment findings and patient history,
and reconcile any gross differences with the
perioperative team to clarify next steps, and document
(A,B,C)
1 1 1 0
D 2.4.14. IF there are specific risks, concerns, or the
case will not proceed THEN communicate with the
surgeon, patient or designee and document(B)
0 1 0 0
A 3. Obtain an informed consent for anesthesia (A,B,C) 1 1 1 0 2 3
A 3.1. Discuss the informed consent for anesthesia
services with the patient/designee (A,B,C)
1 1 1 0
D 3.1.1.IF the patient is obtunded THEN meet or phone
the designated family member to complete the
process(A)
1 0 0 0
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 123
D 3.1.2.IF the patient has a previously obtained consent
THEN review the document for completeness, and
make any changes as necessary (A,B,C)
1 1 1 0
D 3.1.3.IF the preoperative evaluation and consent are
complete THEN proceed to surgery (A,B,C)
1 1 1 0
D 4. IF there is a “red blanket” emergency case, THEN
acquire knowledge of the patient's condition from
desk personnel (B) AND
0 1 0 0 3 20
D 4.1. Contact the trauma team as time permits (B,C,D) 0 1 1 1
D 4.2. Perform a quick survey of the patient's condition
(A,B,D) acquiring the following information:
1 1 0 1
D 4.3.1 Diagnosis (B) 0 1 1 0
D 4.3.2.Emergency type (B) 0 1 0 0
D 4.3.3.Name (B) 0 1 0 0
D 4.3.4.Medical record number (B) 0 1 0 0
D 4.3.5.Age (B) 0 1 0 0
D 4.3.6.Gender (B) 0 1 0 0
D 4.3.7.Allergies (B) 0 1 0 0
D 4.3.8.Patient stability (B) 0 1 0 0
D 4.3.9.Medical problems (D) 0 0 0 1
D 4.3.10.Whether blood was sent to the laboratory for
type and cross (D)
0 0 0 1
A 4.4. Identify whether the patient can answer
questions (A,B,C)
1 1 1 0
4.4.1.IF the patient is able to answer questions THEN
gather the following information
D 4.4.1.1. Allergies (C) 0 0 1 0
D 4.4.1.2. Health history (C) 0 0 1 0
D 4.4.1.3. Medications (C) 0 0 1 0
D 4.4.1.4. Verbal consent (C) 0 0 1 0
4.4.2.IF the patient us unable to answer questions
THEN
D 4.4.2.1. Gather information from the EMR and/or
chart when patient stability has occurred (A,C) OR
1 0 1 0
D 4.4.2.2. Direct a team member to gather and
document information from the EMR and/or hardcopy
chart and read it aloud to guide treatment (B,C)
0 1 1 0
D 4.4.2.3. Write information down on the quick
reference sheet or pocket card as a reference for a
possible handoff, if and when able (B)
0 1 0 0
A 4.5. Perform a head to toe assessment of the patient
while proceeding with surgical and anesthetic care (B)
0 1 0 0
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 124
A 4.6 Proceed to surgery and deliver, monitor and
document anesthesia care until a break or case relief is
expected (A,B,C)
1 1 1 0
A 5. Prepare for the handoff (A,B,C) 1 1 1 0 26 7
A 5.1. Monitor the progress of the surgery by looking at
the surgical field and when appropriate ask the
surgeon for the anticipated end of surgery (A, B)
1 1 0 0
A 5.2. Monitor the time remaining until the end of your
shift or a required break whichever is sooner and
prepare for a break or case relief handoff (A,B,C)
1 1 1 0
A 5.3. Make the preoperative evaluation form readily
available on the anesthesia machine/cart while
anesthesia care is monitored and documented during
surgery (A,B)
1 1 0 0
A 5.4. Create a handoff reference for the oncoming
provider that includes key information (A,B,C):
1 1 1 0
A 5.4.1.Name (C) 0 0 1 0
A 5.4.2.ASA status of patient (B) 0 1 0 0
A 5.4.3.Age (B) 0 1 0 0
A 5.4.4.Gender (B) 0 1 0 0
A 5.4.5.Language (B) 0 1 0 0
A 5.4.6.Allergies (B) 0 1 0 0
A 5.4.7.Comorbidities/significant health history (A,B,C) 1 1 1 0
A 5.4.8.Diagnosis (C) 0 0 1 0
A 5.4.9.Surgical procedure (B) 0 1 0 0
A 5.4.10. Medications (B) 0 1 0 0
A 5.4.11. Fluid intake (A,B,C) 1 1 1 0
A 5.4.12. Blood Loss (A,B,C) 1 1 1 0
A 5.4.13. Antibiotic times (B) 0 1 0 0
A 5.4.14. Patient disposition (B) 0 1 0 0
A 5.4.15. Blood refusal (C) 0 0 1 0
A 5.4.16. Complications (B,C) 0 1 1 0
A 5.4.17. Number and adequacy of IV lines (A,B,C) 1 1 1 0
A 5.4.18. Arterial access (A,B) 1 1 0 0
A 5.4.19. Presence of regional blocks and time frames
(B)
0 1 0 0
A 5.4.20. The anesthetic plan (A,B,C) 1 1 1 0
D 5.5. IF the following conditions are met as follows,
THEN it is safe to handoff the patient (A,B,C):
1 1 1 0
D 5.5.1.The patient is stable (C) 0 0 1 0
D 5.5.2.Necessary tasks have been completed (B) 0 1 0 0
D 5.5.3.The relief person has the prerequisite knowledge
based upon level of training (C)
0 0 1 0
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 125
D 5.5.4.The relief person has the prerequisite skill based
upon their level of training (C)
0 0 1 0
D 5.5.5.The case will end greater than 30 minutes prior
to the change of shift (A,B,C)
1 1 1 0
D 5.5.6.The case is not prohibitively complex (C) 0 0 1 0
A 5.6. Complete documentation of the anesthesia
paper/EMR record (A,B.C)
1 1 1 0
A 6. Conduct the Handoff (A,B,C) 1 1 1 0 20 14
A 6.1. Greet, identify, and look for situational
awareness and readiness cues in the oncoming
provider (A,B)
1 1 0 0
D 6.1.1. IF the oncoming provider lacks readiness or
seems preoccupied THEN verbally determine and
acknowledge their readiness for handoff AND begin
the handoff once ready (A,B)
1 1 0 0
A 6.2. Begin the handoff process by surveying the
surgical and anesthetic environment (A,B,C)
1 1 1 0
A 6.2.1.Ensure safe conditions such as visualization of
the record will provide for safety of information
sharing (C)
0 0 1 0
A 6.2.2.Minimize interruptions in the handoff (A) 1 0 0 0
A 6.2.3.Mutually survey the surgical field (B,C) 0 1 1 0
A 6.3. Visually inspect the patient (B,C) 0 1 1 0
A 6.3.1.Positioning (B,C) 0 1 1 0
A 6.3.2.Eyes and face (B,C) 0 1 1 0
A 6.4. Mutually review each point in the handoff
reference sheet in step 5.4 (B)
0 1 0 0
A 6.5. Refer to the anesthetic record whether paper or
EMR and inspect vital signs trends baseline and trends
(A,B)
1 1 0 0
A 6.6. Discuss key points and current status both
normal occurrences and deviations (B) including
0 1 0 0
A 6.6.1.Induction and intubation (A,C) 1 0 1 0
A 6.6.2.Current Muscle relaxant quantitative measure of
relaxation (A,B)
1 1 0 0
A 6.6.3.Emergence plan for endotracheal extubation and
oxygenation (A,B)
1 1 0 0
A 6.6.4.Anticipated patient postoperative needs (C) 0 0 1 0
A 6.7. Ensure that any deviations from patient baseline
are documented in the EMR/chart prior to completion
of the handoff (D)
0 0 0 1
A 6.8. Clarify any misinformation and elicit discussion of
the handoff information, maintaining patient stability
(A,B)
1 1 0 0
INTRAOPERATIVE HANDOFF OF ANESTHESIA CARE 126
D 6.8.1.IF the oncoming provider exhibits lack of
attention to the report THEN restate the information
(A, B, C)
1 1 1 0
D 6.8.2.IF the oncoming provider has been writing down
information make sure it is correct information and
allow them time to complete their notes (A,C)
1 0 1 0
D 6.8.3.IF the receiver asks a question THEN ensure that
you cover the information and answer the question (A)
1 0 0 0
D 6.8.4.IF handoff is interrupted for a surgical need, or if
the patient has an event that requires immediate
intervention THEN interrupt handoff to take care of
the need (A)
1 0 0 0
A 6.9. Complete and document that handoff process (C) 0 0 1 0
6.9.1.IF the handoff reference sheet and key discussion
points have been covered THEN
0 0 0 0
D 6.9.1.1. Give the oncoming person time to digest
the information (A)
1 0 0 0
D 6.9.1.2. Ask if there are any questions (A,B,C) 1 1 1 0
D 6.9.1.3. Get confirmation that the information
was received (A,C)
1 0 1 0
D 6.9.2.IF the information was not properly received
THEN stop and address questions for clarification (A,C)
1 0 1 0
6.9.3.IF there are no further questions THEN 0 0 0 0
D 6.9.3.1. Introduce the new person to the surgeons
and ask if they have any questions or concerns inform
them of the handoff of personnel (B,C)
0 1 1 0
D 6.9.3.2. Inform the operating room personnel that
a new anesthesia provider is on board (A,C)
1 0 1 0
D 6.9.3.3. Make note in the EMR or paper chart that
a complete and accurate handoff has occurred and
that the specified provider accepts transfer of the
patient (C)
0 0 1 0
A 6.10.Perform a last quick check of the operating room
environment (A)
1 0 0 0
D 6.10.1. IF satisfied THEN give yourself permission to
leave and the handoff is complete (A)
1 0 0 0
D 6.11.IF the above steps have been completed
THEN look for verbal or nonverbal cues that they are
satisfied (B) AND leave the room
0 1 0 0
Abstract (if available)
Abstract
The purpose of this study was to use Cognitive Task Analysis (CTA) methods to capture the critical action and decision steps from experts when they describe how to deliver an intraoperative patient handoff of anesthesia care. This study also sought to identify the percentage of action and decision steps experts omit, as compared to a gold standard, when they recall those action and decision steps they use during that high stakes handoff. Three subject matter experts participated in semi-structured interviews, and protocols were developed and reviewed by the experts. A gold standard protocol was generated from the individual interview protocols and reviewed by a fourth subject matter expert. The resulting gold standard protocol was analyzed for knowledge omissions in the form of action and decision steps, which were quantified. Results indicate that experts omitted 44.73% of the action and decision steps necessary to inform the process of intraoperative handoff of anesthesia care. Although these results do not meet the “70%” omissions findings from previous studies, they support the work of other CTA studies showing that experts have more difficulty recalling decisions they make than the actions they take. The importance of this study is twofold—intraoperative handoff of anesthesia care has not been widely studied and, regulatory bodies mandate standardization of handoff procedures due to the widespread problem of patient complications related to inadequate handoff communication. Recent efforts at handoff standardizations have provided minimal evidence in process improvement. The results of this study are timely and enabled a fuller explication of the task.
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University of Southern California Dissertations and Theses
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Asset Metadata
Creator
Garcia, Charlotte Ann
(author)
Core Title
Using cognitive task analysis to capture how expert anesthesia providers conduct an intraoperative patient care handoff
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Education (Leadership)
Publication Date
04/21/2015
Defense Date
02/17/2015
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
anesthesia care,intraoperative,OAI-PMH Harvest,patient care handoff
Format
application/pdf
(imt)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Yates, Kenneth A. (
committee chair
), Embrey, Karen (
committee member
), Sullivan, Maura (
committee member
)
Creator Email
Cgarcia2@nu.edu,charlotg@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c3-555690
Unique identifier
UC11300144
Identifier
etd-GarciaChar-3359.pdf (filename),usctheses-c3-555690 (legacy record id)
Legacy Identifier
etd-GarciaChar-3359.pdf
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555690
Document Type
Dissertation
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Garcia, Charlotte Ann
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(contributing entity),
University of Southern California Dissertations and Theses
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The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...
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Tags
anesthesia care
intraoperative
patient care handoff