Close
About
FAQ
Home
Collections
Login
USC Login
Register
0
Selected
Invert selection
Deselect all
Deselect all
Click here to refresh results
Click here to refresh results
USC
/
Digital Library
/
University of Southern California Dissertations and Theses
/
The use of cognitive task analysis for the postanesthesia patient care handoff in the intensive care unit
(USC Thesis Other)
The use of cognitive task analysis for the postanesthesia patient care handoff in the intensive care unit
PDF
Download
Share
Open document
Flip pages
Contact Us
Contact Us
Copy asset link
Request this asset
Transcript (if available)
Content
Running head: PATIENT CARE HANDOFF IN THE ICU 1
THE USE OF COGNITIVE TASK ANALYSIS FOR THE POSTANESTHESIA
PATIENT CARE HANDOFF IN THE INTENSIVE CARE UNIT
by
Kari Mai Cole
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 Kari Mai Cole
PATIENT CARE HANDOFF IN THE ICU 2
Dedication
This dissertation is dedicated to my Ohana far and wide. Without your love and support,
this journey would remain unfinished. To my kind and gentle husband, Dale: mahalo nui loa for
your love, patience, and understanding, for taking care of the world while I finished this journey.
To my three wonderful sons, Jens, Hans, and Tor: everyday you fill my heart with joy, you make
me laugh, and you make me a better person. To my mom and dad, thank you for your dedication
to education, to helping others, and for inspiring me. No one could ask for better role models.
PATIENT CARE HANDOFF IN THE ICU 3
Acknowledgements
I would like to express my deepest gratitude to my dissertation chairperson, Dr.
Kenneth Yates, who conveyed unwavering patience, persistence, and mentorship. Without his
understanding and supervision this dissertation would not have been possible. My sincere
appreciation is extended also to Dr. Maura Sullivan and Dr. Kären Embrey for their optimism,
realism, and highly valuable feedback during this process. I felt very fortunate to have a
dissertation committee composed of truly remarkable people, who individually and
collectively contribute much to education in healthcare.
I am also grateful to the anesthesiologists and nurse anesthetists who participated in
this study. Thank you for sharing your knowledge, time, and energy with me during the CTA
interview process. Above all, thank you for your dedication to excellence in patient care and
clinical education. I am grateful for my dissertation collaborators, Dr. Judith Franco and Dr.
Charlotte Garcia, who encouraged me to think critically, accept what I cannot change, and
change what I cannot accept. Above all, thank you for being there as we shared both laughter
and tears.
I am grateful for my friends and colleagues at USC, on both the Health Science
Campus and the University Park Campus, and on both sides of Zonal Avenue who have not
only raised the bar, but have defined it. You have inspired and supported my personal and
professional development over the past years and helped to make work a labor of love.
Finally, I am forever grateful to Dr. Philip Lumb, Chairman, Department of Anesthesiology,
Keck School of Medicine at the University of Southern California for his trust, support, and
inspiration during this process and over the years. May we live long and prosper.
PATIENT CARE HANDOFF IN THE ICU 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 15
Definition of Terms 15
Organization of the Study 17
Chapter Two: Literature Review 18
The Changing Healthcare Landscape 18
The Joint Commission and the World Health Organization 18
Patient Care Handoffs 20
Purpose of Patient Care Handoffs 20
Types of Patient Care Handoff 20
Consequences of Ineffective Patient Care Handoffs 20
Factors That Affect Patient Handoff Quality 21
Organizational/Cultural Factors 22
Communication 24
Patient Handoff Tools 26
Handoff Education 27
Patient Handoff Education 28
Multidisciplinary Education 29
Summary 30
Types of Knowledge 31
Declarative Knowledge 32
Procedural Knowledge 33
Conditional Knowledge 34
Prior knowledge 35
Automaticity 36
Expertise 38
Characteristics of Experts 38
Building Expertise 39
Consequences of Expertise 40
Cognitive Task Analysis (CTA) 41
Definition of CTA 41
CTA History 41
CTA Methodology 43
Effectiveness of CTA for Capturing Expert Knowledge 44
Effectiveness of CTA-Based Training 46
Challenges to Clinical Teaching in Healthcare 47
PATIENT CARE HANDOFF IN THE ICU 5
Effectiveness of CTA Based Training in Healthcare 48
Summary 51
Chapter Three: Methods 52
Participants 53
Data Collection for Question 1 53
Phase 1: Collecting Preliminary Knowledge 53
Phase 2: Identify Knowledge Types Required for the Task 54
Phase 3: Application of Knowledge Elicitation Methods 54
Phase 4: Data Analysis 56
Phase 5. Formatting the Results 57
Summary 58
Data Analysis for Question 2 58
Chapter Four: Results 60
Research Questions 60
Question 1 60
Question 2 66
Chapter Five: Discussion 69
Overview of Study 69
Process of Conducting Cognitive Task Analysis 70
Selection of Experts 70
Collection of Data 71
Discussion of Findings 72
Question 1 72
Question 2 77
Limitations 80
Confirmation Bias 80
Internal Validity 81
External Validity 81
Implications 82
Future Research 83
Conclusions 83
References 85
Appendix A: Cognitive Task Analysis Interview Protocol 101
Appendix B: Inter-Rater Reliability Code Sheet for SME B 103
Appendix C: Job Aid for Developing a Gold Standard Protocol 104
Appendix D: Gold Standard Protocol 105
Appendix E: Incremental Coding Spreadsheets 115
PATIENT CARE HANDOFF IN THE ICU 6
List of Tables
Table 1: Cumulative Action and Decision Steps Captured for Each SME in the Initial
Individual Protocols 63
Table 2: Additional Expert Knowledge Captured, in Action and Decision Steps, During
Follow-Up Interviews 65
Table 3: Number and Percentage of Action and Decision Steps that are Highly Aligned,
Partially Aligned, and Slightly Aligned 66
Table 4: Number and Percentage of Action and/or Decision Steps Omitted by SMEs when
Compared to the Gold Standard Protocol 67
PATIENT CARE HANDOFF IN THE ICU 7
List of Figures
Figure 1. The five stages of the CTA 3i + 3r Method 58
Figure 2. Aggregating Action and Decision Steps for the Preliminary Gold Standard
Protocol (PGSP) 61
Figure 3. Percentage of Action Steps and Decision Steps Elicited from SME A, SME B,
and SME C Through CTA 64
Figure 4. Total Percentage of SME Knowledge Omissions when Compared to the GSP 68
PATIENT CARE HANDOFF IN THE ICU 8
List of Abbreviations
ACGME Accreditation Council for Graduate Medical Education
ACT Adaptive Character of Thought
ACT-R Adaptive Character of Thought-Rational
AORN Association of Perioperative Registered Nurses
ASA American Society of Anesthesiologists
BP Blood Pressure
CDM Critical Decision Method
CLASBI Central Line Associated Blood Stream Infections
CLER Clinical Learning Environment Review
CMS Centers for Medicare and Medicaid Services
CPP Concepts, Processes and Principles
CRNA Certified Registered Nurse Anesthetist
CTA Cognitive Task Analysis
CVC Central Venous Catheter
CXR Chest X-Ray
ECG Electro Cardiogram
EMR Electronic Medical Record
ETT Endotracheal Tube
GSP Gold Standard Protocol
HTN Hypertension
HOB Head of Bed
ICU Intensive Care Unit
PATIENT CARE HANDOFF IN THE ICU 9
IRB Institutional Review Board
IV Intravenous
IRR Inter Rater Reliability
LMA Laryngeal Mask Airway
NC Nasal Cannula
O2 Oxygen
OR Operating Room
PACU Post Anesthesia Recovery Room
PEEP Positive End Expiratory Pressure
PONV Post Operative Nausea and Vomiting
SME Subject Matter Expert
PATIENT CARE HANDOFF IN THE ICU 10
Abstract
The purpose of this study was to utilize Cognitive Task Analysis (CTA) methods to elicit
knowledge from expert critical care anesthesia providers (anesthesiologists and nurse
anesthetists) and define the knowledge, skills, procedures, tools and senses used to conduct a
comprehensive patient care handoff from the operating room to the intensive care unit. This
study also sought to identify the percentage of action and decision steps, when compared to a
gold standard that expert critical care anesthesia providers omit when they describe how they
conduct this high stakes patient handoff. Three subject matter experts (SME) participated in the
semi-structured interviews and the fourth SME was used to verify the preliminary gold standard
protocol, thereby forming the gold standard protocol (GSP). The resulting gold standard protocol
was analyzed for knowledge omissions in the form of action and decision steps, which were
quantified. Results indicate that, on average, the experts omitted 50.41% of the action and
decision steps when describing how to perform a patient handoff from the operating room to the
intensive care unit. 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 – there is a paucity of literature that identifies the essential elements of a transfer of
patient care from anesthesia providers in the operating room to the intensive care unit members.
In addition, recent efforts at handoff standardizations have provided minimal evidence in process
improvement. The results of this study are timely and it is hoped that the results of this study not
only add to the growing library of CTA-based research but that the gold standard protocol
generated in this study becomes the basis for a multidisciplinary training program to improve
communication in the handoff process.
PATIENT CARE HANDOFF IN THE ICU 11
CHAPTER ONE: OVERVIEW OF THE STUDY
Statement of the Problem
Well documented in the literature is the risk to patient care when the transfer of patient
care is incomplete, untimely, or involves inaccurate patient information. Transfer of care is also
known as patient handoff and is defined as:
The transfer and acceptance of patient care responsibility achieved through
effective communication. It is a real time process of passing patient specific
information from one caregiver to another or from one team of caregivers to
another for the purpose of ensuring the continuity and safety of the patient’s care.
(Joint Commission Center for Transforming Healthcare Targeted Solutions Tool
for Hand-off Communication, 2014)
The Joint Commission estimates miscommunication between healthcare providers during
patient transfers constitutes 70%-80% of the medical errors that occur in the healthcare setting
(Joint Commission, 2007). Various professional, licensing, and accrediting organizations, such
as the Centers for Medicare and Medicaid Services (CMS), the Joint Commission, the
Accreditation Council for Graduate Medical Education (ACGME), and the Association of
Perioperative Registered Nurses (AORN) have provided guidelines, mandates, and
recommendations to improve the patient handoff process. The Joint Commission has mandated
that handoff reports include an (a) interactive communication, (b) current patient information,
(c) methods to authenticate information, (d) time for the receiving practitioner to verify
information, and (e) uninterrupted communication between practitioners (Joint Commission,
2008).
PATIENT CARE HANDOFF IN THE ICU 12
In 2011, six competency-based performance standards were set forth by the Accreditation
Council for Graduate Medical Education (ACGME, 2011): Patient Care, Medical/Clinical
Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication
Skills, Professionalism, and Systems-Based Practice. To formalize the requirement for training,
in 2012 the ACGME established a Clinical Learning Environment Review (CLER) Program that
focuses, among other things, on the transition of patient care. According to ACGME, learning
institutions must demonstrate effective standardization and education for the safe transition of
patient care.
The AORN (2012) in collaboration with the U.S. Department of Defense Patient Safety
Program developed a web based patient handoff tool kit. This resource provides information,
recommendations, and guidelines that are designed to standardize the transfer of patient care
among perioperative professionals. Recommendations included using a structured transfer
process (e.g. checklist), using a broad definition of patient hand off to cover across a broad
continuum of care, utilizing up to date information and common terminology, verifying
information received with an opportunity to review information received, indicating a clear
transfer and acceptance of responsibility, limiting interruptions, and using clear language with
commonly accepted terms. In addition to a history of what has happened (assessment) and
suggestions for management of future events (recommendations), it is this author’s belief that an
effective transfer of patient information also includes a discussion of what is likely to happen
(anticipation). The effective transfer of patient care requires an understanding and acceptance of
the information received, as well as the opportunity to process and clarify information. In an
academic medical center where there is a constant influx of new learners, the effective transfer of
patient care is also influenced by the clinical faculty’s ability to train learners in the process. The
PATIENT CARE HANDOFF IN THE ICU 13
AORN recommends that healthcare personnel receive initial and ongoing education and
competency validation (Seifert, 2012).
The problems related to the patient handoff are multifaceted, multidisciplinary, and exist
in virtually every setting that patient care occurs (Koenig, Maguen, Daley, Cohen, & Seal, 2012).
Research has focused on communication patterns (Edmondson, 2003), teamwork (Clarke et al.,
2012), checklists (Boat & Spaeth, 2013; Manser, Foster, Flin, & Patey, 2013), human and
organizational factors (Stecher & Kirby, 2004), and training (Manser & Foster, 2011). Despite
the increasing attention on the safe transfer of patient care, there is no universally accepted and
implemented format for patient handoff in the perioperative setting. While the patient safety
goals are simply stated, it is challenging to develop and implement effective strategies for
handoffs across various health care settings, given the complexity of health care delivery.
The patient handoff process represents a very complex task that requires the transfer of
declarative and procedural knowledge, as well as the transfer of explicit knowledge and tacit
knowledge. The available research literature on transfer of patient care does not include
information derived from the cognitive task analysis of experts in the field of anesthesia. There is
also a paucity of literature that identifies the essential elements of a transfer of patient care from
anesthesia providers in the operating room to a multidisciplinary team in the intensive care unit
setting. In addition, there is no evidence to suggest that the training programs addressing the
patient care handoff process have been standardized and evaluated. Finally, the transfer of
information may be impaired in the teaching of a patient handoff process by experts (Clark &
Estes, 1996; Feldon & Clark, 2006; Kirschner et al., 2006). Clinical instructors in anesthesiology
and/or intensive care may possess the knowledge and skills required to provide a safe and
effective patient handoff but their ability to teach novice providers may be limited. Feldon and
PATIENT CARE HANDOFF IN THE ICU 14
Clark (2006) suggest that experts may omit as much as 70% of the critical action and decision
steps used when performing complex tasks or solving complex problems. The reasons for
omissions will be discussed later in the sections on automaticity and become the rationale for the
use of CTA in this study.
Cognitive task analysis (CTA) is a qualitative research methodology that employs semi-
structured interviews of subject matter experts. The interviews are designed to capture the
conceptual and procedural knowledge experts use in performing complex tasks (Clark, Feldon,
Van Merriënboer, Yates, & Early, 2008; Chipman, Schraagen, & Shalin, 2000). Patient handoffs
from the operating room to the intensive care unit represent a complex task. Studies have shown
that CTA based instructional design is superior to traditional teaching methods in improving,
both declarative knowledge and procedural knowledge as well as, procedural skills and self-
efficacy in performing complex medical tasks (Buckley et al., 2014; Campbell et al., 2011;
Clark, 2014; Crandall & Getchell-Reiter, 1993; Embrey, 2012; Fackler et al., 2009; Sullivan et
al., 2007; Pugh, DaRosa, Santacaterina, & Clark, 2011). The results of a CTA study could
potentially be used for novice health care providers as well as for the ongoing professional
development of experienced health care providers.
Purpose of the Study
The purpose of this study was to utilize Cognitive Task Analysis (CTA) methods to elicit
knowledge from expert critical care anesthesia providers (anesthesiologists and nurse
anesthetists) and define the knowledge, skills, procedures, tools and senses used to conduct a
comprehensive patient care handoff from the operating room to the intensive care unit. The
specific research question that elaborate this research purpose are as follows:
PATIENT CARE HANDOFF IN THE ICU 15
1. What are the action and decision steps that expert critical care anesthesia providers recall
when they describe how they conduct a patient handoff from the operating room to the
intensive care unit?
2. What percentage of action and decision steps, when compared to a gold standard, do
expert critical care anesthesia providers omit when they describe how they conduct a
patient handoff from the operating room to the intensive care unit?
Methodology of the Study
Cognitive Task Analysis was used to elicit knowledge from expert critical care anesthesia
providers (subject matter experts or SMEs) used in performing patient care handoffs from the
operating room to the intensive care unit. Three SMEs participated in the semi-structured
interviews and the fourth SME was used to verify the preliminary gold standard protocol,
thereby forming the gold standard protocol (GSP)
The CTA followed the five phases for knowledge elicitation: (1) identification of tasks
and collection of preliminary domain-specific knowledge; (2) identification of knowledge types
required to perform the tasks and subtasks; (3) application of the knowledge elicitation technique
through semi-structured interviews, (4) data analysis including coding, inter-rate reliability, and
SME verification of respective protocols, and (5) development of a gold standard protocol that
was used to determine expert omissions and may be used in training novice providers.
Definition of Terms
The following are definitions of terms related to cognitive task analysis as suggested by
Zepeda-McZeal (2014).
Adaptive expertise: When experts can rapidly retrieve and accurately apply
appropriate knowledge and skills to solve problems in their fields or expertise; to possess
PATIENT CARE HANDOFF IN THE ICU 16
cognitive flexibility in evaluating and solving problems (Gott, Hall, Pokorny, Dibble, &
Glaser, 1993; Hatano & Inagaki, 2000).
Automaticity: An unconscious fluidity of task performance following sustained and
repeated execution; results in an automated mode of functioning (Anderson, 1996a;
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).
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)
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
PATIENT CARE HANDOFF IN THE ICU 17
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).
Organization of the Study
Chapter Two of this study reviews the literature in two main sections, the first section
of the literature review examines the relevant literature related to conducting a patient care
handoff from the operating room to the ICU and the second section focuses on the relevant
literature related to cognitive task analysis as a knowledge elicitation technique for subject
matter expertise. Chapter Three addresses the methods of this study and the approach to the
research answers the research questions. Chapter Four reviews the result of the study and
compares the findings to each of the research questions. Chapter Five serves as a discussion of
findings, the implication of the findings, limitations of the study, and implications for future
research.
PATIENT CARE HANDOFF IN THE ICU 18
CHAPTER TWO: LITERATURE REVIEW
The Changing Healthcare Landscape
In 1999, The Quality of Health Care in America Committee of the Institute of Medicine
(IOM) published the landmark report To Err is Human: Building a Safer Health System (Kohn,
Corrigan, & Donaldson, 2000). The report highlighted the fact that errors are caused primarily by
faulty systems and processes that then allowed for mistakes to be made. The report also
highlighted the need for a complete redesign of health systems to improve the quality of care and
patient safety. The proposed redesign required participation at every level from a commitment to
education of the public with regard to patient safety, to the implementation of electronic medical
record (EMR) use, to the development of performance standards by professional associations and
oversight organizations. As a result of the report, numerous quality improvement projects have
been implemented in attempt to increase the quality of patient care and patient safety. In
addition, there has been an increase in internal and external accountability, including public
“report cards”, such as LeapFrog and Hospital Compare, as well as external review with
performance contingencies for federal funding based on compliance to certain core measures.
In 2010, the Affordable Care Act mandated the Hospital Value-Based Purchasing (VBP)
Program, an initiative created by the Centers for Medicare & Medicaid Services (CMS) that
rewards hospitals with incentive payments for the quality of care provided to patients, not just
the quantity of patients cared for.
The Joint Commission and the World Health Organization
In response to the IOM report, the Joint Commission (a private, not-for-profit group that
administers accreditation programs for healthcare organizations) began publishing National
Patient Safety Goals. In 2003, the Joint Commission published six patient safety goals; one of
PATIENT CARE HANDOFF IN THE ICU 19
the goals were to improve effectiveness of communication among caregivers through enhanced
electronic medical record documentation. In 2005, the World Health Organization (WHO)
launched the World Alliance for Patient Safety and identified six areas of action. In the same
year, the Joint Commission and the Joint Commission International combined efforts with the
World Health Organization (WHO) to develop the WHO Collaborating Centre for Patient Safety
Solutions. Their underlying philosophy is a simple one:
The traditional medical oath, “First do no harm”, is rarely violated intentionally by
physicians, nurses or other practitioners, but the fact remains that patients are
harmed every day in every country across the globe in the course of receiving
health care. The first things that we must do are to acknowledge this disturbing
truth; to reject the notion that the status quo is acceptable; and, perhaps most
important, to act to correct the problems that are contributing to unsafe care.
(Patient Safety Solutions Preamble, May 2007).
The inaugural patient safety solutions included patient identification, hand-hygiene,
medication safety, correct procedure at correct body site, and communication during patient
hand-over. As a result of the collaborative efforts with the WHO, the Joint Commission
included the following requirement for hand off communication in the 2006 National Patient
Safety Goals: "Implement a standardized approach to "hand off" communications, including an
opportunity to ask and respond to questions." In 2009, the Joint Commission Center for
Transforming Healthcare developed the Hand-off Communications Project. The Project focused
on causes for unsuccessful hand-offs, the problems that result from ineffective hand-offs, and
development of handoff communication solutions. The following is a review of the literature to
PATIENT CARE HANDOFF IN THE ICU 20
address what has contributed to and resulted from the increased awareness surrounding the
patient handoff process and to establish an understanding of why this research is warranted.
Patient Care Handoffs
Purpose of Patient Care Handoffs
According to the Joint Commission (2008), the primary objective of a patient care handoff
is to provide accurate information about a patient’s care, treatment, and services, the patient’s
current condition and any recent or anticipated changes. The information communicated during a
handoff must be accurate in order to meet patient safety goals. It should also be noted that the
patient handoff is highly sensitive to the context in which it occurs. At its very core, the patient
handoff is a highly complex, high stakes form of communication, and an essential component of
hospital care that influences patient safety (Cohen & Hilligoss, 2009).
Types of Patient Care Handoff
Patient handoffs occur across a variety of settings and between various health care
providers. In a hospital setting, patient handoffs occur throughout the day and include nurse-to-
nurse reports at shift changes, physician-to-physician sign outs and transfers, and nurse-to-
physician or physician-to-nurse reports during patient care rounds (Patterson & Wears, 2010). In
a perioperative setting, patient handoffs occur between personnel from multiple disciplines
including perioperative nurses, intensive care unit nurses, anesthesia providers, surgeons, and
ancillary staff, such as radiology and laboratory technicians (Boat & Spaeth, 2013; Catchpole et
al., 2007). In fact, a single surgical visit entails four to five patient care handoffs.
Consequences of Ineffective Patient Care Handoffs
Ineffective patient care handoffs can result in patient complaints, delays in medical
diagnosis, patients receiving wrong treatment, increased hospital length of stay, increased
PATIENT CARE HANDOFF IN THE ICU 21
healthcare expenditure, and life-threatening adverse events (Australian Council for Safety and
Quality on Health Care, 2005; Patterson et al., 2004).
Barriers to effective handoff, according to the literature, include loud background noises,
distractions, disorganized/unstructured process or lack of standardization, too much or too little
communication, incomplete transfer of responsibility, failure to communicate high risk status,
production pressure, hierarchy barriers, poor group cohesion or teamwork, differing information
needs, failure to listen, differing communication expectations between provider types, lack of
individual or institutional buy-in (Greenberg et al., 2007; Kitch et al., 2008; Lingard, Espin,
Evans, & Hawryluck, 2004; Ong & Coiera, 2011; Pham et al., 2012; Segall et al., 2012; Wheeler,
2014). Segall et al. (2012) conducted a literature review of 31 papers on handoffs from the
operating room to postanesthesia and intensive care units. Several recommendations were
broadly supported and included:
1. Use a standardized process, such as checklists and protocols
2. Complete urgent tasks before the actual transfer of information
3. Limit conversations to patient specific information while performing handoff
4. Require all relevant team members present during the handoff
5. Require/provide training in team skills and communication
The
following
section
will
explore
factors
that
affect
patient
handoff
quality,
including
organizational/cultural
factors,
communication,
use
of
patient
handoff
tool,
and
educational
factors.
Factors That Affect Patient Handoff Quality
Research conducted by the World Health Organization (2007) identified root causes that
contribute to the quality of patient handoffs. Patient handoff problems are embedded in the way
PATIENT CARE HANDOFF IN THE ICU 22
that health-care providers are educated or not educated in multidisciplinary training and
communication skills, resulting in lack of good role models. Patient handoff problems stem from
a healthcare system that promotes and rewards autonomy and individual performance and a
paternalistic culture of medicine that, historically, has not placed significant involvement on the
part of patients and families in the delivery of patient care. In addition, the increasing
specialization of health-care practitioners can improve medical treatment but it also means more
people are involved in the patient’s care, which can complicate communication.
Organizational/Cultural Factors
Studies have shown that organizational attitudes and behavioral norms affect patient
safety. Multidisciplinary collaboration improves patient safety, quality of care, and patient
satisfaction. Lingard et al., (2004) examined elements of collaboration in the intensive care unit
and found that collaboration was influenced by both a perception of ownership (of a patient or
work area) and exchange of resources (information, supplies, help, and respect). The researchers
suggested that collaboration must be learned and maintained through ongoing professional
practice evaluation. The World Health Organization (2007) also identified the potential for
challenges to communication stemming from the existence of differences in cultural
backgrounds and language barriers, which may result from a heavy reliance on health-care
professionals from other countries.
Another cultural factor to consider in relation to patient handoffs, is the implementation
of the resident duty hour reform. In 2003, the ACGME implemented new limitations on work
hours for all residents and interns, which included a maximum of 80 hours per week or 24
consecutive hours on duty. Significant controversy ensued after implementation of the duty hour
reform. Concerns expressed were in relation to the increased financial burden (from a reduction
PATIENT CARE HANDOFF IN THE ICU 23
in resident work force), changes in resident educational experiences (less available time for
teaching and educational activities), and the impact on patient care (less continuity and more
patient handoffs with increasing risk for communication errors). A landmark study by Landrigan
et al. (2004) lent support to the regulation by finding a significant reduction in medical errors
when resident work hours were reduced while on rotation in the intensive care unit. Subsequent
studies have failed to demonstrate the same benefits (Patel et al., 2014) and concerns about the
dramatic increase in the number of potentially dangerous handoffs remain (Reed et al., 2007).
In 2007, the WHO Safe Surgery Safe Lives Program pilot study implemented the use of
surgical checklists, standardized protocols, and scheduled communication between team
members, called “surgical timeouts”, to provide structure in task and to foster teamwork.
Although the focus of the pilot program was associated with improved communication in the
operating room, there are many implications for handoffs along the perioperative continuum.
The results of the surgical safety checklist pilot program were studied in eight hospitals in eight
cities worldwide that represented a wide variety of health-care settings, economic circumstances,
and patient populations. Data was prospectively collected on clinical processes and outcomes
from 3733 patients before and 3955 patients after the program was implemented. The results of
the study indicated a reduction in the rate of deaths and surgical complications by more than one-
third across all eight hospitals. The rate of major inpatient complications dropped from 11% to
7%, and the inpatient death rate following major operations fell from 1.5% to 0.8% (Haynes et
al., 2009).
The WHO Safe Surgery Safe Lives Program provided evidence as to the critical
importance of communication and multidisciplinary collaboration in the provision of safe patient
care in surgery. Similar to the findings of Lingard et al., (2004), the WHO Safe Surgery Safe
PATIENT CARE HANDOFF IN THE ICU 24
Lives Program acknowledged the complexity of an operating room team both in membership and
function. Three elements were identified that contributed to the team’s culture including the
structure of the team, perceived team roles, and team members’ attitudes toward patient safety.
Communication
In addition to the knowledge and experience level, a patient handoff is largely dependent
on the interpersonal communication skills of the healthcare providers. Numerous studies have
identified communication breakdowns across the continuum of care, and specifically, in the
perioperative setting, that lead to challenges in maintaining patient safety. The WHO Safe
Surgery Safe Lives Program (2007) found that communication failures were identified in
approximately 30% of the team exchanges and occurred in all phases of perioperative care
(before, during and after surgery). As mentioned previously, the Joint Commission estimated
miscommunication between healthcare providers constituted 70%-80% of the medical errors that
occur in the healthcare setting (The Joint Commission, 2007). Communication remained one of
the leading root causes of sentinel events from 2004 to 2012 in all categories of medical errors
(The Joint Commission, 2012). Communication that is not structured can lead to loss of focus
and sharing of subjective or irrelevant information. Communication techniques reported to
improve care in the perioperative setting include closed loop communication check-backs, read-
backs, call outs of important information to increase situational awareness of the team, and
feedback to improve team performance (AORN Handoff Research, 2013)
Greenberg et al. (2007) investigated 60 surgical malpractice cases involving 81
communication breakdowns. The data showed 38% of the communication breakdowns occurred
preoperatively, 30% occurred intraoperatively, and 32% occurred postoperatively. Status
barriers, role ambiguity, and patient handoff environment were major factors relating to
PATIENT CARE HANDOFF IN THE ICU 25
communication breakdowns. Interestingly, the prevalence of communication errors was not
related to the complexity of the surgical procedure or patient co-morbidities. In a related study,
161 internal medicine and general surgery resident physicians from a large academic medical
center were surveyed about their patient handoff practices and the problems that lead to patient
harm (Kitch et al., 2008). Overall quality of patient handoffs was reported to be fair or poor by
31% of residents. Over half of the residents reported that one or more patients had been harmed
during their most recent clinical rotation because of problematic handoffs, and 12% reported that
this harm had been major. One fourth of the residents reported that handoffs generally took
place in a quiet setting. Other findings were that handoffs occurred face to face but they
occurred in loud areas, the handoff report was interrupted and the recipient (resident) was not
able to ask questions; the content of the handoff report varied, and major active care issues and
code status were not always included. The authors reported that many of the nationally
publicized best-practice recommendations for handoffs were not observed and as a consequence,
the reporting institution launched a handoff-safety educational program (Kitch et al., 2008).
Manser, Foster, Gisin, Jaeckel, and Ummenhofer (2013) conducted a study that provided
insight into the multidimensional concept of handoff quality. The aim of the study was to
develop a rating tool for handoff quality in three different critical care settings. Three factors
were identified that predicted handoff quality and included information transfer, shared
understanding, and working atmosphere. Traditionally handoff procedures have revolved around
accurate exchange of information (technical performance) but evidence shows that socialization,
group cohesion and organizational learning are critical. Many studies define adequate handoff as
adhering to a protocol; it is suggested that anticipation, adaptability, and adequate strategies for
recovery are critical to patient safety (Manser et al., 2010).
PATIENT CARE HANDOFF IN THE ICU 26
Pham et al. (2012) provided a comprehensive review of the literature on medical errors
and adverse events, including errors related to patient handoff. Key factors in a culture of safety
included quality handoffs, transitions, and teamwork. Like Manser et al. (2013), the literature
review highlighted the importance of teamwork and a culture of safety as foundations for safe
patient care. Interventions included use of handoff tools, handoff environment optimization, and
use of information technology wherein the handoff tool is combined with the electronic medical
record. Handoff tools can create a shared mental model but must be coupled with an
environment that is quiet, that minimizes interruptions to allow for prompt exchange of
information, and includes the patient and family in the process (Pham et al., 2012).
Patient Handoff Tools
Handoff tools aim to standardize the content, timing, and structure of the communication
during a patient handoff, however, multiple handoff tools and approaches exist, each with a
seemingly different acronym, design, and implementation plan (Johnson, Jefferies, and Nicholls,
2012; Patterson and Wears, 2010). Johnson et al. (2012) examined the content and organization
of 81 handoff tools. The researchers identified a lack of structure and/or lack of process, the risk
of information overload with handoffs that were too lengthy, and a lack of a question/answer
period. Patterson and Wears (2010) conducted a comprehensive review of the literature in an
attempt to define a quality handoff tool. The researchers identified seven primary functions for
patient handoffs, based on their literature review, which included: information processing,
stereotypical narratives, resilience, accountability, social interaction, distributed cognition, and
cultural norms. The authors concluded that there is no single reliable standardized handoff tool,
perhaps due to a lack of consensus on the primary purpose of a handoff.
PATIENT CARE HANDOFF IN THE ICU 27
Abraham, Kannampallil, and Patel (2014) conducted a review of the literature on the
evaluation of handoff tools. Handoff tools vary in structure and content, which raises concerns
regarding standardization. The study was conducted to compare the effectiveness of
communication between two handoff tools: SOAP and HAND-IT. The handoff tools are
structurally similar but conceptually different. The SOAP tool is a problem-based format that
includes subjective information, objective information, assessment information, and plan-related
information. The HAND-IT tool is based on body-systems such as pulmonary, cardiovascular,
renal/genitourinary, neurology, gastroenterology, and hepatobiliary systems. A total of 82
handoffs was observed, using both tools, for the overall quality of handoff communication. The
researchers found that use of the HAND-IT tool resulted in a greater number of ideal interactive
and bi-directional communication events with fewer communication breakdowns. The
researchers looked at the theoretical foundations underlying the evaluation of handoff tools and
their adequacy and appropriateness in achieving standardized goals and found that the nature,
methodological and theoretical foundations of handoff tool evaluations varied significantly in
terms of their quality, rigor, thereby limiting their ability to inform standardization initiatives.
Handoff Education
In response to the increasing attention on patient handoff and patient safety, various
professional, licensing, and accrediting organizations have provided guidelines, mandates, and
recommendations to improve the patient handoff process, including handoff education. The
Clinical Learning Environment Review (CLER) established by the ACGME mandates that
learning institutions demonstrate effective standardization and education of the safe transition of
patient care. However, little empirical evidence exists as to the best approach in teaching and
PATIENT CARE HANDOFF IN THE ICU 28
evaluating handoff education (Arora, Johnson, Lovinger, Humphrey, & Meltzer, 2005; Gordon
& Findley, 2011; Lane-Fall, Brooks, Wilkins, Davis, & Riesenberg, 2014).
Patient Handoff Education
There is a paucity of information guiding the implementation of educational interventions
to improve patient handoff and the effectiveness of current educational interventions remains
unclear (Gordon & Findley, 2011; Lane-Fall et al., 2014). Gordon and Findley (2011) conducted
a literature review to determine the characteristics of educational interventions employed and
how effective they were amongst undergraduate or postgraduate doctors and nurses. Nine of the
ten studies reviewed showed improvements in attitudes, knowledge, and skill with potential
transfer to the workplace, however, none of the studies showed definitive information leading to
increase in patient safety.
Matney, Maddox, and Staggers (2013) conducted a study to ascertain whether knowledge
and wisdom were exchanged during patient care handoffs. The study focused on the cognitive
task of 25 nurses giving report in a variety of medical-surgical units and used the data-
information-knowledge-wisdom (DIWK) framework to analyze handoff content. As described
by the authors, data are discrete facts that alone have little meaning. Data put into context and
combined with structure, produces knowledge. Knowledge is information derived from
analyzing information and applying critical thinking to solve problems. Wisdom is derived from
knowledge and expertise and involves knowing why things should or should not be done. Results
of the study showed that information and knowledge were present in all of the patient handoffs
but wisdom was not. The researchers suggested that handoff tools include visual and cognitive
support to ensure handoff content includes patient problems, problem-focused care plans, and
patient goals.
PATIENT CARE HANDOFF IN THE ICU 29
Multidisciplinary Education
Despite rapid advances in medical information, education and technology, there has been
little focus on the development of interprofessional health care teams, through formal education
programs (Lingard et al., 2004; Weller et al., 2011) and informal interprofessional learning
(Wagter et al., 2012). In training, nursing students and medical students rarely interact since
their respective learning and clinical work is separated (Fagin, 1992). In 1988, the World Health
Organization (WHO) recommended an interprofessional approach to training. More recently,
researchers have examined the effects of formal interprofessional training as a means to improve
collaboration among providers (Edmundson, 2003; Hansson et al., 2010; Lingard et al., 2004;
Morison & Jenkins, 2007; Wagter et al., 2012; Weng et al., 2008).
A literature review conducted by O’Brien et al. (2008) included studies which showed
collaboration improved patient safety, quality of care, and patient satisfaction by providing a
more comprehensive and holistic view of the patient’s conditions and needs. Collaborative
practice also improved provider knowledge, competency, and job satisfaction while working
towards a common goal. O’Brien et al. (2008) also identified collegial education as a key feature
in creating a collaborative environment
In a qualitative study by Morison and Jenkins (2007), the researchers examined the
understanding, attitudes, and effect of no shared learning, shared learning in class only, and
shared learning in both class and practice among nursing and medical students. Researchers
obtained responses to questionnaires and open-ended questions from 171 students and found that
only a combination of classroom and clinical training which incorporated shared learning
resulted in better understanding and appreciation of the importance of teamwork and
communication. The findings of this study were not supported in research conducted by Hansson
PATIENT CARE HANDOFF IN THE ICU 30
et al. (2010) who found that the success of multidisciplinary collaboration depended more on the
ability of the providers to role model positive attitudes towards collaboration than on whether or
not students participated in interprofessional education or training. The researchers suggested
that the consistent presence and attitude of teachers as role models was more influential than
formal interprofessional training.
Summary
The Joint Commission National Patient Safety Goal requires healthcare organizations
implement a standardized approach to “handoff” communications, including an opportunity to
ask and respond to questions. While the goal is simply stated, it is challenging to select,
develop and implement effective strategies for handoffs across various health care settings,
given the complexity of health care delivery as was indicated by the review of the literature.
Furthermore, a one size fits all handoff tool does not appear to exist, perhaps due to a lack of
consensus on the primary purpose of a handoff and the complexity of the task. A
multidisciplinary approach to training in the patient handoff process has the potential to
improve patient safety.
The patient care handoff is a highly complex task. Handoffs from the operating room
to the intensive care unit may be that much more challenging, given the critical state of the
patient and the reliance on multidisciplinary teams. Cognitive Task Analysis has been shown
to be an effective method for capturing both the conscious and automated knowledge experts
use to perform complex skills and solve difficult problems. To further understand why CTA is
effective, the following sections examine types of knowledge, the advantages and
disadvantages of automaticity, the characteristics and consequences of expertise, and an
overview of cognitive task analysis.
PATIENT CARE HANDOFF IN THE ICU 31
Types of Knowledge
Knowledge is multidimensional, multifaceted, and constantly changing (Ambrose,
Bridges, DiPietro, Lovett, & Norman, 2010). Research from cognitive psychology and the
cognitive neurosciences describe a variety of knowledge types, structures, and processes required
for performance of complex tasks. Merrill (1983; 1994) describes four types of knowledge:
concepts, processes, principles, and procedures, and two primary uses of knowledge: declarative
knowledge and procedural knowledge. Cooke (1994) extends those processes to include
decision-making, reasoning, critical thinking, and problem solving. Anderson’s (1996) theory of
cognition, Adaptive Control of Thought (ACT), describes three basic types of memory: working,
declarative, and procedural memory. Working memory (also known as short term memory) is
used for encoding visual, spatial, and verbal information and is the foundation for conscious
thought. Declarative memory is used in the retrieval and storage of information from the
working memory and is the foundation for knowledge. Procedural memory (also known as
production or long term memory) is used to create actions or processes based on information
from declarative memory and is expressed or executed through working memory.
Performing a complex task, such as a patient handoff, involves the coordination of
knowledge types, including declarative knowledge, procedural knowledge, and conditional
knowledge (Anderson, 1982; Anderson & Fincham, 1994; Clark & Estes, 1996; Corbett &
Anderson, 1995). These knowledge types are not the same and they enable different types of
performance, such as knowing what, how, and when to perform a task. A specific knowledge
type alone is insufficient to execute a complex task. Having knowledge about facts of a complex
task does not result in the ability to perform the task or to know when to perform the task.
Similarly, one may be able to perform a complex task but not necessarily be able to explain the
PATIENT CARE HANDOFF IN THE ICU 32
rationale behind it (Ambrose et al., 2010; Anderson, 1982). The acquisition of knowledge or
skill may be an indication of capability but capability must be combined with motivation for task
execution (Paris, Lipson, & Wixson, 1983).
Declarative Knowledge
Declarative knowledge is described as a broad category of knowledge that is
characterized by a conscious, overt quality and the speed with which it can be learned and
modified in working memory. It is described as goal-independent knowledge that can be
retrieved to manage novel tasks and answer questions about what and why (Anderson & Schunn,
2000; Clark & Estes, 1996; Corbett, & Anderson, 1995; Schraw & Moshman, 1995).
Declarative knowledge is generally divided into two categories: semantic knowledge and
episodic knowledge. Semantic knowledge consists of knowledge about facts, concepts,
principles, and processes. Given the volume of information, it is essential for semantic
knowledge to be organized and categorized in mental frameworks (e.g. schemata) to aid in
retrieval of information. Episodic knowledge consists of memories about specific events,
sequences of events, or experiences. Given the temporal nature of events that lead to episodic
knowledge, construction of “situation models” are needed to encode, organize, and retrieve the
information at a later time (Schraw & Moshman, 1995). For example, it may be easier for a
healthcare provider to list the components of a patient handoff report by using an acronym such
as SBAR (situation, background, assessment, and recommendation), which provides a mental
framework. Likewise, observing or experiencing a patient handoff may provide the contextual
framework from which to draw.
PATIENT CARE HANDOFF IN THE ICU 33
Procedural Knowledge
In the acquisition and performance of a complex skill, Anderson (1982) describes a two-
stage process in which declarative knowledge is converted to procedural knowledge through
repetition and practice. Nearly all knowledge comes into the system in a conscious, declarative
form; it is committed to long-term memory, and then transformed (over time with use) into a
largely unconscious, automated procedural knowledge (Anderson & Fincham, 1994). As such,
declarative and procedural knowledge are required for completing complex tasks and are
acquired as one transitions from novice to expert.
Procedural knowledge is different from declarative knowledge in that it can be directly
applied to performing a task. Procedural knowledge is about “when and how” to perform a task
and includes sequences and steps to be followed during a simple or complex task. It is knowing
how and when to apply specific procedures, skills, or methods. Procedural knowledge is goal-
oriented, facilitation knowledge that promotes problem solving. It is subject specific (e.g.
knowledge of skills or techniques in performing a complex task such as patient handoff) and is
characterized by an unconscious or automated quality (Ambrose et al., 2010; Anderson, 1982;
Anderson & Fincham, 1994; Anderson & Krathwohl. 2001; Clark & Estes, 1996; Corbett &
Anderson, 1995).
Procedural knowledge is difficult to learn and is acquired from direct instruction and/or
repetition. The acquisition of procedural knowledge or skills is dependent upon conditions in
which the learner can reference prior exposure to a problem or situation while engaging in
current problem or situation (Anderson, 1993; Clark & Estes 1996). With repetition and practice,
both declarative and procedural knowledge become stronger and performance becomes more
fluid, consistent, and automated, thereby freeing up working memory. Once automated,
PATIENT CARE HANDOFF IN THE ICU 34
procedural knowledge is quick to execute but is very difficult to change or revise. Expertise or
expert performance develops as a function of more experience and deliberate practice. For
example, a novice healthcare provider may initially need to refer to a checklist to remember the
components and sequence of patient handoff report. With experience, the healthcare provider can
deliver a more efficient and effective patient handoff report while adapting to changes in the
reporting conditions. Procedural knowledge is also knowledge of when to use or not use a given
procedure. This is also known as conditional knowledge (Anderson & Krathwohl, 2001)
Conditional Knowledge
Conditional knowledge is defined as a higher order cognitive process and is described as
the acquisition of condition-action steps or “IF…THEN” couples. Conditional knowledge helps
modulate procedural and declarative knowledge. Procedural knowledge consists of IF/THEN
statements that rely on facts generated from declarative knowledge (IF) that are converted to
decision steps from procedural knowledge (THEN). Conditional knowledge modulates the fact-
to-action process, for example, when or why to use or not use a given procedure, step, or skill.
As such, conditional knowledge provides the circumstances or rational for various actions
(Anderson, 1982; Anderson & Krathwohl, 2001; Anderson & Schunn, 2000; Corbett &
Anderson, 1995; Paris et al., 1983). For example, to increase effectiveness of the patient handoff
report, the experienced healthcare provider may wait to give report until the receiving party
appears ready to take report.
The value of information lies in the accessibility and usefulness of information. The
activation or retrieval of information is influenced by how well it is learned (base-level
activation) and by the context (associative activation) in which they are retrieved. The usefulness
of information includes more advanced cognitive functions such as making inferences and
PATIENT CARE HANDOFF IN THE ICU 35
making predictions (Anderson & Schunn, 2000). According to Paris et al. (1983), skill and will
are also important for task execution. The amount of knowledge or skill may be indicative of
capability but also relies on the will or motivation that directs the individual’s actions.
Prior knowledge
Prior knowledge is defined as the knowledge an individual develops in response to their
preexisting attitudes, knowledge, experiences, and beliefs (Ambrose et al., 2010). It is important
to assess prior knowledge in terms of both declarative and procedural knowledge since prior
knowledge can help or hinder learning. When prior knowledge is activated, sufficient,
appropriate, and accurate, learning is enhanced. Conversely, when prior knowledge is
inactivated, insufficient, inappropriate, and/or inaccurate learning is hindered. Types of prior
knowledge include knowledge that is accurate but insufficient, inappropriate, and/or inaccurate.
Accurate but insufficient prior knowledge. An individual may know facts and
concepts (declarative knowledge) but not know how or when to apply them (procedural
knowledge). As mentioned earlier, an individual may know how to do something but not know
why, which limits understanding in other contexts.
Inappropriate prior knowledge. Information that works in one area may skew
application in other areas, for example, misapplication of cultural information. A firm
handshake and good eye contact may indicate confidence in some cultures but be a sign of
disrespect in other cultures. Thus, it is important to teach conditions of application.
Inaccurate prior knowledge. There is a natural tendency to fit new knowledge into
what we already know but in doing so, new knowledge may become a combination of accurate
and inaccurate information. Inaccurate prior knowledge or misconceptions are very hard to
change since they require energy to overcome.
PATIENT CARE HANDOFF IN THE ICU 36
Declarative, procedural, and conditional knowledge are acquired as one transitions
from novice to expert (Paris et al., 1983). With repetition and practice, both declarative
and procedural knowledge become stronger and performance becomes more fluid,
consistent, and automated.
Automaticity
Automaticity is defined as the unconscious fluidity of task performance following
sustained and repeated execution (Anderson, 1996a; Ericsson, 2004). Characteristics of
automaticity during task execution include mental operations that (a) occur without intention or
effort, (b) occur rapidly, (c) impose little or no cognitive load, and (d) require little in the way of
additional resources (Feldon, 2007; Wheatley & Wegner, 2001). Anderson (1996) identified
three stages of automaticity. The first stage is the interpretive, declarative, or cognitive stage in
which the learner uses declarative knowledge and verbal prompting to complete a task. The
second stage is the associative or knowledge compilation stage in which the learner begins to
convert declarative knowledge into procedural knowledge during task execution. The third stage
is the autonomous stage in which the learner strengthens and fine-tunes the knowledge and skills.
Feldon (2007) explains that as experts develop their conscious declarative knowledge, their
performance becomes gradually more automated. Automated processes often initiate without
prompting and once they initiate, automated processes run to completion without being available
for conscious monitoring. Automated knowledge can involve the “when and how” knowledge
experts use to solve problems. Automaticity moves knowledge from concrete to more abstract
and in experts’ automaticity not only results in more knowledge but also more advanced
knowledge (Hinds, Patterson, & Pfeffer, 2001). Experts construct elaborate schemas to facilitate
performance in complex tasks (Feldon, 2007). Ericsson, Krampe, and Tesch-Römer (1993)
PATIENT CARE HANDOFF IN THE ICU 37
identified a fourth stage of automaticity in which expert performance develops as a result of
deliberate practice and continuous performance improvement.
There are advantages and disadvantages to the development of automaticity. The
advantages of automaticity include a reduction in cognitive load, enhanced working memory,
and improved management of novel and complex tasks. As declarative and procedural
knowledge become automated, task performance becomes unconscious and working memory is
freed up (Wheatley & Wegner, 2001). Automated knowledge helps to alleviate cognitive
overload and/or processes that can impede the efficiency of working memory (Kirschner,
Sweller, & Clark, 2006). Automaticity allows cognitive tasks to become more fluid (Clark,
1999) and it supports the capacity to respond to novel problems with speed, accuracy, and
consistency within an expert’s domain (Clark & Elen, 2006; Wheatley & Wegner, 2001). In
addition to management of novel problems, automaticity in experts is based not only on more
knowledge but also more advanced knowledge that is expressed through abstractions (Hinds,
Patterson, & Pfeffer, 2001).
Automaticity can pose a challenge in both professional development and education in that
the unconscious nature of automated knowledge is resistant to change and difficult to articulate
when teaching. Considerable effort and sustained monitoring of mental processes are required
to unlearn, modify, or eliminate an automated process (Clark, 2008; Wheatley & Wegner, 2001).
Research on expertise in curriculum and pedagogy identified that automated teaching processes
were resistant to change even when the teachers were given clear feedback regarding omissions
in their lecture content. Automaticity results in the inability to attend to these unconscious
processes in order to bring about desired changes (Feldon, 2007). Ericsson (1998) argued that
PATIENT CARE HANDOFF IN THE ICU 38
the development of expertise was actually impaired by the development of automaticity since
adaptation, an essential component to expert performance, was limited by automaticity.
As a consequence of automaticity, experts are unaware of the information they use to
complete complex tasks and knowledge may be difficult to articulate because it has become
automated. In an educational setting, this may become especially problematic as critical
information omitted by experts may confound effective teaching (Kirschner et al., 2006).
Knowledge elicitation methods like CTA are essential to deconstructing the automated
knowledge into its original steps (Clark & Estes, 1996).
Expertise
Characteristics of Experts
Studies on expertise found that experts excel in a specific domain by creating mental
representations and perceiving meaningful, interconnected patterns. The development of mental
representations, or schema, reduces cognitive load and increases efficiency. Experts are
described as resourceful and are reported to have better short- and long-term memory than
novices. They are faster and more accurate than novices when performing the skills of their
domain. The ability to see patterns and cues can be used to their advantage in solving problems.
When solving problems, experts perceive problems in their domain at a deeper level than novices
and they spend more time qualitatively analyzing problems. Experts self-monitor effectively
during problem solving and can differentiate between random decisions and meaningful ones
(Bedard & Chi, 1992: Chi, 2006; Glaser & Chi, 1988). Ericsson et al. (1993) identified two
more characteristics of expertise. First, advanced expertise typically requires a minimum of ten
years of deliberate practice to develop. Second, consistent expert performance requires
adaptation to domain-specific constraints. Although experts outperform novices, research has
PATIENT CARE HANDOFF IN THE ICU 39
shown that expertise does not transfer to domains unfamiliar to the expert. Thus, the domain-
specific nature of experts’ superior performance implies that acquired knowledge and skill are
important to attainment of expert performance. An example in healthcare would be that an
anesthesia provider’s expertise in regional anesthesia does not necessarily translate to expert
performance in other highly specialized areas of anesthesia, such as cardiac anesthesia, although
the general domain is anesthesia. The nuances in patient care handoffs in various subspecialties
may also be influenced by the particular domain.
Building Expertise
Chi (2006) and Ericsson and Charness (1994) described the acquisition of expertise as not
innate or hereditary but as a result of deliberate practice and a capacity to learn material specific
to a domain. Ericsson (2004) describes the acquisition of expert performance as a series of
phases in learning that becomes increasingly more deliberate over time. Initially, the novice’s
primary goal is to reach a level of mastery that will allow her to perform everyday tasks at an
acceptable level or to engage proficiently, such as in recreational activities with her friends.
During the first phase of learning, novices try to understand the activity and concentrate on
avoiding mistakes. With more experience in the middle phase of learning, major mistakes
become increasingly rare, performance appears smoother, and learners no longer need to
concentrate as hard to perform at an acceptable level. After a limited period of training and
experience an acceptable standard of performance is typically attained. As individuals adapt to a
domain and their performance skills become automated, they are able to execute these skills
smoothly and without apparent effort. As a consequence of automation, performers lose
conscious control over execution of those skills, making intentional modifications difficult. Once
the automated phase of learning has been attained, performance reaches a stable plateau with no
PATIENT CARE HANDOFF IN THE ICU 40
further improvements. Ericsson (1998) cautions, “the key challenge for aspiring expert
performers is to avoid the arrested development associated with automaticity” (p.90) and to
acquire cognitive skills to support continued learning and improvement. Expert performance
continues to improve as a function of more experience, coupled with deliberate practice.
Deliberate practice therefore improves specific aspects of performance in a manner that assures
that attained changes can be successfully integrated into representative performance.
Consequences of Expertise
The same elements that enhance the acquisition of expertise, may limit the expert’s
ability to apply his or her knowledge in other domains and/or articulate knowledge to others
(Bedard & Chi, 1992; Chi, 2006; Ericsson, 2004; Feldon, 2006; Feldon, 2007).
As mentioned previously, automaticity is the execution of effortless cognitive procedures that
occur rapidly and impose little or no cognitive load (Feldon, 2007; Wheatley & Wegner, 2001).
Expertise is task specific, which may impose challenges as experts attempt to transfer
knowledge, skills, or strategies from one domain to another (Bedard & Chi, 1992)
Procedures that become automated are deeply ingrained and not only difficult to change
but difficult to articulate. Chi (2006) describes challenges present when experts attempt to teach
novices. The expert can appear overly confident in their approach to a task and/or make the task
execution appear effortless thereby reducing the ability to relate to or understand the perspective
of the novice. In addition, the expert is better with abstract concepts and may overlook details
the novice may need to know when learning how to perform a task or solve a problem.
Furthermore, given the expert’s own fluidity at performing a task, the expert may not be able to
predict novice performance. The burden of expertise combined with the responsibility of direct
PATIENT CARE HANDOFF IN THE ICU 41
patient care in a dynamic situation such as patient handoff in the intensive care unit, makes
clinical instruction that much more challenging.
Cognitive task analyses have emerged as a promising set of methods which can be used
to enhance the teaching of procedural skills, particularly in high stakes environments, by
capturing information about both the overt observable behavior and the cognitive structures and
processes that underlie complex tasks.
Cognitive Task Analysis (CTA)
Definition of CTA
Clark and Estes (1996) define cognitive task analysis (CTA) as a general term used to
describe a set of methods and techniques that elicit the cognitive structures and processes, rather
than observable behaviors, associated with task performance. Action steps are directly
observable behaviors while decision steps involve cognitive processes and structures that are not
directly observable and inform when or when not to perform an action or procedure. CTA uses a
variety of interview and observation strategies and is an extension of traditional task analysis
which identifies the knowledge, thought processes and goals structures that underlie observable
task performance, as well as overt and covert cognitive functions (Clark, Feldon,
vanMerrienboer, Yates, & Early, 2008). CTA methods are particularly useful to elicit the
cognitive aspects of task performance that are not directly observable. The explicit and implicit
knowledge that is elicited by the CTA process can be used to teach, train, assess performance
and develop expert systems (Chipman et al., 2000).
CTA History
Modern cognitive task analysis is a reformation of methods, perspectives, and focus that
have been present throughout modern history. CTA methods have developed and adapted in
PATIENT CARE HANDOFF IN THE ICU 42
response to the social, psychological, cognitive, and political activities in a dynamically changing
world (Annett, 2000; Clarke & Estes, 1996; Cooke, 1994; Hoffman & Woods, 2000; Militello &
Hoffman, 2008). Precursors to modern CTA emerged as far back as the 1880s when self-report
methods and retrospection were used as data collection techniques. In the early 1900s, task
analysis began to include the cognitive elements of work in addition to the directly observable
aspects. Task analysis techniques were influenced by industrial and applied psychology, which,
at the time focused on the cognitive and observable behaviors of experts working in their
workplaces (Militello & Hoffman, 2008). These studies were used to determine likely labor costs
and to develop and design systems that made them more efficient (Annett, 2000).
In the mid 1900s, task analysis studies included human factors and ergonomics in relation
to operation of complex machine systems (Militello & Hoffman, 2008). The foundations for
cognitive psychology began to take hold as the concept of mental workload and information
processing became more important. Behaviorist learning theory was not sufficient to fully
analyze the skills and knowledge necessary to function in a more technologically sophisticated
world (Annett, 2000). Cognitive task analysis methods have continued to evolve in response to
changes in the workplace and modern CTA has become refined over the last 20 years with the
demand of modern technology. Cognitive engineering, naturalistic decision-making, and human-
centered computing are modern research threads with strong links to CTA (Annett, 2000; Clarke
& Estes, 1996; Cooke, 1994; Hoffman & Woods, 2000; Militello & Hoffman, 2008).
Cognitive task analysis studies involve high stakes settings, such as military and
healthcare settings, work cultures in relation to technology, and the computer/human interface.
Task analysis has laid the developmental foundation for learning objectives, job description
PATIENT CARE HANDOFF IN THE ICU 43
schemas, hiring criteria, and performance appraisal systems. CTA may be one of the most
successful training inventions of the past century (Clarke & Estes, 1996).
CTA Methodology
Cognitive task analysis is a process of extracting domain specific knowledge that
underlies human performance. Although there are over 100 varieties of cognitive task analysis
(Cooke, 1994; Yates, 2007), most methods follow a five-stage process for knowledge elicitation
that includes:
1) Identification of tasks and collection of preliminary domain-specific knowledge;
2) Identification of knowledge types required to perform the tasks and subtasks;
3) Application of the knowledge elicitation technique;
4) Verification, analysis, and possible modification of knowledge elicited by the experts;
5) Formatting results into a training tool (Chipman et al., 2000; Clark et al., 2008).
There are four categories of knowledge elicitation: a) observations; b) interviews; c)
process tracing; and d) conceptual methods. Interviews are the most frequently used knowledge
elicitation method (Cooke, 1994). A variety of knowledge elicitation techniques exist, including
the concepts, processes, and principles (CPP) method, the critical decision method (CDM), and
the precursor, action, result, and interpretation (PARI) method (Clark et al., 2008; Hall et al.,
1995). The CPP method involves multi-stage, semi-structured interviews with multiple experts
that capture the automated and unconscious knowledge necessary for performance of a complex
task (Clark et al., 2008). The CPP method is one of the most commonly used evidenced-
based CTA methods (Clark et al., 2008). The CDM method uses semi-structured interviews to
assess experts’ situational awareness and decision-making during natural, non-routine situations
(Klein et al., 1989). The PARI method is designed to elicit the system knowledge, procedural
PATIENT CARE HANDOFF IN THE ICU 44
knowledge, and strategic knowledge that experts use for problem solving in real-world settings.
The PARI method pairs two experts in a structured interview setting: one expert is the “problem
poser” and the other expert is the “problem solver”. The dyadic approach is designed to engage
the experts in articulating their reasoning as they solve problems (Hall et al., 1995).
Cooke (1994) describes differences in various interview techniques that should be
considered. Formal interview methods are less flexible and may feel more artificial, require
more time for preparation of elicitation materials and more methodological training. As a result,
formal interview methods are less commonly used. The less formal techniques usually require
more introspection, verbalization, and a more active role on the part of the knowledge elicitor.
Chipman et al. (2008) suggest the ideal model of CTA is one that is not subject to resource
restrictions. Although the methods may differ in focus and in the types of knowledge elicited,
they share the common goal of eliciting knowledge required for complex problem solving
Effectiveness of CTA for Capturing Expert Knowledge
Research has shown that experts may omit up to 70% of the critical decision steps when
describing how to perform complex task and solve difficult problems to others because
procedures and skills have become so automated and non-conscious (Anderson, 1993; Clark &
Estes, 1996; Clark et al., 2008). Even with CTA knowledge elicitation techniques, SMEs may
provide imprecise, partial, or even erroneous descriptions when asked to describe how to perform
a complex procedure. Chao and Salvendy (1994) found that, regardless of knowledge elicitation
technique (protocol, interview, induction, repertory grid), only 40% of the procedural knowledge
could be elicited from a single SME. The researchers found that the percentage of procedural
knowledge elicited could be doubled when knowledge is elicited from six SMEs using
knowledge eliciting techniques. The researchers recommended acquiring knowledge from three
PATIENT CARE HANDOFF IN THE ICU 45
SMEs as that may provide the best cost-benefit ratio as subsequent SMEs result in only marginal
increases (less than 10%) of action and decision steps. Crispen (2010) replicated the
methodology of Chao and Salvendy (1994) and demonstrated knowledge gains from 56%
complete to 85% complete when he compared elicited knowledge from one CTA guided
interview to three CTA guided interviews with surgical experts describing the procedure of
cricothyrotomy. Furthermore, Crispen found that for both the open cricothyrotomy and CVC
procedures, three experts were required to reach a 10% point of diminishing marginal utility for
the acquisition of additional action steps.
Cognitive task analysis has proven to be an effective method for capturing the overt and
covert cognitive functions of experts and is regarded as a necessary component of research in
complex cognitive work (Hoffman & Militello, 2009). Cognitive task analysis has been utilized
to help build expert systems, aid human performance with computer support, understand a field
of practice, understand the basis for expertise, and develop computer aided instructional systems
(Hoffman & Woods, 2000; Yates & Feldon, 2011). Cognitive task analysis is particularly useful
in domains that emphasize technical-functional capabilities, such as engineers, medical
personnel, or military personnel. Traditional methods of knowledge elicitation, such as
behavioral task analysis or asking experts to list steps, do not accurately account for the abstract
knowledge in experts (Means & Gott, 1988). In information technology, the integration of CTA
allows product designers to manage deviations in function, such as with poorly designed medical
devices, and user response (Crandall, Klein, & Hoffman, 2006). Compared to other strategies,
CTA is more effective at capturing the unconscious, complex cognitive action and decision steps
of experts. Cognitive task analysis is not just knowledge extraction, but rather knowledge co-
creation and co-discovery (Ford & Bradshaw, 1993)
PATIENT CARE HANDOFF IN THE ICU 46
Effectiveness of CTA-Based Training
Studies across a variety of domains, including medicine, military, and special education,
have shown that knowledge elicited from subject matter experts using CTA methodology can
improve instructional outcomes, both in the efficiency and efficacy of training, as well as
economic advantages. The explicit and implicit knowledge that is elicited from the CTA process
can be used to teach, train, assess performance, and develop expert systems (Chipman et al.,
2000; Clark, 2014; Hoffman & Militello, 2009; Tirapelle, 2010; Zepeda-McZeal, 2014). Clark
and Estes (1996) conducted a cost comparison of behavioral and cognitive task analysis methods
and identified that the use of CTA-based instruction required greater front-end investment of
time for design, development and instructor training. This early investment of time resulted in
considerable savings in time at the point of training with evidence of improved performance on
posttests.
Schaafstal, Schraagen, and Marcel (2000) conducted a CTA on troubleshooting weapon
radar systems and examined the training curriculum for novice weapon engineers. The
researchers summarized the challenges faced by novice troubleshooters as information overload,
lack of hierarchical organization, inadequate mental models, inadequate system understanding,
and lack of strategies. The researchers developed a CTA-based method for training novice
weapon engineers in structured troubleshooting and compared the CTA-based training method
with the conventional training group. Compared to the control group, the CTA-based training
group solved twice as many malfunctions and did so in less time. Elements of the test including
systematic processing, understanding of the troubleshooting function, and the correct
identification of problems, were all found to be significantly better in the test group when
compared to the status quo training.
PATIENT CARE HANDOFF IN THE ICU 47
Merrill (2002) compared CTA-based instruction with minimal guidance discovery-based
instruction and conventional instruction for training on the use of spreadsheets. The CTA-based
instruction group outperformed the discovery-based instruction group and the conventional
instruction group in both percent correct and time required to complete the task.
Challenges to Clinical Teaching in Healthcare
Historically, knowledge acquisition in clinical medicine has relied on apprenticeship
models and experiential based learning. In the 1970s, problem-based learning was introduced in
medical education, which showed improvements in student satisfaction, but has not shown
improvements in factual (declarative) or clinical (procedural) knowledge acquisition (Clark,
Yates, Early, Moulton, Silber, & Foshay, 2010; Kirschner et al., 2006; Koh, Khoo, Wong, &
Koh, 2008; Vernon & Blake, 1993). In the last decade, use of simulation-based education has
shown improvements in areas such as operative time and team communication but not in the
transferability of surgical skills, including critical decision steps (Buckley et al., 2014; Pugh et
al., 2011). There is, however, a growing body of literature supporting the use of cognitive task
analysis (CTA) based approaches for teaching procedural knowledge in medicine (Campbell et
al., 2011; Clark, 2014; Clark, Pugh, Yates, Inaba, Green, & Sullivan, 2012; Crandall & Getchell-
Reiter, 1993; Embrey, 2012; Sullivan, Ortega, Wasserberg, Kaufman, Nyquist, & Clark, 2008;
Sullivan, et al., 2007; Yates, Sullivan, & Clark, 2012).
At the point of introduction to nursing school, medical school or residency programs, the
adult learner has already acquired extensive knowledge and skills. The challenge for healthcare
educators is not only helping the learner acquire new skills, but also to modify (or correct)
previously acquired skills (Ericsson, 2004a). This is compounded by two additional challenges
in clinical education. The first challenge lies in the fact that most clinical educators are
PATIENT CARE HANDOFF IN THE ICU 48
healthcare providers who take on the role of teaching in medicine but have no formal training as
teachers. The second challenge is that clinical educators frequently possess expertise in their
respective fields of healthcare. Like experts from other disciplines, experts in nursing or
medicine may unintentionally omit up to 70% of the necessary information when teaching
thereby limiting knowledge sharing and instructional outcomes (Clark & Estes, 1996; Clark et
al., 2008; Clark et al., 2012). It is imperative, then, to utilize a knowledge elicitation method,
such as cognitive task analysis, to deconstruct procedural knowledge into its original steps (Clark
& Estes, 1996).
Effectiveness of CTA Based Training in Healthcare
Multiple studies have shown that the use of CTA based instructional design is superior to
traditional teaching methods in improving declarative and procedural knowledge as well as,
procedural skills and self-efficacy in the performance of complex medical tasks. Specific areas
examined have included decision making and communication in the operating room, physical
assessment in the neonatal intensive care unit, cricothyrotomy and percutaneous tracheostomy,
tracheal extubation, laparoscopic surgery, central line placement, and colorectal surgery
(Buckley et al., 2014; Campbell et al., 2011; Clark, 2014; Crandall & Getchell-Reiter, 1993;
Embrey, 2012; Fackler et al., 2009; Sullivan et al., 2007; Pugh et al., 2011).
Crandall and Getchell-Reiter (1993) utilized a CTA technique called the critical decision
method (CDM) to identify and document key clinical perceptions and assessments used by
NICU nurses in the early detection of sepsis in neonates. The researchers discovered that the
CDM elicited knowledge not found in the nursing and medical literature in use at the time of the
study. From the CDM based knowledge elicitation, the researchers developed and evaluated a
sepsis assessment guide. The guide presented information required for early detection of sepsis
PATIENT CARE HANDOFF IN THE ICU 49
in a comprehensive, rigorous, and systematic fashion. The findings of this study supported CTA
as the more effective method for eliciting critical information that can lead to improvements in
nursing practice by capturing the subtle nuances of what is considered highly subjective material.
Embrey (2012) implemented a double-blinded study comparing CTA-based instruction
with conventional instruction in the performance of tracheal extubation by graduate nurse
anesthetist students and found increases in the declarative and procedural knowledge gains, as
well as increases in task expediency in the CTA-based group. Gucev (2012) examined the
performance of ultrasound guided regional anesthesia by medical students and found
improvements in declarative and procedural knowledge, as well as fewer procedural mistakes in
the CTA-based group when compared to the group receiving conventional training.
Buckley et al. (2014) examined the transferability of procedural skills from simulation-
based learning to the operating room. The researchers found an improvement in some aspects of
performance, such as time required, but not in the critical decision making aspects of skill
acquisition. Pugh et al. (2011) evaluated the usefulness of CTA based simulation surgical
training modules and found that the use of CTA helped focus training on evidence-based,
intraoperative decision making, and on simulation design. It was suggested that CTA based
simulation modules be used throughout training for formative assessment and not just used as an
annual examination.
Compared to traditional teaching methods, CTA supported instruction resulted in
significant improvements in learning performance and a reduction in the number of mistakes
made by learners and recently graduated students (Clark, 2014; Embrey, 2012; Gucev, 2012;
Fackler et al., 2009; Sullivan et al., 2007) and improved communication and decision-making
among physicians (Fackler et al., 2009).
PATIENT CARE HANDOFF IN THE ICU 50
Meta-analysis of studies. A meta-analysis conducted by Lee (2004) and Tofel-Grehl and
Feldon (2013) shows compelling evidence that CTA-based instruction is superior when
compared to traditional non CTA-based instruction. Lee (2004) analyzed eight empirical studies:
four military based settings, three hospital based settings, and one private setting involving
computer interfacing. Inclusion criteria for the studies were as follows: reported pre and posttest
measures of training performance, reported basics statistical results, conducted between 1985
and 2003, used adult population, used CTA methods with an analyst, not using computer-
supported knowledge elicitation tools, reported efficiency data in a standard such as participant,
SME, CT analyst hours involved, and duration of study. The findings of the meta-analysis
demonstrated that CTA is an effective method as measured by pre/post test measures of
performance and learning gains. The overall median percentage gain in all work setting, with any
level of work experience, and regardless of CTA method used, was a 75.2% performance gain.
According to the author, “the results were so conclusive, that they showed CTA is effective in
any setting for anyone” p. 36 (Lee, 2004).
The meta-analysis performed by Tofel-Grehl and Feldon (2013) included 20 empirical
studies conducted between 1987 and 2010 in a variety of settings. The researchers also found
that CTA-based instruction resulted in notable gains when compared to traditional non CTA-
based instruction, however, they also found that the effect size varied by CTA method and
context. The PARI method yielded a mean effect size of 1.589 as compared to 0.329 for CDM
and 0.729 for other CTA methods. The military setting yielded a mean effect size of 1.439 as
compared to mean effect sizes of -0.171 (government/non-military), 0.666 (academic/university),
0.732 (medical), and 1.062 (industry). The authors concluded that CTA-based instruction can
enhance the quality of performance and learning gains across diverse settings.
PATIENT CARE HANDOFF IN THE ICU 51
Summary
CTA is a knowledge elicitation method that uses interview and observation techniques to
capture the explicit and implicit knowledge that experts use to perform complex tasks. When
experts are asked to describe how to perform domain-specific tasks, they unintentionally omit
up to 70% of critical information novices need to learn to successfully perform complex tasks.
The patient handoff process represents a complex task that may require the transfer of
declarative and procedural knowledge, as well as the transfer of tacit knowledge. The available
research literature on transfer of patient care does not include information derived from the
cognitive task analysis of experts in the field of anesthesia. There is also a paucity of literature
that identifies the essential elements of a transfer of patient care from anesthesia providers in the
operating room to the intensive care unit members. In addition, there is no evidence to suggest
that the training programs addressing the patient care handoff process have been standardized
and/or evaluated.
The purpose of this study was to utilize Cognitive Task Analysis (CTA) methods to
elicit knowledge from expert critical care anesthesia providers (anesthesiologists and nurse
anesthetists) and define the knowledge, skills, procedures, tools and use of senses necessary to
conduct a comprehensive patient care handoff from the operating room to the intensive care
unit.
PATIENT CARE HANDOFF IN THE ICU 52
CHAPTER THREE: METHODS
The purpose of this study was to utilize Cognitive Task Analysis to elicit knowledge from
expert critical care anesthesia providers (anesthesiologists and nurse anesthetists) used in
performing patient care handoff from the operating room to the intensive care unit. This inquiry
was undertaken in an effort to define the knowledge, skills, procedures, tools, and use of senses
necessary for patient care handoff between anesthesia providers and critical care staff in order to
design instruction, as well as identify the critical information that is lost during patient handoff.
This inquiry is important as it adds to the existing body of knowledge derived from CTA in
medical education and is the first CTA based study related to patient handoff.
The research methodology used in this study employed CTA guided interviews for
knowledge elicitation from four subject matter experts. The study focused on the development of
a step-by-step protocol for patient care handoff from anesthesia providers in the operating room
to critical care staff in the intensive care unit. The protocol could then be used in the instruction
of patient care handoff. The specific research questions which elaborate this research purpose
are as follows:
1. What are the action and decision steps that expert critical care anesthesia providers recall
when they describe how they conduct a patient handoff from the operating room to the
intensive care unit?
2. What percentage of action and decision steps, when compared to a gold standard, do expert
critical care anesthesia providers omit when they describe how they conduct patient handoffs
from the operating room to the intensive care unit?
PATIENT CARE HANDOFF IN THE ICU 53
Participants
The participants in this study were critical care anesthesia providers identified as experts
in conducting patient care handoffs from the operating room to the intensive care unit. The
subject matter experts (SMEs) were selected based on established criteria by Chipman,
Schraagen, & Shalin (2000). Each SME had a minimum of 10 years of experience with patient
handoffs as anesthesia providers in a variety of settings, including the critical care setting, a solid
track record with regard to patient safety, and good departmental standing. The expert critical
care anesthesia providers had experience as clinical instructors in anesthesia but not specifically
with the patient handoff process. In addition, each SME indicated availability as needed and a
willingness to participate in this study.
Data Collection for Question 1
What are the action and decision steps that expert critical care anesthesia providers recall when
they describe how they conduct a patient handoff from the operating room to the intensive care
unit?
The CTA procedure outlined by Clark et al. (2008) followed the five phases for
knowledge elicitation and includes: (1) identification of tasks and collection of preliminary
domain-specific knowledge; (2) identification of knowledge types required to perform the tasks
and subtasks; (3) applying the knowledge elicitation technique in a semi-structured interview, (4)
verifying and analyzing the results from the interviews, and (5) formatting results into a training
tool.
Phase 1: Collecting Preliminary Knowledge
Relevant literature from peer reviewed critical care, nursing, and anesthesiology
journals and textbooks regarding patient handoff was reviewed. “Bootstrapping” was
PATIENT CARE HANDOFF IN THE ICU 54
undertaken to familiarize the senior researcher with language of anesthesia practice and to
facilitate the acquisition of domain specific knowledge relating to the task of patient handoff.
Phase 2: Identify Knowledge Types Required for the Task
The types of knowledge associated with patient handoff from the operating room to the
intensive care unit were identified. The knowledge types included the concepts, processes,
principles, and procedures in the form of the action and decision steps necessary for the task
performance.
Phase 3: Application of Knowledge Elicitation Methods
Instrumentation. The elicitation of knowledge was conducted via CTA guided semi-
structured interviews with three subject matter experts using the concepts, processes, and
principles (CPP) technique (Clark, 2014). The semi-structured interview protocol is attached as
Appendix A.
The CPPs techniques were used to develop the semi-structured interview protocol for this
CTA. The CPPs technique uses layered interview techniques to gather the automated and often
unconscious knowledge used by experts to accomplish complex tasks (Clark, 2006). The process
begins with the researcher explaining the CTA process to the participant and asking the
participant to list stages required to accomplish the larger task being studied. The expert then
identifies five problems that an expert should be able to solve if the primary task has been
mastered, and for the final step, the researcher leads the expert through a semi-structured
interview that focus on each of the subtasks and how the expert completes the subtasks. The
semi-structured interview focuses on items such as: action steps; decisions; concepts, processes,
and principles; initiating conditions to start a subtask; equipment and materials needed; sensory
PATIENT CARE HANDOFF IN THE ICU 55
experiences needed; and performance standards required among other relevant areas (Clark et
al., 2008).
Action steps are directly observable behaviors while decision steps involve cognitive
processes and structures that are not directly observable and inform when or when not to
perform an action or procedure. Decision steps are critical to performing complex tasks and
serve as cues or prompts for the SME to evaluate, interpret, analyze, and decide among
alternatives. The action and decision steps elicited from the expert critical care anesthesia
providers comprise the information novices need to replicate for performance of this complex
task. Action steps begin with a verb and are statements about what a person should do, such
as “When driving a car, make a full stop at every stop sign.” Decision steps contain two or
more alternatives to consider before taking an action, such as “When driving a car and
approaching an intersection, IF the traffic light is red, THEN stop; IF the traffic light is
yellow, THEN proceed with caution; IF the traffic light is green, THEN continue through the
intersection.”
Interviews. Following exemption from the University of Southern California
Institutional Review Board (IRB), three expert anesthesia providers were asked to participate in
the study. The purpose of the study and the CTA process were described prior to interviewing.
Verbal consent was obtained and recorded from each SME at the time of the interview. In order
to limit confirmation bias by the author, as a junior researcher, who is an instructor in clinical
anesthesiology, a senior researcher, who is not an anesthesia provider, guided one of the SME
interviews. The author, with oversight and guidance from the senior researcher, then conducted
two of the SME interviews. The interviews incorporated questions designed to elicit:
PATIENT CARE HANDOFF IN THE ICU 56
1. The events or conditions (indications and contraindications) that must exist to initiate or
conduct a patient handoff.
2. The required performance standards, such as, time, efficiency, and quality indicators.
3. The necessary equipment, supplies, and personnel needed for safe patient handoff.
4. The action and decision steps necessary to perform a patient handoff.
5. The prerequisite skills and knowledge necessary for this task, including concepts,
processes, and principles.
6. Sensory information relevant to or required for task performance.
The interviews were conducted independently with each of the three expert critical care
anesthesia providers, expert A, B, and C. Each SME was subsequently provided with a
transcribed copy of his or her interview to confirm, clarify, and/or supplement interview content
and provide feedback.
Phase 4: Data Analysis
The interviews were digitally recorded and transcribed verbatim by an independent,
professional transcription service, for subsequent coding of elicited knowledge types and content
verification.
Coding. The interviews were coded to reveal elicited conditional knowledge, specifically
indications (I) and contraindications (CI) for task execution. Transcript coding revealed the
necessary equipment, supplies, and personnel (E), sensory cues such as seeing (SS), touching
(ST), and hearing (SH). The use of Clark’s 5-stage protocol enabled capture of the action steps
(AS) and decision steps (DS) experts use in order to perform the task of patient handoff. The AS
and DS indicated “IF” points and the “IF” points indicated decision step alternatives (DSA). The
DSA elucidated “THEN” points during task execution.
PATIENT CARE HANDOFF IN THE ICU 57
Inter-rater reliability. The junior researcher and another trained knowledge analyst
coded the transcribed CTA interview for the second SME. Data on agreements and
disagreements in coding were collected to establish rigor of inter-rater reliability (IRR). The
percent of consensus for each of the coded items was generated from the tallies of agreements
and disagreements between the coders. Any disagreements in coding not resolved by discussion
were reviewed by a third knowledge analyst for consensus. The IRR was established at 96% and
the results of the inter-rater reliability are presented in Chapter Four.
Subject matter expert protocol and verification. The information gathered during the
semi-structured CTA interviews was employed to generate a draft protocol from each of the
critical care anesthesiology SMEs. Each SME was asked to review and correct his or her
specific protocol.
Phase 5. Formatting the Results
Gold standard protocol (GSP). The feedback and task protocols were aggregated to
generate a preliminary gold standard protocol (PGSP) for the task of postanesthesia patient care
handoff from the operating room to the intensive care unit. The aggregation was accomplished
by using the protocol from SME B as it contained the most complete, clear, and accurate list of
action and decision steps. The action and decision steps from each individual protocol were
compared to the SME B protocol. Comparisons were made for best possible content, sequence,
and terminology used and adjustments were made to the PGSP accordingly. The PGSP was
returned to the three SMEs who participated in the semi-structured interviews. The PGSP was
then given to a fourth SME who was selected as a study participant to provide final review for
development of a summary gold standard protocol (GSP). See Appendix C for a complete
description for developing a GSP.
PATIENT CARE HANDOFF IN THE ICU 58
Summary
The CTA method used in this study is described as the 3i + 3r method which refers to 3 initial
interviews followed by 3 reviews. The following is a visual depiction as suggested by
Hammitt (2014).
Figure 1. The five stages of the CTA 3i + 3r Method
Data Analysis for Question 2
What percentage of action and decision steps, when compared to a gold standard, do expert
critical care anesthesia providers omit when they describe how they conduct patient handoffs
from the operating room to the intensive care unit?
Omission analysis. To answer Question 2, the final stage of data collection was
completed by transferring the action and decision steps of the GSP to a spreadsheet for
comparison to the individual SME protocols. If the individual SME protocols included the action
or decision steps of the GSP, then a “1” was placed in the appropriate cell for that SME protocol.
If the individual SME protocols did not include the action or decision steps of the GSP, then a
“0” was placed in the appropriate cell for that SME protocol. The total number of agreements
!
Figure 1.
!
3i + 3r CTA Method
!
!
Researcher(Conducts(Semi2(
structured(Interviews(
!
!
!
!
SME(A( SME(B( SME(C(
!
!
Individual(Protocol( Individual(Protocol( Individual(Protocol(
!
!
Review(Interview( Review(Interview( Review(Interview(
!
!
Preliminary(Gold(Standard(Protocol((PGSP)( (
SME(D(
Review(of(
Gold(Standard(Protocol((GSP)(
PGSP(
!
!
Figure 1: Provides a visual representation of the five stages of the CTA 3i + 3r Method.
PATIENT CARE HANDOFF IN THE ICU 59
and omissions between the individual SME protocols and the GSP were calculated to determine
the percentage of omission for the individual SME protocols.
PATIENT CARE HANDOFF IN THE ICU 60
CHAPTER FOUR: RESULTS
This study examines the declarative and procedural knowledge elicited from four expert
critical care anesthesia providers in describing patient handoffs from the operating room to the
intensive care unit. The CTA methods used elicited declarative and procedural knowledge,
expressed as objectives, procedures, conditions, cues, standards, and action and decision steps.
The results of the data analysis are organized by research question.
Research Questions
Question 1
What are the action and decision steps that expert critical care anesthesia providers
recall when they describe how they conduct a patient handoff from the operating room to the
intensive care unit?
Inter-rater reliability. As described in Chapter Three, inter-rater reliability was
determined by tallying the number of coded items that were in agreement and dividing that
number by the total number of coded items. The results are shown in Appendix B. The inter-
rater reliability was established at 96%. Following the establishment of high inter-rater
reliability, this researcher coded the remaining two SME interviews prior to the creation of an
individual protocol for each SME.
Flowchart analysis. SME B’s initial individual protocol was used to create a flowchart.
The flowchart was carefully analyzed and reviewed by the researcher to ensure that SME B’s
knowledge flowed logically and that there were no decision steps without appropriate potential
actions. The flowcharting process revealed additional questions regarding the knowledge
captured in SME B’s first interview which were asked during a follow-up interview, resulting
in the final individual protocol for SME B. For example, the flowchart revealed several
decision steps that did not provide two or more alternatives and several action steps that did
PATIENT CARE HANDOFF IN THE ICU 61
not make a logical progression. The process of flowcharting SME B’s protocol and the
subsequent round two interview, also informed the researcher about additional questions to
consider during the protocol review with SME A and SME C.
Gold standard protocol. As described in Chapter Three, individual SME protocols
were reviewed and aggregated to generate a preliminary gold standard protocol (PGSP). The
PGSP was reviewed by a fourth SME for development of a summary gold standard protocol
(GSP). An example of the process is shown in Figure 2.
SME A – Action Step
(underlined is the step
omitted by SME C)
Conduct a thorough chart
review that includes:
surgical procedure,
medical history,
lab results,
EKG,
radiology results,
SME C – Action Step
(underlined is the step
omitted by other SMEs)
Conduct a thorough chart
review that includes:
surgical procedure,
medical history,
lab results,
radiology results,
anesthesia history
SME B Action Step
(underlined is the step
omitted by other SMEs)
Conduct a thorough
chart review that
includes: chief
complaint,
surgical procedure,
surgical history,
medical history,
medications,
lab results, EKG,
radiology results,
anesthesia history
Figure 2. Aggregating Action and Decision Steps for the Preliminary Gold Standard Protocol
(PGSP)
The response to Research Question one is the summary GSP, as shown is Appendix D.
The GSP represents the action and decision steps that expert critical care anesthesia providers
PATIENT CARE HANDOFF IN THE ICU 62
use when they conduct a patient handoff from the operating room to the intensive care unit.
Overall, the experts elucidated five main procedures in conducting a patient handoff:
1. Acquire knowledge of patient condition through chart review, patient interview, and
physical assessment.
2. Acquire knowledge of patient condition based on intraoperative course.
3. Prepare equipment, medications, personnel, and the patient for transfer.
4. Conduct patient transport from the operating room to the ICU.
5. Conduct patient handoff report.
The disaggregated results are described in the following sections.
Recalled action and decision steps. An analysis was conducted of the action and
decision steps recalled by each SME by transferring each action and decision step from the
summary GSP to a Microsoft Excel spreadsheet for the purpose of categorizing, coding, and
tallying each step. In the first column on the spreadsheet, each step from the GSP was coded as
“A” action for action steps or “D” for decision steps. Some of the steps were labeled as “R” for
reasons but had no numerical value in the data analysis. For example, in relation to the action
step 4.10: “Assess engagement of the ICU nurse” and the subsequent decision steps (4.10.1-
4.10.3), the following reason was given: “There tends to be multiple people in the ICU room
trying to help but this can lead to more unnecessary chatter, unnecessary conversation, and
talking. You want to make sure the person you're talking to is actually hearing what you're
saying and not caught up in another conversation with somebody”. SMEs were identified as
“SME A”, “SME B”, “SME C”, or “SME D” in columns on the spreadsheet to allow for tallying
of action and decision steps recalled by each SME. Action and decision steps that were included
in the individual SME protocol and the GSP were marked with a “1”. Action and decision steps
PATIENT CARE HANDOFF IN THE ICU 63
for each SME were totaled at the bottom of that SMEs column. The spreadsheet analysis is
included as Appendix E. Table 2 displays the total action and decision steps for SME A, SME B,
and SME C used in the creation of initial individual protocols.
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 50 36 86
SME B 76 57 133
SME C 50 30 80
Action and decision steps contributed by each SME. Table 2 reports action and
decision steps recalled by each SME. The action and decision steps in Table 2 may not be solely
attributed to one SME, in other words any given action or decision step may have been recalled
one, two, or three SMEs. As a result, the action and decision steps reported in Table 2 when
added together exceed the total number of action and decision steps in the gold standard protocol
reported in Appendix D. Figure 3 displays the percentage action and decision steps elicited from
SME A, SME B, and SME C through CTA.
PATIENT CARE HANDOFF IN THE ICU 64
Percentage
of
Steps
Recalled
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
SME
A
SME
B
SME
C
Total
Action
Steps
Decision
Steps
Figure 3. Percentage of Action Steps and Decision Steps Elicited from SME A, SME B, and
SME C Through CTA
The SMEs collectively described a total of 199 action and decision steps. None of the
individual SME described more than 133 action and decision steps and the percentage of total
recalled action and decision steps across all SMEs was between 39.80% and 66.17%. All of
the SMEs recalled more action steps than decision steps: SME A recalled 50 action steps and
36 decision steps, SME B recalled 76 action steps and 57 decision steps, and SME C recalled
50 action steps and 30 decision steps. The range of the percentages of action steps identified
between each SME was nearly 27%. The lowest percentage identified was 52.08% versus
79.17% for the greatest percentage identified. The range of the percentages of decision steps
identified between each SME was nearly 26%. The lowest percentage identified was 28.57%
versus 54.29% for the greatest percentage identified.
Action and decision steps captured in the follow-up interviews. An analysis of action
and decision steps that were added, modified, or deleted during the follow–up interview with
each SME was also conducted. The results of this analysis are shown in Table 3.
PATIENT CARE HANDOFF IN THE ICU 65
Table 2
Additional Expert Knowledge Captured, in Action and Decision Steps, During Follow-Up
Interviews
Additional Steps Captured
SME Action Decision
A 1 6
B
C
D
4
n/a
5
6
n/a
10
Note: SME C did not review their individual protocol
When SME A and SME B reviewed their individual protocols, additional action and
decision steps were identified; no action or decision steps were deleted. The exception was SME
C who did not review his individual protocol. SME D did not participate in the CTA semi-
structured interviews and reviewed the initial gold standard protocol after review by SME A and
SME B. SME D identified five additional action steps and ten additional decision steps and
made no other deletions or changes.
Alignment of SMEs in describing the same action and decision steps. The
spreadsheet analysis was also used to determine the degree to which the three SMEs were
aligned in recalling the various action and decision steps. The SMEs were described as highly
aligned if all three recalled the same action or decision steps, partially aligned if two of the
SMEs recalled the same steps, or slightly aligned if only one SME recalled any given step. On
the spreadsheet, slightly aligned steps were indicated with the number “1”, partially aligned
steps were indicated with the number “2”, and highly aligned steps were indicated with the
number “3”. A step that was recalled by SME D was not included in the alignment. Table 4
shows the results of the analysis.
PATIENT CARE HANDOFF IN THE ICU
66
Table 3
Number and Percentage of Action and Decision Steps that are Highly Aligned, Partially Aligned,
and Slightly Aligned
Number Percentage
Highly Aligned 36 19.35%
Partially Aligned 41 22.05%
Slightly Aligned 109 58.60%
The SMEs were highly aligned with 19.35% of the action and decision steps, partially
aligned with 22.05% of the action and decision steps, and slightly aligned with the majority,
58.60%, of the action and decision steps. The implications of alignment are discussed in Chapter
five.
Question 2
What percentage of action and decision steps, when compared to a gold standard, do
expert critical care anesthesia providers omit when they describe how they conduct patient
handoffs from the operating room to the intensive care unit?
Total knowledge omissions. To answer Question 2, the spreadsheet analysis was used
to determine the number and percentage of action and decision steps omitted by the individual
SMEs when describing the patient handoff from the operating room to the intensive care unit.
Action and decision steps that were included on the GSP but omitted in the individual SME
protocols were marked with a “0”. Table 5 displays the action and/or decision steps omitted by
the SMEs as compared to the GSP.
PATIENT CARE HANDOFF IN THE ICU
67
Table 4
Number and Percentage of Action and/or Decision Steps Omitted by SMEs when Compared to
the Gold Standard Protocol
Steps Omitted
Total Action &
Decision Steps
Omitted
%
Action
Steps
Omitted
%
Decision
Steps
Omitted
%
SME A 115 57.21% 46 47.92% 69 65.71%
SME B 68 33.83% 20 20.83% 48 45.71%
SME C 121 60.20% 46 47.92% 75 71.43%
Mean Omissions 101.33 50.41% 37.33 38.89% 64 60.95%
Note. Total non-repeating action and decision steps from the CTA process represented in the gold
standard protocol: action and decision steps – 201; action steps – 95; decision steps 105.
All of the SMEs omitted a greater number of decision steps than action steps. Of the
96 action steps and 105 decision steps on the GSP, SME A omitted 46 action steps and 69
decision steps, SME B omitted 20 action steps and 48 decision steps, and SME C omitted 46
action steps and 75 decision steps. The overall percentage of knowledge omissions, in the
form action and decision steps omitted, was 50.41% with a range from 33.83% for SME B to
60.20% for SME C. The percentage of action steps omitted ranged from 20.83% for SME B
to 47.92% for both SME A and SME C. The percentage of decision steps omitted ranged
from 45.71% for SME B to 71.43% for SME C. action steps
Analysis of action and decision step omissions. Figure 4 represents the action and
decision step omissions, or expert knowledge omissions, data for SME A, SME B, and SME
C when compared to the cumulative gold standard protocol.
PATIENT CARE HANDOFF IN THE ICU
68
80%
70%
60%
50%
40%
30%
20%
10%
Action
and
Decision
Steps
Omitted
Action
Steps
Omitted
Decision
Steps
Omitted
0%
SME
A
SME
B
SME
C
Figure 4. Total Percentage of SME Knowledge Omissions when Compared to the GSP
The next chapter will include an overview of the study, a discussion of the findings,
limitations, implications, and future research.
PATIENT CARE HANDOFF IN THE ICU
69
CHAPTER FIVE: DISCUSSION
Overview of Study
The purpose of this study was to utilize cognitive task analysis to elicit the knowledge
from expert critical care anesthesia providers (anesthesiologists and nurse anesthetists) use in
performing patient care handoffs from the operating room to the intensive care unit. This inquiry
also sought to identify the knowledge and skills that expert critical care anesthesia providers omit
when describing this complex task when compared to a gold standard protocol. Research on
expertise in curriculum and pedagogy identified that while automaticity reduces cognitive load
and improves performance, experts are unaware of the information they use to complete complex
tasks. The information may be difficult to access and/or articulate because it has become an
automated. In an educational setting, this phenomenon may become especially problematic as
experts may omit up to 70% of the critical information novices need to replicate a complex task
thereby confounding effective teaching (Feldon, 2007, Kirschner et al., 2006).
The patient handoff process represents a very complex task that may require the transfer
of declarative and procedural knowledge, as well as the transfer of explicit knowledge and tacit
knowledge. A number of studies across a variety of domains, including medicine, the military,
and special education, have shown that knowledge elicited from subject matter experts using
CTA methodology can improve instructional outcomes. The explicit and implicit knowledge
that are elicited from the CTA process can be used to teach, train, assess performance, and
develop expert systems (Chipman, 2000; Clark, 2014; Hoffman & Militello, 2009; Tirapelle,
2010; Zepeda-McZeal, 2014). The available research literature on patient care handoffs does not
include information derived from the cognitive task analysis of experts in the field of anesthesia.
There is also a paucity of literature that identifies the essential elements of a patient handoff from
PATIENT CARE HANDOFF IN THE ICU
70
anesthesia providers in the operating room to the intensive care unit members. In addition, there
is no evidence to suggest that training programs addressing the patient care handoff process have
been standardized and evaluated.
Process of Conducting Cognitive Task Analysis
Selection of Experts
The selection of experts for this study was based on recommendations from the literature
on CTA. Three experts were selected for participation in the CTA portion of the study that
resulted in the development of a PGSP for a patient handoff from the operating room to the
intensive care unit. A fourth expert was selected for participation in the final review that resulted
in the development of a GSP.
Chao and Salvendy (1994) found that, regardless of knowledge elicitation technique, only
40% of the procedural knowledge could be elicited from a single SME. While the percentage of
procedural knowledge elicited could be doubled when knowledge is elicited from six SMEs, the
researchers recommended acquiring knowledge from three SMEs due to the marginal increases
(less than 10%) in the number of action and decision steps. Replicating Chao and Salvendy’s
(1994) methodology, Bartholio (2010) and Crispen (2010) also found that three to five experts
captured an acceptable amount of expert knowledge that could be used to create a GSP that can
be used for training purposes.
In addition to the number of participants, the experts were selected based on six criteria
identified in the literature. The experts should: (a) have a minimum of five years and preferably
ten years of consistent success in performing the task under investigation; (b) have experience
performing the task in a wide variety of settings (to represent potential contexts that students
may face when they graduate); (c) have success in performing this task as recognized by
PATIENT CARE HANDOFF IN THE ICU
71
colleagues in the field; (d) not have experience as instructors in the performance of this task
within the last year; (e) available in three to four hour segments for CTA interviews and
subsequent review of protocols; and (f) be willing to have their interviews audio recorded
(Chipman et al., 2000; Clark, 2014; Clark et al., 2008; Flynn, 2012).
The experts in this study were critical care anesthesia providers, each with a minimum of
10 years of experience with patient handoffs as anesthesia providers in a variety of settings,
including the critical care setting. The experts had a solid track record with regard to patient
safety, and were in good departmental standing. The experts had experience as clinical
instructors in anesthesia but not specifically with the patient handoff process. According to
Yates (2007), this is an important consideration in the selections of SMEs since the instructor
will describe how they teach the task as opposed to describing how they perform the task. In
addition, each SME indicated availability as needed, a willingness to participate in this study,
and were agreeable to having their interviews audio recorded. Identifying the experts was not a
problem, in part because of the size of the medical campus and the large number of expert
critical care anesthesia provider this researcher has exposure to. The other reason for relative
ease in identifying and enlisting experts was the awareness that improvements are needed in the
patient handoff process, nationally as well as locally, thus increasing interest in participation.
Collection of Data
The data were collected for this study by conducting independent semi-structured
interviews with three of the four expert critical care anesthesia providers. Each SME was
subsequently provided with a transcribed copy of their interview to confirm, clarify, and/or
supplement interview content and provide feedback. This CTA method is described as the 3i + 3r
method which refers to 3 initial interviews followed by 3 reviews. The 3i + 3r method has been
PATIENT CARE HANDOFF IN THE ICU
72
shown as an effective way to capture expert knowledge to inform instructional design and the
development of related instructional materials (Clark et al., 2008; Zepeda-McZeal, 2014).
Discussion of Findings
This study was guided by two primary research questions.
Question 1
What are the action and decision steps that expert critical care anesthesia providers
recall when they describe how they conduct a patient handoff from the operating room to the
intensive care unit?
Action steps versus decision steps. As described in Chapter Four: Results, all of the
SMEs recalled more action steps than decision steps when describing how they conduct a patient
handoff from the operating room to the intensive care unit. On average, the SMEs recalled
61.11% of the action steps and 39.05% of the decision steps as compared to the GSP. The SMEs
were consistently better at recalling knowledge on how to execute this complex task in an action
step, than the knowledge of when to execute the task in a decision step. Previous CTA research
has shown a similar trend whereby more action steps are recalled than decision (Canillas, 2010;
Crispen, 2010; Hammitt, 2014; Tolano-Leveque, 2010; Zepeda-McZeal, 2014). In a review of
CTA based instruction in healthcare, Clark (2014) explained this trend based on the experts’ use
of mental images to describe a complex task. In doing so, the experts are more likely to recall
the conscious action steps rather than the non-conscious decision steps. The tendency of the
experts to recall more action steps than decision steps may also be explained by the
understanding the cognitive load imposed by highly complex environments, tasks, and routine
and non-routine or emergency states (Clark & Clark, 2010; Clark et al., 2008).
PATIENT CARE HANDOFF IN THE ICU
73
The perioperative area is a highly complex, dynamic, time-constrained and stressful
environment. The anesthesia provider must manage a multifaceted interaction between the
patient, the patient’s response to the stress of surgery and anesthesia, sophisticated clinical
equipment, and diverse perioperative personal (surgeons, nurses, technicians, and others).
The ability of an expert anesthesia provider to transfer critically ill patients to the intensive
care unit in a safe, efficient, and effective manner relies on extensive prior knowledge, the
development of schema and automation so as to not overload working memory (Clark &
Clark, 2010; Clark et al., 2008; Vogel-Walcutt, Gebrim, Bowers, Carper, & Nicholson,
2011). Nearly all knowledge comes into the system in a conscious, declarative form; it is
committed to long-term memory, and then transformed (over time with use) into a largely
unconscious, automated procedural knowledge (Anderson & Fincham, 1994). Automated
knowledge helps to alleviate cognitive overload and/or processes that can impede the
efficiency of working memory (Kirschner, Sweller, & Clark, 2006) and allows cognitive
tasks to become more fluid (Clark, 1999). As a consequence of automaticity, experts are
unaware of the information they use to complete complex tasks and this knowledge or
information may be difficult to articulate because it has become an automated (Kirschner et
al., 2006). The performance of a complex task, such as transferring a critically ill patient to
the intensive care unit, is dependent on retrieval of information from LTM and information
processing, in the form of schema while in the working memory. This may be explanation
of why more action than decision steps were elicited from the CTA interviews.
As demonstrated in Table 2 in Chapter Four: Results, the total number of action and
decision steps contributed by each SME varied with each interview (SME A - 86, SME B - 133,
and SME C - 80). Prior to participation in the interviews, each SME was provided with
PATIENT CARE HANDOFF IN THE ICU
74
prerequisite information regarding the CTA methodology and research purpose. Interview times
and locations were scheduled to optimize participation convenience for the SMEs and to
minimize environmental distractions. The interview for SME A, in which two other researchers
were present to observe, lasted approximately 1.5 hours. The interview with SME B lasted
approximately 3.5 hours in length and included a 15-minute break as agreed upon by both the
researcher and the expert. The interview for SME C, in which the senior researcher participated,
lasted approximately 1.5 hours.
Explanations for the increase in the total number of action and decision steps contributed
by SME B may be due to a number of factors: the increased interview skills of this researcher,
the increased comfort with the SME, the increased time allotted for this interview, and the
motivation on the part of the SME. By the second SME interview, this researcher had an
increased level of confidence with the CTA interview process having observed two other CTA
interviews, reviewing the transcripts and subsequent protocols, and performing one other
interview (SME A). In addition, the conditions surrounding the interview of SME B seemed
most conducive to the CTA knowledge elicitation process as the interview was conducted
without time constraints and in an environment with little or no interruptions. The last
explanation may be the most significant factor in that SME B was highly motivated to impart his
knowledge. According to Anderson and Schunn, (2000), the activation or retrieval of
information is influenced not only by how well it is learned (base-level activation) and by the
context (associative activation) in which it is retrieved but also by the motivation that underlies
task execution. According to Paris et al. (1983), the amount of knowledge or skill may be an
indication of capability but capability must be combined with motivation for task execution
(Paris, Lipson, & Wixson, 1983). It is the will or motivation that direct the individual’s actions.
PATIENT CARE HANDOFF IN THE ICU
75
All three of the SME appeared to be motivated to impart their knowledge as they agreed to
participate in the CTA interviews. Despite providing the same information to each SME before
the interviews, SME B seemed the most prepared for his interview; his thoughts flowed in a
logical manner and he tended to loop back to complete a response and to ensure this researcher
understood the information he was imparting.
Action and decision steps captured during the review of the initial individual
protocols and preliminary gold standard protocol. As described in Chapter Four: Results,
SME A and SME B reviewed their individual protocols during their independent follow–up
interviews and identified additional action and decision steps. Each of the initial individual
protocols were emailed to the respective SMEs with request for follow up meeting, phone call,
email contact or a combination depending on SME preference. A follow up meeting was
scheduled with SME A. Action and decision steps were reviewed and the expert was asked to
make additions, modifications, and deletions while this researcher took notes. One additional
action step and four additional decision steps were identified. SME B was on a leave of absence
at the time of review so review and follow-up were conducted via email. Four additional action
steps and six additional decision steps were identified. SME C did not review his individual
protocol owing to the researcher’s inability to contact the SME for the follow up review. After
approval from the senior researcher, the feedback and task protocols were aggregated to generate
the PGSP.
A fourth SME, SME D, agreed to review the PGSP generated from the protocols of the
previous three SMEs. SME D did not participate in the CTA semi-structured interview but was
selected to provide final review for development of a summary gold standard protocol (GSP).
SME D was provided the same prerequisite information (CTA methodology and research
PATIENT CARE HANDOFF IN THE ICU
76
purpose) as the other SMEs. Despite having to relocate twice, the in-person meeting with SME
D proved fruitful in that SME D highly approved of the PGSP, identified five additional action
steps and ten additional decision steps, and made no other deletions or changes. 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.
Alignment of action and decision steps. In this study, 19.35% of the action and decision
steps were identified by all three SMEs; 22.05% of the action and decision steps were identified
by two of the SMEs; and 58.60% of the action and decision steps were described by only one
SME. These findings support the research that three experts was required to reach a 10% point of
diminishing marginal utility for the acquisition of action steps (Bartholio, 2010; Chao &
Salvendy, 1994; Crispen, 2010). The variation in alignment may reflect the fact that the complex
task of patient handoff from the operating room to the intensive care unit is standardized. It
should be noted, however, that all three SMEs were highly aligned in elucidating five main
procedures in conducting the patient handoff. This finding may be explained by a number of
influences. First, the main steps aligned with the normal sequence of perioperative events, from
preop assessment to intraoperative management to postanesthesia recovery. What was added in-
between those three main steps was preparation of equipment and patient transport, which are
critical steps to the transfer of a patient from the operating room to the intensive care unit.
Second, the alignment of the five main steps may have been influenced by this researcher’s CTA
technique. As mentioned previously, this researcher found there was a balance between
validating and leading the SME responses during the interviews. Third, it was in preparing the
final GSP that this researcher found trends and special circumstances in each of the SME
responses. The special circumstances resulted in one of the five main steps if there was sufficient
PATIENT CARE HANDOFF IN THE ICU
77
evidence in each of the interviews. An example would be the main step of equipment
preparation. While the risk of confirmation bias existed, the creation of this main step resulted
from asking the SMEs about necessary equipment, which is the CTA process.
Question 2
What percentage of action and decision steps, when compared to a gold standard, do
expert critical care anesthesia providers omit when they describe how they conduct patient
handoffs from the operating room to the intensive care unit?
Expert knowledge omissions. The total number of agreements and omissions between
the individual SME protocols and the GSP were calculated to determine the percentage of
omissions for the individual SME protocols. On average, the experts omitted 50.41% of the
action and decision steps when describing how to perform a patient handoff from the operating
room to the intensive care unit. The SMEs omitted 38.89% of the action steps and 60.95% of the
decision steps as compared to the GSP. These findings are similar to findings to Canillas (2010)
and Tolano-Leveque (2010) who both found greater omissions in decision steps than action steps
when describing complex surgical tasks. More recently, Garcia (2015) found greater omissions
in decision steps (52.12%) than action steps (44.73%) when experts describe how to perform an
intraoperative patient handoff of anesthesia care. Hammitt (2014) found no significant
difference in the average percentage of omissions in action steps (54.20%) and decision steps
(54.58%) when expert principles describe how to perform classroom walk-throughs and provide
feedback to teachers.
The variation in total recall or omissions has been attributed to task complexity, prior
knowledge, expert motivation, and CTA technique (Canillas, 2010, Chao and Salvendy, 1994;
Flynn, 2012; Garcia, 2015; Hammitt, 2014; Tolano-Leveque, 2010). The complexity and length
PATIENT CARE HANDOFF IN THE ICU
78
of the task may influence the number of action and decision steps captured or omitted. As the
task complexity and task duration increase, the unintentional omission of action and decision
step may increase as well (Chao and Salvendy, 1994; Hoffman, 1987; Zepeda-McZeal, 2014).
Chao and Salvendy (1994) compared four CTA knowledge elicitation techniques (protocol,
interview, induction, and repertory grid) on three tasks related to computer programming
(diagnosis, debugging, and interpretation). The researchers found that, regardless of knowledge
elicitation technique, the overall percentage of procedural knowledge extracted was lowest for
the task of interpretation as this task is more multifactorial than the task of diagnosing or
debugging computer programming errors.
Prior knowledge may influence the number of action and decision steps captured or
omitted as well. Canillas (2010) and Tolano-Leveque (2010) compared critical omissions data
between two CTA studies involving highly complex medical procedures: central venous catheter
(CVC) placement and open cricothyrotomy procedure. The percentage of action steps and
decision steps omitted were higher for experts describing how to perform an open
cricothyrotomy (41.92% and 76.92%) when compared to those same experts describing how to
perform CVC placement (29.92% and 34.52%). The researchers attributed the fewer omissions
in recalling the task of CVC placement to the fact that the participants (expert surgeons)
possessed greater knowledge about the task. CVC placement is more commonly performed than
cricothyrotomy and, while both procedures introduce patient risk, there is more attention given to
the risk of CVC insertions based on national efforts to reduce central line associated blood
stream infections (CLASBI) (Joint Commission, 2013). Similar to the task of CVC insertion,
patient handoffs from the operating room to the intensive care unit are performed on a regular
PATIENT CARE HANDOFF IN THE ICU
79
basis and have received national attention with regard to patient safety. This may help to explain
the lower overall percentage of omissions in the expert recall of action and decision steps.
In addition to task complexity and prior knowledge, motivation on the part of the expert
may influence the number of action and decision steps captured or omitted. Hammit (2014)
suggested that the improved recall and lower percentage of omissions on the part of one his
SMEs was due, in part, to the expert’s nearing retirement and a desire to impart critical
information to successors. In the present study, the percentage of total action and decision steps
omitted for SME B (33.83%) was considerably less than the percentages omitted for SME A
(57.21%) or SME C (60.20%). Although not statistically analyzed, SME B conveyed increased
attention to particular areas in each of the main procedures, specifically the preparation of
equipment, the safety of transport team, and the readiness of the receiving team. In doing so,
SME B articulated a greater percentage of total action and decision steps than SME A or SME B.
The CTA technique may also influence the number of action and decision steps captured
or omitted. Chao and Salvendy (1994) examined the percentage of procedural knowledge
acquired as a function of the number of experts, the CTA knowledge elicitation technique used
(protocol, interview, induction, and repertory grid) and the task examined (diagnosis, debugging,
and interpretation related to computer programming errors). The researchers found that the
percentage of procedural knowledge acquired increased with the addition of SMEs (from one to
six SMEs). The addition of the fourth SME in this study resulted in 5 additional action steps and
10 additional decision steps. The percentage of increase was influenced by the elicitation
technique and the task examined. Flynn (2012) compared two CTA techniques for the task of
army recruiting: 1i+3r incremental method and 3i+3r independent method and found that the
1i+3r incremental method captured more decision steps, took less time, and cost less. The 1i+3r
PATIENT CARE HANDOFF IN THE ICU
80
CTA method uses a final, revised independent interview generated from a single SME serves as
a template for semi-structured incremental interviews with two other SMEs to develop a GSP.
The results of this study have not been replicated.
Limitations
The present study produced findings consistent with findings of previous CTA research
related to expert knowledge elicited in the form of action and decision steps and expert
knowledge omissions. The next section will discuss the limitations of the present study.
Confirmation Bias
The first limitation of this present study is related to potential confirmation bias, the
tendency to search for and interpret information in a way that confirms one's beliefs or
hypotheses. The CTA process itself requires human judgment in selecting the experts, eliciting
their knowledge, and formatting the results identified. Knowledge analysts who are highly
experienced in the domain of study tend to “edit what they are told…in CTA interviews so that
the information they collect is consistent with their own experience and expectations” (Clark,
2014, p. 544). This researcher has 24 years of experience in healthcare with 20 years
specifically in anesthesia and knowledge of the task domain. As such, the threat to the validity
of the qualitative conclusions was apparent and extra effort was taken to limit confirmation bias.
This included “bootstrapping” to familiarize the senior researcher, who is not an anesthesia
provider, with language of anesthesia practice and to facilitate the acquisition of domain specific
knowledge relating to the task. The senior researcher then guided one of the SME interviews
and the author, with oversight and guidance from the senior researcher, conducted two of the
SME interviews. As a knowledge analyst, this researcher remained cognizant of preexisting
knowledge and expectations so as to not modify the knowledge elicited from the experts.
PATIENT CARE HANDOFF IN THE ICU
81
Internal Validity
Internal validity refers to the ability to attribute observed outcomes or findings (e.g. the
gold standard protocol) to the intended program or intervention (CTA based knowledge
acquisition). Threats to internal validity pose another potential limitation to the study and may
stem from factors such as selection bias or change in instrumentation. Although the selection of
SMEs for this study was based on criteria described in the literature, the selection was also one of
convenience as all of the SMEs work on the same medical campus. In addition to selection bias,
the threat to internal validity may also stem from the variation in cognitive task analysis
interview protocol that was intended. SME A and SME B reviewed their individual protocols
and additional action and decision steps were identified. The exception was SME C who did not
review his individual protocol. Whether or not selection bias or change in protocol influenced
the development of the GSP is not a focus of this study, however these are important
considerations for future research.
External Validity
External validity refers to the extent to which results of study can be generalized across
places, people, or time. Threats to external validity pose another potential limitation to the study
and may stem primarily from the practice environment from which the SMEs were selected: two
of the SMEs worked in a large public medical center and the other two worked in a large private
medical center. All four of the SMEs were selected from the same Department of
Anesthesiology and both medical centers were on the same medical campus. At the time of the
interviews, the Department had not implemented a specific patient handoff tool and, as such, it
appeared that personal and professional experiences guided the various responses from each of
the SMEs. An example was the specific concerns expressed by the two SMEs working in the
PATIENT CARE HANDOFF IN THE ICU
82
large public medical center. The concerns were based on experiences about patient management
while transferring long distances from the operating room the intensive care unit. These same
concerns did not surface for the SMEs from the large private medical center. The benefits
stemming from the selection of these four SMEs included SMEs from two very diverse
locations, representing private and public sectors. In addition, two of the SMEs are board
certified critical care anesthesiologists and two are board certified nurse anesthetists with
extensive backgrounds in critical care. Each of the SMEs has subspecialty experience including
provision of anesthesia for cardiac surgery, trauma surgery, burn surgery, and liver surgery. One
of the SMEs has a military background, which became evident in the discussion of resource
utilization. The goal in selecting this composition of SMEs was to obtain as comprehensive a
view as possible with regard to patient handoff considerations thereby improving external
validity.
Implications
Multiple studies have shown that the use of CTA supported instruction is superior to
traditional teaching methods in improving, both declarative and procedural knowledge as well
as procedural skills and self-efficacy in performing complex medical tasks. Specific areas
examined using CTA include decision making and communication in the operating room,
physical assessment in the neonatal intensive care unit, cricothyrotomy and percutaneous
tracheostomy, tracheal extubation, laparoscopic surgery, central line placement, and colorectal
surgery (Buckley et al., 2014; Campbell et al., 2011; Clark, 2014; Crandall & Getchell-Reiter,
1993; Embrey, 2012; Fackler et al., 2009; Sullivan et al., 2007; Pugh et al., 2011).
The current study has identified the action and decision steps that can be used to deliver
a comprehensive patient handoff from the operating room to the intensive care unit.
PATIENT CARE HANDOFF IN THE ICU
83
Developing a gold standard protocol may have benefits for training of novice anesthesia
providers, as well as, ongoing professional development of experienced anesthesia providers,
and ultimately for increased patient safety.
Future Research
Future research could examine the use of the gold standard protocol generated by this
study is a randomized controlled study to compare the effectiveness of CTA guided instruction
to conventional clinical instruction for the task of patient handoff from the operating room to
the intensive care unit. The study could examine the generalizability of the results of
conducting and applying CTA to training in anesthesia practice by replicating the methods used
by Embrey (2012), which examined learning outcomes following CTA guided instruction of
adult postoperative tracheal extubation in novice anesthesia providers.
Conclusions
The purpose of this study was to utilize Cognitive Task Analysis (CTA) methods to elicit
knowledge from expert critical care anesthesia providers (anesthesiologists and nurse
anesthetists) to identify the action and decision steps the experts use when conducting a
comprehensive patient care handoff from the operating room to the intensive care unit. The
secondary purpose of the study was to identify the percentage of action and decision steps the
experts inadvertently omitted when describing the performance of that task. As a consequence
of automaticity, experts are unaware of the information they use to complete complex tasks as
this knowledge or information may be difficult to articulate because it has become automated.
Herein lies the utility of the knowledge elicitation technique used in cognitive task analysis.
Using the semi-structured interview technique with three SMEs and a review by a fourth SME, a
gold standard protocol for patient care handoff from the operating room to the intensive care
PATIENT CARE HANDOFF IN THE ICU
84
unit was generated. In the future, the gold standard protocol may be used to train novice
anesthesia providers in performing the complex task of patient handoff from the operating room
to the intensive care unit.
Fifteen years have passed since the Quality of Health Care in America Committee of the
Institute of Medicine (IOM) published the landmark report To Err is Human: Building a Safer
Health System which resulted in numerous studies, programs, and mandates yet communication
has remained one of the leading root causes of sentinel events in all categories of medical errors
(The Joint Commission, 2012). The patient care handoff from the operating room to the
intensive care unit represents a high stakes form of communication between multiple disciplines.
It is hoped that the results of this study not only add to the growing library of CTA-based
research but that the gold standard protocol generated in this study becomes the basis for a
multidisciplinary training program to improve communication in the handoff process.
PATIENT CARE HANDOFF IN THE ICU
85
References
Abraham, J., Kannampallil, T., & Patel, V. L. (2014). A systematic review of the literature on the
evaluation of handoff tools: Implications for research and practice. Journal of American
Medical Informatics Association, 21, 154-162.
Accreditation Council for Graduate Medical Education (2013). ACGME Common Program
Requirements. Retrieved September 21, 2014, from
http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.p
df
Agency for Healthcare Research and Quality (2008, April). Becoming a high reliability
organization: Operational advice for hospital leaders. Retrieved from
http://psnet.ahrq.gov/resource.aspx?resourceID=4686.
Ambrose, S. A., Bridges, M. W., DiPietro, M., Lovett, M. C., & Norman, M. K. (2010). How
learning works, 7 research-based principles for smart teaching. San Francisco, CA:
Jossey-Bass
Anderson, J.R. (1982). Acquisition of cognitive skill. Psychological Review, 89(4), 369- 406.
Anderson, J. R. (1993). Problem solving and learning. American Psychologist, 48(1), 35-44.
Anderson, J.R. (1996). ACT: A simple theory of complex cognition. American Psychologist,
51(4), 355-365.
Anderson, J.R., & Fincham, J.M. (1994). Acquisition of procedural skills from examples.
Journal of experimental psychology: Learning, memory, and cognition 20(6), 1322-1340.
Anderson, L.W. & Krathwohl (Eds.). (2001). A Taxonomy for learning, teaching, and assessing:
A revision of Bloom's taxonomy of educational objectives. New York: Longman.
PATIENT CARE HANDOFF IN THE ICU
86
Anderson, J. R. & Schunn, C.D. (2000). Implications of the ACT-R learning theory: No magic
bullets. In R. Glaser (Ed.), Advances in instructional psychology (Vol. 5). Mahwah, NJ:
Erlbaum.
Annett, J. (2000). Theoretical and pragmatic influences on task analysis methods. In J.M.
Schraagen, S.F. Chipman & V.L. Shalin (Eds.), Cognitive Task Analysis (pp. 24-
36). Mahwah, NJ: Lawrence Erlbaum Associates.
Association of periOperative Registered Nurses. (2012). Recommendations for Perioperative
Patient Hand-off. Retrieved from:
http://www.aorn.org/Clinical_Practice/ToolKits/Patient_Hand_Off_Tool_Kit/Patient_Ha
nd_Off_Tool_Kit.aspx
Arora, V., Johnson, J., Lovinger, D., Humphrey, H. J., & Meltzer, D. O. (2005). Communication
failures in patient sign-out and suggestions for improvement: a critical incident analysis.
Quality and Safety in Health Care, 14(6), 401-407.
Australian Council for Safety and Quality in Health Care (2005). Clinical handover and patient
safety literature review report. Retrieved from: http://www.safetyandquality.gov.au/wp-
content/uploads/2012/01/clinhovrlitrev.pdf.
Bartholio, C. W. (2010). The use of cognitive task analysis to investigate how many experts must
be interviewed to acquire the critical information needed to perform a central venous
catheter placement (Doctoral dissertation). Retrieved from
http://digitallibrary.usc.edu/cdm/ref/collection/p15799coll127/id/385767
Bedard, J., & Chi, M.T.H. (1992). Expertise. Current Directions in Psychological Science, 1(4),
135-139.
PATIENT CARE HANDOFF IN THE ICU
87
Boat, A. C. & Spaeth, J. P. (2013). Handoff checklists improve the reliability of patient handoffs
in the operating room and postanesthesia care unit. Pediatric Anesthesia, 23, 647–654.
Buckley, C. E., Kavanagh, D. O., Traynor, O., & Neary, P. C. (2014). Is the skillset obtained in
surgical simulation transferable to the operating theatre? The American Journal of
Surgery, 207(1), 146-157.
Campbell, J., Tirapelle, L., Yates, K., Clark, R., Inaba, K., Green, D., & Sullivan, M. (2011). The
effectiveness of a cognitive task analysis informed curriculum to increase self-efficacy
and improve performance for an open cricothyrotomy. Journal of surgical education,
68(5), 403-407.
Canillas, E. N. (2010). The use of cognitive task analysis for identifying the
critical information omitted when experts describe surgical procedures
(Unpublished doctoral dissertation). University of Southern California,
Los Angeles.
Catchpole, K. R., De Leval, M. R., Mcewan, A., Pigott, N., Elliott, M. J., Mcquillan, A., &
Goldman, A. J. (2007). Patient handover from surgery to intensive care: using Formula 1
pit-‐ stop and aviation models to improve safety and quality. Pediatric Anesthesia, 17(5),
470-478.
Chao, C-J., & Salvendy, G. (1994). Percentage of procedural knowledge acquired as a function
of the number of experts from whom knowledge is acquired for diagnosis, debugging,
and interpretation of tasks. International Journal of Human-Computer Interaction, 6(3),
221-233.
Chi, M.T.H., (2006). Two approaches to the study of experts’ characteristics. In K.A. Ericsson,
(Ed). The Cambridge handbook of expertise and expert performance, 21-30.
PATIENT CARE HANDOFF IN THE ICU
88
Chipman, S. F., Schraagen, J. M., & Shalin, V. L. (2000). Introduction to cognitive task analysis.
Cognitive task analysis, 3-23.
Clark, R.E. (2014). Cognitive task analysis for expert-based instruction in healthcare. In Spector,
J.M. Merrill, M.D. Elen, J. and Bishop, M.J. (Eds.). Handbook of research on
educational communications and technology (4
th
ed., pp.541-551). New York, NY:
Springer.
Clark, R. E. and Clark, V. P. (2010). From Neobehaviorism to Neuroscience: Perspectives
on the Origins and Future Contributions of Cognitive Load Research. In Plass, J.,
Moreno, R., and Brünken (Eds.) Perspectives, problems and future directions in
cognitive load research (pp. 203-228). New York: Cambridge University Press..
Clark, R., & Elen, J. (2006). When less is more: Research and theory insights about
instruction for complex learning. In J. Elen & R.E. Clark (Eds.), Handling complexity
in learning environments: Theory and research (pp. 283-295). New York, NY:
Elsevier.
Clark, R., & Estes, F. (1996). Cognitive Task Analysis for Training. International Journal of
Educational Research, 25(5), 403-417.
Clark, R. E., Feldon, D., Van Merriënboer, J.G., Yates, K.A., & Early, S. (2008). Cognitive task
analysis. In J.M. Spector, M.D. Merrill, J.J.G. Van Merriënboer, & M.P. Driscoll (Eds.),
Handbook of Research on Educational Communications and Technology (3
rd
ed.)
(pp.578-591). Mahwah, NJ: Lawrence Erlbaum Associates.
Clark, R. E., Pugh, C. M., Yates, K. A., Inaba, K., Green, D. J., & Sullivan, M. E. (2012). The
use of cognitive task analysis to improve instructional descriptions of procedures.
Journal of Surgical Research, 173(1), e37-e42
PATIENT CARE HANDOFF IN THE ICU
89
Clark, R. E., Yates, K., Early, S., Moulton, K., Silber, K. H., & Foshay, R. (2010). An analysis
of the failure of electronic media and discovery-based learning: Evidence for the
performance benefits of guided training methods. Handbook of training and improving
workplace performance, 1, 263-287.
Clarke, D., Werestiuk, K., Schoffner, A., Gerard, J., Swan, K., Jackson, B., Steeves, B., &
Probizanski, S. (2012). Achieving the perfect handoff in patient transfers: Building
teamwork and trust. Journal of Nursing Management, 20, 592–598.
Cohen, M. D., & Hilligoss, P. B. (2009). Handoffs in Hospitals: A review of the literature on
information exchange while transferring patient responsibility or control.
Cohen, M. D., & Hilligoss, P. B. (2010). The published literature on handoffs in hospitals:
deficiencies identified in an extensive review. Quality and Safety in Health Care, 2009.
Cooke, N. J. (1994). Varieties of knowledge elicitation techniques. International Journal of
Human-Computer Studies, 41, 801-849.
Corbett, A. T., Anderson, J. R. (1995). Knowledge Tracing: modeling the acquisition of
procedural knowledge. User Modeling and User-Adapted Interaction, 4, 253-278.
Crandall, B. & Getchell-Reiter, K. (1993). Critical decision method: A technique for eliciting
concrete assessment indicators from the intuition of NICU nurses. Advances in Nursing
Science, 16(1), 47-51
Crandall, B., Klein, G., & Hoffman, R. R. (2006). Working minds: A practitioner’s guide to
cognitive task analysis. Cambridge, MA: MIT Press.
Crispen, P. D. (2010). Identifying the point of diminishing marginal utility for cognitive task
analysis surgical subject matter expert interviews (Doctoral dissertation). Available
from ProQuest Dissertations and Theses database. (UMI No. 3403725)
PATIENT CARE HANDOFF IN THE ICU
90
Edmondson, A. C. (2003). Speaking Up in the Operating Room: How Team Leaders Promote
Learning in Interdisciplinary Action Teams. Journal of Management Studies, 40 (6),
1419-1452.
Ericsson, K. A. (2004a). Invited Address: Deliberate practice and the acquisition and
maintenance of expert performance in medicine and related domains. Academic
Medicine, 79(10), s70-s81.
Ericsson, K.A. & Charness, N. (1994). Expert performance its structure and acquisition.
American Psychologist, 49(8), 725-747.
Ericsson, K.A., Krampe, R.T., & Tesch-Romer, C. (1993). The role of deliberate practice in the
acquisition of expert performance. Psychological Review, 100 (3), 363-496.
Embrey, K. K. (2012). The use of cognitive task analysis to capture expertise for tracheal
extubation training in anesthesiology. University of Southern California
Fackler, J. C., Watts, C., Grome, A., Miller, T., Crandall, B., & Pronovost, P. (2009). Critical
care physician cognitive task analysis: an exploratory study. Critical Care, 13(2), R33
Fagin, C. M. (1992). Collaboration between nurses and physicians: no longer a choice.
Academic Medicine, 67(5), 295-303.
Feldon, D.F. (2007a). The Implications of research on expertise for curriculum and pedagogy.
Educational Psychology Review, 19 (2), 91-111.
Feldon, D.F. (2007b). Cognitive load and classroom teaching: The double-edged sword of
automaticity. Educational Psychologist, 42(3), 123-137.
Feldon, D. F., & Clark, R. E. (2006). Instructional implications of cognitive task analysis as a
method for improving the accuracy of experts’ self-report. Avoiding simplicity,
PATIENT CARE HANDOFF IN THE ICU
91
confronting complexity: Advances in studying and designing (computer-based) powerful
learning environments, 109-116.
Flynn, C. L. (2012). The relative efficiency of two strategies for conducting cognitive
task analysis. (Doctoral dissertation). Retrieved from
http://gradworks.umi.com/35/61/3561771.html
Ford, K. M., Bradshaw, J. M., Adams-‐ Webber, J. R., & Agnew, N. M. (1993). Knowledge
acquisition as a constructive modeling activity. International Journal of Intelligent
Systems, 8(1), 9-32.
Garcia, C. A (2015). Using cognitive task analysis to capture how expert anesthesia providers
conduct an intraoperative patient care handoff. (Unpublished doctoral dissertation).
University of Southern California, Rossier School of Education, Los Angeles, California.
Glaser, R., & Chi, M.T.H. (1988). Overview. In M.T.H. Chi, R. Glaser, & M.J. Farr (Eds.). The
nature of expertise (pp. xv-xxviii). Mahwah, NJ: Lawrence Erlbaum Associates.
Gordon, M., & Findley, R. (2011). Educational interventions to improve handover in health care:
a systematic review. Medical education, 45(11), 1081-1089.
Greenberg, C. C., Regenbogen, S. E., Studdert, D. M., Lipsitz, S. R., Rogers, S. O., Zinner, M.
J., & Gawande, A. A. (2007). Patterns of communication breakdowns resulting in injury
to surgical patients. Journal of the American College of Surgeons, 204, 533-540.
Gucev, G. V. (2012). Cognitive task analysis for instruction in single-injection
ultrasound guided-regional anesthesia (Doctoral dissertation). Available from
ProQuest Dissertations and Theses database. (UMI No. 3513770)
PATIENT CARE HANDOFF IN THE ICU
92
Hall, E.M., Gott, S.P., & Pokorny, R.A. (1995). A procedural guide to cognitive task analysis:
The PARI methodology. Brooks Air Force Base, TX: Manpower and Personnel Division,
U.S. Air Force.
Hammitt, C.S., (2014). Using cognitive task analysis to capture how expert principals conduct
informal classroom walk-throughs and provide feedback to teachers. (Unpublished
doctoral dissertation). University of Southern California, Rossier School of Education,
Los Angeles, California.
Hansson, A., Arvemo, T., Marklund, B., Gedda, B. & Mattsson, B. (2010). Working together –
primary care doctors’ and nurses’ attitudes to collaboration. Scandinavian Journal of
Public Health, 38, 78–85.
Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. S., Dellinger, E. P.,
Herbosa, T., Joseph, S., Kibatala, P.L., Lapitan, M.C.M., Merry, A. F., Moorthy, K.,
Reznick, R. K., Taylor, B., and Gawande, A. A. (2009). A Surgical Safety Checklist to
Reduce Morbidity and Mortality in a Global Population. New England Journal of
Medicine, 360, 491-499.
Hinds, P. J., Patterson, M., & Pfeffer, J. (2001). Bothered by abstraction: the effect of
expertise on knowledge transfer and subsequent novice performance. Journal of
applied psychology, 86(6), 1232.
Hoffman, R. & Militello, L. (2009). Perspectives on cognitive task analysis: Historical
origins and modern communities of practice. New York: Psychology Press.
Johnson, M., Jefferies, D., & Nicholls, D. (2012). Exploring the structure and organization of
information within nursing clinical handovers. International Journal of Nursing Practice,
18, 462–470
PATIENT CARE HANDOFF IN THE ICU
93
Joint Commission on Accreditation of Healthcare Organizations (2007): 2007 National Patient
Safety Goals Hospital Version Manual Chapter, including Implementation Expectations.
Retrieved from
http://www.jointcommission.org/PatientSafety/NationalPatientSafeyGoals/07_hap_cah_n
psgs.htm.
Joint Commission on Accreditation of Healthcare Organizations (2008). 2008 National patient
safety goals. Hand-off Communications.
http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards/09FAQs/NPSG/Co
mmunication/NPSG.02.05.01/handoff communications.htm
Joint Commission on Accreditation of Healthcare Organizations. (2008). Handoff
communications. Retrieved January 27, 2014, from
http://www.jointcommission.org/issues/article.aspx?Article=RZlHoUK2oak83WO8RkC
mZ9hVSIJT8ZbrI4NznZ1LEUk%3D
Joint Commission on Accreditation of Healthcare Organizations. (2012). Hot topics in health
care, transitions of care: The need for a more effective approach to continuing patient
care. Retrieved August 29, 2013.
Joint Commission Center for Transforming Healthcare. (2014). Targeted Solutions Tool for
Hand-off Communication. Retrieved from
https://apps.jointcommission.org/TST/HOC/StartOverview.aspx
Kirschner, P. A., Sweller, J., & Clark, R. E. (2006). Why minimal guidance during instruction
does not work: An analysis of the failure of constructivist, discovery, problem-based
experiential and inquiry-based teaching. Educational Psychologist, 41(2), 75-86.
PATIENT CARE HANDOFF IN THE ICU
94
Kitch, B. T., Cooper, J. B., Zapol, W. M., Marder, J. E., Karson, A., Hutter, M., & Campbell, E.
G. (2008). Handoffs causing patient harm: A survey of medical and surgical house staff.
The Joint Commission Journal on Quality and Patient Safety, 34(10), 563-570.
Koenig, C. J., Maguen, S., Daley, A., Cohen, G., & Seal, K. H. (2012). Passing the baton: A
grounded practical theory of handoff communication between multidisciplinary providers
in two Department of Veterans Affairs outpatient settings. Journal of General Internal
Medicine, 28 (1), 41–50
Koh, G. C., Khoo, H. E., Wong, M. L., Koh, D. (2008). The effects of problem-based learning
during medical school on physician competency: A systematic review. Canadian Medical
Association Journal, 178(1), 34-41.
Kohn, L.T., Corrigan, J.M., & Donaldson, M. S. (2000). To err is human: Building a safer health
system. Washington, DC: National Academy Press.
Landrigan, C. P., Rothschild, J. M., Cronin, J. W., Kaushal, R., Burdick, E., Katz, J. T., ... &
Czeisler, C. A. (2004). Effect of reducing interns' work hours on serious medical errors in
intensive care units. New England Journal of Medicine, 351(18), 1838-1848.
Lane-Fall, M. B., Brooks, A. K., Wilkins, S. A., Davis, J. J., & Riesenberg, L. A. (2014).
Addressing the mandate for hand-off education: A focused review and recommendations
for anesthesia resident curriculum development and evaluation. Anesthesiology, 120(1),
218-229.
Lee, R. L. (2004). The impact of cognitive task analysis on performance: A meta-analysis
of comparative studies (Unpublished doctoral dissertation). University of Southern
California, Los Angeles, CA.
PATIENT CARE HANDOFF IN THE ICU
95
Lingard, L., Espin, S., Evans, C., & Hawryluck, L. (2004). The rules of the game:
interprofessional collaboration on the intensive care unit. Critical Care, 8, 403-408.
Manser, T. & Foster, S. (2011). Effective handover communication: An overview of research
and improvement efforts. Best Practice & Research Clinical Anaesthesiology, 25, 181–
191.
Manser, T., Foster, S., Flin, R., & Patey, R. (2013). Team communication during patient
handover from the operating room: More than facts and figures. Human Factors and
Ergonomics Society, 55(1), 138-156.
Manser, T., Foster, S., Gisin, S., Jaeckel, D., & Ummenhofer, W. (2013). Assessing the quality
of patient handoffs at care transitions. Quality & Safety in Health Care. 19(6).
Matney, S. A., Maddox, L. J., & Staggers, N. (2013). Nurses As Knowledge Workers Is There
Evidence of Knowledge in Patient Handoffs? Western journal of nursing research, 36(2),
171-190.
Means, B., & Gott, S. (1988). Cognitive task analysis as a basis for tutor development:
Articulating abstract knowledge representations. In J. Psotka, L. D. Massey, & S. A.
Mutter (Eds.), Intelligent Tutoring Systems: Lessons Learned (pp. 35-58).
Merrill, M. (1983). Component Display Theory. In C. M. Reigeluth (Ed.), Instructional-design
theories and models: An overview of their current status (pp. 279-333). Hillsdale, NJ:
Lawrence Erlbaum Associates.
Merrill, M. D. (1994). Instructional Design Theory. Englewood Cliffs, NJ: Educational
Technology Publications.
Merrill, M. D. (2002). First principles of instruction. Educational Technology Research and
Development, 50(3), 43-49.
PATIENT CARE HANDOFF IN THE ICU
96
Militello, L. G., & Hoffman, R. R. (2008). The forgotten history of cognitive task analysis.
Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 52, 383-
387.
Morison, S., & Jenkins, J. (2007). Sustained effects of interprofessional shared learning on
student attitudes to communication and team working depend on shared learning
opportunities on clinical placement as well as in the classroom. Medical Teacher, 29(5),
450-456.
O’Brien, J. L., Martin, D.R., Hayworth, J., and & Meyer, N. R. (2008). Negotiating
transformational leadership: A key to effective collaboration. Nursing and Health
Science, 10, 137-143.
Ong, M. S., & Coiera, E. (2011). A systematic review of failures in handoff communication
during intrahospital transfers. Joint commission Journal on quality and patient safety,
37(6), 274.
Paris, S.G., Lipson, M.Y., & Wixson. (1983). Becoming a strategic reader. Contemporary
Educational Psychology 8, 293-316.
Patel, M. S., Volpp, K. G., Small, D. S., Hill, A. S., Even-Shoshan, O., Rosenbaum, L., & Silber, J. H.
(2014). Association of the 2011 ACGME resident duty hour reforms with mortality and
readmissions among hospitalized Medicare patients. JAMA, 312(22), 2364-2373.
Patterson, E. S., Roth, E. M., Woods, D. D., Chow, R., & Gomes, J. O. (2004). Handoff
strategies in settings with high consequences for failure: lessons for health care
operations. International Journal for Quality in Health Care, 16(2), 125-132.
Patterson, E. S., & Wears, R. L. (2010) Patient handoffs: Standardized and reliable measurement
tools remain elusive. Joint Commission Journal Quality Patient Safety. 36(2), 52–61.
PATIENT CARE HANDOFF IN THE ICU
97
Pham, J. C., Aswani, M. S., Rosen, M., Lee, H., Huddle, M., Weeks, K., & Pronovost, P. J.
(2012). Reducing medical errors and adverse events. The Annual Review of Medicine, 63,
447-463.
Pugh, C. M., DaRosa, D. A., Santacaterina, S., & Clark, R. E. (2011). Faculty evaluation of
simulation-based modules for assessment of intraoperative decision making. Surgery,
149(4), 534-542
Reed, D.A., Levine, R.B., Miller, R.G., Ashar, B.H., Bass, E.B, Rice, T.N., Cofrancesco, J.
Jr.(2007). Effect of residency duty-hour limits: views of key clinical faculty. Archives of
Internal Medicine, 167(14), 1487-1492.
Schaafstal, A., Schraagen, J. M., & Marcel, v. B. (2000). Cognitive task analysis and
innovation of training: The case of structured troubleshooting. Human Factors, 42(1),
75. Retrievedfrom Schraw, G. & Moshman, D. (1995). Metacognitive theories.
Educational psychology review, 7(4), 351-371.
Segall, N., Bonifacio, A. S., Schroeder, R. A., Barbeito, A., Rogers, D., Thornlow, D. K., &
Mark, J. B. (2012). Can we make postoperative patient handovers safer? A systematic
review of the literature. Anesthesia Analgesia, 115(1), 102-115.
Seifert, P.C. (2012). Implementing AORN Recommended Practices for Transfer of Patient Care
Information. Association of periOperative Registered Nurses Journal, 96, (5), 475-493.
Stecher, B., & Kirby, S. N. (2004). Introduction. In B. Stecher & S. N. Kirby, Organizational
improvement and accountability: Lessons for education from other sectors (pp. 1-7).
Santa Monica, CA: Rand Corporation.
PATIENT CARE HANDOFF IN THE ICU
98
Sullivan, M. E., Brown, C. V., Peyre, S. E., Salim, A., Martin, M., Towfigh, S., & Grunwald, T.
(2007). The use of cognitive task analysis to improve the learning of percutaneous
tracheostomy placement. The American journal of surgery, 193(1), 96-99.
Sullivan, M. E., Ortega, A., Wasserberg, N., Kaufman, H., Nyquist, J., & Clark, R. (2008).
Assessing the teaching of procedural skills: can cognitive task analysis add to our
traditional teaching methods?. The American Journal of Surgery, 195(1), 20-23.
Sullivan, M. E., Yates, K. A., Inaba, K., Lam, L., & Clark, R. E. (2014). The Use of Cognitive
Task Analysis to Reveal the Instructional Limitations of Experts in the Teaching of
Procedural Skills. Academic Medicine, 89(5), 811-816.
Sweller, J. (1988). Cognitive load during problem solving: Effects on learning. Cognitive
Science, 12, 257-285.
Sweller, J., van Merrienboer, J.J.G., & Paas, F.G. (1988). Cognitive architecture and
instructional design. Educational Psychology Review, 10, 251-296.
Tirapelle, L. A. (2010). The effect of cognitive task analysis based instruction on surgical skills
expertise and performance. Available from ProQuest Dissertations and Theses
database. (UMI No. 3403766)
Tofel-Grehl, C., & Feldon, D. F. (2013). Cognitive task analysis-based training: A meta-
analysis of studies. Journal of Cognitive Engineering and Decision Making, 7(3), 293-
304.
Tolano-Leveque, M. (2010). Using cognitive task analysis to determine the percentage of
critical information that experts omit when describing a surgical procedure
(Doctoral dissertation). Available from ProQuest Dissertations and Theses database.
(UMI No 3418184)
PATIENT CARE HANDOFF IN THE ICU
99
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality
Patient Safety Network, Patient Safety Primer. Handoffs and Signouts. Retrieved
November 7, 2014 from http://www.psnet.ahrq.gov/primer.aspx?primerID=9.
Vernon, D. T., & Blake, R. L. (1993). Does problem-based learning work? A meta-analysis of
evaluative research. Academic medicine, 68(7), 550-63.
Vogel-Walcutt, J. J., Gebrim, J. B., Bowers, C., Carper, T. M., Nicholson, D. (2011). Cognitive
load theory vs. constructivist approaches: Which best leads to efficient, deep learning?
Journal of Computer Assisted Learning, 27, 133-145.
Wagter, J.M., van de Bunt, G., Honing, M., Eckenhausen, M., & Scherpbier, A. (2012).
Informal interprofessional learning: Visualizing the clinical workplace. Journal of
Interpersonal Care, 26, 173-182.
Wears, R. L., Parker, S. H., Cohen, M., Carroll, J., Perry, S., & Manser, T. (2012, September). A
wealth of information creates a poverty of attention? Understanding information
requirements at handovers. In Proceedings of the Human Factors and Ergonomics
Society Annual Meeting (Vol. 56, No. 1, pp. 860-862). SAGE Publications.
Weller, J. M., Barrow, M., & Gasquoine. (2011). Interprofessional collaboration among junior
doctors and nurses in the hospital setting. Medical Education, 45, 478-487.
Wheatley, T., & Wegner, D. M. (2001). Automaticity of action, psychology of. In N. J. Smelser
& P. B. Baltes (Eds.), International encyclopedia of the social and behavioral sciences
(pp. 991-993). Oxford, UK: Elsevier Science Ltd
Wheeler, K. K. (2014). Effective handoff communication. OR Nurse. Retrieved April 1, 2014,
from http://www.ORNurseJournal.com.
PATIENT CARE HANDOFF IN THE ICU
100
World Health Organization: Communication during patient hand-overs. Patient Safety Solutions
1(3), May 2007. Retrieved from: http://www.who.int/
patientsafety/solutions/patientsafety/PS-Solution3.pdf
World Health Organization Guidelines for Safe Surgery, 2008; Published June 2008.
Yates, K.A., (2007). Towards a taxonomy of cognitive task analysis methods: A search for
cognition and task analysis interactions (Doctoral dissertation).
Yates, K. A., & Feldon, D. F. (2011). Advancing the practice of cognitive task analysis: A
call for taxonomic research. Theoretical Issues in Ergonomics Science, 12(6), 472-
495.
Yates, K., Sullivan, M., & Clark, R. (2012). Integrated studies on the use of cognitive task
analysis to capture surgical expertise for central venous catheter placement and
open cricothyrotomy. The American Journal of Surgery, 203(1), 76-80.
Zepeda-McZeal, D. (2014). Using cognitive task analysis to capture expert reading instruction
in informational text for students with mild to moderate learning disabilities
(Unpublished doctoral dissertation). University of Southern California, Los Angeles,
CA.
PATIENT CARE HANDOFF IN THE ICU
101
Appendix A
Cognitive Task Analysis Interview Protocol
Begin the Interview: Introduce self and Subject Matter Expert (SME). Explain the purpose of
the interview: “we are here today to talk about the patient handoff”. 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 the task: Patient care handoff from the operating room to the intensive care unit.
Performance Objective:
a. Ask: “In your own words, what is/are the objectives of patient handoff from OR to ICU”.
Step 1:
Objective: Capture a complete list of outcomes for patient handoff from the operating room to
the intensive care unit.
a. Ask: “What are the outcomes when this tasks are complete”. “Make the list as complete
as possible”.
b. Ask: “How are the outcomes assessed?”
Step 2:
Objective: Capture a complete list of all the contexts in which these tasks are performed.
a. Ask “How does the tasks change for each job setting
b. Ask: “What are the cues that start this task, i.e. what must happen for the task to start?”
c. Ask: “Are there any contraindications-is there a time you would not transfer care?”
Step 3:
Objective: Identify main steps or stages to accomplish the task.
a. Ask SME the key steps or stages required to accomplish the task.
b. 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.
b. Ask: “Please describe how you accomplish this task step-by-step, so a novice
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 there is a decision being
made. If SME indicates that a decision must be made…
PATIENT CARE HANDOFF IN THE ICU
102
Ask: “Please describe the most common alternatives (up to a maximum of three) that must be
considered to make the decision and the criteria novices 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 trainee
Ask for a definition and at least one example (e.g. SBAR)
Ask how the expert learned it (ask this to inform decisions that are being made)
Processes - How something works
How does patient handoff fit within the larger process of patient care?
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?
If not offered, keeping asking if there are other materials…
4. Ask the SME to identify standards to performing this task
Ask: “Are there any time limits or quality standards you must observe?”
5. Ask the SME if there are any sensory experiences required for task
Ask: “Are there any senses being used in this task, such as sight, smell…”
Ask: “Is there anything in the actions of the receiver that influence what you do?”
Step 6:
Objective: Identify problems that can be solved by using the procedure
1. Ask the SME to describe at least one routine problem and 2-3 complex problems that
the novice should be able to solve if they can perform each of the tasks on the list you
just made.
PATIENT CARE HANDOFF IN THE ICU
103
Appendix B
Inter-Rater Reliability Code Sheet for SME B
PATIENT CARE HANDOFF IN THE ICU 104
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 and 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:
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. 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)
PATIENT CARE HANDOFF IN THE ICU 105
Appendix D
Gold Standard Protocol
Patient Care Handoff from the Operating Room to the ICU
1. Objective
Capture pertinent, accurate, and complete patient information to provide a safe transfer of
patient care from the operating room to the care of receiving staff members (the ICU nurse,
the respiratory therapist, the intensivist) in the intensive care unit (A,B,C)
2. Reasons
To provide safe transport and transfer of patient care postoperatively (A,B,C)
To optimize patient care along the continuum from admission to discharge (A,B,C)
To relinquish control of the patient from the anesthesia provider in the operating room to the
healthcare staff in the ICU (A,B,C)
The overall process of gathering patient information is ongoing (ABC).
The preoperative and intraoperative assessments will inform what the ICU team needs to
know and the post-op disposition is part of the consideration in the pre-op period (ABC)
3. Conditions
Indications:
• Surgery complete (transfer is a physical and verbal transfer)
• Hospital standard: Presence of ≥ 2 licensed providers
• Patient is stable
• Phone call to ICU has been done
• ICU bed is available
• Agreement that patient goes to ICU
• Preparation/readiness of receiving party
• Equipment is ready
• Clear pathway
Contraindications: Indications not to transfer patient and deliver a handoff report
• An unstable patient
• Lack of ICU bed
4. Standards
The time for handoff varies based on stability of patient
5. Equipment
Mandatory
PATIENT CARE HANDOFF IN THE ICU 106
• Transport monitor (A432-436)
• Pulse oximeter (number and tracing) (A464-465)
• Electrocardiogram (5 lead preferred) (A470, A505, A513-516)
• Blood pressure monitor (arterial or cuff) (A477-481, A499-500)
• Airway device: ETT, LMA, 02 mask, NC (A940-942)
• Oxygen cylinder ≥ 50% full (A1209)
• Ambu bag (A1201)
• Medications (A1343-1348)
• Roller board (A1021)
Recommended
• IV pumps (A1355-1358)
• Additional personnel (A1048)
6. Procedure List
1. Acquire knowledge of patient condition through chart review, patient interview, and
physical assessment.
2. Acquire knowledge of patient condition based on intraoperative course.
3. Prepare equipment, medications, personnel, and the patient for transfer.
4. Conduct patient transport from the operating room to the ICU.
5. Conduct patient handoff report.
7. Procedure Steps
1. Acquire knowledge of patient condition through chart review, patient interview, and physical
assessment.
1.1. Review scheduled cases for need for ICU post operatively based on surgeon preference,
type of surgery, and patient condition (C).
1.2. Assess specific institutional policies related to ICU admission criteria and options for
postoperative levels of care (AC)
1.2.1.IF patient is in ICU preoperatively, THEN
1.2.1.1. Communicate with ICU team either by phone or, if possible, in person (A)
1.2.1.2. Assess hemodynamic stability (D)
1.2.1.3. Assess respiratory stability (D)
1.2.1.4. Assess current drips (D)
1.3. Conduct a thorough chart review (ABC) that includes:
1.3.1.Chief complaint (B),
1.3.2.Surgical procedure (ABC),
1.3.3.Medical history (ABC),
1.3.4.Medications (B),
1.3.5.Surgical history (B),
1.3.6.Labs (ABC),
1.3.7.EKG (AB),
1.3.8.Radiology results (ABC),
1.3.9.Anesthesia history (C) and
1.3.10. Document findings in the anesthesia preoperative assessment form (ABC).
1.3.11. IF patient has history of anesthetic problems, THEN
1.3.11.1. Obtain and review previous anesthetic record if available (C)
1.3.11.2. Obtain specific information from patient if possible (C)
PATIENT CARE HANDOFF IN THE ICU 107
1.3.12. IF patient has history of hypertension, THEN
1.3.12.1. Assess duration of hypertension, current medications, blood pressure range,
and
EKG correlations (B)
1.3.12.2. Assess blood pressure control in the preoperative period to determine
need for additional monitoring intraoperatively and postoperatively (B).
1.4. Conduct preoperative physical exam of the patient with focus on cardiac, pulmonary, and
airway status (ABC).
1.5. Assess patient’s:
1.5.1.General appearance (BC),
1.5.2.Heart and lung sounds (B)
1.5.3.Airway status (BC),
1.5.4.Skin color (B),
1.5.5.Hydration status (B),
1.5.6.Skin turgor (B),
1.5.7.IV access (B),
1.5.8.Height (D),
1.5.9.Weight (D)
1.5.10. Document findings in the anesthesia preoperative assessment form (D)
1.5.11. IF IV access is inadequate, THEN place IV catheter of appropriate size in
appropriate location (B)
1.5.12. IF potential for large blood loss and/or fluid derangement, THEN
1.5.12.1. Consider large bore IVs for stable patient (B)
1.5.12.2. Consider central line for unstable patient or poor peripheral access (A)
1.5.12.3. Call blood bank and check blood availability (D)
1.5.12.3.1. IF blood not available (i.e. due to antibodies) THEN discuss
potential for case delay with surgeon (D)
1.5.13. IF patient has history or evidence of a difficult airway, THEN
1.5.13.1. Follow difficult airway algorithm (B)
1.5.13.2. Anticipate need for ventilator support postoperatively (ABC).
1.5.13.3. Adjust anesthesia plan accordingly (C)
1.5.13.4. Consider avoiding airway instrumentation (i.e. consider regional
anesthesia) as indicated (C).
1.5.13.5. Confirm necessary equipment is in the operating room (C)
1.6. Assess any psych-social issues that healthcare providers may need to consider
1.6.1.IF minor, THEN confirm parents present whenever possible/needed
1.6.2.IF incarcerated patient, THEN confirm presence of deputy before and after
surgery per hospital protocol
1.7. Anticipate perioperative patient care needs based on:
1.7.1.chart review (ABC)
1.7.2.physical exam (ABC)
1.7.3.type of surgery (ABC)
1.7.4.patient optimization (C)
1.8. Consider patient expectations, preference, and concerns (C)
1.8.1.IF appropriate for surgery and surgeon agrees, THEN try to meet patient request (C)
1.9. Prepare patient for surgery and anesthesia by developing patient bond, providing
patient education, and addressing patient questions (C)
1.10. Devise anesthetic care plan (C)
1.11. Prepare equipment and set up operating room (C)
2. Acquire knowledge of patient condition based on intraoperative course.
PATIENT CARE HANDOFF IN THE ICU 108
2.1. Assess and document patient response to surgery and anesthesia, including
hemodynamic response, estimated blood loss (EBL), intake and output (I/Os)
2.1.1.IF prolonged surgery, THEN assess for greater fluid requirements, blood loss,
fluid loss, and/or third spacing (C)
2.1.2.IF EBL high and/or blood transfusion provided, THEN check PT/PTT and H/H
2.1.3.IF patient in a trendelenberg position, THEN assess for airway edema prior to
extubation (C)
2.1.4.IF patient in a prone position, THEN assess for airway edema prior to extubation (D)
2.1.5.IF significant airway edema present, THEN keep patient intubated (D)
2.1.6.IF untoward patient event and ICU bed un anticipated (e.g. vasopressor
medications to maintain blood adequate blood pressure intraoperatively or requires
mechanical ventilation postoperatively), THEN
2.1.6.1. Talk with surgeons regarding concerns (ABC)
2.1.6.2. Call ICU coordinator to arrange for bed and confirm availability of
necessary equipment such as ventilator (ABC)
2.1.7.IF patient required transfusion of blood products, THEN
2.1.7.1. Assess patient’s response to blood therapy (B)
2.2. Preemptively treat any hemodynamic issues that arise (C)
2.3. Monitor progress of surgery and stay in communication with surgeon (ABC)
2.3.1.IF surgeons have concerns, THEN
2.3.1.1. Assess anything unusual about the case (C)
2.3.1.2. Assess for specific postoperative needs after surgery (C)
Procedure 3: Prepare equipment, medications, personnel, and the patient for transfer
3. Prepare for transfer as follows
3.1. Confirm that the transport monitor is
3.1.1.Available (ABC)
3.1.2.Properly set up (B)
3.1.3.Equipped with pulse oximetry (AB)
3.1.4.Equipped with plethysmography (B)
3.1.5.Equipped with EKG (ABC)
3.1.6.Equipped with blood pressure monitor (ABC)
Note: the ASA does not have clear guidelines regarding selection of monitors for transport to
the ICU. Selection of monitors is based in clinical judgment (AC)
3.2. Confirm that all cables, equipment, and tubing reach and do not become dislodged
during the transfer from the OR table to the ICU bed (B).
3.2.1.IF patient has a urinary catheter, drains, or chest tubes, THEN confirm items are
positioned such that they do not get dislodged (B)
3.2.2.IF the ICU headrest is in the way, THEN remove it during transfer of patient from
OR table to ICU bed and replace before transfer to the ICU (B).
3.3. Prepare airway equipment for transfer including:
3.3.1. An oral airway (ABC)
3.3.2.ET tube (AB)
3.3.3.Laryngoscope handle (AB)
3.3.4.Laryngoscope blade (AB)
3.3.5.Nasal trumpet (D).
3.3.6.IF patient’s airway history in unknown and/or the patient’s airway looks difficult,
THEN bring additional airway devices such as laryngeal mask airway (LMA) (B).
3.4. Confirm presence of oxygen cylinder (AB) that is ≥ 50% full and in a secure location on
or under ICU bed (B)
PATIENT CARE HANDOFF IN THE ICU 109
3.4.1.1. IF oxygen cylinder that is ≤ 50% full, request full oxygen cylinder prior to
transport (B)
3.5. Confirm presence and proper functioning of Ambu bag and mask (AB)
3.5.1.IF Ambu bag equipped with PEEP valve, THEN confirm setting (B)
3.6. Confirm the OR nurse has called the ICU to give phone report (ABC) to provide report
regarding ventilator settings, IV fluids, medications, and any specific concerns (C)
3.6.1.IF specific anesthesia-related information is needed and/or information goes beyond ability
or knowledge of OR nurse, THEN anesthesia to participate in the phone report to the ICU
nurse (B).
3.6.2.IF specific anesthesia-related patient needs and/or equipment are needed, THEN confirm
that information is provided to the ICU nurse (C).
3.6.3.IF patient requires ventilator support, THEN confirm RT is aware and will be respiratory
therapist at the bedside when patient arrives (A)
3.7. Prepare medications for transfer including pain medications, muscle relaxants, sedation agents,
and emergency medications (AB).
3.7.1.IF patient requires additional muscle relaxation, THEN
3.7.1.1. Provide amount adequate to last throughout transfer process (B).
3.7.1.2. Confirm adequate sedation is provided throughout the duration of the muscle
relaxation (B)
3.7.2.IF patient requires continuous sedation, THEN obtain and prepare IV medication (A)
3.7.3.IF patient requires continuous infusion of vasoactive medications, THEN obtain and
prepare IV pumps (AB).
3.7.4.IF movement will cause patient pain, THEN give analgesic agents prior to moving the
patient (B)
3.8. Maintain visualization of the patient and attached equipment by removing redundant sheets and
linens (AB).
3.8.1.IF patient is hypothermic, THEN
3.8.1.1. Keep patient covered (AB) and
3.8.1.2. Consider maintain warming devices during transport (A).
3.9. Confirm patient is presentable for transfer: all residual blood on patient’s skin is removed,
patient is covered with clean sheets, eye tape removed, and patient identifiers covered (B)
3.10. Confirm that there is a minimum of four people (positioned at head, feet, and either side)
to transfer the patient from the OR table to the ICU bed (B)
3.10.1. IF the patient is very heavy, enlist help of additional personnel to assist with transfer (B).
3.10.2. IF additional equipment or devices are attached to the patient and need to be transferred,
enlist help of additional personnel to assist with transfer (B).
3.11. Confirm both the OR table and ICU beds are locked (B).
3.12. The anesthesia provider maintains control of the patient’s head, neck, and shoulders for
neutral alignment throughout the transfer process (B).
3.12.1. IF surgical specialty equipment is attached to patient and needs to be transferred (e.g.
external fixation device, cervical stabilization device), THEN consult and coordinate with
surgeon to confirm responsibility for the physical transfer of that device (B)
3.12.2. IF the patient can tolerate being disconnected from the oxygen source for <90 seconds,
THEN disconnect patient from the breathing circuit just before patient is moved from the
OR table to the ICU bed and reconnect the breathing circuit immediately after (B)
3.12.3. IF the patient cannot tolerate being disconnected from the oxygen source for <90 seconds
(i.e. 02 sat drops below 90%), THEN do not disconnect patient from the breathing circuit
and transfer with oxygen connected (B).
3.13. Transfer of the patient from the OR table to the ICU bed is coordinated by the anesthesia
provider, which includes the 3-2-1 or a 1-2-3 countdown (B).
PATIENT CARE HANDOFF IN THE ICU 110
3.14. Confirm team members (OR nurses, techs, surgeons (D)) are ready to move the patient
(BC)
3.15. After patient is transferred onto the ICU bed, disconnect anesthesia machine monitors
and attach transport monitors (AB).
3.16. Confirm the transport monitor is easily visible to the anesthesia provider while taking
caution not to let the monitor touch the patient (AB)
3.16.1. IF the volume of the pulse oximeter is too low, THEN turn up to (A)
3.17. Evaluate stability of the patient for transport (AB)
3.17.1. IF the patient is optimized for transport, THEN proceed to ICU (AB)
3.17.2. IF the patient is critically unstable, THEN determine cause and optimize patient before
leaving the operating room to optimize patient safety while in transit (AB).
3.17.3. IF transport monitor is displaying abnormal waveforms, THEN trouble shoot before
leaving the operating room (B).
3.17.4. IF concerned about patient going into cardiac arrest, THEN place external pads and bring
defibrillator or external pacer (A).
3.18. Confirm availability of at least two licensed providers for transport: the anesthesia
provider and the operating room nurse (AB)
3.18.1. IF additional equipment needed, THEN recruit additional personnel to assist with transfer
of equipment (AB)
Procedure 4: Conduct patient transport from the operating room to the ICU
4.
4.1. Confirm someone is dedicated to providing manual ventilation to the patient appropriate rate,
volume, and PEEP. Disconnect patient from anesthesia machine/mechanical ventilation and
begin manual ventilation via Ambu bag and 100% oxygen (AB)
4.2. Assess response to manual ventilation including saturation, chest rise, ETCO2, and need for
sedation (AB)
4.2.1.IF patient cannot tolerate ventilation via Ambu bag, THEN resume mechanical ventilation
and re-assess pulmonary status (A).
4.2.2.IF patient’s ventilation status changes, THEN adjust accordingly (B)
4.2.3.IF patient continues to shows signs of strain due to change in ventilation, THEN give
sedation (B)
4.3. Confirm someone is dedicated to guiding ICU bed (B).
4.3.1.IF transferring patient through public hallway, THEN
4.3.1.1. Confirm the hallway is clear of obstructions (B).
4.3.1.2. Make sure bystanders are aware the bed is approaching (B).
4.3.1.3. Assure family members they will receive an update as soon as patient is situated
and ICU report has been given (B).
4.4. Monitor patient throughout transport from OR to ICU (A)
4.4.1.IF patient becomes critically unstable during the actual transport, THEN
4.4.1.1. Determine if patient condition can be managed in the hallway (AB)
4.4.1.2. Determine distance from ICU or operating room and decide whether it is safer to
proceed to the ICU or go back to the operating room (AB).
4.5. Assist with positioning bed in the ICU room (B)
4.6. Facilitate transfer process to optimize patient care and build cooperation for subsequent patient
transfers (BC).
4.7. Assess ICU environment (ABC)
4.7.1.IF unknown to the ICU team, THEN introduce oneself (A)
4.7.2.IF ICU appears busy, THEN prepare to facilitate more of the physical transfer (ABC)
4.7.3.IF ventilator not present, THEN call respiratory therapy (RT) and continue with manual
ventilation (AB)
PATIENT CARE HANDOFF IN THE ICU 111
4.8. Assess stability of patient (AB)
4.8.1.IF patient critically unstable THEN:
4.8.1.1. Prioritize information so that immediate patient needs are met (AB)
4.8.1.2. Assist with hooking up monitors and obtain vital signs (AB)
4.8.1.3. Engage the surgeon and other members of the ICU team such as the ICU
manager and ICU attending (AC).
4.8.1.4. Confirm respiratory therapist is present to receive report as part of the ICU team
(AB)
4.8.1.4.1. IF ventilator or respiratory therapy (RT) not present, THEN call RT and
continue with manual ventilation (A)
4.8.2.IF ICU team needs to turn patient on side for initial physical assessment, THEN anesthesia
provider must remain vigilant for patient’s pain, airway, and safety issues while in the
process of relinquishing care (B).
4.9. Assess knowledge, experience, and readiness of ICU nurse to receive report on the patient (BC).
4.9.1.If ICU nurse receiving report is the same person who took report over the phone, THEN
modify report as needed (B).
4.9.2.IF patient is returning to the same ICU provider, THEN modify report as needed (B).
4.9.3.IF ICU nurse does not appear ready, THEN assess why using senses and asking questions
(B).
4.9.4.IF ICU nurse appears novice, THEN provide assistance and obtain additional ICU support
as needed (BC).
4.10. Assess engagement of ICU nurse (ABC)
4.10.1. IF excessive talking, THEN ask for their attention (ABC)
4.10.2. IF excessive noise, THEN create quiet reporting environment (AB)
4.10.3. IF ICU nurse not engaging, THEN give verbal prompt “Can I give you report now?”
(ABC).
Procedure 5: Conduct patient handoff report
5. Provide patient information as follows:
5.1. Refer to mnemonic or checklist to avoid forgetting information (A)
5.1.1.IF hospital or institution uses a specific mnemonic or checklist (e.g. SBAR), THEN use the
same one to maintain consistency (A)
5.2. Refer to ICU protocol for admitting a patient (C)
5.2.1.IF the ICU uses a specific transfer of care record, THEN use the same one to maintain
consistency (C)
5.3. Patient identification including two patient identifiers (AB)
5.4. Surgical procedure and indication (ABC)
5.5. Patient’s response to surgery and any unexpected events (BC)
5.6. Anesthetic management including medications given, current drips, airway management (BC).
5.6.1.IF patient given antibiotics, THEN indicate what was given and when (D)
5.6.2.IF patient on scheduled medications, THEN indicate when medication was given and when
next dose is due (B)
5.6.3.IF patient given neuromuscular blockers, THEN indicate last dose (C)
5.6.4.IF patient’s analgesic requirement were excessive intraoperatively, THEN consider
continuous infusion of analgesics in the ICU (A)
5.7. Provide pertinent past surgical history and past medical history with a focus on the patient’s
cardiac, pulmonary status, other pertinent comorbidities, and systems most affected or involved
by existing or surgical issues (ABC);
5.7.1.IF patient remains intubated, THEN include recommended ventilator settings (ABC)
PATIENT CARE HANDOFF IN THE ICU 112
5.7.2.IF patient was a difficult airway and/or at risk for airway edema, THEN confirm ICU nurse
and intensivist aware. (C)
5.7.3.IF patient had failed extubation attempt immediate postoperatively, THEN confirm RT and
ICU team are aware (A)
5.7.4.IF patient is hypotensive, THEN
5.7.4.1. Determine need for fluid or blood if patient is bleeding (C)
5.7.4.2. Consider vasoactive agents (D)
5.7.4.3. Hold epidural activation until intravascular volume is replaced and blood
pressure is stable (C).
5.7.5.IF patient on beta-blockers, THEN
5.7.5.1. Continue medications throughout perioperative period per Surgical Care
Improvement Project (B).
5.7.6.IF patient has spine injury, THEN report that prior to any patient movement in the ICU (B)
5.8. Report on lab work including hemoglobin/hematocrit and blood gas (ABC).
5.8.1.IF patient was hypo/hyperglycemic, THEN report any treatment and latest blood glucose
levels and anticipated or recommended needs.
5.9. Identify IV access including invasive lines (BC)
5.9.1.Confirm chest x-ray has been ordered to confirm CVP placement (D)
5.10. Report on intake and outputs including estimated blood loss, urine output, and fluids
given (ABC).
5.10.1. IF patient required transfusion of blood products, THEN report what and how much was
transfused, and patient’s response to transfusion (B)
5.11. Recommend interventions based on patient’s preoperative history, intraoperative course,
current condition, and specific concerns (ABC)
5.12. Include post-operative pain management plan and post-operative nausea-vomiting plan
(C)
5.12.1. IF specific pain management control issues are addressed, THEN
5.12.1.1. Discuss with surgeon and ICU team (277, 378)
5.12.1.2. Provide recommendations (276)
5.12.2. IF patient at risk for post-operative nausea and vomiting (PONV), THEN
5.12.2.1. Treat accordingly (378)
5.12.2.2. Provide recommendations (378)
5.13. Obtain initial set of vital signs once patient has been transferred to ICU monitors for
documentation of immediate postoperative vital signs (C)
5.14. Complete postoperative patient handoff to the ICU team (nurse, attending, fellow,
resident, and nurse practitioner) (ABC)
5.14.1. IF patient remains critically unstable, THEN confirm with ICU team that they do not
need additional assistance (B)
5.14.2. IF ICU team is not prepared to assume care of the patient, THEN maintain responsibility
for the patient until a proper transfer has occurred (C)
5.14.3. IF ICU attending, fellow, or resident is not present at time of patient handoff, THEN
communicate either by phone or, if possible, in person (A)
5.15. Invite and address questions the ICU nurse may have and assess for understanding
(ABC), and obtain verbal confirmation that the ICU team has accepted care of the patient (C)
5.15.1. IF ICU team does not have questions, THEN prompt the team to ask (A)
REASON: This encourages the team to think of things that maybe they want to ask but they forgot or
if they're busy doing something. It also signals the completion of the transfer of care and is a form of
closed loop communication..
5.16. Remove any personal protective equipment (PPE) and hand wash (B)
5.17. Complete anesthesia documentation and return transport monitor, medications, and
airway supply back to anesthesia workroom. (B)
PATIENT CARE HANDOFF IN THE ICU 113
NOTE: It is important to maintain focus on patient care with providing verbal report, answering questions
and assessing understanding by the ICU team, and documentation of patient care and report (C).
8. Cues
Surgery is complete (ABC)
Operating room team is ready to move patient from OR table to ICU bed (B)
Patient is ready for transport
ICU is ready to receive patient (ABC)
9. Prerequisite Skills/Knowledge
• A novice should have knowledge of what constitutes patient history, including how to conduct
patient interview and review the patients EMR (B)
• A novice should have knowledge of what constitutes patient assessment, including how to perform
a physical exam and an airway exam (B)
• A novice should know how to assess and troubleshoot IV access (B)
• A novice should have knowledge of basic pharmacology, including beta-blocker therapy, all
commonly used anesthetic agents, and vasoactive agents (B)
• A novice should know how to transfer an anesthetized patient from bed to bed (B)
• A novice should know how to manage patient’s transport monitors such as how to zero an arterial
line (B)
• A novice should know how to manually ventilate patient using Ambu bag (B)
10. New Concept
• Patient teaching and discharge begins with admission (ABC)
• Overall process of gathering patient information is ongoing (ABC)
• Goal of intraoperative care is to optimize immediate postoperative course and avoid postoperative
complications (ABC)
• Preoperative and intraoperative assessment will inform what the ICU team needs to know (ABC)
11. New Principles
• Must consider length of hallway, elevators, or other obstacles going from the operating to the ICU
(B)
12. Sensory Information
• Touch
Touch the patient’s skin to check if they are moist, dry, warm, cold (B)
• Visual
Look at patients color and affect (ABC)
Look at patients skin condition to determine skin turgor or any skin breakdown (B)
Look at patients overall appearance and level of consciousness (AB)
Look at patient for IV access and security (B)
Look for presence and security of drains, devices, etc. (B)
Look at environment transferring to and from (B)
Look to determine readiness of team and patient for transfer (ABC)
Make eye contact with person receiving report (AB)
Observe actions of the ICU team to assess experience (ABC)
• Sound
Listen to the patient to determine orientation/awareness (BC)
Auscultate breath sounds to assess for airway patency versus obstruction (B)
Assess for language/communication barriers (B)
PATIENT CARE HANDOFF IN THE ICU 114
13. Safety Factors
• A patient handoff will not occur when the patient is unstable
• A patient handoff will not occur if the receiver is incapable of assuming care of the patient
• A patient must have a functioning IV prior to transport (A246-247)
• Potential barriers to safe transfer of care from the OR to the ICU such as long hallway and/or
presence of elevators (A444-445)
• Arterial wave form and/or plethysmography provides information about pulsations (A467, A480)
since they provide beat to beat information about perfusion.
• The transport monitor must be visible at all times (A1072).
• Protect patient from impingement of devices (e.g. 02 tank, transport monitor, etc.).
• Place oxygen cylinder in a secure location on, under or attached to ICU bed
• Use good ergonomics during transport to avoid injury to personnel (A1250-1257)
14. Environmental Considerations
• Assess availability of family members (B)
• Assess for environmental factors: calm vs. chaos, cooperative vs. obstructive (ABC)
• Prepare patient for transfer in public areas (B)
15. References
• American College of Cardiology/American Heart Association Task Force on Practice Guidelines
• Surgical Care Improvement Project (SCIP)
• National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network
16. Problems
• Misinterpretation of EKG if leads are in different location (B)
• Unplanned ICU admission may result in admission delay due to unavailability of ICU bed,
preparing necessary equipment such as ventilator, and obtaining skilled staff (A)
PATIENT CARE HANDOFF IN THE ICU 115
Appendix E Incremental 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
patient
condition
through
chart
review,
patient
interview,
and
physical
assessment
[Reason:
The
overall
process
of
gathering
patient
information
is
ongoing.
The
preoperative
and
intraoperative
assessments
will
inform
what
the
ICU
team
needs
to
know,
and
the
post-‐op
disposition
is
part
of
the
consideration
in
the
pre-‐op
period]
(A,B,
C).
1
1
1
0
32
21
1
A
1.1.
Review
scheduled
cases
for
need
for
ICU
post
operatively
based
on
surgeon
preference,
type
of
surgery,
and
patient
condition
(C).
0
0
1
0
2
A
1.2.
Assess
specific
institutional
policies
related
to
ICU
admission
criteria
and
options
for
postoperative
levels
of
care
(AC)
1
0
1
0
D
1.2.1.
IF
patient
is
in
ICU
preoperatively,
THEN
communicate
with
ICU
team
either
by
phone
or,
if
possible,
in
person
(A)
1
0
0
0
A
1.2.1.2.
Assess
hemodynamic
stability
(D)
0
0
0
1
A
1.2.1.3.
Assess
respiratory
stability
(D)
0
0
0
1
A
1.2.1.4.
Assess
current
drips
(D)
0
0
0
1
A
1.3.
Conduct
a
thorough
chart
review
(ABC)
that
includes
1
1
1
0
A
1.1.1.
Chief
complaint
(B),
0
1
0
0
A
1.1.2.
Surgical
procedure
(ABC),
1
1
1
0
A
1.1.3.
Medical
history
(ABC),
1
1
1
0
A
1.1.4.
Medications
(B),
0
1
0
0
A
1.1.5.
Surgical
history
(B),
0
1
0
0
A
1.1.6.
Labs
(ABC),
1
1
1
0
A
1.1.7.
EKG
(AB),
1
1
0
0
A
1.1.8.
Radiology
results
(ABC),
1
1
1
0
A
1.1.9.
Anesthesia
history
(C)
and
0
0
1
0
A
1.1.10.
Document
findings
in
the
anesthesia
preoperative
assessment
form
(ABC).
1
1
1
0
1.3.1.
IF
patient
has
history
of
anesthetic
problems,
THEN
D
1.3.1.1.
Obtain
and
review
previous
anesthetic
record
if
available
(C)
0
0
1
0
PATIENT CARE HANDOFF IN THE ICU 116
D
1.3.1.2.
Obtain
specific
information
from
patient
if
possible
(C)
0
0
1
0
1.3.2.
IF
patient
has
history
of
hypertension,
THEN
D
1.3.2.1.
Assess
duration
of
hypertension,
current
medications,
blood
pressure
range,
and
EKG
correlations
(B)
0
1
0
0
D
1.3.2.2.
Assess
blood
pressure
control
in
the
preoperative
period
to
determine
need
for
additional
monitoring
intraoperatively
and
postoperatively
(B).
0
1
0
0
A
1.4.
Conduct
preoperative
physical
exam
of
the
patient
with
focus
on
cardiac,
pulmonary,
and
airway
status
(ABC).
1
1
1
0
1.5.
Assess
patient’s:
A
1.1.1.
General
appearance
(BC),
0
1
1
0
A
1.1.2.
Heart
and
lung
sounds
(B)
0
1
0
0
A
1.1.3.
Airway
status
(BC),
0
1
1
0
A
1.1.4.
Skin
color
(B),
0
1
0
0
A
1.1.5.
Hydration
status
(B),
0
1
0
0
A
1.1.6.
Skin
turgor
(B),
0
1
0
0
A
1.1.7.
IV
access
(B),
0
1
0
0
A
1.1.8.
Height
(D),
0
0
0
1
A
1.1.9.
Weight
(D)
0
0
0
1
A
1.1.10.
Document
findings
in
the
anesthesia
preoperative
assessment
form
(D)
0
0
0
1
D
1.5.1.
IF
IV
access
is
inadequate,
THEN
place
IV
catheter
of
appropriate
size
in
appropriate
location
(B)
0
1
0
0
1.5.2.
IF
potential
for
large
blood
loss
and/or
fluid
derangement,
THEN
D
1.5.2.1.
Consider
large
bore
IVs
for
stable
patient
(B)
0
1
0
0
D
1.5.2.2.
Consider
central
line
for
unstable
patient
or
poor
peripheral
access
(A)
1
0
0
0
D
1.5.2.3.
Call
blood
bank
and
check
blood
availability
(D)
0
0
0
1
D
1.5.2.3.1.
IF
blood
not
available
(i.e.
due
to
antibodies)
THEN
discuss
potential
for
case
delay
with
surgeon
(D)
0
0
0
1
1.5.3.
IF
patient
has
history
or
evidence
of
a
difficult
airway,
THEN
D
1.5.3.1.
Follow
difficult
airway
algorithm
(B)
0
1
0
0
D
1.5.3.2.
Anticipate
need
for
ventilator
support
postoperatively
(ABC).
1
1
1
0
D
1.5.3.3.
Adjust
anesthesia
plan
accordingly
(C)
0
0
1
0
D
1.5.3.4.
Consider
avoiding
airway
instrumentation
(i.e.
consider
regional
anesthesia)
0
0
1
0
PATIENT CARE HANDOFF IN THE ICU 117
as
indicated
(C).
D
1.5.3.5.
Confirm
necessary
equipment
is
in
the
operating
room
(C)
0
0
1
0
A
1.6.
Assess
any
psych-‐social
issues
that
healthcare
providers
may
need
to
consider
(B)
0
1
0
0
D
1.6.1.
IF
minor,
THEN
confirm
parents
present
whenever
possible/needed
(B)
0
1
0
0
D
1.6.2.
IF
incarcerated
patient,
THEN
confirm
presence
of
deputy
before
and
after
surgery
per
hospital
protocol
(B)
0
1
0
0
1.7.
Anticipate
perioperative
patient
care
needs
based
on:
A
1.1.1.
chart
review
(ABC)
1
1
1
0
A
1.1.2.
physical
exam
(ABC)
1
1
1
0
A
1.1.3.
type
of
surgery
(ABC)
1
1
1
0
A
1.1.4.
patient
optimization
(C)
0
0
1
0
A
1.8.
Consider
patient
expectations,
preference,
and
concerns
(C)
0
0
1
0
D
1.8.1.
IF
appropriate
for
particular
surgery
and
surgeon
agrees,
THEN
try
to
meet
patient
request
(C)
0
0
1
0
A
1.9.
Prepare
patient
for
surgery
and
anesthesia
by
developing
patient
bond,
providing
patient
education,
and
addressing
patient
questions
(C)
0
0
1
0
A
1.10.
Devise
anesthetic
care
plan
(C)
0
0
1
0
A
1.11.
Prepare
equipment
and
set
up
operating
room
(C)
0
0
1
0
A
2.
Acquire
knowledge
of
patient
based
on
intraoperative
course
(ABC)
1
1
1
4
10
A
2.1.
Assess
and
document
patient
response
to
surgery
and
anesthesia,
including
hemodynamic
response,
estimated
blood
loss
(EBL),
intake
and
output
(I/Os)
(ABC)
1
1
1
0
D
2.1.1.
IF
prolonged
surgery,
THEN
assess
for
greater
fluid
requirements,
blood
loss,
fluid
loss,
and/or
third
spacing
(C)
0
0
1
0
D
2.1.2.
IF
EBL
high
and/or
blood
transfusion
provided,
THEN
check
PT/PTT
and
H/H
(D)
0
0
0
1
D
2.1.3.
IF
patient
in
a
trendelenberg
position,
THEN
Assess
for
airway
edema
prior
to
extubation(C)
0
0
1
0
D
2.1.3.
IF
patient
in
prone
position,
THEN
Assess
for
airway
edema
prior
to
extubation
(D)
0
0
0
1
D
2.1.3.1.1.
IF
significant
airway
edema
present,
THEN
keep
patient
intubated
(D)
0
0
0
1
PATIENT CARE HANDOFF IN THE ICU 118
2.1.4.
IF
untoward
patient
event
and
ICU
bed
un
anticipated
(e.g.
vasopressor
medications
to
maintain
blood
adequate
blood
pressure
intraoperatively
or
requires
mechanical
ventilation
postoperatively),
THEN
0
D
2.1.4.1.
Talk
with
surgeons
regarding
concerns
(ABC)
1
1
1
0
D
2.1.4.2.
Call
ICU
coordinator
to
arrange
for
bed
and
confirm
availability
of
necessary
equipment
such
as
ventilator
(ABC)
1
1
1
0
D
2.1.5.
IF
patient
required
transfusion
of
blood
products,
THEN
assess
patient’s
response
to
blood
therapy
(B)
0
1
0
0
A
2.2.
Preemptively
treat
any
hemodynamic
issues
that
arise
(C)
0
0
1
0
A
2.3.
Monitor
progress
of
surgery
and
stay
in
communication
with
surgeon
(ABC)
1
1
1
0
2.3.1.
IF
surgeons
have
concerns,
THEN
D
2.3.1.1.
Assess
anything
unusual
about
the
case
(C)
0
0
1
0
D
2.3.1.2.
Assess
for
specific
postoperative
needs
after
surgery
(C)
0
0
1
0
A
3.
Prepare
equipment,
medications,
personnel,
and
the
patient
for
transfer
(ABC)
1
1
1
0
28
26
3.1.
Confirm
that
the
transport
monitor
is:
A
3.1.1.
Available
(ABC)
1
1
1
0
A
3.1.2.
Properly
set
up
(B)
0
1
0
0
A
3.1.3.
Equipped
with
pulse
oximetry
(AB)
1
1
0
0
A
3.1.4.
Equipped
with
plethysmography
(B)
0
1
0
0
A
3.1.5.
Equipped
with
EKG
(ABC)
1
1
1
0
A
3.1.6.
Equipped
with
blood
pressure
monitor
(ABC)
1
1
1
0
A
3.2.
Confirm
that
all
cables,
equipment,
and
tubing
reach
and
do
not
become
dislodged
during
the
transfer
from
the
OR
table
to
the
ICU
bed
(B).
0
1
0
0
D
3.2.1.
IF
patient
has
a
urinary
catheter,
drains,
or
chest
tubes,
THEN
confirm
items
are
positioned
such
that
they
do
not
get
dislodged
(B)
0
1
0
0
D
3.2.2.
IF
the
ICU
headrest
is
in
the
way,
THEN
remove
it
during
transfer
of
patient
from
OR
table
to
ICU
bed
and
replace
before
transfer
to
the
ICU
(B).
0
1
0
0
3.3.
Prepare
airway
equipment
for
transfer
including:
A
3.3.1.
An
oral
airway
(ABC)
1
1
0
0
A
3.3.2.
ET
tube
(AB)
1
1
0
0
A
3.3.3.
Laryngoscope
handle
(AB)
1
1
0
0
PATIENT CARE HANDOFF IN THE ICU 119
A
3.3.4.
Laryngoscope
blade
(AB)
1
1
0
0
A
3.3.5.
Nasal
trumpet
(D).
0
0
0
1
D
3.3.6.
IF
patient’s
airway
history
in
unknown
and/or
the
patient’s
airway
looks
difficult,
THEN
bring
additional
airway
devices
such
as
laryngeal
mask
airway
(LMA)
(B).
0
1
0
0
A
3.4.
Confirm
presence
of
oxygen
cylinder
(AB)
that
is
≥
50%
full
and
in
a
secure
location
on
or
under
ICU
bed
(B)
1
1
0
0
D
3.4.1.1.
IF
oxygen
cylinder
that
is
≤
50%
full,
THEN
request
full
oxygen
cylinder
prior
to
transport
(B)
0
1
0
0
A
3.5.
Confirm
presence
and
proper
functioning
of
Ambu
bag
and
mask
(AB)
1
1
0
0
D
3.5.1.
IF
Ambu
bag
equipped
with
PEEP
valve,
THEN
confirm
setting
(B)
0
1
0
0
A
3.6.
Confirm
the
OR
nurse
has
called
the
ICU
to
give
phone
report
to
provide
report
regarding
ventilator
settings,
IV
fluids,
medications,
and
any
specific
concerns
(ABC)
1
1
1
0
D
3.6.1.
IF
specific
anesthesia-‐related
information
is
needed
and/or
information
goes
beyond
ability
or
knowledge
of
OR
nurse,
THEN
anesthesia
to
participate
in
the
phone
report
to
the
ICU
nurse
(B).
0
1
0
0
D
3.6.2.
IF
specific
anesthesia-‐related
patient
needs
and/or
equipment
are
needed,
THEN
confirm
that
information
is
provided
to
the
ICU
nurse
(C).
0
0
1
0
D
3.6.3.
IF
patient
requires
ventilator
support,
THEN
confirm
RT
is
aware
and
will
be
respiratory
therapist
at
the
bedside
when
patient
arrives
(A)
1
0
0
0
A
3.7.
Prepare
medications
for
transfer
including
pain
medications,
muscle
relaxants,
sedation
agents,
and
emergency
medications
(AB).
1
1
0
0
3.7.1.
IF
patient
requires
additional
muscle
relaxation,
THEN
D
3.7.1.1.
Provide
amount
adequate
to
last
throughout
transfer
process
(B).
0
1
0
0
D
3.7.1.2.
Confirm
adequate
sedation
is
provided
throughout
the
duration
of
the
muscle
relaxation
(B)
0
1
0
0
D
3.7.2.
IF
patient
requires
continuous
sedation,
THEN
obtain
and
prepare
IV
medication
(A)
1
0
0
0
D
3.7.3.
IF
patient
requires
continuous
infusion
of
vasoactive
medications,
THEN
obtain
and
prepare
IV
pumps
(AB).
1
1
0
0
D
3.7.4.
IF
movement
will
cause
patient
pain,
THEN
give
analgesic
agents
prior
to
moving
the
0
1
0
0
PATIENT CARE HANDOFF IN THE ICU 120
patient
(B)
A
3.8.
Maintain
visualization
of
the
patient
and
attached
equipment
by
removing
redundant
sheets
and
linens
(AB).
1
1
0
0
3.8.1.
IF
patient
is
hypothermic,
THEN
D
2.1.1.1.
Keep
patient
covered
(AB)
1
1
0
0
D
2.1.1.2.
Consider
maintain
warming
devices
during
transport
(A).
1
0
0
0
A
3.9.
Confirm
patient
is
presentable
for
transfer:
all
residual
blood
on
patient’s
skin
is
removed,
patient
is
covered
with
clean
sheets,
eye
tape
removed,
and
patient
identifiers
covered
(B)
0
1
0
0
A
3.10.
Confirm
that
there
is
a
minimum
of
four
people
(positioned
at
head,
feet,
and
either
side)
to
transfer
the
patient
from
the
OR
table
to
the
ICU
bed
(B)
0
1
0
0
D
3.10.1.
IF
the
patient
is
very
heavy,
enlist
help
of
additional
personnel
to
assist
with
transfer
(B).
0
1
0
0
D
3.10.2.
IF
additional
equipment
or
devices
are
attached
to
the
patient
and
need
to
be
transferred,
enlist
help
of
additional
personnel
to
assist
with
transfer
(B).
0
1
0
0
A
3.11.
Confirm
both
the
OR
table
and
ICU
beds
are
locked
(B).
0
1
0
0
A
3.12.
The
anesthesia
provider
maintains
control
of
the
patient’s
head,
neck,
and
shoulders
for
neutral
alignment
throughout
the
transfer
process
(B).
0
1
0
0
D
3.12.1.
IF
surgical
specialty
equipment
is
attached
to
patient
and
needs
to
be
transferred
(e.g.
external
fixation
device,
cervical
stabilization
device),
THEN
consult
and
coordinate
with
surgeon
to
confirm
responsibility
for
the
physical
transfer
of
that
device
(B)
0
1
0
0
D
3.12.2.
IF
the
patient
can
tolerate
being
disconnected
from
the
oxygen
source
for
<90
seconds,
THEN
disconnect
patient
from
the
breathing
circuit
just
before
patient
is
moved
from
the
OR
table
to
the
ICU
bed
and
reconnect
the
breathing
circuit
immediately
after
(B)
0
1
0
0
D
3.12.3.
IF
the
patient
cannot
tolerate
being
disconnected
from
the
oxygen
source
for
<90
seconds
(i.e.
02
sat
drops
below
90%),
THEN
do
not
disconnect
patient
from
the
breathing
circuit
and
transfer
with
oxygen
connected
(B).
0
1
0
0
A
3.13.
Transfer
of
the
patient
from
the
OR
table
to
the
ICU
bed
is
coordinated
by
the
anesthesia
provider,
which
includes
the
3-‐2-‐1
or
a
1-‐2-‐3
countdown
(B).
0
1
0
0
PATIENT CARE HANDOFF IN THE ICU 121
A
3.14.
Confirm
team
members
(OR
nurses,
techs,
surgeons,
are
ready
to
move
the
patient
(BC)
0
1
1
0
A
3.15.
After
patient
is
transferred
onto
the
ICU
bed,
disconnect
anesthesia
machine
monitors
and
attach
transport
monitors
(AB).
1
1
0
0
A
3.16.
Confirm
the
transport
monitor
is
easily
visible
to
the
anesthesia
provider
while
taking
caution
not
to
let
the
monitor
touch
the
patient
(AB)
1
1
0
0
D
3.16.1.
IF
the
volume
of
the
pulse
oximeter
is
too
low,
THEN
turn
up
to
(A)
1
0
0
0
A
3.17.
Evaluate
stability
of
the
patient
for
transport
(AB)
1
1
0
0
D
3.17.1.
IF
the
patient
is
optimized
for
transport,
THEN
proceed
to
ICU
(AB)
1
1
0
0
D
3.17.2.
IF
the
patient
is
critically
unstable,
THEN
determine
cause
and
optimize
patient
before
leaving
the
operating
room
to
optimize
patient
safety
while
in
transit
(AB).
1
1
0
0
D
3.17.3.
IF
transport
monitor
is
displaying
abnormal
waveforms,
THEN
trouble
shoot
before
leaving
the
operating
room
(B).
0
1
0
0
D
3.17.4.
IF
concerned
about
patient
going
into
cardiac
arrest,
THEN
place
external
pads
and
bring
defibrillator
or
external
pacer
(A).
1
0
0
0
A
3.18.
Confirm
availability
of
at
least
two
licensed
providers
for
transport:
the
anesthesia
provider
and
the
operating
room
nurse
(AB)
1
1
0
0
D
3.18.1.
IF
additional
equipment
needed,
THEN
recruit
additional
personnel
to
assist
with
transfer
of
equipment
(AB)
1
1
0
0
A
4.
Conduct
patient
transport
from
the
operating
room
to
the
ICU
(ABC):
1
1
1
0
11
24
A
4.1.
Confirm
someone
is
dedicated
to
providing
manual
ventilation
to
the
patient
appropriate
rate,
volume,
and
PEEP.
Disconnect
patient
from
anesthesia
machine/mechanical
ventilation
and
begin
manual
ventilation
via
Ambu
bag
and
100%
oxygen
(AB)
1
1
0
0
A
4.2.
Assess
response
to
manual
ventilation
including
saturation,
chest
rise,
ETCO2,
and
need
for
sedation
(AB)
1
1
0
0
D
4.2.1.
IF
patient
cannot
tolerate
ventilation
via
Ambu
bag,
THEN
resume
mechanical
ventilation
and
re-‐assess
pulmonary
status
(A).
1
0
0
0
D
4.2.2.
IF
patient’s
ventilation
status
changes,
THEN
adjust
accordingly
(B)
0
1
0
0
PATIENT CARE HANDOFF IN THE ICU 122
D
4.2.3.
IF
patient
continues
to
shows
signs
of
strain
due
to
change
in
ventilation,
THEN
give
sedation
(B)
0
1
0
0
A
4.3.
Confirm
someone
is
dedicated
to
guiding
ICU
bed
(B).
0
1
0
0
4.3.1.
IF
transferring
patient
through
public
hallway,
THEN
D
4.3.1.1.
Confirm
the
hallway
is
clear
of
obstructions
(B).
0
1
0
0
D
4.3.1.2.
Make
sure
bystanders
are
aware
the
bed
is
approaching
(B).
0
1
0
0
D
4.3.1.3.
Assure
family
members
they
will
receive
an
update
as
soon
as
patient
is
situated
and
ICU
report
has
been
given
(B).
0
1
0
0
A
4.4.
Monitor
patient
throughout
transport
from
OR
to
ICU
(A)
1
0
0
0
4.4.1.
IF
patient
becomes
critically
unstable
during
the
actual
transport,
THEN
D
4.4.1.1.
Determine
if
patient
condition
can
be
managed
in
the
hallway
(AB)
1
1
0
0
D
4.4.1.2.
Determine
distance
from
ICU
or
operating
room
and
decide
whether
it
is
safer
to
proceed
to
the
ICU
or
go
back
to
the
operating
room
(AB).
1
1
0
0
A
4.5.
Assist
with
positioning
bed
in
the
ICU
room
(B)
0
1
0
0
A
4.6.
Facilitate
transfer
process
to
optimize
patient
care
and
build
cooperation
for
subsequent
patient
transfers
(BC).
0
1
1
0
A
4.7.
Assess
ICU
environment
(ABC)
1
1
1
0
D
4.7.1.
IF
unknown
to
the
ICU
team,
THEN
introduce
self
(A)
1
0
0
0
D
4.7.2.
IF
ICU
appears
busy,
THEN
prepare
to
facilitate
more
of
the
physical
transfer
(ABC)
1
1
1
0
D
4.7.3.
IF
ventilator
not
present,
THEN
call
respiratory
therapy
(RT)
and
continue
with
manual
ventilation
(AB)
1
1
0
0
A
4.8.
Assess
stability
of
patient
(AB)
1
1
0
0
4.8.1.
IF
patient
critically
unstable
THEN:
D
4.8.1.1.
Prioritize
information
so
that
immediate
patient
needs
are
met
(AB)
1
1
0
0
D
4.8.1.2.
Assist
with
hooking
up
monitors
and
obtain
vital
signs
(AB)
1
1
0
0
D
4.8.1.3.
Engage
the
surgeon
and
other
members
of
the
ICU
team
such
as
the
ICU
manager
and
ICU
attending
(AC).
1
0
1
0
D
4.8.1.4.
Confirm
respiratory
therapist
is
present
to
receive
report
as
part
of
the
ICU
team
(AB)
1
1
0
0
PATIENT CARE HANDOFF IN THE ICU 123
D
4.8.1.4.1.
IF
ventilator
or
respiratory
therapy
(RT)
not
present,
THEN
call
RT
and
continue
with
manual
ventilation
(A)
1
0
0
0
D
4.8.2.
IF
ICU
team
needs
to
turn
patient
on
side
for
initial
physical
assessment,
THEN
anesthesia
provider
must
remain
vigilant
for
patient’s
pain,
airway,
and
safety
issues
while
in
the
process
of
relinquishing
care
(B).
0
1
0
0
A
4.9.
Assess
knowledge,
experience,
and
readiness
of
ICU
nurse
to
receive
report
on
the
patient
(BC).
0
1
1
0
D
4.9.1.
If
ICU
nurse
receiving
report
is
the
same
person
who
took
report
over
the
phone,
THEN
modify
report
as
needed
(B).
0
1
0
0
D
4.9.2.
IF
patient
is
returning
to
the
same
ICU
provider,
THEN
modify
report
as
needed
(B).
0
1
0
0
D
4.9.3.
IF
ICU
nurse
does
not
appear
ready,
THEN
assess
why
using
senses
and
asking
questions
(B).
0
1
0
0
D
4.9.4.
IF
ICU
nurse
appears
novice,
THEN
provide
assistance
and
obtain
additional
ICU
support
as
needed
(BC).
0
1
1
0
A
4.10.
Assess
engagement
of
ICU
nurse
(ABC)
1
1
1
0
D
4.10.1.
IF
excessive
talking,
THEN
ask
for
their
attention
(ABC)
1
1
1
0
D
4.10.2.
IF
excessive
noise,
THEN
create
quiet
reporting
environment
(AB)
1
1
0
0
D
4.10.3.
IF
ICU
nurse
not
engaging,
THEN
give
verbal
prompt
“Can
I
give
you
report
now?”
(ABC).
1
1
1
0
R
There
tends
to
be
multiple
people
in
the
ICU
room
trying
to
help
but
this
can
lead
to
more
unnecessary
chatter,
unnecessary
conversation,
and
talking.
You
want
to
make
sure
the
person
you're
talking
to
is
actually
hearing
what
you're
saying
and
not
caught
up
in
another
conversation
with
somebody
(A)
R
It
is
important
to
remain
professional,
respectful,
and
maintain
open
communication
with
ICU
nurse,
ICU
physician,
and
surgeon
to
facilitate
transfer
of
care
and
optimize
patient
safety
(C)
A
5.
Conduct
patient
handoff
report
(ABC):
1
1
1
0
19
24
A
5.1.
Refer
to
mnemonic
or
checklist
to
avoid
forgetting
information
(A)
1
0
0
0
D
5.1.1.
IF
hospital
or
institution
uses
a
specific
mnemonic
or
checklist
(e.g.
SBAR),
THEN
use
the
same
one
to
maintain
consistency
(A)
1
0
0
0
A
5.2.
Refer
to
ICU
protocol
for
admitting
a
patient
(C)
0
0
1
0
PATIENT CARE HANDOFF IN THE ICU 124
D
5.2.1.
IF
the
ICU
uses
a
specific
transfer
of
care
record,
THEN
use
the
same
one
to
maintain
consistency
(C)
0
0
1
0
A
5.3.
Provide
patient
identification
including
two
patient
identifiers
(AB)
1
1
0
0
A
5.4.
Include
surgical
procedure
and
indication
(ABC)
1
1
1
0
A
5.5.
Provide
patient’s
response
to
surgery
and
any
unexpected
events
(BC)
0
1
1
0
A
5.6.
Describe
anesthetic
management
including
medications
given,
current
drips,
airway
management
(BC).
0
1
1
0
D
5.6.1.
IF
patient
given
antibiotics,
THEN
indicate
what
was
given
and
when
(D)
0
0
0
1
D
5.6.2.
IF
patient
on
scheduled
medications,
THEN
indicate
when
medication
was
given
and
when
next
dose
is
due
(B)
0
1
0
0
D
5.6.3.
IF
patient
given
neuromuscular
blockers,
THEN
indicate
last
dose
(C)
0
0
1
0
D
5.6.4.
IF
patient’s
analgesic
requirement
were
excessive
intraoperatively,
THEN
consider
continuous
infusion
of
analgesics
in
the
ICU
(A)
1
0
0
0
A
5.7.
Provide
pertinent
past
surgical
history
and
past
medical
history
with
a
focus
on
the
patient’s
cardiac,
pulmonary
status,
other
pertinent
comorbidities,
and
systems
most
affected
or
involved
by
existing
or
surgical
issues(
ABC)
;
1
1
1
0
D
5.7.1.
IF
patient
remains
intubated,
THEN
include
recommended
ventilator
settings
(ABC)
1
1
1
0
D
5.7.2.
IF
patient
was
a
difficult
airway
and/or
at
risk
for
airway
edema,
THEN
confirm
ICU
nurse
and
intensivist
aware.
(C)
0
0
1
0
D
5.7.3.
IF
patient
had
failed
extubation
attempt
immediate
postoperatively,
THEN
confirm
RT
and
ICU
team
are
aware
(A)
1
0
0
0
5.7.4.
IF
patient
is
hypotensive,
THEN
D
5.7.4.1.
Determine
need
for
fluid
or
blood
if
patient
is
bleeding
(C)
0
0
1
0
D
5.7.4.2.
Consider
vasoactive
agents
(D)
0
0
0
1
D
5.7.4.3.
Hold
epidural
activation
until
intravascular
volume
is
replaced
and
blood
pressure
is
stable
(C).
0
0
1
0
5.7.5.
IF
patient
on
beta-‐blockers,
THEN
D
5.7.5.1.
Continue
medications
throughout
perioperative
period
per
Surgical
Care
Improvement
Project
(B).
0
1
0
0
PATIENT CARE HANDOFF IN THE ICU 125
D
5.7.6.
IF
patient
has
spine
injury,
THEN
report
that
prior
to
any
patient
movement
in
the
ICU
(B)
0
1
0
0
A
5.8.
Report
on
lab
work
including
hemoglobin/hematocrit
and
blood
gas
(ABC).
1
1
1
0
D
5.8.1.
IF
patient
was
hypo/hyperglycemic,
THEN
report
any
treatment
and
latest
blood
glucose
levels
and
anticipated
or
recommended
needs
(A).
1
0
0
0
A
5.9.
Identify
IV
access
including
invasive
lines
(BC)
0
1
1
0
A
5.9.1.
Confirm
chest
x-‐ray
has
been
ordered
to
confirm
CVP
placement
(D)
0
0
0
1
A
5.10.
Identify
intake
and
outputs
including
estimated
blood
loss,
urine
output,
and
fluids
given
(ABC).
1
1
1
0
D
2.1.1.
IF
patient
required
transfusion
of
blood
products,
THEN
report
what
and
how
much
was
transfused,
and
patient’s
response
to
transfusion
(B)
0
1
0
0
A
5.12.
Recommend
interventions
based
on
patient’s
preoperative
history,
intraoperative
course,
current
condition,
and
specific
concerns
(ABC)
1
1
1
0
A
5.13.
Include
post-‐operative
pain
management
plan
and
post-‐operative
nausea-‐
vomiting
plan
(C)
0
0
1
0
5.13.1.
IF
specific
pain
management
control
issues
are
addressed,
THEN
D
5.13.1.1.
Discuss
with
surgeon
and
ICU
team
(C)
0
0
1
0
D
5.13.1.2.
Provide
recommendations
(C)
0
0
1
0
5.13.2.
IF
patient
at
risk
for
post-‐operative
nausea
and
vomiting
(PONV),
THEN
D
5.13.2.1.
Treat
accordingly
(C)
0
0
1
0
D
5.13.2.2.
Provide
recommendations
©
0
0
1
0
A
5.14.
Obtain
initial
set
of
vital
signs
once
patient
has
been
transferred
to
ICU
monitors
for
documentation
of
immediate
postoperative
vital
signs
(C)
0
0
1
0
A
5.15.
Complete
postoperative
patient
handoff
to
the
ICU
team
(nurse,
attending,
fellow,
resident,
and
nurse
practitioner)
(ABC)
1
1
1
0
D
5.15.1.
IF
patient
remains
critically
unstable,
THEN
confirm
with
ICU
team
that
they
do
not
need
additional
assistance
(B)
0
1
0
0
D
5.15.2.
IF
ICU
team
is
not
prepared
to
assume
care
of
the
patient,
THEN
maintain
responsibility
for
the
patient
until
a
proper
transfer
has
occurred
(C)
0
0
1
0
D
5.15.3.
IF
ICU
attending,
fellow,
or
resident
is
not
present
at
time
of
patient
handoff,
THEN
communicate
either
by
phone
or,
if
possible,
in
person
(A)
1
0
0
0
PATIENT CARE HANDOFF IN THE ICU 126
A
5.16.
Invite
and
address
questions
the
ICU
nurse
may
have
and
assess
for
understanding
(ABC),
and
obtain
verbal
confirmation
that
the
ICU
team
has
accepted
care
of
the
patient
(C)
0
0
1
0
D
5.16.1.
IF
ICU
team
does
not
have
questions,
THEN
prompt
the
team
to
ask
(A)
1
0
0
0
R
This
encourages
the
team
to
think
of
things
that
maybe
they
want
to
ask
but
they
forgot
or
if
they're
busy
doing
something.
It
also
signals
the
completion
of
the
transfer
of
care
and
is
a
form
of
closed
loop
communication..
A
5.17.
Remove
any
personal
protective
equipment
(PPE)
and
hand
wash
(B)
0
1
0
0
A
5.18.
Complete
anesthesia
documentation
and
return
transport
monitor,
medications,
and
airway
supply
back
to
anesthesia
workroom.
(B)
0
1
0
0
NOTE:
It
is
important
to
maintain
focus
on
patient
care
with
providing
verbal
report,
answering
questions
and
assessing
understanding
by
the
ICU
team,
and
documentation
of
patient
care
and
report
(C).
0
Abstract (if available)
Abstract
The purpose of this study was to utilize Cognitive Task Analysis (CTA) methods to elicit knowledge from expert critical care anesthesia providers (anesthesiologists and nurse anesthetists) and define the knowledge, skills, procedures, tools and senses used to conduct a comprehensive patient care handoff from the operating room to the intensive care unit. This study also sought to identify the percentage of action and decision steps, when compared to a gold standard that expert critical care anesthesia providers omit when they describe how they conduct this high stakes patient handoff. Three subject matter experts (SME) participated in the semi-structured interviews and the fourth SME was used to verify the preliminary gold standard protocol, thereby forming the gold standard protocol (GSP). The resulting gold standard protocol was analyzed for knowledge omissions in the form of action and decision steps, which were quantified. Results indicate that, on average, the experts omitted 50.41% of the action and decision steps when describing how to perform a patient handoff from the operating room to the intensive care unit. 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—there is a paucity of literature that identifies the essential elements of a transfer of patient care from anesthesia providers in the operating room to the intensive care unit members. In addition, recent efforts at handoff standardizations have provided minimal evidence in process improvement. The results of this study are timely and it is hoped that the results of this study not only add to the growing library of CTA-based research but that the gold standard protocol generated in this study becomes the basis for a multidisciplinary training program to improve communication in the handoff process.
Linked assets
University of Southern California Dissertations and Theses
Conceptually similar
PDF
The use of cognitive task analysis to capture expert patient care handoff to the post anesthesia care unit
PDF
Using cognitive task analysis to capture how expert anesthesia providers conduct an intraoperative patient care handoff
PDF
Using cognitive task analysis to capture palliative care physicians' expertise in in-patient shared decision making
PDF
Using incremental cognitive task analysis to capture expert instruction in expository writing for secondary students
PDF
The use of cognitive task analysis for identifying the critical information omitted when experts describe surgical procedures
PDF
The use of cognitive task analysis to capture exterptise for tracheal extubation training in anesthesiology
PDF
Using cognitive task analysis to capture expert instruction in division of fractions
PDF
Using individual cognitive task analysis to capture expert writing instruction in expository writing for secondary students
PDF
Using cognitive task analysis to capture how expert principals conduct informal classroom walk-throughs and provide feedback to teachers
PDF
Using cognitive task analysis for capturing expert instruction of food safety training for novice employees
PDF
Cognitive task analysis for instruction in single-injection ultrasound-guided regional anesthesia
PDF
Towards a taxonomy of cognitive task analysis methods: a search for cognition and task analysis interactions
PDF
The use of cognitive task analysis to determine surgical expert's awareness of critical decisions required for a surgical procedure
PDF
The use of cognitive task analysis to capture expert instruction in teaching mathematics
PDF
The effect of cognitive task analysis based instruction on surgical skills expertise and performance
PDF
Identifying the point of diminishing marginal utility for cognitive task analysis surgical subject matter expert interviews
PDF
Using cognitive task analysis to determine the percentage of critical information that experts omit when describing a surgical procedure
PDF
Employing cognitive task analysis supported instruction to increase medical student and surgical resident performance and self-efficacy
PDF
Using cognitive task analysis to capture expert reading instruction in informational text for students with mild to moderate learning disabilities
PDF
The use of cognitive task analysis to investigate how many experts must be interviewed to acquire the critical information needed to perform a central venous catheter placement
Asset Metadata
Creator
Cole, Kari Mai
(author)
Core Title
The use of cognitive task analysis for the postanesthesia patient care handoff in the intensive care unit
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Education (Leadership)
Publication Date
04/08/2015
Defense Date
02/17/2015
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
cognitive task analysis,CTA,OAI-PMH Harvest,patient care handoff,postanesthesia
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
kcole@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c3-542765
Unique identifier
UC11298611
Identifier
etd-ColeKariMa-3251.pdf (filename),usctheses-c3-542765 (legacy record id)
Legacy Identifier
etd-ColeKariMa-3251.pdf
Dmrecord
542765
Document Type
Dissertation
Format
application/pdf (imt)
Rights
Cole, Kari Mai
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
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...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Tags
cognitive task analysis
CTA
patient care handoff
postanesthesia