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The use of cognitive task analysis to capture expert patient care handoff to the post anesthesia care unit
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The use of cognitive task analysis to capture expert patient care handoff to the post anesthesia care unit
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Running head: PATIENT CARE HANDOFF TO THE POST ANESTHESIA CARE UNIT 1
THE USE OF COGNITIVE TASK ANALYSIS TO CAPTURE EXPERT PATIENT CARE
HANDOFF TO THE POST ANESTHESIA CARE UNIT
by
Judith Anne Franco
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 Judith Anne Franco
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 2
Dedication
To all learners who continue to strive for knowledge despite obstacles,
and for my parents
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 3
Acknowledgements
It is my honor to acknowledge the individuals who supported this project. First I would
like to thank Dr. Kenneth Yates for his unyielding strength and dedication to the study of
cognitive task analysis. It was with his guidance and expert knowledge that this endeavor
resulted in success. It is my pleasure to express gratitude to my dissertation committee members
Dr. Maura Sullivan and Dr. Karyn Embrey, who answered inquiries, asked insightful questions,
provided guidance, and valuable feedback on this dissertation. I am indebted to my friends and
colleagues from the Program of Nurse Anesthesia, Dr. Michele Gold and Dr. Terrie Norris, who
have encouraged and supported me along this journey. Further, I would like to express my
gratitude to my sister Jacqueline O’Connor, and colleagues Jenilyn Casalme, Sarah Giron, and
Crystal Trinooson. Their support through scheduling and proofreads as well as their patience
facilitated completion of this project.
To my cohort, I wish you further success as you forge ahead. To Megan McGuinness,
Christine Gayle Corpus, Kari Cole, Charlotte Ann Garcia, Chad Hammitt, Milo Jury, Deidre
Larson, Nicholas Lim, and Douglas Weiland. It is my pleasure to have you as colleagues.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 4
Table of Contents
Dedication 2
Acknowledgements 3
List of Tables 6
List of Figures 7
List of Abbreviations 8
List of Domain Abbreviations 9
Abstract 10
Chapter One: Overview Of The Study 11
Statement of the Problem 11
Purpose of the Study 13
Research Questions 13
Methodology of the Study 14
Definition of Terms 14
Organization of the Study 16
Chapter Two: Literature Review 17
Defining Patient Handoff 17
Practitioner Involvement 18
Patient Handoff Initiatives 20
Barriers to Effective Patient Handoffs 21
Patient Handoff to the Post Anesthesia Care Unit 22
Patient Handoff Omissions 23
Patient Handoff Tools 25
Importance of Communication 26
Current Training of Patient Handoff to the Post Anesthesia Care Unit 27
Summary 28
Knowledge Types 29
Declarative Knowledge 29
Procedural Knowledge 30
Automaticity 31
Influence of Information Processing Model (IPM) 32
Expertise 33
Characteristics of Experts 34
Consequences and Omissions of Expertise 35
Expertise in Anesthesia 37
Consequences of Expertise in Anesthesia 37
Sharing Expertise in Training 38
Cognitive Task Analysis 39
Definition of CTA 39
CTA History 40
CTA Methodology 41
Effectiveness of CTA for Capturing Expert Knowledge 43
Effectiveness of CTA Based Training 44
Effectiveness of CTA Based Training in Medicine 45
Additional Benefits of CTA 47
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 5
Meta-Analyses in CTA 47
Summary 48
Conclusion 48
Chapter Three: Methods 49
Participants 50
Data Collection 51
Data collection for Question 1 51
Summary 57
Data Collection for Question 2 57
Spreadsheet Analysis 57
Chapter Four: Results 59
Overview of the Results 59
Research Questions 59
Question 1 59
Question 2 66
Chapter Five: Discussion 69
Overview of the Study 69
Process of Conducting CTA 69
Selection of Experts 69
Collection of Data 71
Discussion of Findings 73
Research Question 1 73
Question 2 78
Limitations 80
Conformational Bias 80
Internal Validity 81
External Validity 81
Implications 81
Anesthesia Practice 81
Education and Training 82
Conclusion 82
References 84
Appendix A: Interview Protocol 100
Appendix B: Inter-Rater Reliability Code Sheet for SME A 103
Appendix C: Job Aid for Developing a Gold Standard Protocol 104
Appendix D: SME A Individual Flowchart 106
Appendix E: Gold Standard Protocol 116
Appendix F: Spreadsheet Analysis 126
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 6
List of Tables
Table 1: Cumulative Action and Decision Steps for Each SME in the Initial
Individualized Protocol 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: Total Action and Decision Steps, or Expert Knowledge, Omissions by SME
when Compared to the Gold Standard Protocol 67
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 7
List of Figures
Figure 1: Process for Generating the Gold Standard Protocol 57
Figure 2: Progression of a Decision Step 61
Figure 3: Number of Action Steps, Decision Steps, and Action and Decision Steps
Contributed from SME A, B, and C 64
Figure 4: Knowledge Omissions: Action steps, Decision Steps, and Combined Action
and Decision Steps 67
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 8
List of Abbreviations
CDM: Critical Decision Method
CPP: Concepts, Processes, and Principles
CTA: Cognitive Task Analysis
GSP: Gold Standard Protocol
IRB: Institutional Review Board
PARI: Precursors, Action, Result, and Interpretation
PGSP: Preliminary Gold Standard Protocol
SME: Subject Matter Expert
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 9
List of Domain Abbreviations
ACGME: Accredited Council for Graduate Medical Education
CRNA: Certified Registered Nurse Anesthetist
DO: Doctor of Osteopathy
IOM: Institute of Medicine
MD: Medical Doctor
OC: Open Cricothyrotomy
PACU: Post Anesthesia Care Unit
PHR: Patient Handoff Report
WHO: World Health Organization
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 10
Abstract
The purpose of this study was to use cognitive task analysis (CTA) methods to elicit knowledge
from expert anesthesia providers in describing a patient handoff report (PHR) from the operating
room to the Post Anesthesia Care Unit (PACU). Using information gained from four subject
matter experts (SME) the results were synthesized and aggregated into a gold standard protocol
(GSP). A fourth SME reviewed the results for completeness and accuracy. The results found that
when compared to the GSP the individual SMEs in this study on average omitted 42.31% of the
total action and decision steps. These results only partially support research that indicates that
experts may omit up to 70% of critical information when providing instruction to a novice.
Moreover, the experts demonstrated full alignment on only 23.97% of the action decision steps
suggesting that either multiple experts are necessary to capture complete action and decision
steps representing expertise, the interview interrogation was not as thorough as expected, or the
scope of anesthesia is so broad that a more focused approach is warranted. The findings suggest
that CTA techniques may be used to capture expertise for training novice anesthesia providers in
the task of performing a PHR to the PACU.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 11
CHAPTER ONE: OVERVIEW OF THE STUDY
Statement of the Problem
The transfer of care between healthcare providers is commonly referred to as a patient
handoff report (PHR). The purpose of a PHR is to transfer patient care information efficiently
and effectively enhancing patient continuity of care, prohibiting patient injury or harm, and
ensuring safety (Alvarado et al., 2006). The PHR is an essential element of care delivered to a
patient (Dowdling, 2001). Studies have demonstrated a disparity in communication between
health care providers during the transfer phase of patient care (Greenberg et al., 2007; Segall et
al., 2012). Such gaps in information sharing between heath care professionals can potentiate
poor patient outcomes (Kitch et al., 2008). The Joint Commission (2008) reports that 80% of
medical errors are the result of ineffective communication leading to sentinel events. These
events result in increased hospital stay, acquired costs, poor outcomes, and in an increase in
mortality and morbidity (Haynes et al., 2009). The Joint Commission therefore mandates that all
hospitals develop and institute standardized protocols for handoff delivery. Current handoff
tools range from mnemonics to electronic medical records and these tools provide some
guidance for health care practitioners to communicate the transfer of information succinctly
(Wheeler, 2014). However, despite these guidelines, patient handoffs remain inconsistent,
subjective, and the omission of factual and pertinent information continues to result in patient
harm (Kitch et al., 2008).
The PHR occurs numerous times and between multiple practitioners within the
perioperative environment (Gogan, Baxter, Boss, & Chircu, 2013; Maughan, Lei, & Cydulka,
2011). The transfer of care to an anesthesia provider begins in the pre-operative holding area,
continues throughout the surgical arena, and terminates in either the postoperative anesthesia
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 12
care unit (PACU) or the intensive care unit. Patient handoff occurs between anesthesia providers
(anesthesia medical doctor (MD), anesthesia doctor of osteopathy (DO), anesthesia resident, or
certified registered nurse anesthetists [CRNA]) during breaks or at the change of shift
(Riesenberg, Leitzsch, & Cunningham, 2010). Patient handoff report also takes place between
non-comparable practitioners when the anesthesia provider transfers the care of the patient to the
PACU nurse. In this instance, the PACU nurse assumes care of the postoperative patient. With
every transfer of care to the PACU the anesthesia provider is responsible for the delivery of
comprehensive patient information.
Historically, education and training in PHR delivery has transpired in an informal and
less extensive fashion. In medicine, the see one, do one, teach one (Halstead, 1904) has
traditionally guided instruction. As a result, reporting practices are seldom the same among
providers and potentially the dissimilarity in reporting practices leaves room for error. The
variation in practitioner experience levels, the multiple training sites, and the minimal guidance
during handoff training contribute to incomplete reporting practices (Nasca, Day, & Amis,
2010). Further, instruction via either a novice or expert practitioner may result in inconsistent
teaching practices leading to medication error or patient injury (Joint Commission, 2008;
Wohlauer et al., 2012). Last, research illustrates that experts may omit up to 70% of critical
information during instruction that is necessary for novice learners (Feldon & Clark, 2006).
Exploration of the key steps and elements in a PACU handoff report is essential for the
development of a standardized protocol that may eliminate deficits in reporting practices. The
use of cognitive task analysis (CTA) to capture expertise in postoperative patient handoff could
guide anesthesia practitioners in streamlining patient reporting, in enhancing critical thinking,
and in ensuring concise and comprehensive patient reporting practices.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 13
Purpose of the Study
A cognitive task analysis has not been conducted specifically for patient handoff
practices from the operating room to the post anesthesia care unit (PACU). Research however
has focused on elucidating factors that affect job performance in anesthesia that may result in
fewer errors and improved outcomes. Weinger and Slagel (2002) used task analysis techniques to
study decision-making in the anesthesia clinical area. Although the research evaluated how
clinical systems and processes work, the study also elicited knowledge through eight anesthesia
providers via cognitive task analysis. The information was intended to be used for training and to
improve performance.
The purpose of the current study was to utilize CTA methods to elicit knowledge from
expert anesthesia providers in performing a PHR from the operating room to the PACU. A CTA
was performed to capture the knowledge and skill in patient handoff delivery in an attempt to
define the key elements for a standardized tool. Further, the development of a standardized tool
to guide anesthesia healthcare providers in the delivery of a comprehensive PHR will lessen the
omissions that currently plague reporting practices. The result of this research will add to the
CTA based education by providing a framework for patient handoff reporting practices in the
postoperative arena.
Research Questions
1. What are the action and decision steps that expert anesthesia providers recall when they
describe how they conduct a patient handoff report to the PACU?
2. What percentage of action and/or decision steps, when compared to a gold standard, do
expert anesthesia providers omit when they describe how to perform a patient handoff
report?
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 14
Methodology of the Study
A mixed methods study was conducted. Anesthesia practitioners who perform at a high
level of expertise served as subject matter experts (SME) and were interviewed using CTA
methods. Three SMEs were solicited to provide in depth information describing the concepts,
processes, and principles (CPP) required of a complete PHR to extract the knowledge and skill
necessary to perform a concise yet comprehensive PHR between anesthesia providers and PACU
nurses. The SMEs responses were transcribed, coded, and aggregated as a preliminary gold
standard protocol (PGSP). A fourth SME reviewed the PGSP for accuracy and completeness and
to rectify any disparities or confusion that existed in the PGSP.
Definition of Terms
The following are definitions of terms related to cognitive task analysis as suggested by
Embrey (2012) and Zepeda-McZeal (2014).
Adaptive expertise: When experts can rapidly retrieve and accurately apply appropriate
knowledge and skill to solve problems in their field of expertise; to possess 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, 1996; Ericsson,
2004).
Automated knowledge: Knowledge about how to do something: operates outside of
conscious awareness due to repetition of task (Wheatley & Wegner, 2001).
Cognitive load: Simultaneous demands placed on working memory during information
processing that can present challenges to learners (Sweller, 1988).
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 15
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; Schraagen, Chipman, & Shalin, 2000).
Conditional knowledge: Knowledge about why and when to do something; a type of
procedural knowledge to facilitate the strategic application of declarative and procedural
knowledge to problem solve (Paris, Lipson, & Wixson, 1983).
Critical Decision Method (CDM): CDM is a method of cognitive task analysis developed
by Klein, Calderwood, and MacGregor (1989) that has been employed to capture decision
making on real world contexts and to explore decisions surrounding untoward or adverse events
for later analysis, discussion, instruction, product design or for the institution of safety measures.
Declarative knowledge: Knowledge about why or what something is; information that is
accessible in long-term memory and consciously observable in working memory (Anderson,
1996; Clark & Elen, 2006).
Expertise: The point at which an expert acquires knowledge and skills essential for
consistently superior performance and complex problem solving in a domain; typically develops
after a minimum of 10 years of deliberate practice or repeated engagement in domain-specific
tasks (Ericsson, 2004).
Gold standard: An aggregate of the expertise elicited from the CTA guided interviews
with subject matter experts, which includes the necessary equipment, performance objectives,
conceptual knowledge, procedural knowledge and performance standards employed when
experts execute a particular task (Clark et al., 2008).
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 16
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).
The following definitions of terms are related to patient handoff.
Patient handoff: the transfer of information between two caregivers to ensure safe care
(Wayne et al., 2008).
Post Anesthesia Care Unit: An area adjacent to the operating room where patients are
taken for care and for the recovery of anesthesia (The Free Dictionary, 2015).
Organization of the Study
The review of the literature in Chapter Two defines a PHR and examines the mandates
and the barriers to effective reporting performance. The review focuses on a PHR between an
anesthesia provider and a PACU nurse. Chapter Two also addresses knowledge types, expertise,
and CTA. Chapter Three describes the methodology of the study and introduces the research
questions. Chapter Four reports the results of the study. Chapter Five provides a discussion of the
study results, the implications to PHR using CTA guided methods, and the limitations. Chapter
Five concludes with suggestions for future research.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 17
CHAPTER TWO: LITERATURE REVIEW
Accurate reporting of patient information along the continuum of care is a key element in
maintenance and safety of surgical patients (Joint Commission, 2014). The task of patient
reporting is frequently referred to as a patient handoff report (PHR). PHR is referenced in the
literature as: handover, handoff, bedside reporting, transfer of care, transfer of accountability,
transitions of care, interdisciplinary transfer, sign out, and sign-over (Alvarado et al., 2006;
Paterson & Wears, 2010; Perry, 2004; Petersen, Orav, Teich et al, 1998). The goals of a patient
handoff are to deliver accurate information regarding a patient’s care, treatment, services, current
condition, needs, trajectory of care, and any recent or anticipated changes: and to influence the
direction of the plan of care to illuminate safety issues (Alvarado et al., 2006; Berger, Sten, &
Stockwell, 2012; Joint Commission, 2008; Patterson & Wears, 2010).
Historically, the PHR was viewed as a one-way encounter where communication
influenced values, outcomes, and work standards (Kopp & Shafer, 2000). The receiver passively
listened, asked questions, and the relay of information was under the purview of the presenter of
the report with clarification via the receiver. Riesenberg, Leitzsch, & Cunningham, (2010) state
that the transfer of information is a practice during which individual attention should transpire
between two health care practitioners (the sender and the receiver of information) facilitating a
correct and thorough discussion of patient information. The information exchanged between
these two practitioners must be clear, correct, consistent, concise, and meet the patient’s
healthcare goals (Amato-Vealey, Barba, & Vealey, 2008; Manser, Foster, Flin, & Patey, 2004).
Defining Patient Handoff
The patient handoff, a fundamental component of professional care delivered to a patient,
(Dowdling, 2001) is defined as the “interactive process of passing patient specific information
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 18
from one caregiver to another for the purpose of ensuring the continuity and safety of patient
care” (Wayne et al., 2008, p.476). Patient handoffs should be accurate, relevant, clear, specific,
and complete (Amato-Vealey et al., 2008; Manser et al., 2013). A handoff includes shared
cognition, collaborative cross-checking, audit points, time to recover inaccurate information and
prioritize, and time to create a future plan of care for the patient (Perry, 2004; Peterson et al.,
1998). Patterson and Wears (2010) claim that the primary task of patient handoff is to affect
information processing where inputs and outputs regulate data that may be recalled, remembered,
or discarded. Second, handoffs emphasize deviations in status related to relevant patient
information and initial diagnosis. Third, handoff considers assumptions and hunches, and
detects gaps during a question and answer session. Last, personal accountability for the patient
while in the charge of the practitioner cannot be overemphasized. Jeffcott, Evans, Cameron,
Chin, and Ibrahim (2009) suggest a model for handoff should also include an element of
teamwork and leadership. Manser et al. (2013) claim that tacit knowledge, knowledge that is
known but hard to articulate (Masters, 1992), is seldom a component in the patient handoff
activity.
Practitioner Involvement
The continuum of care impacts various care areas resulting in multiple handoffs with
similar and different foci and expectations depending on the area of expertise (Carroll, Williams,
& Gallivan, 2012: Kopp & Shafer, 2000; Manser & Foster, 2013; Smith, Pope, & Goodwin,
2008). Handoff exchanges are comparable when temporary responsibility is necessary such as
with a break or at the change of shift (Riesenberg et al., 2010). Non-comparable transfer of care
occurs when post surgical patients are delivered to the PACU or to the intensive care unit, for
example (Crum, 2006). In the perioperative area both comparable and non-comparable reports
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 19
are executed and the experience and expert level of the provider dictates thoroughness
(Wohlauer et al., 2012). As a result of the diverse experience levels and cognitive thought
processes and reasoning among providers, elements in information transfer are interpreted
differently, omitted, or overlooked (Wohlauer et al., 2012). Carroll et al. (2012) claim that the
expectation between comparable practitioners during a transfer of care can be dissimilar. The
lack of formal training in reporting practices compounds the subjectivity that is prevalent in
reporting styles (Inglehart, 2008). Additionally training facilities are not uniform in teaching
PHR, and minimal guidance during trainee performance affects the understanding and
thoroughness of a patient handoff (Nasca, et al., 2010).
The increased amount of patient care transfers at shift change, multiple practitioner
involvement, and variation in expertise contribute to continued inconsistencies in reporting
practices. Another contributor to the increase in patient handoffs resulted from the change in the
resident duty hour restrictions (Date, Sanfey, Mellinger, & Dunnington, 2013; Inglehart, 2008;
Pringle, Collins, & Santry, 2013). In 2003, the Accreditation Council for Graduate Medical
Education (ACGME) established guidelines indicating that resident duty hour must cap at 80
hours per week over a four-week span (Inglehart, 2008). This limitation in duty hours is
intended to provide safer working conditions for medical trainees (residents, interns, and medical
students) who were experiencing fatigue during long training hours that could result in harm for
a patient assigned to the medical trainees care. Although the intent of the limited duty hours was
to deter fatigue and increase patient safety, the regulation instead affected the number of
practitioner-to-practitioner exchanges during patient handoffs and contributed to the already
existent problem of substandard reporting practices (Date et al., 2013). The regulation did result
in increased training and education of residents in patient handoff by mandating resident
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 20
supervision during the practice of reporting patient status (Pringle et al., 2013). Despite the
mandate for resident supervision during the PHR process, many patient sign-outs remain
unsupervised (Inglehart, 2008).
Patient Handoff Initiatives
The lack of PHR standardization renders reporting practices diverse, resulting in
omissions or incorrect information transference. The 1999 report titled To Err is Human:
Building a Safer Health System concluded that 44,000 to 98,000 patient deaths each year are a
result of preventable mistakes that occur from substandard communication exchange (Institute of
Medicine (IOM), 2000). Additionally, the Joint Commission (JC) (2008) reports that 80% of
medical error is directly related to communication deficiencies between practitioners. These
deficiencies leads to injury, delay in treatment, wrong treatment, increased length of stay,
increased costs, and increased mortality and morbidity (Alvarado et al., 2006; Haynes, et al.,
2009; Joint Commission, 2008; Kitch et al., 2008). Furthermore, the World Health Organization
(WHO) (2014) published safety solutions and instituted the “High 5’s” initiative in 2006. The
expectation of the High 5’s was to reduce five safety issues in five countries over five years. The
issue of patient handoff reporting practices was targeted as an important safety issue. The WHO
also developed a surgical safety checklist and stated that the use of checklists reduced
complications and improved information exchange (Lyons & Popejoy, 2014).
Standardization of PHR practices aims to improve communication and to ensure that
information is consistent with the patient’s actual condition. However, when information
provided in report is different from the patient’s actual condition, this raises concern (Riesenberg
et al., 2010). Therefore a number of initiatives are aimed at addressing and improving PHR.
The JC, IOM, and WHO mandate that standardized protocols are essential to guide the delivery
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 21
of a patient handoff report and to prohibit gaps in the transfer of information (Joint Commission,
2008; IOM, 2000; WHO, 2006). As a result, the Joint Commission, in 2006, instituted the
National Patient Safety Goals (NPSG) in 2006 ( NPSG, 2008). The purpose of these goals was to
enhance provider-to-provider communication during transitions in patient care (Wheeler, 2014).
The NPSG require a standardized approach to handoff communication and are viewed as a
standard in health care (Patterson & Wears, 2010). The patient handoff must include:
1. Interactive communication with an opportunity for questions and answers;
2. Patient information that is entirely relevant and recent including care, medications,
treatment, and changes;
3. A system in place to verify received information;
4. An opportunity for the receiver to review information; and
5. A minimum of interruptions and distractions (Berger et al., 2012).
Although many initiatives exist, there is a paucity of literature assessing PHR in anesthesia
(Smith & Mishrak, 2010; Smith et al., 2008). More studies are warranted.
Barriers to Effective Patient Handoffs
Despite the adoption of standardized protocols for the delivery of an efficient and
complete handoff, multiple obstacles prohibit the delivery of streamlined reporting. First, the
differences in practitioner experience prohibit homogeneous reporting (Wolhauer et al., 2012).
Second, as a result of various levels of understanding and expertise, the information transferred
to the receiver may not be viewed as important or pertinent and consequently may be disregarded
(Wheeler, 2014). Third, an increase in practitioner involvement exists and can potentially
contribute to omissions or deletions of relevant information (Riesenberg et al., 2010). Fourth,
time pressures, such as efficient room turnover, affect both the sending and receiving
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 22
practitioner’s communication during the reporting encounter (Amato-Vealey et al., 2008). Fifth,
the average handoff report identified in this dissertation by SME A takes approximately 12
minutes; however, this brief exchange is plagued with interruptions (Lane-Fall, Brooks, Wilkins,
Davis, & Riesenberg, 2014). Threats to quality PHR include noise, disruptions via phone calls,
questions, alternate patients needing attention, and unprofessional behavior (Manser & Foster
2011). Last, the more experienced practitioners may accept an abbreviated report, particularly
when they are familiar with the case (Carroll et al., 2012). Although the Joint Commission
demands professional and uninterrupted reporting practices, it is posited that PHR remains an
informal encounter that is fraught with the potential for error (Smith et al., 2008).
Patient Handoff to the Post Anesthesia Care Unit
In the perioperative area various anesthesia providers are involved in the patient handoff
(Riesenberg et al., 2010; Wheeler, 2014). These providers include an anesthesia medical doctor
(MD), anesthesia doctor of osteopathy (OD), anesthesia resident (physician in specialty training),
or a certified registered nurse anesthetist (CRNA). The postoperative PHR takes place at the
conclusion of surgery when the patient transfers out of the operating room environment and is
admitted to the PACU. In this instance, the care of the patient is delivered to a non-comparable
level practitioner, the PACU nurse.
Patient handoff reports are verbal, written, or tape-recorded but the anesthesia provider to
PACU nurse information exchange is historically a face-to-face verbal encounter (Dowling,
2001). During this exchange the admission to the PACU represents a vulnerable moment in the
care of the patient that is unique in focus and expectation (Amato-Vealey et al., 2008; Wheeler,
2014). Entry to the PACU signifies a transition phase for a post-surgical patient. It is during the
PACU admission that the operation has concluded and the patient is eliminating the anesthetic
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 23
and returning to the pre-surgical state. Further, during this transition time, the sending and
receiving practitioners (anesthesia provider and PACU nurse) possess dissimilar education,
training and experience, and they have a varied focus for the plan of care for the patient (Berger
et al., 2012).
Patient Handoff Omissions
Riesenberg et al. (2010) estimate that approximately 4,000 patient handoffs occur each
day in the perioperative arena. Further, 1.6 million handoffs are delivered each year and of
these, 1.4% of adverse events occur in the perioperative area often resulting from inadequate
communication. Forty three percent of malpractice claims are the result of communication
breakdown (Segall et al., 2012) and 39% occur during patient transfers (Beckmann, Gillies,
Brenholz, Wu, & Pronovost, 2004). Further, 14% of anesthesia providers fail to deliver pertinent
information during a transfer of care to the PACU (Nagpal et al., 2013). Drachler (2012) asserts
that this deficit may be related to the many checkpoints that a surgical patient is exposed to
during an operative admission.
Substandard reporting practices are addressed in the literature. Reported events, suggest
Jayasuriya and Anandaciva (1995), are those events that are considered severe and unfortunately
the less severe events are often omitted or disregarded in the transfer of care. Patent handoff
reports to the PACU are cited as informal, non-uniform, and incomplete (Lamond, 2000; Manser
et al., 2013; Smith, et al., 2008). Further, omissions in patient reporting coupled with mistakes
and distractions, result in a loss of information and an increase in patient complications (Lane-
Fall et al., 2014; Milby, Bohmer, Gerbershagen, Joppich, & Wappler, 2014). Anwari (2002)
asserts that receivers of patient care handoff were noted to be dissatisfied with the information
presented to them during the information exchange. Anwari (2002) evaluated the quality of PHR
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 24
on 276 patients presenting to the PACU. Specifically quality of information, patient status,
professionalism, and the receiver’s satisfaction with the patient report were evaluated. The
survey revealed that the overall quality of report delivery was poor in 20% of the PHR transfers,
satisfactory in 38%, and good in only 42% of the patient transfers.
Bother, Georgieff, and Schwilk (2000) reported that anesthetic incidents, events, and
complications (IEC) amounted to 22%. IECs were defined as an incident occurring during the
anesthetists care of the patient, an event that resulted in an intervention, and an event that may
have resulted in death had an intervention not taken place. IECs, claim these researchers, have
relevance for the care the patient will receive postoperatively and may alter the direction of care
when the patient is discharged from the PACU. The authors focused on including and reporting
IEC that occurred intraoperatively to the PACU nurse claiming that the lack of disclosure might
prohibit appropriate transfer to the receiving ward. Bother et al. (2000) cite an example that
when information regarding an IEC is withheld and a patient is transferred to a ward bed, the
patient’s care and health may be compromised. Conclusions were discussed questioning the
defining characteristics of what constituted an adverse event, how often or consistently these
events occurred, or the impact of any event through the transitions of care. IECs are not always
communicated during the patient transfer.
Manser et al. (2013) also claim that intraoperative events remain underreported. Events
that may impact PHR care include alterations in vital signs, arrhythmia, difficult airway, and
bronchospasm (Cohen et al., 1992; Forrest et al., 1990). Anawri (2002) reported a third of
postoperative patients experience oxygen saturation less than 90% on admission to the PACU.
Borowitz, Waggonner-Fountain, Bass, and Sled (2008) surveyed medical residents. Thirty one
percent responded to the survey indicating a patient event took place during their shift and the
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 25
PHR failed to reflect the event. Pezzolesi et al. (2010) additionally reported that of 334 patient
handoffs 45.2% were incomplete and 29.3% failed to provide a handoff report at all. Kopp and
Schafer (2000) assert that critical events must be communicated as quality and safety can be
traced back to adverse incidents and to substandard PHR.
Patient Handoff Tools
Many handoff tools are available to help bridge the information gap during delivery of a
report between an anesthesia provider and the PACU nurse (Jeffcott et al., 2009; Patterson &
Wears, 2010; Van Eaton et al., 2005; Wheeler, 2014). The SBAR was originally created to assist
physician-to-physician information exchange (Riesenberg et al., 2010). This mnemonic includes
a description of (a) the situation where the patient is immediately identified and reason for
admission is conveyed to the receiver, (b) the patient’s background which includes the patient’s
history, laboratory results, and test results, (c) the patient’s assessment of the course of care and
the current patient condition, and (d) the practitioners recommendations for the continuum of
care.
The I PASS the BATON is another script describing a systematic way to communicate
patient information (Sandlin, 2007). This mnemonic includes (a) introduction (the practitioner
and his/her title are disclosed), (b) patient (patient identification), (c) assessment (discuss patient
complaint, vital signs, symptoms, and diagnosis), (d) situation (status, medications,
circumstances, and code status), and (e) safety concerns (lab values, allergies, fall precautions).
The latter half of the tool describes the (f) background (history, previous medical problems,
family history, medications), (g) actions (interventions taken or required and the rationale), (h)
timing (level of urgency), (i) ownership (who is accepting the responsibility of the patient), and
(j) next (what is the new plan). The SHARQ (situation, history, assessment, recommendations,
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 26
and questions) and the 5 P’s (patient plan, precautions, plan of care, problems, and purpose) are
supplementary tools meant to systematize handoff practices as well. The purpose of each script
is to address the salient points in a patient transfer of care prohibiting elimination of pertinent
information.
There are other strategies health care practitioners rely on to recall information. These
include: read-back activity, referencing, electronic medical records, verbal encounter, paper and
pen, and hand-off summaries (Van Eaton et al., 2005; Wheeler, 2014). Despite the availability
of tools to guide delivery and increase awareness no reliable tool exists (Berger et al., 2012).
Although algorithms and checklists are available to direct these encounters verbalizing hunches
and anticipations is practiced and can be of value in the transfer of information as well (Manser
et al., 2013). Furthermore, the Joint Commission does not mandate the use of a particular tool so
facilities are free to develop their own protocols resulting in inconsistency (Berger et al., 2012;
Wheeler, 2014). As a result, continued variations in practice persist; these variations include the
exclusion of IEC’s that may impact the transfer process and patient outcomes. Further research
is needed.
Importance of Communication
The patient handoff tools are used to facilitate the communication of a comprehensive
PHR. However, without thorough and effective communication between both the sender and
receiver, the handoff tools are rendered ineffective. Regardless of the tool used, communication
that is clear and concise conveys information more effectively and with less room for omissions
or error. The communication cycle (Clark, 2013) is viewed as a three-step process between the
sender and the receiver. First, an individual organizes thoughts and ideas so that communication
is fluid and succinct. Second, the sender encodes information that will be delivered to the
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 27
receiver. Third, the receiver decodes the information. An important step that closes the loop of
the communication cycle is the delivery of timely feedback via a question and answer session.
Here the sender and the receiver ensure understanding and comprehension. The most prevalent
reason for incomplete PHRs is poor practitioner-to-practitioner communication leading to critical
incidents (Carroll et al., 2012; Joint Commission, 2008). Gawande, Zinner, Studdert, and
Brennan (2003) studied incidents reported by surgical staff and found that 43% of the incident
reports were the result of communication breakdown and two thirds were associated with the
patient handoff.
Clear and concise communication is an essential element in the process of patient transfer
(Anwari, 2002). Communication encompasses many elements and the interpretation and
meaning may vary based on individual understanding and experience specifically when
delivering a PHR. In the absence of sound communication that includes thought organization,
encoding, decoding, and directed feedback, PHR will remain incomplete.
Current Training of Patient Handoff to the Post Anesthesia Care Unit
Currently there is a lack of formal training protocols on the task of PHR. Most often, the
Halstead (1904) approach is utilized which prohibits the transfer of the specific cognitive and
procedural knowledge that is necessary for the delivery of a complete handoff report. Further,
few facility protocols exist and those that do lack standardization and competency checks in
performance. Direct supervision with each report during the training period is inconsistent or
absent (Nasca et al., 2010). The absence of a more knowledgeable practitioner during the
handoff process perpetuates substandard reporting practices during training. Often times
experience alone guides the instruction of PHR and the most experienced practitioners may not
be the best instructor due to their automated knowledge. Although training by an expert in the
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 28
practice of PHR is ideal, expert training often omits important information and additionally this
knowledge may be inaccurate. The omission and inaccuracy of information provided by experts
places the learner in a position of “filling in the gaps” resulting in an inferior and incorrect
understanding of the task. In order to transfer expert knowledge effectively, a clear
understanding of the declarative and procedural knowledge specific to PHR must be available.
Otherwise errors in judgment could occur and may result in patient injury and harm.
Summary
The consistent delivery of a thorough PHR remains a problem in the postoperative arena.
The lack of standardized protocols renders patient handoff subjective and indiscriminant. Many
barriers prevalent during a handoff encounter persist. Further, the expertise levels of practitioners
may dictate what patient information is deemed relevant. As a result, more novice practitioners
may not understand pertinent facts in a patient’s history and omit this information during the
delivery of a patient report. Despite initiatives and tools to facilitate PHR, without good
communication these tools are ineffective and gaps and barriers in reporting persist. Proper
education and training is lacking on how to efficiently use handoff tools and perform a PHR.
Additionally, the presence of a more knowledgeable practitioner providing training in PHR
practices is fraught with problems such as inaccuracy and incompleteness due to the automaticity
of the individual’s expertise. As a result of expertise, automated knowledge becomes
unconscious and is not readily available for recall.
In order to gain expertise in the task of PHR, it is essential to define and understand
declarative and procedural knowledge such that pertinent information in patient status is
understood and then transferred effectively and correctly to the receiving practitioner so that
errors or omissions in critical information do not occur. To further examine the advantages and
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 29
disadvantages of expertise the following sections will examine the nature of knowledge types,
automaticity, expertise, and the characteristics of expertise. Following this, a discussion on how
to capture expertise through CTA methods is presented.
Knowledge Types
Different scientific disciplines agree there are many types and levels of knowledge
involved in the process of complex reasoning. Clark and Estes (1996) discuss declarative,
procedural, and conditional knowledge in the literature. Evaluating the basic components of
knowledge types (declarative, procedural, and conditional) is essential in examining cognitive
task analysis (CTA). Understanding information types is useful when comparing the acquisition
of knowledge between a novice and an expert professional. Equally understanding knowledge
types can assist in the appropriate training in the performance of patient handoff reporting
practices.
Declarative Knowledge
The transition of novice to expert learner involves a multifaceted assortment of knowledge,
skills, and processes. Such processes begin with declarative knowledge. Declarative knowledge
is concrete information. Simply, declarative knowledge is knowing the “what” about a subject or
process in order to explain the “why and that” of a query (Anderson & Schunn, 2000; Clark &
Estes, 1996). Declarative knowledge is also described as schematic where facts and events are
recalled. These events are formatted in long-term memory as mental representations and schemas
so that the information can be retrieved with ease (Schraw & Moshman, 1995). Merrill (1994)
defines four areas of knowledge: concept, processes, principles, and procedures. Such knowledge
consists of symbols, trends, events, problem-solving paradigms, memories, and facts (Oosterhof,
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 30
2011). Information is learned via instruction or text and is recalled from long-term memory.
Declarative knowledge in itself is unproductive unless processed and applied (Anderson, 1982).
Procedural Knowledge
The act of generalizing and applying declarative knowledge in professional practice is the
essence of procedural knowledge. Procedural knowledge is also considered a form of memory.
It is defined as the skill in “when and how” to perform a task (Anderson & Krathwohl, 2001).
This knowledge type consists of IF (declarative)/THEN (procedural) statements used to guide
decision-making. Procedural knowledge requires the expertise and direction of a more
knowledgeable other as well as timely and corrective feedback (Ambrose, Bridges, Lovett,
DiPietro, & Norman, 2010). Additionally, prior knowledge and repeated exposure to a specific
task assists in problem solving and mastery of this type of knowledge (Anderson, 1993: Clark &
Estes, 1996). Conditional knowledge is essential in one’s journey toward expertise. First,
conditional knowledge is a component of procedural knowledge and dictates “when” to act
during a particular situation. Second, conditional knowledge allows the performer to make a
sound decision and choose the most appropriate course of action in order to solve problems.
Third, critical thinking via conditional knowledge mandates that declarative and procedural
knowledge be appropriately applied (Anderson & Krathwohl, 2001). Last, conditional
knowledge modulates the fact to action process (Anderson, 1982; Paris et al., 1983).
Anderson and Schunn (2000) suggest retention is affected by practice. Further, a simple
act of performance is not enough to maintain procedural knowledge, thus study and deliberate
practice are constantly required to assure information is maintained and applied consistently and
correctly leading to automaticity (Clark et al., 2008; Feldon, 2007).
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As applied to the medical domain, the social act of knowledge exchange between two
medical professionals involves a complex exchange of information. The merging of declarative
and procedural knowledge is essential for complex problem solving. Understanding knowledge
types can assist with awareness of one’s personal expertise and the level of expertise of others.
Individualizing the information relayed to the receiving party and accounting for level of
experience and knowledge serves to eliminate potential information processing errors.
Automaticity
Through repeat performance and deliberate practice of a task, declarative and procedural
knowledge become automated and unconscious, and the speed of performing the task increases
while the amount of active mental effort decreases (Feldon, 2007). Automaticity of declarative
skill evolves as the individuals encode information into their long- term memory (Anderson,
1996). Automaticity of procedural knowledge develops as skills are practiced (Clark & Estes,
1996). The retrieval of knowledge from long-term memory enables the expert to initiate a task
with minimal cognitive effort. Once in motion, the task runs to completion long before the expert
consciously considers the individual steps (Clark & Elen, 2006; Feldon, 2007). The expert has
mastered the training from coaches and peers and once an expert is automated, mastery of skill is
evident.
Automaticity benefits the expert in that it enables the expert to adapt and respond quickly
and with precision to novel problems (Clark & Elen, 2006). The benefit to automaticity is that
one can apply strategies to new problems with minimal effort and draw off of long-term
memory. Last, automation lessens the cognitive load known to plague learners in training
(Kirschner, Sweller, & Clark, 2006).
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Anderson (1996) suggests three phases of knowledge acquisition that result in
automaticity.
1. In the first phase, termed the interpretive stage or cognitive stage, the learner practices
declarative and procedural knowledge. In this phase the learner tends to speak aloud
when learning and performing a task.
2. As the student enters the second stage, the associative phase, the learner is able to apply
the learned declarative knowledge and correct procedural mistakes identified while
problem solving. The cueing of verbal instructions is no longer necessary.
3. The third and final stage, automation, fine tunes knowledge and skill. Procedures are
performed automatically without prompting or direction.
It is in this third stage that Anderson (1996) suggests automaticity emerges. Ericsson and
Charness (1994) claim that the three phases in Anderson’s theory result in proficiency. Ericsson
(2009) asserts that Anderson’s theory fails to address a fourth and most important phase,
engagement in deliberate practice that ultimately leads to expertise.
Influence of Information Processing Model (IPM)
Information-processing model (IPM) also provides an explanation for how knowledge
becomes automated and thus beneficial for expert strategy and recall (Ericsson & Charness,
1994). Information enters via visual and auditory paths into the sensory memory. In the IPM
information is screened and transferred to working memory only if the information is
meaningful. If the information is considered non-useful, it is discarded. If information is
meaningful it is ultimately transferred to long-term memory. As the working memory is limited
in its capacity, a new task can render a novice overwhelmed and fatigued. When procedures are
new, the novice lacks both the skill and cognitive strategies to work through problems efficiently
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 33
and often times correctly. Their working memory becomes saturated. The novice cannot create
schemas or find pattern recognitions (Hoffman & Militello, 2009). The new learners ability to
solve problems remains immature until he/she gains sufficient exposure and experience in a
given domain and can draw on unconscious scripts that guide decision-making.
It is with rehearsal of the task, elaborating on a task that assists in connecting concepts,
and organizing the concepts of a task that information is transferred to long-term memory.
Retrieval of information from long-term memory does not required effort, can easily be recalled
by the expert, and the ability to store information frees up working memory so that alternatives
can be considered (Dunphy & Williamson, 2004; Wheatley & Wenger, 2001). The expert
demonstrates ease in performing a task or solving problems. The novice learner uses the working
memory to recall facts and organize the steps necessary to perform tasks. The novice fatigues
easily due to an increase in cognitive load and becomes overwhelmed where the expert executes
tasks effortlessly.
Expertise
The study of expertise can be viewed from an absolute and relative approach. From an
absolute lens, the acquisition of expertise was bestowed on an individual by the gods and these
individuals were born with an exceptional talent (Ericsson & Charness, 1994). This absolute
approach to expertise, claims Chi (2006), was evident in exceptional individuals such as
prodigies or savants. The relative approach to the study of expertise compares novices to experts
and dictates that a non-expert can become more proficient with practice and experience in a
domain. This modern view claims that expertise evolves over time with extensive repetition and
exposure; this is evident in super athletes.
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Expertise has been studied in the domain of chess. Simon and Chase (1973) examined the
way in which expert chess players performed diligently and consistently, with speed and
precision during a chess match. These researchers found that expert chess players remembered
far greater numbers of chess patterns than non-expert players. An expert chess player can recall
an estimated 50,000 chess patterns in their memory, where a good player can recall perhaps
1,000 moves. Chess experts demonstrate superior memory in that the player is able to recognize
configurations based on the number of patterns recalled (Ericsson & Lehman, 1996). The more
knowledge of chess the player accrues, the more “chunks” of information are recalled and thus
the more strategies created from mental representations (Ericsson, Whyte, & Ward, 2007).
Pattern recognition and the formation of schema accounts for the excellent memory in the
domain of chess.
Characteristics of Experts
Exploration of expertise in other areas such as music and medicine has expanded research
in expertise and lead to the discovery that specific characteristics are common to superior
performers. Chi (2006) and Ericsson, Krampe, and Tesch-Römer (1993) define the expert as an
individual with extensive professional experience, typically at least ten years. In medicine
experts are identified by peer nomination and have devoted 10,000 hours of time to develop their
craft (Ericsson et al., 2007). A skilled performer is reliable, consistent, and executes tasks with
precision and speed (Chi, 2006; Feldon 2007). The erudite professional has superior levels of
declarative knowledge (the knowledge of facts, what, and why) as well as immense procedural
knowledge (knowledge of how to do something) rendering the expert adept in task execution
(Dunphy & Williamson, 2004; Paris, Lipson, & Wixson 1983). Ericsson et al. (1993) add to this
asserting that expertise is domain specific. Experts have vast and organized knowledge and are
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 35
skilled at creating mental models or representations that form patterns, which assist in problem
solving based on principles (Bédard & Chi, 1992; Glaser & Chi, 1988). They can anticipate
challenges grounded on cues, demonstrate flexibility and adaptability, and are proficient at
separating relevant and irrelevant information to arrive at an often correct conclusion (Bédard
and Chi, 1992; Chi, 2006; Hoffmann & Militello, 2009). Experts are additionally able to encode
and decode information effortlessly and can outperform novices. Their ability to create patterns
and schema is accomplished by developing a deeper understanding of context by considering
concepts, processes, and connections (Ericsson & Lehman, 1996). Experts self-monitor their
thought processes and behavior and are motivated to analyze and re-analyze problems and
scenarios in order to develop a number of solutions or pathways to remedy a problem. Expertise
is a blend of cognitive acquisition and performance ability (Anderson & Schunn, 2000).
Consequences and Omissions of Expertise
Although an expert has the advantage of speed, consistency, and superior performance,
the acquisition of expertise has drawbacks, mainly due to the automaticity of knowledge and
skills. Automaticity of skill can render knowledge unconscious for recall (Feldon, 2007). In
particular, the expert may omit critical information during instruction. Experts are also reluctant
to change and have difficulty articulating specific steps during task execution.
First, an expert may inadvertently omit up to 70 % of the critical action and decision
steps necessary when providing instruction to a novice learner (Clark et al., 2011; Feldon, 2004).
Experts omit critical knowledge and skill as a result of automated knowledge. Both declarative
and procedural knowledge become automated. Through repeated practice the action and decision
steps become unconscious and thus unavailable for recall (Clark & Elen, 2006). Automaticity
limits the expert from step by step retrieval of information and strategies and knowledge that
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 36
drive performances (Crandall, Klein, & Hoffman, 2006). However, the expert’s speed in task
execution increases as the amount of mental effort in problem solving decreases (Feldon, 2007).
Knowledge and skill become implicit and non-conscious (Campbell et al., 2011). As a result,
information becomes intuitive and the execution of the task is completed before the expert
processes the information (Feldon, 2007).
Second, the consequence of an expert’s automaticity during teaching or training is that
the learner misses critical action and decision steps necessary to perform a task. Without the
essential information, (Clark et al., 2011) novices begin to fill in the blanks based on what they
may have observed during the learning process. The lack of thorough information leads to
misconceptions that become automated, deeply fixed, and hard to change. Further, when
problem-solving using misdirected information, the novice may arrive at incorrect solutions to
problems. In medicine, this behavior and end-point may affect patient care, safety, and outcome
(Berner & Graber, 2008).
Third, once a task is automated the expert is less apt to change or revise behavior
(Wheatley & Wenger, 2001). The process of changing automated behavior necessitates
considerable mental effort and behavior modification requiring revisiting a former stage of
learning. Vygotsky’s zone of proximal development illustrates this process (The Gale Group,
2009). When a novice is beginning to learn a task the novice requires guidance and direction. As
the task becomes familiar the learner identifies and corrects mistakes. Less scaffolding is
necessary from the coach and the learner transitions toward a higher level of proficiency. The
return to a more remedial stage is necessary to modify automated behavior. The expert must
adjust thought processes and behavior and draw from working memory in order to change
ingrained misconceptions. This process of relearning can be exhausting (Ericsson et al., 1994).
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 37
Articulating the specific action and decision steps in problem solving is also difficult for an
expert as a result of automated knowledge and performance (Kirschner et al., 2006). Often,
details are overlooked, knowledge becomes tacit, and intuitions are flawed (Chi, 2006).
Expertise in Anesthesia
Expertise permeates the very core of the practice of anesthesia. Dunphy and Williamson
(2004) suggest that anesthesia providers are expected to remain expert in their field. Therefore,
expertise in anesthesia is the foundation for what anesthesia providers do, how they teach, and
how they transfer information to students, colleagues, patients, and patient families. These
authors also support the premise that as expertise in medicine is acquired, anesthesia
practitioner’s knowledge and skill become intuitive and information is stored into the
subconscious. Actions become automated the more rehearsed the task. However, despite the
development of exceptional skill, mistakes in judgment occur and errors in patient care emerge
(Berner & Graber, 2008). Moreover, as experts teach novices the art of anesthesia, studies reveal
that critical information is omitted and not transferred to the novice practitioner efficiently
during their training (Embrey, 2014). Last, as technology evolves, there are increased demands
on practitioners to remain up to date on the latest advances in technology as well as evidence-
based practices.
Consequences of Expertise in Anesthesia
There are consequences to patient outcomes when expertise in anesthesia is not evident.
Young, Smith, Guerlain, and Nolley (2007) claim that medical errors are a major cause of
morbidity and mortality. The unfortunate results of these events are often revisited at conferences
and grand round meetings. Incomplete or ineffective communication prohibits the accurate and
thorough transfer of information and may lead to adverse events such as medical errors. The
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 38
skilled practitioner must be able to encode a situation in order to select and execute actions
quickly to avoid patient harm.
Sharing Expertise in Training
The literature is lacking evidence-based studies describing the training of practitioners in
performing a postoperative handoff. The apprenticeship model has historically been used to train
practitioners (Jackson, 1985). In this model, learners observed and copied the actions of the more
experienced individual. The apprenticeship model of learning is adequate when the task is
performance driven but is inadequate when a learner is required to use cognitive strategies to
solve more complex problems.
Halstead’s (1904) “see one do one teach one” is another method that has traditionally
been used as a means for directing training. Nehr and Stevens (2003) introduced the “one minute
preceptor” method that offers quick tutorials for the practitioner. Each of these methods fails to
include a step-by-step process in which the learner can gather information thus resulting in
reliance on error-prone trial and error. These methods force a novice to rely on observation skill
and a “fill in the blanks” strategy in order to arrive at a potential solution (Sullivan, 2014). In
order to overcome this drawback to instruction (trial and error learning) multiple scenarios of
patient problems are necessary to tap into cognitive problem solving and facilitate transfer of
knowledge (Ericsson, 2009). In the absence of expert instruction on patient handoff practices, the
Halstedean (1904) method of learning will persist.
In order to capture declarative and procedural knowledge experts are called upon to
share their knowledge and skill to effectively teach novices, inform curriculum, and develop
expert systems. The apprentice model is no longer the mainstay of educational training as this
outdated model omits the step-by-step cognitive processes in task performance. Research
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 39
demonstrates that instruction by experts may omit up to 70% of the key elements necessary for
educating novices. Further, experts often deliver substandard, inaccurate, and incomplete
explanations of task rationale during instruction (Feldon & Clark, 2006). These omissions cause
a novice learner to fill in gaps where expert information is left out, often leading to misguided
misconceptions. The process of CTA, therefore, may be a useful method to capture the elements
necessary for the clear and consistent delivery of a PHR.
Cognitive Task Analysis
Definition of CTA
Cognitive task analysis (CTA) is a knowledge elicitation method “to identify the mental
processes and decisions that experts use to achieve a goal and/or solve a complex problem”
(Clark, 2014, p. 541). Clark et al. (2008) define a complex task as one that “requires the use of
controlled and automated knowledge to perform a task that can extend over many hours or days”
(p. 579). CTA captures conscious, non-conscious, and automated knowledge in a domain (van
Merriënboer, Clark, & de Croock, 2002) by engaging in interviews and observations of experts
describing how to perform complex tasks (Clark et al., 2008). CTA investigators capture
knowledge processes that can then be incorporated into training, education and assessment,
replication of cognition and behavior (declarative and procedural knowledge), identification of
necessary equipment for task execution, and identification of performance standards. CTA
evolved from earlier work in cognitive investigation, termed ‘traditional task analysis,’ whereby
thought processes, knowledge, and goal structures describe a task. (Hoffman & Militello, 2009;
Schraagen et al., 2000).
Cognitive task analysis has been used in military training, air traffic control, and in
engineering systems (Annett, 2000; Means & Gott, 1988). Currently the use of CTA to inform
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 40
instructional design in medicine has demonstrated elevated procedural skill and enhanced
knowledge acquisition (Gucev, 2012; Embrey, 2012, Sullivan, 2008).
CTA History
Cognitive task analysis has its roots as far back as the 1800s in applied psychology,
industrial engineering, and in human factors (Clark, 2014; Militello & Hoffman, 2008). In 1911,
Taylor’s time motion studies focused on knowledge of primarily human behavior. Unfortunately
a behavioral perspective, notes Clark (2014), failed to focus on “complex mental decisions and
analytical strategies because they could not be directly observed” (Clark, 2014, p. 542). The
work of Frank and Lillian Gilbreth explored the use of time and motion studies to improve the
human performance of bricklayers by recording and evaluating the physical movements they
employed to lay brick and mortar. The goal of the study was to identify and eliminate extraneous
physical movements to create improved labor performance and efficient work completion
(Annett, 2000). The results of these studies were decreased labor costs, less worker exhaustion
and injuries, and improved and more efficient industrial production systems.
In the 1950s, cognitive science researchers focused on how much mental effort was
required when learning and performing a complex task and how this effort impacted information
processing (Annett, 2000). The popular connection between the behavioral model and
knowledge and skill acquisition began to fade and an interest in the study of expertise emerged.
Academic arenas began to consider the benefit of cognitive methods as a more favorable method
of knowledge elicitation.
In the 1980s, as advances in technology placed increased mental demands on workers,
applied psychology, human factors, and expert systems began to converge on a greater
appreciation for these cognitive methods of knowledge elicitation, which collectively became
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 41
known as CTA (Clark & Estes, 1996). The use of CTA methods demonstrated improvement in
capturing knowledge to create systems that could replicate human expertise (Annett, 2000;
Hoffman & Woods, 2008; Militello & Hoffman, 2008). In psychology, through the use of CTA
methods, the expert action and decision steps necessary to perform complex tasks and explicate
declarative and procedural knowledge created improved learning and training environments
(Clark & Estes, 1996).
CTA Methodology
The goal of CTA is to capture and represent the explicit and implicit knowledge experts
use to perform complex tasks (Schraagen, Chipman & Shalin, 2000; Clark et al., 2008).
Knowledge encompasses domain content, concepts, processes, principles and procedures
(Militello & Hoffman, 2008; Merrill, 1994). Cooke (1999) categorized knowledge elicitation
methods as:
1. Observation of a subject performing a task in a specific domain and the observer draws
conclusions;
2. Performance of structured or unstructured interviews;
3. Process training via evaluation of similar events creating inferences regarding cognitive
processes.
Clark et al. (2008) assert that most CTA methods are employed as a five-stage process:
1. The collection of primary knowledge (the analyst identifies the task and reviews
knowledge regarding the task);
2. The identification of knowledge representations (experts describe the task in terms of
“large chunks” of concepts, processes, principles, and procedures);
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 42
3. The application of focused knowledge (the experts dissect each “chunk” and explain the
specific action and decision steps for the task);
4. The analysis and verification of the information (the CTA researcher evaluates, and
verifies the information) and;
5. The formatting and interpretation of the results (the researcher creates a template of the
results and formats the information to action and decision steps for use in training).
Although there are over a hundred types of CTA techniques, these techniques vary in method
and application (Cooke, 1994: Clark, 2014). Only six are evidence based and widely used (Clark,
2014; Clark et al., 2008; Yates & Feldon, 2011). Most CTA processes adhere to the five-stage
process.
Cognitive task analysis, suggested by Clark et al. (2008), is similar to traditional mixed
methods research strategy that includes observations, interviews, and document analysis whereby
an expert applies his or her expertise to a given situation (Creswell, 2003). Semi-structured
interviews are the preferred method of knowledge elicitation for CTA as the interviews can
provide more robust information especially when executed by a trained and seasoned analyst
(Yates & Feldon, 2011). Clark (2014) asserts that careful selection of three to four subject
matter experts is necessary to solicit the most thorough and exact knowledge regarding a pre-
determined task. The use of additional experts beyond three or four does not provide additive
information and does not prove efficient during the interview process. Subject matter experts
(SME) are chosen based on an advanced sum of declarative and procedural knowledge, years of
experience in a domain, their consistently superior knowledge and performance when compared
with non-experts, and as a result of peer nomination.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 43
During the initial introduction to the interview process the SMEs are informed of the
specific expectations for the interview. The pre-interview orientation is expected to lessen any
frustration or fatigue the participant may experience. The SMEs are interviewed separately so
that their contributions are unique and reflect their individual decisions and analytical thought
processes. Each SME is asked to identify three to five broad steps in task performance of the
same procedure and subsequently break down those large steps into specific and focused action
steps (prompted by action verbs) and decision steps (IF/THEN statements) to incorporate
conditional knowledge. The SMEs are also asked to describe problems unique and rare to the
task and explain what cues and prior knowledge influenced the potential solutions developed to
solve a complex problem. Additionally, the SMEs are prompted to explain risks and benefits of
the task, any concepts, processes, and principles related to the task, any indicators or contra-
indicators, tools, equipment, sensory indicators, or quality standards. Protocols are then
generated from the individual interviews. The individual protocols are then synthesized and
aggregated into a preliminary gold standard (PGSP). The PGSP is presented to a fourth SME for
verification and modification to generate a gold standard protocol (GSP).
Effectiveness of CTA for Capturing Expert Knowledge
Cognitive task analysis is a successful method for capturing explicit, implicit, observable,
and unobservable knowledge from experts. The knowledge captured, asserts Hoffman and
Militello (2009), includes domain knowledge, concepts and principles, schema, and mental
models. Although experts omit information during instruction, the use of CTA can bridge this
gap by creating a gold standard protocol derived from SMEs expertise for use in work settings,
technological environments, and educational areas. Chao and Salvendy (1994) demonstrated that
three to five experts are sufficient in explicating the declarative and procedural knowledge
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 44
necessary to perform a complex task. This optimal number of experts is sufficient to capture the
action and decision steps often omitted. Any more than three to five experts does not
meaningfully add to the body of information required to create a GSP.
Effectiveness of CTA Based Training
Cognitive task analysis has proven effective in training and education, and in improving
problem solving ability. The knowledge elicited from experts includes domain content, concepts,
principles, expert schemas, reasoning, and mental models (Hoffman & Militello, 2009).
Cognitive task analysis allows for the capture the explicit and implicit knowledge experts use for
training education, performance improvement, and building expert systems.
Cognitive task analysis-based instruction is superior to traditional teaching methods as
well and examples of its superiority are well described in the literature (Embrey, 2012; Gucev,
2012; 2008; Sullivan et al., 2007; Tirapelli, 2010) Radar technicians trained via CTA
methodology were shown to efficiently solve complex computer problems when compared with
the non-CTA trained technicians (Schraagan, Chipman, & Shalin, 2000). The study revealed a
78% increase in reasoning and a 60% increase in system knowledge. In another study, Chao and
Salvendy (1994) evaluated 24 computer analysts. A CTA technique was used to elicit knowledge
in debugging, diagnosis, and interpretation. These authors used elicitation methods such as
interviews, induction, repertory grid, and protocol methods. The results of their inquiry showed
that the interview and induction method of CTA surpassed repertory grid and protocol methods.
Crandall et al. (2006) studied critical decision-making among firefighters. The aim was to
improve firefighter training by examining decision points, judgments, and patterns during fire
exercises. The use of a CTA approach surpassed the traditional method of training. The use of
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 45
CTA results in a 30-45% increase in learning performance when compared to traditional
instructional methods Clark (2014).
Effectiveness of CTA Based Training in Medicine
Cognitive task analysis methods have been used successfully to capture expertise in the
medical field for training purposes. Clark et al. (2008) asked ten trauma surgeons to explain how
they perform an emergency femoral shunt procedure to decrease hemorrhage from a damaged
artery. Nine surgeons were interviewed via “self report” and one surgeon was interviewed with
CTA methodology. In the absence of CTA guidance, the surgeons omitted up to 70% of the
decision steps necessary to perform an emergency femoral shunt procedure.
In another study, Sullivan et al. (2008) asked colorectal physicians to “think aloud” and
explain each step while performing a colonoscopy. These researchers wanted to determine if
CTA could better elicit knowledge from these experts. The focus was steps and decision points
during the colonoscopy procedure. Each surgeon was videotaped. A 26-step checklist and a 16
step cognitive table were created and used as tools for data collection. The participant’s actions
were compared to the checklist. The surgeons described 26-50% of the “how to” steps and only
25-43% of the decision steps indicating that critical information was omitted.
Campbell et al. (2011) conducted a study using CTA guided instruction on open
cricothyrotomy (OC) with twenty-six medical students and postgraduate year one and two
residents. The control group received traditional instruction on how to perform a simulated OC
and the experimental group received CTA guided instruction. The findings revealed that, on a
19-point checklist, the experimental group far outperformed the control scoring 17.75 points
compared to 15.14 points (p = 0.029). Additionally, the study measured the participant’s self-
efficacy in performing an OC. Of the 140-point self-efficacy survey, the experimental group
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 46
scored 126 points over the control group who scored 110.76 points. Overall the study
demonstrated that CTA guided instruction was superior to traditional methods in increasing
performance.
In another study, Embrey (2014) evaluated expertise in endotracheal extubation using
CTA-based instruction. The study demonstrated an increased in declarative and procedural
knowledge for student registered nurse anesthetists (SRNA) on a post-test and when the SRNAs
performed a postoperative extubation in a simulated setting. Additional speed in task
performance was also evident following CTA based instruction.
In an earlier study, Crandall and Gretchell-Reiter (1993) conducted a CTA with 13
neonatal intensive care nurses. These nurses were asked to identify signs and symptoms of
sepsis and critical incidents that affect the neonate. The study revealed that the information
collected from the 13 nurses collected through CTA methods was more complete than
information available in textbooks. In another study conducted in the domain of emergency
medicine, Velmahos et al. (2004) used CTA in a skills laboratory to evaluate technical skill
instruction. Twenty-six medical students were divided into two groups. The control received
traditional emergency instruction on how to insert a central venous catheter. The experimental
group was given course material, a presentation, a demonstration, and time to practice central
venous catheter insertion in lieu of traditional teaching methods. The study findings showed that
with CTA guided instruction the medical students had significantly higher scores on a posttest
when compared to the control group (11.0 +/- 1.86 versus 8.64 +/- 1.82, P = 0.03). Additionally
the experimental group was studied over the following year and continued to outperform the
traditionally trained group.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 47
Additional Benefits of CTA
Employing the use of CTA methodology is important for many additional reasons.
Woods and Roth (1988) assert that CTA can be used to comprehend human behavior and to
understand how complex problems are solved. CTA methods are useful in the working and
academic environment. These methods lay the foundation for learning objectives, job
descriptions, hiring criteria, performance evaluations, and supply the critical action and decision
steps that are often overlooked during traditional instruction (Clark & Estes, 1996; Crandall et
al., 2006). Means and Gott (1988) add to these benefits by asserting that CTA methods
emphasize aspects of a task that are applicable and thus important for learners. CTA helps
learners grasp abstract knowledge in a domain and the learner can then extend that knowledge
across subsequent domains. CTA also provides a framework for problem solving. Of note, CTA
based education requires less training time and therefore can be cost effective and a CTA trained
individual may be a more attractive candidate for employment than a non-trained candidate
(Clark et al., 2008; Clark, 2014).
Meta-Analyses in CTA
Two meta- analysis studies report on the effectiveness of CTA methodology. (Lee, 2004;
Tofel-Grehl & Feldon, 2013). Lee (2004) conducted a meta-analysis of empirical studies of CTA
using a more conservative measurement of effect size; the Cohen D. Eight of these studies met
the criteria for pre-and post-test reporting. The researchers findings indicated that CTA is an
effective method of knowledge elicitation as demonstrated by a 1.72 effect size. When
employing CTA methodology the mean performance gain in this study was 75.2%. In an
additional study Tofel-Grehel and Feldon (2013) examined effect size across CTA studies. They
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 48
found the effect size to be large (Hedge’s g = 0.871) which translates as a percentage gain of
31% (Clark, 2014).
Summary
Cognitive task analysis application is growing as a method of knowledge elicitation and
is used in many domains: spreadsheets (Merill, 2002), medicine (Embrey, 2012, Gucev, 2012,
Sullivan, 2007), self-efficacy (Campbell, 2011), and to demonstrate expediency in task execution
(Embrey, 2012). Despite the growing body of literature on CTA use, multiple methods of CTA
are employed rendering variable effect sizes. However, the overall effectiveness of CTA
methods is well supported (Tofel-Grehl & Feldon, 2013).
Conclusion
Cognitive task analysis is a knowledge elicitation method that captures observable and
unobservable knowledge and skills from experts when they perform complex tasks. When
experts are called upon to describe the specific action and decision steps they use to perform a
complex task, studies demonstrate that experts may omit up to 70 % of the critical steps
necessary for novices to perform at task. Current methods for training an anesthesia provider
consist of primarily observing a more senior practitioner. Although many protocols exist to guide
an anesthesia practitioner on patient handoff, practitioners continue to rely primarily on the
traditional Halsteadean (1904) method. The purpose of this study was to conduct a CTA to elicit
expert knowledge on the specific action and decision steps necessary to create a gold standard
protocol that could be used to train novices in the performance of a patient handoff from the
operating room to the PACU.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 49
CHAPTER THREE: METHODS
The purpose of the study was to conduct a cognitive task analysis (CTA) to elicit the
knowledge and skills, represented by action and decision steps, that expert anesthesia
practitioners recall when they describe how to perform postoperative patient handoff report
(PHR). Expert knowledge is highly automated and therefore it was postulated that these experts
would demonstrate difficulty recalling and articulating both declarative and procedural
knowledge regarding PHR during the CTA guided interview. This knowledge is described as the
what, how, and why in task performance. A mixed methods approach was designed to capture
the knowledge when subject matter experts (SME) describe the process of the postoperative
transfer of care. Qualitative methods were used in conducting the interviews guided by Clark et
al. (2008) and quantitative methods were used for frequency counts of omissions, additions, and
alignments tallied from the gold standard protocol (GSP). This chapter will address the study
participants, design, and process.
The research questions that guided the study included:
1. What are the action and decision steps that expert anesthesia providers recall when they
describe how they conduct a patient handoff report to the PACU?
2. What percentage of action and/or decision steps, when compared to a gold standard, do
expert anesthesia providers omit when they describe how to perform a patient handoff
report?
To answer the research questions, CTA methods were used to capture the knowledge,
thought processes, and action and decision steps necessary to perform a task (Chipman, 2000). In
this study the CTA was centered on the action and decision steps of an anesthesia expert
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 50
representing the critical information a provider needs when transitioning the surgical patient to
the care of the postoperative anesthesia care unit (PACU) nurse.
Participants
Chi (2006) and Ericsson and Lehmann (2006) define an expert as an exceptional journeyman
who is regarded by his peers, is reliable, and is accurate. An expert’s knowledge and
performance is consistently superior to non-experts and an expert is known to have advanced
knowledge that is expressed through abstractions (Feldon, 2007; Hinds, Patterson, & Pfeffer,
2001). Further, experts embody vast amounts of declarative and procedural knowledge. It is the
development of schemas, complex problem solving, and forward reasoning that sets experts apart
from their novice counterparts (Bédard & Chi, 1992). Clark et al. (2008) defines an expert as one
with “extensive experience who is able to perform a class of tasks rapidly and successfully” (p.
578).
Four SMEs who represented these qualities were recruited from three various hospitals in
southern California. The four subject matter experts (SME) were selected based on their expert
knowledge, consistent performance, years in anesthesia practice (defined as possessing greater
than ten years experience), current employment status, and delivery of patient handoff report to
the PACU. The experts were also recruited based on their reputation as expert anesthesia
providers. Although these experts provide instruction to novice practitioners, the four experts
recruited for this study do not provide instruction 100% of the time.
As the researcher is employed as an anesthesia provider in an academic institution, the
decision was made to solicit three SMEs for the interviews that worked outside of this type of
environment and had greater than 10 years experience. Chi (2006) and Ericsson, Krampe, and
Tesch-Römer claim that experts are individuals with at least ten years experience. Additionally,
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 51
the experts were chosen because their practice included delivering autonomous postoperative
PHR without direct supervision from a physician team member. One anesthesiologist and two
CRNAs were contacted as interview participants. A fourth SME (an anesthesiologist) was
recruited for the purpose of evaluating the preliminary gold standard protocol aggregated from
the three interviews for completeness and accuracy.
Data Collection
Data collection for Question 1
The first question asked, What are the action and decision steps that expert anesthesia
providers recall when they describe how they conduct a patient handoff report to the PACU?
Five-stage process. The framework for the data collection follows the Clark et al. (2008)
five-step process for knowledge elicitation in CTA. These steps include:
1. Collect preliminary knowledge;
2. Identify knowledge types;
3. Apply knowledge elicitation techniques;
4. Analyze and verify the results from the interviews; and
4. Format the results.
Stage 1: Collect preliminary knowledge. A literature review was conducted on the
current patient handoff practices, the mandates required from governing agencies, the barriers
that exist prohibiting efficient handoff practices, and the tools available to facilitate PHR.
Collecting preliminary knowledge provided the researcher with the necessary background
information to become knowledgeable of the elements expected of a PHR and the barriers that
interfere with reporting practices.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 52
Stage 2: Identify the knowledge types. The knowledge representations linked with the
execution of a patient handoff report were reviewed from the literature. These knowledge
representations include the concepts, processes, principles, and procedures in the form of action
and decision steps necessary to perform the task of patient handoff. This knowledge also
included the declarative knowledge, procedural skill necessary to perform the task, the goals of
the task, any necessary equipment, and any information deemed necessary for a novice to
comprehend the task. In this way, declarative and procedural knowledge representations elicited
from the SMEs could be identified.
Stage 3: Apply knowledge elicitation techniques. A semi-structured interview protocol
based on Clark et al. (2008) was used to capture the knowledge and skill experts demonstrate to
perform a PHR (Appendix A).
Instrument. The CPP method was used to create the interview protocol. The goal in CPP
CTA is to gather the automated and unconscious knowledge to perform a task. A thorough
explanation regarding the format of the interview is communicated to the interviewee. As the
discussion begins, the SME is asked to describe three to five overarching steps in the
performance of the task. The expert is also asked to identify problems that are unique to the task
and to provide the solutions to these problems. The interview highlights the concepts, processes,
principles, specific action and decision steps, equipment, standards and any sensory cues
necessary to perform the task (Clark et al., 2008). Last, the expert is asked to identify the
subtasks that fall under the larger task. The larger steps are referred to as action steps and the
subtasks are referenced as decision steps.
The action step begins with a “verb” and an “IF/THEN” statement identifies a decision
step. For example, an action step while driving might be identified as “stop when the traffic light
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 53
is red.” A decision step for the cited action step may include be “IF the light is yellow, THEN
slow down and prepare to stop, IF the light is green, THEN proceed through the intersection, and
IF the light is not functioning properly, THEN stop, look both ways and proceed with caution.”
In anesthesia an action step might be “attach the pulse oximeter.” Decision steps for the cited
action might include “IF the pulse oximeter is greater than 96%, THEN proceed to the next step
no action required, IF the pulse oximeter is less than 96%, THEN assess the patients respiratory
status, IF the respiratory status is greater than eight to ten breaths per minute, THEN check to see
if the oxygen is turned on.”
Interviews. Following Institutional Review Board approval from the University of
Southern California, four SME were asked to participate in the CTA interviews using the
protocol based on Clark et al. (2008). With the consent of each SME, the interviews took place in
an informal, quiet, and private area where interruptions would be limited. With consent each
SME was audiotaped via a personal recording device. To maintain anonymity, each SME was
identified by a letter of the alphabet (SME A, SME B, SME C, SME D). Three SMEs were
interviewed individually using the CPP method for approximately two to two and a half hours
each. A trained CTA assisted the researcher in the first interview. The researcher independently
conducted the remaining two interviews. The researcher referred to the semi-structured protocol
to capture the expert’s automated and unconscious knowledge, action and decision steps, and
judgments used when performing a patient handoff report.
The semi-structured interviews targeted areas suggested by Clark et al. (2008), which include:
1. The indications for the patient handoff;
2. The action and decision steps necessary for a comprehensive patient handoff;
3. The concepts, processes and principles required of a patient handoff;
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 54
4. The relevant equipment or monitors involved in patient handoff;
5. The inclusion of sensory indicators that might influence the task, for example, smells,
sounds, or tactile cue; and
6. The presence of performance standards such as speed or time to complete the task.
The audiotapes were uploaded to a personal computer and then emailed to an outside
transcription company for verbatim transcription. The transcriptions were line numbered and
time stamped to facilitate coding. The individual transcriptions were then reviewed sentence-by-
sentence and coded for common and recurrent themes as well as for knowledge representations.
An individual protocol was created from each SME interview. Once completed, the three SMEs
were interviewed a second time for “round 2” and asked to review, add, delete, and/or modify
their individual protocol. Tracked changes were used to incorporate additions and deletions and
these changes were saved. This process continued until each SME had no further additions or
deletions to contribute to their individual protocols. When the three individual SMEs were
satisfied with the information present in their individual protocols the documents were
aggregated into a PGSP. A fourth SME was enlisted to review the aggregated protocol and to
add, delete, or modify the information. Once the fourth SME reviewed the job aid (a guide to
instruct the fourth SME on how to approach the aggregated protocol) and the PGSP, SME D and
the researcher met for discussion. All items on the PGSP were reviewed for accuracy and
completeness. Any area that might appear foreign or confusing to a novice was discussed for
clarity. Once this task was complete a gold standard protocol (GSP) was generated.
Stage 4: Data Analysis. Upon conclusion of the interview, the expert information was
immediately transcribed verbatim through an outside transcriber. The transcription was time
stamped and line numbered for easy retrieval of information when coding.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 55
Coding. A coding scheme based on Clark’s CPP (Clark, 2006) method was used to code
the data from the three SME interviews Declarative and procedural knowledge, action and
decision steps, and relevant and recurring themes were identified throughout the transcription.
The coding scheme was used to establish inter rater reliability and is listed in Appendix B.
Inter-rater reliability (IRR). The researcher and a second trained coder coded SME A’s
transcript as this interview was the most comprehensive. The coding scheme provided the
indicators for coding the transcript. Both coders coded the transcript line by line defining the
action or decision step or theme in the transcript. For example, if SME A referred to the “noises
in the PACU” that line was coded with an “S” for a sensory indicator. Once each transcript was
completely coded, the coders reviewed the transcript line by line to establish agreement and/or
disagreement on the pre-established codes. In areas of disagreement, discussion lead to a
consensus. At this point, all agreements and disagreements were tallied on an IRR code sheet and
then calculated for IRR (Appendix B). The agreements plus the disagreements equaled the
frequency for the individual code. Once the frequency was established the total number of
agreements was divided by the frequency in order to gain the percentage of the cumulative IRR.
An agreement greater than 85% in IRR yields a reliable and consistent coding result between
coders (Hoffman, Crandall, & Shadbolt, 1998). A percentage less than 85% requires re-
assessment by the coders. A 98% IRR was calculated for this study. The IRR result is discussed
in Chapter Four.
Subject-matter expert and protocol. The data collected from each individual SME
interview was coded and the material then formatted to generate individual protocols that
included action and decision steps, indications, contraindications, judgments, sensory cues and
performance standards. These individual step-by-step protocols were reviewed for accuracy and
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 56
completeness by each SME during a follow-up interview with the researcher. The individual
SMEs had the opportunity to adjust, correct, or delete any steps in their individual protocol until
the SME was satisfied with the protocol. The three protocols were then aggregated into a PGSP.
Stage 5: Formatting the results. Three individual SMEs were interviewed and three
unique protocols were created. The revised and corrected individual protocols were aggregated
to create a PGSP.
Gold standard protocol. The template from which the PGSP was developed originated
from the most comprehensive interview that contained the language and terminology evident in
real time practice of handoff reporting. Each action and decision step from each individual
protocol was compared to this template. Similarities in the action and decision steps were
identified. If the action and decision step was interpreted similarly, then the action and decision
step was attributed to both SMEs. When the language or terminology differed, the more
appropriate and acceptable terminology was modified and both SMEs were credited with the
contribution to the PGSP. If there was a step that was not shared by the SMEs, then that step was
added to the PGSP and that step was then integrated into the aggregated PGSP. The PGSP was
then distributed to a fourth SME who reviewed the content and discussed additions, deletions,
and modifications with the researcher. Also any information present on the PGSP that might
appear foreign to a novice was addressed and rectified so that this information was clear and
understandable. Alterations were incorporated into the PGSP and a final gold standard protocol
emerged. The fourth SME did not participate in a formal CTA guided interview. The final gold
standard included action and decision steps to perform patient handoff as well as goals, subtasks,
equipment, concepts, indications and contraindications. The development of the GSP was guided
by the job aid for creating a GSP attached as Appendix C.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 57
Summary
The concepts, processes, and principles CTA method identified by Clark et al. (2008) is
represented as a visually in Figure 1.
Figure 1. Process for Generating the Gold Standard Protocol (Hammitt, 2015)
Data Collection for Question 2
The second research question asked, What percentage of action and/or decision steps,
when compared to a gold standard, do experts anesthesia providers omit when they describe
how to perform a patient handoff report?
Spreadsheet Analysis
To answer Question 2, the GSP was transferred to a Microsoft Excel spreadsheet. Each
individual SME’s protocol was compared to the GSP. If the SME contributed to an action and
decision step, then a number “1” was placed into the cell corresponding to that action or decision
step. If the SME did not contribute to an action or decision step, then a “0” was placed into the
corresponding cell identifying that action or decision step. Each action and decision step was
Researcher Conducts Semi-
structured Interviews
SME A
Individual Protocol
Review Interview
SME B
Individual Protocol
Review Interview
SME C
Individual Protocol
Review Interview
Preliminary Gold Standard Protocol (PGSP)
Gold Standard Protocol (GSP)
SME D
Review of
PGSP
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 58
tabulated for frequency and transformed into percentages demonstrating the number of
agreements and omissions between the individual SMEs protocol and the GSP. The spreadsheet
was additionally used to calculate the alignment between the three SMEs responses.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 59
CHAPTER FOUR: RESULTS
Overview of the Results
The purpose of this study was to determine what action and decisions steps expert
anesthesia providers recall when they describe how they conduct a patient handoff report (PHR)
to the post anesthesia care unit (PACU). This process was initiated by interviewing three subject
matter experts (SME) in the field of anesthesia. The results from the three cognitive task analysis
(CTA) guided interviews reflect the concepts, processes, principles, action and decision steps,
standards, and equipment necessary in patient handoff delivery identified by three SMEs.
Chapter Four sets forth the results from the study.
Research Questions
Question 1
What are the action and decision steps that expert anesthesia providers recall when they
describe how they conduct a patient handoff report to the PACU?
Inter-rater reliability. Inter-rater reliability (IRR) was established by evaluating the
coded items in SME A’s transcript by two trained coders. The number of coded items that the
two assessors agreed upon was divided by the total number of coded items. IRR for this
transcript was 98%. The results of the IRR are attached as Appendix B. As a result of the high
inter-rater reliability score, the researcher was able to proceed and code the additional two SME
protocols and create individualized protocols.
Flowchart analysis. SME A’s first interview was used to create a flow chart attached as
Appendix D. The purpose of the flowchart was to demonstrate via the first interview whether a
logical algorithm describing the process of a postoperative PHR by SME A existed. Each of the
five procedures had a start and an end point. A legend defined the type of action in each
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 60
flowchart. For example, a rectangle defined an action step where a diamond defined a decision
step. The action and decision steps were plotted on the flow chart in this fashion. Arrows were
incorporated into the design to illustrate the pathway that completes each procedure. The
flowchart illustrated how each decision step was a result of an action step. By developing a
flowchart from SME A’s interview, gaps and areas that required further interrogation emerged.
In the second interview with SME A, the gaps that were noted on the flowchart were discussed,
questioned, and expanded upon by SME A. Additions and deletions were incorporated into the
final SME A protocol resulting in a more fluid, understandable, and thorough algorithm.
Evaluation of SME A’s protocol via flowchart analysis also guided the researcher’s interview of
SME B and SME C so that a more robust and directed interview was possible.
Gold standard protocol. Each individual SME protocol was evaluated and aggregated
into a final gold standard protocol for describing PHR from the anesthesia provider to the post
anesthesia care unit (PACU) nurse attached as Appendix E. The most inclusive protocol was that
of SME A, therefore this interview was used as the framework on which the preliminary gold
standard protocol (PGSP) was based. The action and decision steps from each procedural task in
SME B and C’s protocol were compared with SME A’s protocol. When the action and decision
steps were similar both SMEs were affiliated with that action or decision step. When the action
and decision steps were different or an additional step was not addressed by SME A, the step was
added and associated with the specific SME who contributed that step. Therefore, some of the
action and decision steps were associated with all three SME’s (A, B, C) while other steps
included only two (A, B) or one SME (C). An example of the process is shown as Figure 1.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 61
Figure 2. Progression of a Decision Step. Box 1 illustrates similarities in information. Box 2
illustrates additions to the decision step. Box 3 illustrates the aggregated decision steps to the
GSP.
A fourth SME (SME D) was contacted via email to evaluate the PGSP and adjust or
modify the content. SME D received a copy of the PGSP as well as step-by-step instructions on
how to review the protocol. Once SME D had an opportunity to examine the protocol, the
researcher met with SME D to discus additions, deletions, or any potential modifications to the
PGSPs action and decision steps.
The answer to Research Question 1 is found in the final GSP that lists the elements
necessary in the delivery of a PHR to the PACU (Appendix E). The GSP lists five major
procedural tasks. These five tasks include:
1. Acquire prior knowledge of patient’s history and condition;
2. Transport the patient to the PACU;
3. Admit the patient to the PACU;
4. Conduct the verbal encounter of the patient handoff report; and
5. Conclude the patient handoff report.
The disaggregated results are addressed in the following sections.
SME A, B, C –Decision Step:
IF the patient is bradycardic
THEN consider glycopyrrolate
and/or atropine (A, B, C)
SME C’s –Additions (in bold)
to SME A, & B’s Decision
Step:
Consider ephedrine or
electrical pacing (C)
SME C’s –Additions
(underlined) to SME A, B, C’s
Decision Step:
IF the patient is bradycardic,
THEN consider glycopyrrolate
and/or atropine, ephedrine or
electrical pacing (A, B, C)
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 62
Recalled action and decision steps. Action steps are those behaviors that can be
observed. Decision steps are unobservable and are cognitive judgments experts use when
analyzing a problem in order to arrive at a viable conclusion. The action and decision steps
aggregated from the three experts are intended to guide novice anesthesia practitioners in
learning to deliver a PHR. The protocol will illuminate the decision steps experts use but fail to
share during instruction to novice learners.
The transcripts from the three interviews were analyzed so that the action and decision
steps could be tabulated and compared. The researcher transferred the gold standard protocol to a
Microsoft Excel spreadsheet to display the data as shown in Appendix F. The spreadsheet was
formatted such that each action and decision step occupied its own row. If the step was an action
step, that step was coded with an “A” in the left column left of the steps. If the step was a
decision step, that step was coded with a “D.” Each action and decision step was tabulated by
frequency. The protocol additionally included concepts, standards, processes, and principles.
Although this information is crucial in PHR protocol development, the information was not
included in the tabulations with the action and decision steps. Additionally a few action and
decision steps were added by the researcher to address PHR interruptions and distractions during
the performance of the task. This information was also not included in the tabulations of the
action and decision steps. The information was merely added for completeness.
The three SME’s were individually identified as SME A, SME B, and SME C and the
experts’ anonymity was maintained. The lettering reflected the order in which the experts were
interviewed. SME A, B, and C’s action and decision steps were plotted separately in the
spreadsheet in a column specific to the individual SME. The columns tracked the action and
decision steps. If the SME contributed to an action or decision step, the GSP was marked with a
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 63
“1” in the SME’s column. All the actions and decision steps were tallied at the conclusion of the
column.
Action and decision steps contributed by each SME. Table 1 shows the number of
action and decision steps contributed by the individual SME as well as the individual action and
decision steps. The total action and decision steps presented by the individual SME do not
reflect an absolute individual tally. In many instances the SMEs shared similar contributions. For
example, SME A contributed 82 action and decision steps and SME B contributed 84 though the
total number of steps does not equal the cumulative steps in the GSP. Figure 2 displays the
number of action and decision steps contributed from each SME. The disaggregated results are
discussed in the section that follows.
Table 1
Cumulative Action and Decision Steps for Each SME in the Initial Individualized Protocol
______________________________________________________________________________
Steps
Action Steps Decision Steps Total Steps
SME A 33 52 85
SME B 24 43 67
SME C 30 42 73
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 64
Figure 3. Number of Action Steps, Decision Steps, and Action and Decision Steps Contributed
from SME A, B, and C
Action and decision steps captured in the follow-up interviews. At the time of the first
interview each SME was informed that a subsequent interview would be required. The
importance of a secondary interview was to allow the SME to review their individual protocol
and make any additions, deletion, or modifications. Also, this second look provides an
opportunity for the SME to identify any area that a novice might fail to comprehend. The follow-
up interview allowed the researcher to analyze the additions and deletions in the expert’s
knowledge by comparing the first interview with the second interview. By comparing the first
interview with the second interview, omissions and deletions can be tabulated. The results of this
captured data are listed in Table 2.
33
24
30
52
43
42
85
67
73
0
10
20
30
40
50
60
70
80
90
SME A SME B SME C
Action Steps Decision Steps Total
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 65
Table 2
Additional Expert Knowledge Captured, in Action and Decision Steps, During Follow-up
Interviews
_____________________________________________________________________________
Additional Steps Captured
SME Action Decision
A 3 19
B 3 20
C 1 19
D 0 0
Note: SME A, B, and C evaluated their individual protocols during the follow-up interview. SME D did not
participate in the CTA semi-structured interviews and only reviewed the aggregated protocol for additions,
deletions, and modifications. SME D did not add or delete any action or decision steps.
Alignment of SMEs in describing the same action and decision step. As an additional
analysis, the spreadsheet was also set up to evaluate the alignment or agreement of the action and
decision steps between the three SMEs and whether the steps were highly aligned, partially
aligned, or slightly aligned. If an action or decision step was included by only one of the SMEs,
the step was considered “slightly aligned.” In this instance, the step was coded with a number
“1” in the column specific to alignment. If the action and decision step was included by two of
the SMEs, that step was considered “partially aligned” and a number “2” was assigned to the
column. If the action or decision step was described by all three of the SMEs, then that the step
was “highly aligned” and the step was coded with a number “3”. Table 3 displays the results of
this analysis.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 66
Table 3
Number and Percentage of Action and Decision Steps that are Highly Aligned, Partially Aligned,
and Slightly Aligned
_____________________________________________________________________________________
Number Percentage
Highly Aligned 29 23.97%
Partially Aligned 29 23.97%
Slightly Aligned 63 52.07%
_____________________________________________________________________________
Together the three SMEs were “highly aligned” on 29 total points or 23.97%, “partially
aligned” on 29 total points or 23.97%, and “slightly aligned” on 63 total points or 52.07% of the
action and decision steps. These results are discussed in Chapter 5.
Question 2
What percentage of action and/or decision steps, when compared to a gold standard, do
expert anesthesia providers omit when they describe how to perform a patient handoff report?
Total knowledge omissions. The Microsoft Excel spreadsheet was additionally used to
review and evaluate the percentage of omitted action and decision steps when SMEs describe
how to perform a PHR. Those steps that were included on the GSP but were excluded by the
individual SMEs were marked with a “0.” The total number of actions and decision steps was
added and divided by the total number of cumulative action and decision steps for all the SMEs
in the GSP that resulted in a percentage of omissions for action steps, decision steps, and total
steps. Table 4 illustrates the percentage of omitted action and decision steps by each SME. The
results of this study show that 34.62% to 48.46% of the total action and decision steps were
omitted by the three SMEs. Further, Table 4 illustrates the differences between the SMEs action
and decision steps when compared to the GSP.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 67
Table 4
Total Action and Decision Steps, or Expert Knowledge, Omissions by SME when Compared to
the Gold Standard Protocol
______________________________________________________________________________
Steps Omitted
Total Action & Action Decision
Decision Steps Steps Steps
Omitted % Omitted % Omitted %
SME A 45 34.62% 10 23.26% 35 40.23%
SME B 63 48.46% 19 44.19% 44 50.57%
SME C 57 43.85% 13 30.23% 45 51.72%
Mean
Omissions 55 42.31% 14 32.56% 41 47.50%
Analysis of action and decision step omissions. Figure 3 represents the total action and
decision steps omissions for SME A, SME B, and SME C when compared to the gold standard
protocol.
Figure 4. Knowledge Omissions: Action steps, Decision Steps, and Combined Action and
Decision Steps
10
19
13
35
44
45 45
63
57
0
10
20
30
40
50
60
70
SME A SME B SME C
Omitted Action Steps Omitted Decision Steps
Combined Action and Decision Steps
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 68
The following chapter will review an overview of the study, discuss the findings,
implications, limitations, and will conclude with future research.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 69
CHAPTER FIVE: DISCUSSION
The final chapter of this study “The Use of Cognitive Task Analysis to Capture Expert
Patient Care Handoff to the Post Anesthesia Care Unit” incorporates a discussion of the findings,
limitations, and implications for the study.
Overview of the Study
The purpose of the study was to capture the knowledge and skill necessary to perform a
patient handoff report (PHR). The study attempted to uncover the implicit knowledge that is
often omitted during instruction when describing a PHR. It has been hypothesized that experts
may omit up to 70% of critical steps when providing instruction to novices (Feldon & Clark,
2006; Clark, Pugh, Yates, Early, & Sullivan, 2008). If this omitted knowledge can be captured
and replicated novices may benefit from more complete and accurate instruction. In the absence
of expert instruction novices may be unable to effectively replicate the performance of complex
tasks (Clark, 2014; Clark et al., 2008; Feldon & Clark, 2006).
The Joint Commissions mandate to standardize PHR is continuously evaluated and
researched to uncover gaps in verbal information transmission that are often omitted during a
handoff. Despite increased awareness of the reasons for substandard communication and
omissions, training on PHR practices in the field of anesthesia is limited and often under-
supervised (Inglehart, 2008; Nasca et al., 2010). The institution of CTA based training will fill
this void by providing expert knowledge during training of handoff delivery.
Process of Conducting CTA
Selection of Experts
The process of selecting anesthesia experts for this study required methodical processes.
As the provider scope is wide and many anesthesia related subspecialties exist, the goal was to
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 70
choose experts that would represent the general surgical population. Three experts who primarily
administer anesthetics to general surgical populations were asked to participate in the interviews.
Two providers were certified registered nurse anesthetists (CRNA) and one was an
anesthesiologist. The importance of this interdisciplinary panel lends itself to the current practice
of an anesthesia care team. The two CRNAs (SME A and SME B) are employed in a southern
California hospital that provides care to post war veterans and is a teaching facility. This
teaching facility uses a cognitive aid to guide reporting practices. Cognitive aids in the form of
checklists are shown to improve the inclusion of captured information (Arora & Johnson, 2006).
In this study, the use of the cognitive aids by the SMEs may have played a role in the average
total action and decision steps of 57.69% when compared to the Gold Standard Protocol (GSP).
The two CRNAs (SME A and SME B) have over 25 years of experience in anesthesia
delivery and perform as didactic and clinical instructors in anesthesiology. The anesthesiologist
(SME C) has administered anesthesia for greater than 25 years and works in a private facility in
southern California where he administers anesthesia for a variety of clinical services.
All three providers were chosen based upon years of service in anesthesia and reputation
within the anesthesia community. They were highly motivated to improve handoff practices in
their institutions. The literature indicated that expert characteristics include: greater than 10 years
of experience in a domain, superior declarative and procedural knowledge, skilled and reliable
performance, are peer nominated, and should not serve as instructors of the task (Chi, 2006;
Clark et al., 2008; Clark, 2014; Ericsson et al., 1993; Paris, Lipson, & Wixson, 1983). These
SMEs participating in this study fit this profile.
The literature discussed the optimal number of experts necessary to gain the most complete
information. The use of three to five is necessary to capture knowledge to perform complex tasks
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 71
Chao and Salvendy (1994). The use of 3-5 experts has been demonstrated to capture 70% of the
critical information that is often lost in instruction. The use of greater than five experts fail to add
substantial action and decision steps for a given task thus three experts were used.
Collection of Data
Each SME verbalized motivation to participate in the CTA process. Although the time
commitment for the first of the two SME interviews was extensive (approximately 2.5 hours)
each participant was compliant with the process and expressed support for the study. The
literature cites concern that the participant might grow weary, uninterested, or overloaded by the
CTA approach (Canillas, 2010) but this response was not evident in the initial SME interviews.
In the follow up interviews, SME B seemed less enthusiastic about contributing any additional
information. SME B contributed 67 total steps when compared to SME As contribution of 85
steps and SME C 73 steps.
Three explanations are suggested to explain the decreased number of decision steps
described from SME B. First, Perhaps SME B became reticent and too frustrated with the
process of CTA methodology to continue participation. It is conceivable that SME B grew
uninterested and overloaded by the second interview. Clark (2014) asserts that the process of
undergoing CTA interview can be taxing as the expert is expected to dissect the action steps into
specific decision steps. In the absence of adequate preparation for this task the participant may
fatigue and excuse him or herself from further participation. Second, despite the reduction of
action and decision steps SME B did contribute on average nearly as many steps as the other
SMEs. Although perhaps fatigued, the additional decision steps infer that this SME like the
others omitted pertinent information as a result of expertise and automated behavior. Perhaps
SME Bs difficulty lay in articulating the declarative and procedural knowledge necessary for
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 72
PHR. Experts are often challenged when asked to recall the specific action and decision steps in
task performance. Third, it is conceivable that this SME may not have valued the importance in
dissecting the knowledge that is performed automatically. This was apparent in the interview as
she expressed a feeling of “silliness” and “everyone knows this.”
At the onset of the interviews the SMEs were asked to define the task and to describe the
task in terms of large steps or “chunks” that assist the expert to create schemas (Clark et al.,
2008). The SMEs were subsequently encouraged to specify and cite subtasks relating to each
chunk of information. The researcher probed all responses to effectively capture declarative and
procedural knowledge. The collection of data included 5 large steps (how to acquire prior
knowledge, how to transport to the PACU, how to admit the patient to the PACU, how to
verbalize report, and how to conclude report) and multiple decision steps as described above.
As the SMEs verbalized the action and decision steps necessary to perform the postoperative
PHR, they each became aware of the need to reanalyze and or rotate the order of the action and
decision steps, rethink rationales, and correct misconceptions or inaccurate explanations. For
example, SME A in round one of the interview process commented that “if the receiver was
known to her or she trusted her,” an abbreviated PHR was acceptable. However, in round two
she retracted this decision noting that all patient handoff reports should be thorough and
comprehensive or mistakes are made.
Cognitive errors can explain the reason leading to the correction in SME A’s protocol.
Cognitive errors are thought-process discrepancies that can lead to incorrect medical decisions
(Steigler & Ruskin, 2012). Knowledge-based errors can be resolved with education and training;
however remedies to cognitive-based errors are wanting. Though researched in other specialties,
the psychology of decision-making has received little formal attention in anesthesiology (Steigler
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 73
& Tung, 2014). Kahneman (2003) postulated that decision making errors may be a form of
“cutting corners” to reduce cognitive load such that decisions can be executed swiftly when
solving complex problems. Subconscious processes including bias, which most providers may
not recognize, can potentially contribute to omissions resulting in medical errors or incorrect
information as well. The use of meta-cognitive techniques is suggested to overcome such
impediments (Stiegler & Ruskin, 2012) and as such may explain why SME A reflected on her
initial decision point and instituted a change. Stiegler and Ruskin (2012) identify the decision
change described by SME A as a form of cognitive error.
Ericsson (2004) would explain that her behavior was a result of automation. SME A stated in
her interview that the PACU nurses were well known to her and had worked in her facility for
many years. This would mean that SME A has delivered thousands of PHR to these PACU
nurses. With deliberate practice she has become an expert in this task. Further, in this instance
SME A corrected a procedural error by performing a critical step in the PHR incorrectly. The JC
mandates that PHR must be concise and comprehensive. Failing to communicate a
comprehensive PHR because the “receiver was known to her” in itself results in a task error.
Future research that focuses on how anesthesia practitioners make decisions in the postoperative
phase of care using CTA methods is warranted.
Discussion of Findings
The study was guided by two research questions.
Research Question 1
What are the action and decision steps that expert anesthesia providers’ recall when they
describe how they conduct a patient handoff report to the PACU?
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 74
Action steps versus decision steps. Action and decision steps are those behaviors and
cognitive thought processes that are used to perform complex tasks. As one develops expertise
the action and decision steps become automatic and the expert no longer has to exert mental
effort to think through the steps to perform a task. The declarative and procedural knowledge
become automated through deliberate practice freeing up working memory as information is
transferred to long-term memory (Wheatley & Wenger, 2001).
The results of CTA studies often show that experts verbalize a greater number of action
steps when compared to decision steps (Canillas, 2010; Crispen, 2010; Hammit, 2014; Tolano-
Leveque, 2010; Zepeda-MacZeal, 2014). This is particularly evident in healthcare where
practitioners form mental images of a task and thus can recall the action step easier than the
decision steps (Clark, 2014). However, in this study, the three SMEs – in their initial interview
(Round 1) and in the follow-up meeting (Round 2) -- contributed a greater number of decision
steps than action steps. In Round 1, SME A described 52 decision steps and 33 action steps.
SME B described 43 decision steps to 24 action steps and SME C verbalized 42 decision steps to
30 action steps. During round two 1-3 additional action steps were captured and 19-20 additional
decision steps were verbalized. Moreover, these results on PHR via expert description are
contrary to the findings in Cole (2015) and Garcia (2015) who found that individual SMEs
described a greater number of action steps than decision steps in round 1 and round 2 discussions
when describing PHR.
Hammitt (2014) identified in his study that one SME described a greater number of
decision steps. He attributed this finding to the “top down” leadership style of the SME. All
anesthesia care providers who teach delegate decisions consistently as patient status changes.
There can be more than one intervention to a change in patient status. For example, during an
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 75
anesthetic a patient’s blood pressure may decrease. The provider can intervene by administering
fluid, decreasing the level of the inhalational agent, or administering vasopressor medications.
Each of these options might be discussed or employed during instruction. Experts also address
potential adverse events so that a novice can learn from their expertise and experience. Adverse
events are infrequent, but when they do occur, the practitioner must be able to intervene swiftly
and acutely (Stiegler & Tung, 2014). In the current study, this could explain why SME A, B, and
C included more decision than action steps.
Another explanation for the increase in decision steps might be a reflection of the
complexity of the task. There is no “one size fits all” philosophy in the administration of
anesthetics. Patients respond differently to surgery and anesthesia. Each patient arrives with a
unique medical history and is not expected to respond in any uniform manner. The increase in
decision points articulated by AME A, B, and C may have been the result of the “rule of three”
strategy employed in anesthesia (Stiegler and Ruskin, 2012). With this tactic the provider creates
three plausible reasons before settling on a diagnosis. The rule of three may explain why these
anesthesia providers described more decision points. The three SMEs might have described their
IF/THEN statements based on the many potential changes in blood pressure, respiratory rate and
heart rhythm, and the various interventions that are employed. Patient conditions change
moment-to-moment and this highly complex task of delivering a PHR requires critical decisions.
As these three SMEs are experts in anesthesia care delivery, they are highly skilled at making
decision. It is not surprising that decision steps would outnumber action steps.
Anderson (1996) describes stages resulting in automaticity. Anderson (1996) refers to the
first stage of automaticity as the interpretative stage where a learner practices declarative and
procedural knowledge and speaks aloud when learning and performing the task. The second
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 76
stage, the associative stage, describes how the learner uses declarative and procedural knowledge
to solve problems. In anesthesia the DECIDE model helps healthcare members consider the best
course of action (Stiegler and Ruskin, 2014). This model suggests that there are two types of
reasoning when making a decision. The first, type I, allows the practitioner to think fast and
intuitively. Type II is described as a slower phase that requires mental effort and re-evaluation
similar to Anderson’s second phase in developing automaticity. Anesthesia instructors must
clearly elucidate information repetitiously to the students in their charge. The learner is exposed
to information that is ultimately considered important or unimportant. Perhaps the increased
number of decision points in the SMEs recollections resulted from regularly engaging in
teaching.
Action and decision steps captured during the review of the initial individual
protocols and preliminary gold standard protocol. The initial interviews with each SME were
conducted in person such that face-to-face communication would produce the greatest number of
action and decision points. After the initial interviews were concluded, a preliminary protocol
was generated for each SME. In the follow up meeting termed “round 2” the individual SMEs
were then given an opportunity to review and adjust their protocols and to identify any area that
a novice learner might find challenging. In round 2 SME A, SME B, and SME C added 1 to 3
additional action steps and 19 to 20 decision steps.
Three reasons may explain the additions to the action and decision steps in the round two
meeting. First experts may omit up to 70% of the critical action and decision steps when
providing instruction (Clark et al., 2008; Feldon, 2004). Declarative and procedural knowledge is
inadvertently overlooked as knowledge becomes automated through deliberate practice
(Ericsson, 2004). Second experts have difficulty articulating specific unconscious action and
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 77
decision steps due to their automated knowledge and skill that renders knowledge unconscious
for recall (Feldon, 2007). For example, SME B demonstrated expert automaticity and difficulty
articulating action steps during her interview, despite prompting. When asked to describe how to
attach the patient monitors when she verbalized, “but it’s so obvious” and “everybody knows
that.” Third, a model for decision-making is termed “expected utility” (Shoemaker, 1982). This
model invites the practitioner to weigh choices and evaluate the benefit of each decision. The
decision with the greatest expected value is selected. The use of this decision-making model
benefits expert practitioners as patient history, diagnosis, and response to surgery and anesthesia
vary. Having to weighing the many options when responding to changes in patient status may
explain the increase in decision points when compared to action points from these three SMEs in
round 2.
Alignment. The data from this study showed that only 23.97% of the action and decision
steps were highly aligned meaning all three SMEs identified those steps. The percent of partially
aligned (two SMEs identified the steps) items was 23.97% and the slightly aligned (one SME
described the steps) items totaled 52.07%. The results of alignment in this study were an
unexpected finding as each SME is experienced in their craft and has delivered thousands of
PHRs. The research reviewed the spreadsheet to evaluate if there was any connection in the high
alignment percentage of only 23.97%. High alignment included those areas of action steps that
described the elements necessary in verbalizing the PHR and potential intervention when
hemodynamic or respiration variations present in the PACU. Mnemonics and templates for PHR
are cited in the literature for PHR and may explain the higher degree of alignment on these items.
Another explanation is that practitioners experience can influence how they practice and
how the practitioner arrives at a decision point. Stiegler and Tung (2014) assert that medical
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 78
personnel often fail to agree on treatment modalities. The approach to medical interventions is
guided by practice variations as “illness scripts” are created during training. Individual
preferences, bias, and experience affect preferences in care and may explain why the action and
decision steps were not highly aligned. This may mean that for performance of a PHR there is no
“magic PHR” other than perhaps the large “chunks” that are mentions in many of the templates
listed in the literature. Patient care must be tailored to the individual patient care needs, status,
and surgery. Some CTA studies illustrate how expert instruction can effectively teach one
procedure one-way addressing action and decision steps (Embrey, 2012; Tirapelli, 2010;
Sullivan, 2007). PHR teaches one procedure as well but because of the endless patient scenarios
(past medical histories, co-morbidities, surgical procedures, and unique responses to anesthesia)
potentially multiple and endless outcomes exist. More research is needed on specific elements
specific to co-morbidities and PHR.
Question 2
What percentage of action and/or decision steps, when compared to a gold standard, do
expert anesthesia providers omit when they describe how to perform a patient handoff report?
Omissions compared to the gold standard protocol. A gold standard protocol was
created from three aggregated protocols. When the individual SME protocols were compared to
the aggregated gold standard protocol 57.69% of the total action and decision steps were
captured. Only 34.62% to 48.46% of the total action and decision steps were omitted (mean =
42.31%). Of the 42.31% total action and decision steps omitted, 47.51% were decision steps.
Clark et al. (2008) asserts that experts omit up to 70% of critical information novices
need to replicate expert performance. Through practice expertise can be acquired. Ericsson
(2004) claims that ordinary practice does not produce expert performance. The type of practice
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 79
that is required to gain expertise must be deliberate, continual, contain feedback from peers or
mentors, and must challenge the expert in order to elevate performance and become automated
(Clark & Estes, 1996; Ericsson, 2004; Feldon, 2007). Unfortunately the acquisition of expertise
is a double-edged sword. Once automated the expert has difficulty recalling critical elements in
problem solving for the novice learner. Articulation of the task is challenging and often the
expert omits information or communicates information that is inaccurate.
As a result of automaticity the SMEs omitted essential information in explication of the task
of PHR to the PACU. Although the findings show that an average of 47.51% of decision steps
were omitted, the number is below the “70% rule”. The templates suggested in the literature for
conducting a PHR do not consider omissions related to automaticity. These omissions can
include declarative knowledge that is stored in long-term memory or procedural knowledge that
develops as skills are practiced (Anderson, 1996; Clark & Estes, 1996). However the intent of
these templates is to provide a roadmap for practitioners so that information is transferred
effectively during PHRs. Although the percentage of omissions is less than the expected “70%
rule,” automaticity may explain why these experts omitted critical information when describing
the PHR.
The study conducted by Tolano-Leveque (2010) sheds light on a plausible explanation
for the current studies finding as well. Tolano-Leveque conducted a comparison study suggesting
that expert surgeons omit 70% of the critical action and decision steps when performing routine
procedures. The researcher compared the performance of an open cricothyroidotomy (OC)
versus the placement of a central venous catheter (CVC). The results of her study showed that
although the SMEs omitted 76.92% of the decision steps in the OC, the decision steps in the
CVC resulted in an omission rate of only 34.52%. This author attributes this finding to the recent
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 80
publicity surrounding central line placement that perhaps increased the prior knowledge for these
surgeons resulting in a decreased omission percentage.
PHR is currently a popular topic in the medical literature. The performance of
substandard and incomplete PHR is associated with medical error and adverse events. As a result
of the omissions the JC mandates that hospitals standardize, create, and enforce the use of
protocols that will guide comprehensive reporting practices such that oversights do not occur.
Perhaps with the publicity surrounding patient handoff practices, these experts had increased
awareness regarding the regulations and components necessary for a thorough report. Further,
these three experts receive PHR with regularity and may have experienced poor handoffs
prompting them to improve their own practice of facilitating recall of their action and decision
steps. Future research is necessary to address the receiver’s perspective regarding substandard
handoff practices and how the practitioner compensates to remedy ineffective reporting
practices.
Limitations
The current study’s findings were similar to those of previous CTA studies that focused
on capturing declarative and procedural knowledge in the form of action and decision steps. The
following section will address the limitations of the current study.
Conformational Bias
A limitation of the study addresses conformational bias. The researcher has 10 years
experience as an anesthesia provider, provides instruction in the Program of Nurse Anesthesia,
and has 17 years of experience as a critical care nurse. Therefore it was incumbent upon the
researcher to recognize the potential for researcher bias when conducting the CTA study so that
knowledge captured during the study would not be altered.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 81
Internal Validity
Another limitation of the study is that these results have not been validated. GSP would
require validation by comparing it to the three SMEs actually delivering a PHR to the PACU.
Declarative and procedural knowledge would be validated via direct observation to insure
internal validity. Further research would require the comparison of the GSP to actual task
performance.
External Validity
An additional limitation of the study is the threat to generalizability related to the small
sample size of four SMEs and the large domain in anesthesia (patient diagnosis, co-morbidities,
and type of surgery). Last reliance on one SME to provide additions and deletions to the PGSP
lends subjectivity to the GSP. Including experts from various institutions and subspecialties in
anesthesia perhaps would increase generalizability.
Implications
There are many implications for patient care as a result of this study.
Anesthesia Practice
The findings are significant to anesthesia training and education. Currently there is no
standardization for how PHR is taught, delivered, or supervised. Therefore omissions and errors
in judgment persist. Experts eliminate critical information and novices fill in the blanks. A CTA
guided methodology that produces a GSP can be used for training purposes, which could lead to
improved communication and patient outcomes Further recommendations for future research
include:
1. A larger sample size of SMEs to validate the results in this study particularly when it is
unknown how many experts are required in medical CTA;
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 82
2. Due to the many subspecialties in anesthesia the researcher recommends that CTA is
extended into those areas to evaluate comparison on reporting practices; and
3. A CTA performed on experts on the receiving end of PHR to the PACU might fill in
some of the communication gaps that exist.
Education and Training
Cognitive task analysis is a superior means of capturing knowledge which can be used to
train and to improve instruction in the PHR. Although CTA methods are costly and time
consuming, the use of this methodology will reduce the cost and time required to train another on
the task of PHR practices.
Conclusion
Cognitive task analysis is a knowledge elicitation method used to capture expert
knowledge from experts in a domain. Research shows that experts may omit up to 70% of the
critical action and decision steps necessary to perform a complex task. The purpose of the current
study was to conduct a CTA to elicit expert anesthesia provider knowledge of action and
decision steps necessary to perform a patient handoff report. The development of a gold standard
protocol can be used for training novices in the task of PHR to the PACU.
The findings in this study indicate that experts omit critical information. Further findings
indicate that prior knowledge plays a pivotal role in the steps necessary to perform a patient
handoff that is complete and comprehensive. The study also illustrates that the creation of a
comprehensive PHR protocol is met with significant challenges as a result of the many patient
diagnosis, co-morbidities, and surgical procedures. Equally the expertise of the sender and the
receiver of the patient report cannot be discounted.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 83
Despite efforts to standardize, each facility has the opportunity to create an individualized
protocol or has failed to implement a standardized protocol. Until such time that patient handoff
is made a priority reporting practices will remain indiscriminate. Further, until practitioners on
all levels view the PHR as an integral portion of patient care and continuity, practices will
remain lax, interruptions will continue, and patients will remain in harms way. Additionally, the
ability to become expert in the delivery of a patient handoff report will remain elusive until
which time the value of this task is appreciated.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 84
References
Alvarado, K., Lee, R., Fran, N., Boblin, S., Poole, N., Lucas, J., & Forsyth, S. (2006). Transfer of
accountability: Transforming shift handover to enhance patient safety, Healthcare
Quarterly, 9, 75-70.
Amato-Vealey, E.J., Barba, M.P., & Vealey, R.J. (2008). Hand-off communication: A requisite
for perioperative patient safety. APRN Journal, 88(5), 763-770.
Ambrose, S.A., Bridges, M.W., Lovett, M.C., DiPietro, 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 skill. Psychology Review, 89(4), 369-406
Anderson, J.R. (1993). Problem solving learning. American Psychologist, 48(1), 35-44.
Anderson, J.R. (1996). The Architecture of Cognition. Mahwah, NJ: Lawrence Erlbaum
Associates.
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.
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.
Anwari, J.S. (2002). Quality of handover to the post anesthesia care unit nurse. Anaesthesia, 57,
484-500.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 85
Arora V., Johnson J., Lovinger D., Humphrey H., Meltzer D. (2005). Communication failures in
patient sign-out and suggestions for improvement: A critical incident analysis. Quality
and Safety in Healthcare. 14(6), 401-7.
Beckmann, U., Gillies, D.M., Berenholtz, S.M., Wu, A.W., Provonost, P. (2004). Incidents
relating to intra-hospital transfer of critically ill patients: an analysis of the reports
submitted to the Australian incident monitoring study in intensive care. Intensive Care
Medicine, 30, 1579-1585.
Bédard, J., & Chi (1992). Expertise. Current Directions in Psychological Science, 1(4), 135-139.
Berger, J.T., Sten, M., & Stockwell, D.C. (2012). Patient handoffs: delivering content efficiently
and effectively is not enough. International Journal of Risk and Safety in Medicine, 24,
201-205.
Berner, E.S., & Graber, M.L. (2008). Overconfidence as a cause of diagnostic error in medicine,
The American Journal of Medicine, 121(5), s2-s23.
Bother, U., Georgieff, M., & Schwilk, B. (2000). Building a large-scale perioperative anaesthesia
outcome-tracking database: methodology implementation and experiences from one
provider within the German quality project. British Journal of Anaesthesia, 80, 271-80.
Borowitz, S.M., Waggoner-Fountain, L.A., Bass, E.J., & Sledd, R.M., (2008). Adequacy of
information transferred at resident sign-out (in-hospital handover of care): a prospective
survey. Quality and Safety in Health Care, 17, 6-10.
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, CA.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 86
Campbell, J., Tirapelli, L., Yates, K., Clark, R., Inaba, K., Gren, D., Plurad, D., Lam, L., Tang,
A., Cestero, R., & Sullivan, M. (2011). The effectiveness of a cognitive task analysis to
increase self-efficacy and improve performance for an open cricothyrotomy. Journal of
Surgical Education, 68(5), 403-407.
Carroll, J.S., Williams, M., & Gallovan, T.M. (2012). The ins and outs of change of shift
handoffs between nurses: a communication challenge. British Medical Journal Quality
and Safety, 21, 586-593 doi:10.1136/bmjqs_2100-000614
Chao, C.J. & Salvendy, G. (1994). Percentage of procedural knowledge acquired as a function of
the number of experts from whom unknown knowledge is acquired for diagnosis,
debugging, and interpretation of tasks. International Journal of Computer Interaction,
6(3), 221-233.
Chi, M.T.H. (2006). Two approaches to the study of experts’ characteristics. In K.A. Ericsson,
N. Charness, P.J., Feltovich, & R.R. Hoffman (Eds.), The Cambridge handbook of
expertise and expert performance. (p. 21-30) New York: Cambridge University Press
Clark, D. (2013). Communication and Leadership. Retrieved from:
http://www.nwlink.com/~donclark/leader/leadcom.html
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) Ney York, NY:
Springer.
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
environmental Theory and research (pp.283-295). New York: Elsevier
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 87
Clark, R.L. & Estes, F. (1996). Cognitive task analysis for training. International Journal of
Education, 25(5), 403-417.
Clark, R. E., Feldon, D., Van Merriënboer, J., Yates, K., & 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 (3rd ed., pp. 578 -
591). Mahwah, NJ: Lawrence Erlbaum.
Clark, R.E., Pugh, C.M., Yates, K.A., Inaba, K., Green, D.J., & Sullivan, M.E. (2011). The use
of cognitive task analysis to improve instructional descriptions of procedures. The
Journal of Surgical Research, 173(1), e37-e42 doi: 101016/j.jss2011.09.003
Cohen, M.M., Duncan, P.G., Pope, W.D.B., et al., (1992). The Canadian four-center study of
anaesthetic outcomes: II can outcomes be used to assess the quality of anaesthesia care?
Canadian Journal of Anaesthesia, 39, 430-439.
Cole, K. (2014). Using cognitive task analysis to capture how expert anesthesia providers
conduct postoperative patient care handoffs in the intensive care unit (Unpublished
doctoral dissertation). University of Southern California, Los Angeles, CA.
Cooke, N. J. (1994). Varieties of knowledge elicitation techniques. International Journal of
Human-Computer Studies, 41(6), 801-849.
Cooke, N. J. (1999). Knowledge elicitation. In F. T. Durso (Ed.), Handbook of Applied
Cognition (pp. 479-509). New York: Wiley.
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
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 88
cognitive task analysis. Cambridge, MA: MIT Press.
Creswell, J.W. (2003). Research design: qualitative quantitative and mixed methods approaches.
3
rd
. ed. Thousand Oakes, CA: Sage Productions.
Crispen, P. D. (2010). Identifying the point of diminishing marginal utility for cognitive task
analysis surgical subject matter expert interviews (Doctoral dissertation). Retrieved from
ProQuest Dissertations and Theses database. (UMI No. 3403725)
Crum, B.S.G. (2006). Standardizing handoff processes. Association of Operating Room Nurses,
84(6), 1059-1061.
Date, D.F., Sanfey, H., Mellinger, J., Dunnington, G. (2013). Handoffs in general surgery
residency, an observation of intern and senior residents. The American Journal of
Surgery, 206, 693-697.
Dowding, D. (2001). Examining the effects that manipulating information given in the change of
shift report has on nursing care planning ability. Journal of Advanced Nursing, 33(6),
836-846.
Drachler, H., Kicken, W., van der Klink, M., Stoyanov, S., Bushuizen, H.P., & Barach, P.
(2012). The handover toolbox: a knowledge exchange and training platform for
improving patient care. British Medical Journal Quality and Safety, 21 Suppl, 114-120,
doi: 10.1136/bmjqs-2012-00176
Dunphy, B.C., & Williamson, S.L. (2004). In pursuit of excellence. Advances in Health Science
Education, 9, 107-127.
Embrey, K. K. (2012). The use of cognitive task analysis to capture expertise for tracheal
extubation training in anesthesiology (Doctoral dissertation). Retrieved from
http://digitallibrary.usc.edu/cdm/ref/collection/p15799coll127/id/678652
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 89
Ericsson, K.A. (2004). 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. (2009). Development of Professional Expertise. Edited Anders Ericsson.
Cambridge University Press: New York
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-Römer (1993). The role of deliberate practice in the
acquisition of expert performance. Psychology Review, 100(3), 363-406.
Ericsson, K.A., & Lehmann, A.C. (1996). Expert and exceptional performance: Evidence of
maximal adaptation to task constraints. Annual Review of Psychology, 47, 273-305
doi:10.1146/annurev.psych.47.1.273
Ericsson, K.A., Whyte, J., & Ward, P. (2007). Expert performance in nursing: review in research
on expertise in nursing within the framework of the expert-performance approach.
Advances in Nursing Science, 30(1), E58-71.
Feldon, D.F. (2004). Inaccuracies in expert self-report: errors in the description of strategies for
designing psychology experiments (Doctoral dissertation), Retrieved from ProQuest
Dissertations and Theses database. (UMI No. 3145196). University of Southern
California, Los Angeles, CA.
Feldon, D. F. (2007). Implications of research on expertise for curriculum and pedagogy.
Educational Psychology Review, 19(2), 91-110.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 90
Feldon, D.F., & Clark, R.E. (2006). Instructional implications of cognitive task analysis as a
method of improving accuracy of experts’ self-report. In G. Clarebout & J. Elen (eds.),
Avoiding simplicity, confronting complexity: Advances in studying and designing
(computer-based) powerful learning environments. (pp. 109-116). Rotterdam, The
Netherlands: Sense Publishers.
Forrest, J.B., Cahalan, M.K., Rehder, K., et al, (1990). Multicenter study of general anesthesia.
II. Results. Anesthesia, 72, 262-268.
Garcia C.A. (2014). Using cognitive task analysis to capture how anesthesia providers conduct
an intraoperative patient handoff (Unpublished doctoral dissertation). University of
Southern California, Los Angeles, CA.
Gawande, A. A., Zinner, M.J., & Studdert, D.M., & Brennan, T.A. (2003). Analysis of errors
reported by surgeons at three teaching hospitals. Surgery, 133, 614-621.
Glaser, R., & Chi, M. T. H. (1988). Overview. In M. T. H. Chi, R. Glaser, & M. Farr (Eds.), The
Nature of Expertise (p. xv-xxviii). Mahwah, NJ: Lawrence Erlbaum Associates.
Gogan, J. L., Baxter, R. J., Boss, S. R., & Chircu, A. M. (2013). Handoff processes, information
quality and patient safety: A trans-disciplinary literature review. Business Process
Management Journal, 19(1), 70-94.
Gott, S. P., Hall, E. P., Pokorny, R. A., Dibble, E, & Glaser, R. (1993). A naturalistic study of
transfer: Adaptive expertise in technical domains. In D. K. Detterman & R. J. Sternberg
(Eds.), Transfer on trial: Intelligence, cognition, and instruction (pp. 255-288).
Norwood, NJ: Ablex.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 91
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 Surgery, 204, 533-540.
Gucev, G. V. (2012). Cognitive task analysis for instruction in single-injection ultrasound
guided-regional anesthesia (Doctoral dissertation). Retrieved from ProQuest
Dissertations and Theses database. (UMI No. 3513770)
Halstead, W.S. (1904). The training of the surgeon. Bulletin of John Hopkins Hospital, 15, 267-
76.
Hatano, G. & Inagaki, K. (2000). Practice makes a difference: Design principles for adaptive
expertise. Presented at the Annual Meeting of the American Education Research
Association. New Orleans, LA: April, 2000.
Haynes, A.B., Weiser, T.G., Berry, W.R., Lipsitz, S.R., Breizat, A.S., Dellinger, E.P., … (2009).
Surgical safety checklist to reduce morbidity and mortality in a global population. New
England Journal of Medicine, 360, 491-499.
Hind, 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), 1232-1243.
Hoffman, R., Crandall, B., & Shadbolt, N. (1998). Use of the critical decision method to elicit
expert knowledge: A case study in the methodology of cognitive task analysis. Human
Factors, 40(2), 254-276. doi:10.1518/001872098779480442
Hoffman, R. & Militello, L. (2009). Perspectives on cognitive task analysis: Historical origins
and modern communities of practice. New York: Psychology Press.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 92
Hoffman R., Woods D. (2000). Studying cognitive systems in context: Preface to the special
section. Human Factors: Journal of Human Factors Ergonomics Society, 42(1), 1-7.
Inglehart, J.K. (2008). Revising duty hour limits- IOM recommendations for patient safety and
resident education. New England Journal of Medicine, 359(25), 2633-2635.
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, D.C:
National Academy Press.
Jackson, P.W. (1985). Private lessons in public schools. Remarks on the limits of adaptive
instruction. In M.C. Wang & H.J. Walberg (Eds.) Adapting instruction to individual
differences. (pp. 68-81). Berkely, CA: McCutchan.
Jayasuriya, J.P., & Anandaciva, S. (1995). Compliance with an incident report scheme in
anesthesia. Anesthesia, 50, 846-849.
Jeffcott, S.A., Evans, S.M., Cameron, P. A. S., Chin, G.S.M, & Ibrahim, J.E. (2009). Improving
measurements in clinical handover. Quality Safety Health Care, 18, 272-277.
Joint Commission. (2014). National Patient Safety Goals Effective January 1, 2014. Retrieved
October 16, 2014 from
http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf
Joint Commission. (2008). Handoff communications. Retrieved January 27, 2014, from
http://www.jointcommission.org/issues/article.aspx?Article=RZlHoUK2oak83WO8Rkm
Z9hVSIJT8ZbrI4NznZ1LEUk%3D
Kahneman, D.A. (2003). A perspective on judgment and choice: mapping bounded rationality.
American Psychology, 58, 697-720.
Kirschner, P. A, Sweller, J., & Clark, R. E. (2006). Why minimally guided instruction does not
work: An analysis of the failure of constructivist, discovery, problem based, experiential,
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 93
and inquiry based teaching. Educational Psychologist, 41(2), 75-86. doi:
10.1207/s15326985ep4102_1
Kitch, B.T., Cooper, J.B., Zapol, W.M., Marder, J.E., Karson, A., Hutter, M., & Cambell, E.G.
(2008). Handoffs causing patient harm: A survey of medical and surgical house staff.
Joint Commission Journal on Quality Patient Safety, 34(10), 563-70.
Klein, G. A., Calderwood, F., & Macgregor, D. (1989). Critical decision method for eliciting
knowledge. IEEE Transections on Systems, Man, and Cybernetics, 19(3), 461-472 .
Kopp, V.J., & Shafer, A. (2000). Anesthesiologists and perioperative communication.
Anesthesiology, 93, 548-555.
Lamond, D. (2000). The information content of the nurse change of shift report: a comparative
study. Journal of Advanced Nursing, 31(4), 794-804.
Lane-Fall, M.B., Brooks, A.K., Wilkins, S.A., Davis, J.J., Riesenberg, L.A. (2014). Addressing
the mandate for handoff education. 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.
Lyons, V.E., & Popejoy, L.L. (2014). Meta-analysis of surgical safety checklist effects on
teamwork, communication, morbidity, mortality, and safety. West Journal of Nursing
Research, 36(2), 245-261 doi: 10.1177/0193945913505782
Manser, T., Foster, S., Flin, R., & Patey, P. (2013). Team communication during patient
handover from the operating room: more than facts and figures. Human Factors, 55(1),
138-156.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 94
Manser, T., & Foster, S. (2011). Effective handover communication: An overview of research
and improvement efforts. Best Practice and Research Clinical Anaesthesiology, 25, 181-
191.
Masters, R.S.W. (1992). Knowledge, knerves, and know-how: the role of explicit versus implicit
knowledge in the breakdown of a complex motor skill under pressure. British Journal of
Psychology, 83, 343-358.
Maughan, B. C., Lei, L., & Cydulka, R. K. (2011). ED handoffs: Observed practices and
communication errors. American Journal of Emergency Medicine, 29, 502-511.
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). Hills
Merrill, M. D. (1994). Instructional Design Theory. Englewood Cliffs, NJ: Educational
Technology Publications.
Milby, A., Bohmer, A., Gerbershagen, M.U., Joppich, R., & Wapplwe, F. (2014). Quality of
postoperative handover in the post-anaesthesia care units: a prospective analysis. Acta
Anaesthesiologica Scandinavica, 58, 192-197.
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.
Nagpal, K., Abboudi, M., Machanda, C., Vats, A., Sevdialis, N., Bicknell, C., Vincent, C., &
Moorthy, K. (2013). Improving postoperative handover: a prospective observational
study. The American Journal of Surgery, 206, 494-501.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 95
Nasca, T.J., Day, D.S.H., & Amis, E.S. (2012). The new recommendations on duty hour from the
ACGME task force. The New England Journal of Medicine, 363e3, 1-6.
National Patient Safety Goals. (2008). Retrieved from:
http://www.joingcommision.org/PatientSafety/NationalPatientSafetyGoals/08_cah_npsg.
htm ???
Nehr, J.O. & Stevens, N. (2003). The one-minute preceptor. Shaping the teaching conversation.
Family Medicine, 35, 391-393.
Oosterhof, A. (2011). How different types of knowledge are assessed. Retrieved from
http://wwwcala.fsu.edu/modules/assessing_knowedge/
Paris, S.G., Lipson, M.Y., & Wixson. (1983). Becoming a strategic reader. Contemporary
Educational Psychology 8, 293-316.
Perry, S. (2004). Transitions in care: studying safety in emergence department signovers. Focus
on Patient Safety, 7(2), 1-3.
Petersen, L.A., Orav, E.J., Teich, J.M. et al. (1998). Using a computerized sign-out program to
improve continuity of inpatient and prevent adverse events. Joint Commission Journal on
Quality Improvement, 24(2), 77-87.
Patterson, E., & Wears, R.L. (2010). Patient handoffs: Standardized and reliable measurement
tools remain elusive, Joint Commission Journal on Quality and Patient Safety, 36(2), 52-
61.
Pezzolesi, C., Schifano, F., Pickles, J., Randell, W., Hussain, Z., Muir, H., & Dhillon, S. (2010).
Clinical handover incident reporting in one UK general hospital. International Journal
for Quality in Health care, 22(5), 396-401.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 96
Pringle, P.L., Collins, C., Santry, H.P. (2013). Utilization of morning report by acute care
surgery teams: Results from a qualitative study. The American Journal of Surgery, 206,
647-654.
Riesenberg, L.A., Leitzsch, J., & Cunningham, J.M. (2010). Nursing handoffs: A systematic
review of the literature. American Journal of Nursing, 110(4), 24-34.
Sandlin, D. (2007). Improving patient safety by implementing a standardized and consistent
approach to handoff communication. Journal of Perianesthesia Nursing, 22(4), 289-292.
Schraw, G. & Moshman, D. (1995). Metacognitive theories. Educational Psychology Review,
7(4), 351-371.
Segall, A., 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 and Analgesia, 115(1), 102-115.
Schraagen, J. M., Chipman, S. F., & Shalin, V. L. (2000). Cognitive Task Analysis. Mahwah, NJ:
Lawrence Erlbaum Associates.
Simon, W., & Chase, H.A. (1973). Perceptions in chess. Cognitive Psychology, 5, 55-81.
Shoemaker, P.H.J. (1982). The expected utility model- its variants, purposes, evidence and
limitations. Journal Econ Lit, 20, 529-563.
Smith, A.F., & Mishrak, K. (2010). Interactions between anaesthetists, their patients, and the
anaesthesia team. British Journal of Anaesthesia, 105(1), 60-68.
Smith, A.F., Pope, C., & Goodwin, D. (2008). Interprofessional handover and patient safety in
anesthesia: an observational study of handovers in the recovery room. British Journal of
Anaesthesia, 101(3), 332-337.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 97
Steigler, M.P., & Ruskin, K.J. (2012). Decision-making and safety in anesthesiology. Current
Opinion in Anesthesiology, 25(6), 724-729.
Stiegler, M.P., Tung, A. (2014). Cognitive processes in anesthesiology decision making.
Anesthesiology, 120(1), 204-217.
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 instructional limitations of experts in the teaching of procedural skills.
Academic Medicine, 89(5), 1-6.
Sweller, J. (1988). Cognitive load during problem solving: Effects on learning. Cognitive
Science, 12(2). 257-285.
Tirapelli, L.A. (2010). The effect of cognitive task analysis based instruction on surgical skills
expertise and performance (Doctoral dissertation). Retrieved from ProQuest Dissertation
and Thesis database. (UMI No. 3403766).
The Free Dictionary. (2015). Retrieved from: http://medical
dictionary.thefreedictionary.com/ASA+III
The Gale Group. (2009). Sociocultural Theory. Retrieved from:
http://www.education.com/reference/article/sociocultural-theory/
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 98
Tofel-Grehl, C. & Feldon, DF.F. (2013). Cognitive task analysis-based training: A meta-analysis
of studies. Journal of Cognitive Engineering and Decision-making, 73(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) Retrieved from ProQuest Dissertations and Thesis, (UMI No. 3418184).
Van Eaton, E.G., Horvath, K. D., Lober, W.B., Rossine, A.J., & Pelligrini, C.A. (2005). A
randomized control trial evaluating the impact of a computerized rounding and sign-out
system on continuity of care and resident work hours. Journal of American College of
Surgery, 200(4), 538-545.
Van Merrienboer, J.J.G., Clark, R.E., deCroock, M.B.M. (2002). Blueprints for complex
learning. The 4C/ID Model. Educational Technology and Research Development, 50(2),
39-64.
Velmahos, G., Toutouzas, K., Sillin, L., Chan, L., Clark, R.E., Theodorou, D, & Maupin, F.
(2004). Cognitive task analysis for teaching technical skill in a animate surgical skills
laboratory. The American Journal of Surgery, 187, 114-119.
Wayne. J.D., Tyagi, R., Reinhardt, G., Rooney, D., Makoul, G., Chopra, S., & DaRosa, D.A.
(2008). Simple standardized patient handoff system that increases accuracy and
completeness. Journal of Surgical Education, 65(6), 476-485.
Weinger, M.B., & Slagle, J. (2002). Human factors research in anesthesia patient safety. Journal
of the American Medical Informatics Association, 9, s58-s63 doi: 1-.1197/jamia.M1229
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: Elsevier Science Ltd.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 99
Wheeler, K.K. (2014) Effective handover communication. OR Nurse, Retrieved from
http:/www.ORNurseJournal.com
Wohlauer, M.V., Arora, V.M., Horwitz, L.I., Bass, E.J., Mahar, S.E. & Philibert, I. (2012). The
patient handoff: A comprehensive curricular blueprint for resident education to improve
continuity of care. Academic Medicine, 87(4), 411-418.
Woods, D. D., & Roth, E. M. (1988). Cognitive engineering: Human problem solving with tools.
Human Factors: the Journal of the Human Factors and Ergonomics Society, 30(4), 415-
430.
World Health Organization. (2014) Action on Patient Safety- High 5s. Retrieved from
http://www.who.int/patientsafety/implementation/solutions/high5s/en/
Young, J.S., Smith, R.L., Guerlain, S & Nolley, B. (2007). How residents think and make
medical decisions: implications for education and patient safety. American Journal of
Surgery, 73,548-553.
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.
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 TO THE POSTANESTHESIA CARE UNIT 100
Appendix A
Interview Protocol
Cognitive Task Analysis Interview Protocol
Begin the Interview: Meet the Subject Matter Expert (SME) and explain the purpose of the
interview. Ask the SME for permission to record the interview. Explain to the SME the
recording will be only used to ensure information will not be missed.
Name of task(s): Patient care handoff from the operating room to the post anesthesia care
unit (PACU).
Performance Objective: To conduct an accurate and complete exchange of patient care
information between the anesthesia provider (sender) from the operating room to the nurse
(receiver) in the post anesthesia care unit in order to achieve consistency in communication
and information exchange during the patient care handoff.
Ask: “What is the objective of this task? What action verb should be used?”
Step 1:
Objective: To capture 100% accurate transfer of patient information during the patient care
handoff from the operating room to the post anesthesia care unit.
A. Ask the SME to list provider outcomes when these tasks are complete. Ask them to make
the list as complete as possible
B. How is the provider assessed on these outcomes?
Step 2:
Objective: Provide practice exercises that are authentic to the job environment in which the
tasks are performed
A. Ask the SME to list all the contexts in which these tasks are performed
B. Ask the SME how the tasks would change for each job setting
Step 3:
Objective: Identify main steps or stages to accomplish the task
A. Ask the 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.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 101
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 can
perform the task.”
For each step the SME gives you, ask yourself, “Is there a decision being made by the
SME here?” If there is a possible decision, ask the SME.
If SME indicates that a decision must be made…
C. 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.
Ask SME about the prerequisite knowledge and other information required to perform the
task.
Ask the SME about Cues and Conditions
A. 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?”
Ask the SME about New Concepts and Processes
B. 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
Processes - How something works
If the novice is operating equipment, or working on a team that may or may not
be using equipment, ask the SME to “Please describe how the team and/or the
equipment work - in words that novice will understand. Processes usually consist
of different phases and within each phase, there are different activities – think of
it as a flow chart”
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 102
C. Ask: “Must novices know this process to do the task?” “Will they have to use it
to change the task in unexpected ways?”
IF the answer is NO, do NOT collect information about the process
Equipment and Materials
D. Ask: “What equipment and materials are required to succeed at this task in
routine situations?
Where are they located? How are they accessed?
Performance Standard
E. Ask: “How do we know the objective has been met? What are the criteria, such
as time, efficiency, quality indicators (if any)?”
Sensory experiences required for task
F. Ask: “Must novices see, hear, smell, feel, or taste something in order to learn any
part of the task? For example, are there any parts of this task they could not
perform unless they could smell something?”
Step 6:
Objective: Identify routine or simple problems that can be solved by using the procedure.
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.
A. Ask: “Of the task we just discussed, describe at least one routine problem that
the novice should be able to solve IF they learn to perform the task”.
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 103
Appendix B
Inter-Rater Reliability Code Sheet for SME A
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 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 end of the step.
5. Repeat Step 4 by comparing P3 with P1, and so forth for each protocol.
6. Repeat Steps 4 and 5 for the remaining components of the CTA report such as triggers,
main procedures, equipment, standards, and concepts to create a “preliminary gold
standard protocol” (PGSP).
7. Verify the PGSP by either:
a. Asking a senior SME, who has not been interviewed for a CTA, to review the
PGSP and note any additions, deletions, revisions, and comments.
b. Asking each participating SME to review the PGSP, and either by hand or using
MS Word Track Changes, note any additions, deletions, revisions, or comments.
i. IF there is disagreement among the SMEs, THEN either
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 105
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 TO THE POSTANESTHESIA CARE UNIT 106
Appendix D
SME A Individual Flowchart
Begin Procedure 1
Acquire prior
knowledge of
patient
Locate chart and/or
patient
Research patient
information and
evaluate safe vital
signs
Preop clinic
or EMR
End Procedure
1
Begin and End
Process
My Actions
Decision
Point
Off
Page
Connector
Y = YES
N = NO
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 107
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 108
Begin Procedure 3
Admit the patient
to the PACU
Attach pulse
oximeter and
evaluate respiratory
rate
Is the rate
normal
Proceed to next step
Intervene
Attach
ECG
Is the
rhythm
normal
Proceed to next step Intervene
Y N
Y N
Procedure
3 Continued
on next page
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 109
a
Procedure
3 Continued
previous
page
Attach BP
Is the BP
normal
Proceed to next step Intervene
Attach additional
monitoring devices
Procedure
3 Continued
on next page
Y N
Attach, verify and
assess values
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 110
a
Procedure
3 Continued
from
previous
page
Evaluate
Temperature
Proceed to next step Intervene
Is the temp
normal
Evaluate LOC level
Y
N
Is LOC
normal
Proceed to next step
Intervene
Procedure
3 Continued
on next page
Y
N
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 111
Procedure
3 Continued
from
previous
page
Assess any
additional
postoperative
considerations
End Procedure 3
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 112
Begin Procedure 4
Conduct patient
handoff
Are vital
signs
stable
Continue to monitor Proceed to next step
Identify receiver of
report
Prepare
documentation
Is receiver
capable
Procedure
4 Continued
on next
Continue to monitor
Proceed to next step
Y
N
Y N
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 113
Procedure
4 Continued
from
previous
page
Begin report
Communicate situation,
background, surgical
background, assessment
and recommendations
Any
unusual
events
Communicate the
abnormality
Proceed to next step
to next step
Procedure
4 Continued
on next page
Y
N
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 114
Procedure
4 Continued
from
previous
page
If at any time the
patient becomes
unstable stop report
Call for assistance
Do you
need help
N
Y
Y
End of Procedure
4 Initiate handoff
report
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 115
Begin Procedure 5
Reanalyze
Are the vital
signs stable
Intervene Proceed to next step
Conclude patient
handoff
Answer the
questions
Conclude handoff
report
Are there
questions
Y N
Y N
Conclude handoff
report
End Procedure 5
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 116
Appendix E
Gold Standard Protocol
Task Title: Postoperative Patient Handoff to the Post Anesthesia Care Unit
1. Objective
To capture pertinent patient information and to provide the safe transfer of care from the
operating room to the care of the receiving staff member in the post anesthesia care unit
(PACU)
To provide safe recovery from anesthesia
2. Reasons
To transfer the responsibility of care from the anesthesia provider to the PACU nurse
(transfer is a physical and verbal encounter)
Ensure continuity of care and best patient outcome
Risks of not performing a patient handoff safely
Missed information
3. Conditions
Indications
Conclusion of surgical procedure
Patient stable
PACU informed of the arrival time
Contraindications (Indications not to deliver a patient handoff report)
An unstable patient does not leave the operating room or transport to the PACU
An incapable practitioner
4. Standards
Time: approximately 10-15 minutes or longer if necessitated by clinical condition
Patient hook up: 2-3 minutes
5. Equipment
Mandatory
Oxygen (O 2) tank/wall source > 50% full
Pulse oximeter
Electrocardiogram (ECG)
Blood pressure (BP) monitor
Variable size airways (nasal and oral)
Intubating equipment
Ambu bag with flow meter
Suction
Medication access
Intravenous supplies
Intravenous pressure bags
Warm blankets
Anesthesia record
Pen
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 117
Anesthesia related forms
Recommended
Transport monitor
Medication
NOTE: The process of accruing patient information and updated status is ongoing. Information is
delivered to ensure a continuous picture of the patient’s previous and current status.
6. Procedure List
1. Acquire prior knowledge of patient history and condition
2. Transport the patient to the PACU
3. Admit the patient to the PACU
4. Conduct the verbal encounter of the patient handoff
5. Conclude the patient handoff
7. Procedure Steps
Procedure 1: Acquire prior knowledge of patient history and condition
Step: Action and Decision
1.1 Prior to meeting the patient the anesthesia provider will read the patient’s history, medical record,
specialty progress notes; consult with specialties if necessary, review physician note; and evaluate
laboratory results, patient scans, and xrays. Additional inquiry includes:
cardiac/pulmonary/neurologic/renal/hepatic/ hematologic/coagulopathic system disease and
medication review (A, B, C)
1.2 Assess vital signs (VS) and VS variations. Decide what the VSs theoretical “safe range” is for the
patient during the operative time (A, B)
1.3 Evaluate patient information via patient interview, chart or electronic medical record (EMR) (A,
B, C)
1.3.1 IF the patient was seen in the preoperative clinic, THEN review and verify the pre-
assessment notes or any pre-anesthetic note (A, B)
1.3.1.1 IF the patient was assessed by an individual other than yourself, THEN re-assess the
patient airway and any pertinent history affecting the anesthetic plan (B, D)
1.3.2 IF the patient is a scheduled AM admit, THEN consider calling the patient the night
before to discuss and review the anesthetic plan (C)
1.3.3 IF you meet the patient in the preoperative holding area, THEN verify the patient
information, perform an airway assessment including auscultation of the cardiac and
pulmonary system (B)
1.3.4 IF the patient was previously admitted to the hospital, THEN review the patient’s records,
go see the patient for preoperative anesthetic discussion, perform an airway, assessment,
and auscultate cardiac and pulmonary system (A, C)
1.3.5 IF the patient is an emergent admission, THEN see the patient immediately and complete
a preoperative assessment as efficiently as time permits (B)
1.4 Develop and anesthetist plan based on patients current condition
1.5 Review any prescription and non-prescription medications (C)
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 118
1.5.1 IF the patient was given instructions on which medications should be taken the night
before surgery or the morning of surgery, THEN review and verify the medications taken
(C)
1.5.2 IF the patient is taking narcotics preoperatively or is a chronic pain medication patient,
THEN discuss the optimal pain regime with the patient and family prior to surgery (C)
1.5.3 IF the patient took h/her aspirin or theinopryidine, THEN inform the surgical team
preoperatively (C)
1.6 Be prepared to report pertinent past history, current condition, and the intraoperative course (type
of anesthesia, all trends in VS, medications, antibiotic/narcotic/antiemetic administration and
time, intravenous line location, room air saturation, and any intraoperative incidents) to the
PACU nurse (A)
1.7 Report to the PACU should include incidents or events that may impact PACU care (A)
Procedure 2: Transport the patient to the PACU
Steps: Action and Decision
2.1. Determine that the patient is stable for transport to the PACU (A, B, C)
2.1.1. IF the patient is unstable, THEN do not transport to the PACU. The patient should be
admitted directly to the intensive care unit (A)
2.2. Ask the circulating nurse to call ahead to the PACU and inform the unit of your estimated time
of arrival and any supplies the patient may require on admission (Example: cool mist, breathing
treatment, warming measures, ventilator) (B, C)
2.3. Prepare to exit the operating room (OR) (A, B, C)
2.3.1. Verify stable VS (A)
2.3.1.1. IF the patient had both hemodynamic and respiratory stability intraoperatively,
THEN transport monitors are not required for transport (C)
2.3.2. Transfer the patient to the gurney or bed (D)
2.3.3. Verify that the O 2 tank is full and place the patient on O 2 (8-10 liter flow) (A)
2.3.4. Position the patient supine so that you can visualize the patients head and chest at all
times and perform airway assistance if necessary (B, C)
2.3.5. Remove the ECG and BP monitors (D)
2.3.6. Stand at the head of the bed (A, B, C)
2.3.7. Remove the pulse oximeter and transport (E)
2.4. Place the patient on 8-10 liters O 2 mask flow prior to leaving the OR to alleviate the risk of
carbon dioxide, nitrous oxide, and volatile re-breathing, and have an oral or nasal airway
available (C)
2.4.1. IF the patient required increased controlled substances or vasoactive medications
intraoperatively, THEN bring the medication with you to the PACU (A, B)
2.4.2. IF the anesthesia provider had to remain in the OR after the completion of surgery to
reverse muscle relaxant, THEN bring extra reversal agents (glycopyrrolate &
neostigmine) to the PACU (B)
2.5. Avoid the use of towels or pillows that may cause head tilt and airway obstruction (C)
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 119
2.6. Position the patient supine so that you can visualize and perform airway assistance if necessary
(B, C)
2.6.1. IF the patient has a history of passive gastric regurgitation, THEN position the head of
the bed 30 degrees up to help avoid aspiration risk (C)
2.6.2. IF the patient is obese or has a history of obstructive sleep apnea, THEN position the
head of the bed up 30 degrees, stand at the side of the bed, stimulate the patient to ensure
adequate respirations (A, B, C)
2.6.3. IF the patient requires airway patency assistance during transport, THEN perform a
maneuver to ensure airway patency (open the airway, chin lift, nasal or oral airway, sit
the patient up) (B, C)
Procedure 3: Admit the patient to PACU
Steps: Action and Decision
3.1 Inform the receiving unit if the patient has any condition that may harm the staff. (Hepatitis C,
VRE, HIV, MRSA c-diff, Post-traumatic stress disorder, emergence delirium). Do not allow the
staff to touch the patient until proper barrier precautions have been initiated (A, C)
3.2 Ask the PACU nurse will attach the patient to the monitoring system (E)
3.2.1 IF the PACU nurse is not ready, THEN the anesthesia provider will attach the patient to
the monitoring system and evaluate the VS (E)
3.3 Maintain open communication with the PACU nurse regarding any unexpected or suboptimal VS
during the hook up process (E)
3.4 Continuously evaluates the respiratory rate (RR) and rhythm (A, B, C)
3.4.1 IF adequate RR (8-10 breath per minute (bpm)), THEN no action required proceed to
next step: 3.5 (A, B, C)
3.4.2 Initiate interventions when the respiratory rate and pattern are inadequate (RR < 8 bpm,
shallow, or rapid respirations) (A, B, C)
3.4.2.1 IF the patient has trouble clearing the airway, THEN suction the patient
immediately (B)
3.4.2.2 IF RR is < 8 bpm, saturation < 95% despite 10 liters O 2, patient is breathing
shallowly or is somnolent, THEN consider a narcotic or benzodiazepine antagonist
if you suspect liberal narcotic or benzodiazepine administration intraoperatively,
and assist the airway (A, B)
3.4.2.3 IF RR < 8 bpm, THEN do not medicate for pain (B)
3.4.2.4 IF the patient is wheezing, THEN sit the patient up, and ask the PACU nurse to call
for a breathing treatment immediately (B)
3.4.2.5 IF the patient has stridor, THEN sit the patient up, increase O 2 flows, ask the
PACU nurse to call for a breathing treatment immediately, reassess
anticholineterase reversal. Consider terbutiline, racemic epinephrine, draw an
arterial blood gas, or advanced airway techniques (B)
3.4.2.6 IF decreased RR is related to weakness from residual paralysis (assess train of four,
hand grasp, lift head for 5 seconds), THEN place a nasal airway and administer the
recommended dose reversal agents (glycopyrrolate & neostigmine) (B)
3.4.2.6.1 IF reversal agent was necessary, THEN do not administer narcotics until
the RR is adequate and saturation > 95% (B,E)
3.4.2.7 If saturation < 95% and the patient appears cyanotic, THEN reestablish the patient
airway (jaw thrust, nasal or oral airway, consider ventilator assistance with bag
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 120
mask, non-rebreather, and or advanced airway technique and equipment). Request
additional assistance from nursing and medical staff. (A, B, C)
3.4.2.8 IF the patient has respiratory compromise and does not respond to the above
interventions, THEN call for nursing and medical staff assistance, emergency
equipment, and prepare to reestablish the airway (C)
3.5 Remove the O 2 and attach the pulse oximeter to the wall flow meter for analysis (place on finger,
toe, ear lobe) (A, B, C)
3.5.1 Evaluate saturation (A, B, C).
3.5.1.1 IF the saturation is > 95% (B) on 10 (L) or within 2% of the patients baseline,
THEN no action required proceed to next step: 3.6 (A, B, C)
3.5.2 Initiate interventions when the saturation is suboptimal (A, B, C)
3.5.2.1 IF the saturation is 95% (B) and not within 2% of the patient’s baseline, THEN
verify that the pulse oximeter is correct (evaluate the wave form, change the
position of the pulse oximeter) (A, B)
3.5.2.2 IF the value is correct, THEN increase the O 2 flows, encourage the patient to take
deep breaths, and identify the cause of hypoxemia (low inspired FiO 2,
hypoventilation, VQ mismatch, diffusion abnormality, right to left cardiac shunt)
(A, B, C)
3.6 Attach and analyze the surface ECG (A, B, C)
3.6.1 IF the postoperative ECG is unchanged (within 15-20%) from the preoperative and
intraoperative period, THEN no action required proceed to next step: 3.7 (A, B, C)
3.6.2 Assess causation of ECG rate related abnormalities, arrhythmias, evidence of ischemia
or injury (A, B, C)
3.6.2.1 IF new onset arrhythmias, THEN assess for hypotension (A, B, C) and hypercarbia
(C)
3.6.2.2 IF the patient is bradycardic but within 20% of the patient baseline, THEN no
action required, proceed to next step: 3.10
3.6.2.3 IF bradycardic and < 20% baseline, THEN consider excess anticholinesterase as a
potential cause and administer glycopyrrolate (B)
3.6.2.4 IF the patient is bradycardic and symptomatic, THEN consider glycopyrrolate,
atropine, (A, B), ephedrine, or electrical pacing (C)
3.6.2.5 IF the patient is tachycardic and symptomatic, THEN evaluate for adequate pain
control and hypovolemia (C)
3.6.2.6 IF tachycardia and the BP is baseline or elevated, THEN treat with beta blockers if
not contraindicated (example: asthma or COPD) (A)
3.6.2.7 IF ECG suggests ischemia (ST elevation) or infarct (ST depression), THEN do a
12-lead ECG STAT and call for cardiology evaluation and assistance (A, B, C)
3.6.2.8 IF the heart rhythm is unstable and/or a non-perfusing rhythm, THEN call for
nursing and medical assistance immediately and initiate Advanced Cardiac Life
Support (A, B)
3.7 Attach BP cuff and evaluate the BP (A, B, C)
3.7.1 IF the BP is the patient’s baseline, THEN no action required, proceed to next step: 3.8
(A, B)
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 121
3.7.2 IF the BP is < or > than 20% of the preoperative baseline, THEN recycle, reassess, and
assess if the patient is symptomatic (A, C)
3.7.3 Consider assessing the BP on the opposite extremity to ensure accuracy before
treatment is initiated (C)
3.7.4 Identify and evaluate the causation of hypotension (C)
3.7.4.1 IF hypotension is related to residual anesthetic, THEN assure adequate
ventilation and stimulate the patient (C)
3.7.4.2 IF hypotension is related to hypovolemia, THEN consider lowering the head of
the bed (if no contraindication), administering intravenous (IV) crystalloids,
vasopressors (neosynephrine or ephedrine), consider blood bank communication
to ensure blood product availability if necessary (A, C)
3.7.4.3 IF the patient is hypotensive with a history of stroke or myocardial infarction,
THEN administer IV fluids with consideration of underlying patient condition.
Consider blood bank communication to ensure blood product availability if
necessary (C)
3.7.4.4 IF hypotension is related to blood loss, THEN administer IV fluids with
consideration of underlying patient condition. Consider blood bank
communication to ensure blood product availability if necessary (C)
3.7.4.5 IF the patient demonstrates critical hypotension (BP systolic < 50 mmHg), THEN
request additional nursing and medical staff to assist with resuscitation, establish
further IV access, consider arterial or central line placement, aggressive
crystalloid or colloid resuscitation, vasopressor support, and emergent blood
bank notification. (A, C)
3.7.5 Identify and evaluate causation of hypertension (A, C)
3.7.5.1 IF systolic BP is < 170 mmHg and diastolic BP < 110 mmHg in a patient without
co-morbidities, THEN no action required unless the patient remains hypertensive
before discharge from the PACU (C)
3.7.5.2 IF the patient is in pain, THEN administer pain medication (A, B, C)
3.7.5.3 IF the patients bladder is full, THEN drain the bladder (A)
3.7.5.4 IF the patient exceeds 20% of h/her baseline with co-morbidities such as
coronary, cerebrovascular disease or if a plastic case, THEN administer
medication to decrease BP to an appropriate range (consider esmolol if heart rate
is elevated > 70 beats and no history of asthma, nitroglycerine or longer acting
agents such as labetolol or metoprolol) (A, B, C)
3.7.5.5 IF BP is critically elevated (210/115), THEN treat regardless of the cause with
short acting agents (esmolol) and consider administering longer acting anti-
hypertensive agents (labetolol or metroprolol), or IV antihypertensive
medications (nitroglycerine) (A, B)
3.8 Assess level of consciousness (A, B)
3.8.1 Ask the patient to open h/her eyes, squeeze your hand, and follow simple commands
(A)
3.8.1.1 IF altered orientation or combative THEN request that the patient be restrained (A,
B)
3.8.1.2 IF the patient has a history of emergence delirium, THEN consider phsysostimine
(B)
3.9 Assess the patients pain (A, B, C)
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 122
3.9.1 IF responsive, without respiratory compromise, awake, coherent and complaining of
pain, THEN medicate for pain (A, C)
3.9.2 IF the patient is having pain with respiratory compromise, THEN consider a non-
narcotic analgesic, regional anesthesia, or a ketamine infusion. Evaluate the cause of the
disproportional pain level (Example: opioid dependent patient (A, B, C)
3.9.3 IF the patient has an increased level of pain in the presence of respiratory depression
following narcotic administration, THEN discuss the problem with the surgeon, PACU
nurse, patient, an family members (C)
3.9.4 IF unresponsive, adequate RR, airway reflexes intact but appears to be in pain
(grimaces, tearing, rigid, agitated, increased heart rate), THEN do not medicate for pain,
consider alternate cause (B)
3.10 Assess the patients temperature (A, B)
3.10.1 IF the temperature is = or < 100 degrees, THEN no action required, proceed to next
step: 4.1 (A, B)
3.10.2 IF the temperature is < 96 degrees, THEN initiate warming measures and/or consider
narcotics for shivering (A, B)
3.10.3 IF the temperature is > 100 degrees, THEN remove the warm blankets (A)
3.10.4 IF the temperature is > 102 degrees without a precipitating cause such as infection,
THEN assess RR and muscle tone, draw an arterial blood gas, attach a portable end tidal
monitor, call for assistance from nursing and medical staff, and consider dantrolene (A)
Procedure 4: Conduct the verbal encounter of the patient handoff report
Step: Action and Decision
4.1. Re-verify that the 5 vital signs (O 2 saturation, heart rate and rhythm, blood pressure, pain,
temperature) are stable (A)
4.2. Have charting available (paper chart, EMR, anesthesia, and/or any specialty forms (A)
4.3. Ask that the receiving nurse identify h/herself (E)
4.4. Assess the readiness, knowledge, and experience of the receiving nurse (E)
4.5. Initiate the verbal handoff report when patient reassessed, in stable condition, sender and
receiver are face to face, and the environment is quiet and uninterrupted (A, B, C, E)
4.5.1. IF the PACU nurse is at the bedside and ready for report (states h/she ready), THEN
proceed with the patient handover (A, B, C)
4.5.2. IF the PACU nurse is not ready (A), if there is not a receiver (A) or if the nurse is not
capable of accepting or is uncomfortable with the patients acuity (A,B), THEN continue
to monitor until another receiver is available
4.5.3. IF there is excess talking, THEN ask for attention (E)
4.5.4. IF there is noise, THEN wait for a quiet reporting environment (E)
4.5.5. IF the receiving nurse is not engaged, THEN provide a verbal prompt “let me know when
you are ready for report” and wait until you have the receivers attention (E)
4.5.6. IF the PACU nurse is writing things down, THEN review the nurses notes to ensure
accuracy in transfer of information (A)
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 123
4.6. Verbalize aspects of pertinent past history and current status (A, B, C)
(cardiac/pulmonary/hepatic/hematologic/coagulopathic/malignancy/stroke/hyper or
hypotension/medication usage). Identify the patient, age, medical record number, ASA status,
past medical history, allergies, and any medications taken pre-operatively (A, B, C)
4.7. Inform the PACU nurse about the baseline pre-operative O 2 saturation and medications (C)
4.7.1. IF midazolam administered preoperatively in a short duration surgical procedure, THEN
inform the PACU nurse of the possibility that the drug side effect may exacerbate
respiratory depression (C)
4.8. Inform the PACU nurse about the intraoperative course and transfer the information in a way
that addresses the postoperative course (type of anesthesia, airway analysis and issues, induction,
surgical procedure, antibiotic type and timing, fluids, narcotic amount and last does, anti-nausea
medications, estimated blood loss, vasoactive medications, intake and output, intraoperative
events, emergence, pre-operative mental status, and plan for transitional care) (A, B, C)
4.8.1. IF the patient was abnormally anxious preoperatively or has a history of post traumatic
stress disorder, THEN inform the PACU nurse and order anxiolytics (A)
4.8.2. IF the patient was a difficult intubation, THEN inform the PACU nurse to page
anesthesia immediately if the patient demonstrates airway difficulty. Additionally
communicate any airway maneuvers that facilitated ventilation (B,E)
4.8.3. IF the patient complained of a history of post operative nausea and vomiting, THEN
inform the PACU nurse and order antiemetic medications (A)
4.8.4. IF the case was short (< 15 minutes), THEN inform the PACU nurse that the induction
medications may still have an effect in the PACU (C)
4.8.5. IF the patient demonstrated increased sensitivity to narcotics intraoperatively, THEN
inform the PACU nurse that careful administration of narcotics is necessary and to
observe for respiratory depression (A, B)
4.8.6. IF the patient demonstrated decreased sensitivity to narcotics intraoperatively, THEN
inform the PACU nurse that the patient may experience high tolerance and that more
narcotic administration may be required (A)
4.8.7. IF the patient was given neuromuscular blockade, THEN inform the PACU nurse of the
timing of the reversal dose (C)
4.8.8. IF the patient received vasoactive agents, THEN inform the PACU nurse of the timing
and dosage (A, C)
4.8.9. IF the urine output was low or excessive, THEN decide on an appropriate course of
action depending on the etiology (C)
4.8.10. IF the patient requires lab draws or xrays, THEN inform the PACU nurse of the rationale
(A)
4.9. Additional considerations
4.9.1. IF airway abnormality (tracheostomy, HALO, intra-oral procedure), THEN address
directly with the PACU nurse on arrival (A)
4.9.2. IF the patient has invasive monitoring (central, pulmonary artery), an arterial line, or a
cerebral monitor, THEN request the PACU nurse to attach and monitor (A, B, C)
4.9.3. IF the patient has chest tubes or surgical drains, THEN inform the PACU nurse what
suction settings and connections have been requested by the surgeon (C)
4.9.4. IF any condition is present that could be harmful to the staff, THEN communicate the
condition immediately (A)
4.9.5. IF excessive bleeding, THEN assess vital signs, contact surgeon, draw labs, and consider
crystalloid, colloid resuscitation, or blood component administration (A, B)
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 124
4.10. Provide specific measurements for all monitoring devices. Instructions regarding staff
notifications must be given for measurements outside these parameters as these changes may
indicate patient deteriorations necessitating immediate intervention (A, C)
Procedure 5: Conclude the patient handoff report
Step: Action and Decision
5.1. Re-analyze the 5 VS (A, B)
5.1.1. IF VS stable and patient is responsive, THEN reorient the patient and proceed to 5.2 (A, B)
5.1.2. IF inadequate, THEN return to steps 3.1-3.10
5.2. Ask the PACU nurse if there are any questions or concerns (A, B)
5.2.1. IF the answer is “yes”, THEN address the PACU nurse concerns (A, B)
5.2.2. IF the answer if “no”, THEN leave a contact number and inform the nurse that you are
leaving (A)
5.2.3. IF the patient experienced a post-operative complication or you have a post-operative
concern, THEN return for re-assessment and re-evaluation (E)
5.3. Complete anesthesia documentation (A)
8. Conditions and Cues
The PACU is ready to receive the patient
When the PACU nurse is ready for the verbal patient handoff report he/she will state
“I’m ready”
9. Prerequisite Skills/Knowledge
Patient history and current condition
Assess preoperative vital signs
Intended surgical procedure and appropriate anesthetic plan
Recognize and treat airway compromise
Recognize and treat airway obstruction
Recognize and treat hypoxemia
Recognize and treat hemodynamic instability
Recognize and treat pain
Recognize and treat nausea and vomiting
Recognize and treat excessive narcotic administration
Recognize and treat the need for fluid resuscitation
Recognize and treat residual paralysis
Recognize and treat hypothermia and hyperthermia
Recognize and treat hypo and hyperglycemia
Recognize and troubleshoot IV access
Formulate and execute a post anesthesia care patient handoff report
Basic pharmacology
Understand the use of equipment
Perform safe patient transfer from OR table to bed or gurney
Understand the facilities paperwork
Professionalism, respect, and courtesy to staff, patients, and family members
Basic Life Support
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 125
Advanced Cardiac Life Support
10. Process Knowledge
Transition in care from admitting unit to the operating room to the PACU
Information gathering is ongoing
11. Principles
Ask for help
12. Sensory Information
Touch
Airway maneuvers
Hold hand over the patient’s mouth to feel exhalation
Assess skin temperature
Palpate expanding abdomen
Visual
Respiratory rate and rhythm
Respiratory obstruction
The “mist” in the oxygen mast does not ensure adequate ventilation
Assess patient color and affect
Verify that the staff is present to receive the patient
Sound
Listen for obstructive airway sounds
Listen for a decreased pulse oximeter tome
Listen for a decreased heart rate tone
Auscultate cardiac and pulmonary sounds
Listen for moaning, crying, or retching
Listen for bubbling in pleuravac
13. Safety factors
Always focus on the patient during transport to the PACU
Continually assess the respirations
Oxygen is required for all patient transports
Oxygen cylinder is positioned in a secure location attached to the bed/gurney
Ensure functioning IV prior to transport
Maintain vital signs in a safe range
Do not deliver a patient handoff if the patient is unstable
Do not deliver a patient handoff if the receiver is incapable of assuming care of the
patient
14. Environmental Considerations
Privacy
Professionalism
Environmental awareness
Limit distractions and interruptions
Speak softly and away from the patient when reporting bad news
Keep the patient warm
Awareness of work colleagues
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 126
Appendix F
Spreadsheet Analysis
Type
Final Gold Standard Protocol
Analysis
A B C E A D
1, 2, or
3
Procedure 1: Acquire prior
knowledge of patient history and
condition 7 9
A
1.1 Prior to meeting the patient the
anesthesia provider will read the
patient’s history, medical record,
specialty progress notes; consult
with specialties if necessary, review
physician note; and evaluate
laboratory results, patient scans, and
xrays. Additionally, inquiry
includes:
cardiac/pulmonary/neurologic/renal/
hepatic/ hematologic/coagulopathic
system disease and medication
review (A,B,C) 1 1 1 3
0
A
1.2 Assess vital signs (VS) and VS
variations. Decide what the VSs
theoretical “safe range” is for the
patient during the operative time
(A,B) 1 1 0 2
0
A
1.3 Evaluate patient information via
patient interview, chart or electronic
medical record (EMR) (A,B,C) 1 1 1 3
D
1.3.1 IF the patient was seen in the
preoperative clinic, THEN review
and verify the pre-assessment notes
or any pre-anesthetic note (A,B) 1 1 0 2
D
1.3.1.1 IF the patient was assessed
by an individual other than yourself,
THEN re-assess the patient airway
(B) 0 1 0
1
and any pertinent history affecting
the anesthetic plan (E)
D
1.3.2 IF the patient is a scheduled
AM admit, THEN consider calling
the patient the night before to
discuss and review the anesthetic
plan (C) 0 0 1 1
D
1.3.3 IF you meet the patient in the
preoperative holding area, THEN
verify the patient information,
perform an airway assessment
including auscultation of the cardiac
and pulmonary system (B)
0 1 0 1
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 127
D
1.3.4 IF the patient was previously
admitted to the hospital, THEN
review the patient’s records, go see
the patient for preoperative
anesthetic discussion, perform an
airway, assessment, and auscultate
cardiac and pulmonary system (A,C) 1 0 1 2
D
1.3.5 IF the patient is an emergent
admission, THEN see the patient
immediately and complete a
preoperative assessment as
efficiently as time permits (B)
0 1 0 1
0
A
1.4 Develop an anesthetic plan based
on the patients current condition (A)
1 0 0 1
0
A
1.5 Review any prescription and
non-prescription medications (C)
0 0 1
D
1.5.1 IF the patient was given
instructions on which medications
should be taken the night before
surgery or the morning of surgery,
THEN review and verify the
medications taken (C) 0 0 1
D
1.5.2 IF the patient is taking
narcotics preoperatively or is a
chronic pain medication patient,
THEN discuss the optimal pain
regime with the patient and family
prior to surgery (C) 0 0 1
1
D
1.5.3 IF the patient took h/her
aspirin or theinopryidine, THEN
inform the surgical team
preoperatively (C) 0 0 1
0
A
1.6 Be prepared to report pertinent
past history, current condition, and
the intraoperative course (type of
anesthesia, all trends in VS,
medications,
antibiotic/narcotic/antiemetic
administration and time, intravenous
line location, room air saturation,
and any intraoperative incidents) to
the PACU nurse (A) 1 0 0 1
0
A
1.7 Report to the PACU should
include incidents or events that may
impact PACU care (A) 1 0 0 1
0
Procedure 2: Transport the
patient to the PACU 10 7 0
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 128
0
Steps: Action and Decision
0
0
A
2.1. Determine that the patient is
stable for transport to the PACU
(A,B,C) 1 1 1 3
D
2.1.1. IF the patient is unstable,
THEN do not transport to the
PACU. The patient should be
admitted directly to the intensive
care unit (A) 1 0 0 1
0
A
2.2. Ask the circulating nurse to call
ahead to the PACU and inform the
unit of your estimated time of arrival
and any supplies the patient may
require on admission (Example: cool
mist, breathing treatment, warming
measures, ventilator) (B,C) 0 1 1 2
0
A
2.3. Prepare to exit the operating
room (OR) (A,B,C) 1 1 1 3
A
2.3.1. Verify stable VS (A)
1 0 0 1
D
2.3.1.1. IF the patient had both
hemodynamic and respiratory
stability intraoperatively, THEN
transport monitors are not required
for transport (C)
0 0 1 1
2.3.2. Transfer the patient to the
gurney or bed (E)
A
2.3.3. Verify that the O 2 tank is full
and place the patient on O 2 (8-10
liter flow) (A) 1 0 0 1
A
2.3.4. Position the patient supine so
that you can visualize the patients
head and chest at all times and
perform airway assistance if
necessary (B,C) 0 1 1 2
2.3.5. Remove the ECG and BP
monitors (E)
A
2.3.6. Stand at the head of the bed
(A,B,C) 1 1 1
2.3.7. Remove the pulse oximeter
and transport (E)
0
A
2.4. Place the patient on 8-10 liters
O 2 mask flow prior to leaving the
OR to alleviate the risk of carbon
dioxide, nitrous oxide, and volatile
re-breathing, and have an oral or
nasal airway available (C) 0 0 1 1
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 129
D
2.4.1. IF the patient required
increased controlled substances or
vasoactive medications
intraoperatively, THEN bring the
medication with you to the PACU
(A,B) 1 1 0 2
D
2.4.2. IF the anesthesia provider had
to remain in the OR after the
completion of surgery to reverse
muscle relaxant, THEN bring extra
reversal agents (glycopyrrolate &
neostigmine) to the PACU (B) 0 1 0 1
0
A
2.5. Avoid the use of towels or
pillows that may cause head tilt and
airway obstruction (C) 0 0 1 1
0
A
2.6. Position the patient supine so
that you can visualize and perform
airway assistance if necessary (B,C,) 0 1 1 2
D
2.6.1. IF the patient has a history of
passive gastric regurgitation, THEN
position the head of the bed 30
degrees up to help avoid aspiration
risk (C)
0 0 1 1
D
2.6.2. IF the patient is obese or has a
history of obstructive sleep apnea,
THEN position the head of the bed
up 30 degrees, stand at the side of
the bed, stimulate the patient to
ensure adequate respirations (A,B,C)
1 1 1
D
2.6.3. IF the patient requires airway
patency assistance during transport,
THEN perform a maneuver to
ensure airway patency (open the
airway, chin lift, nasal or oral
airway, sit the patient up) (B,C)
0 1 1 2
0
Procedure 3: Admit the patient to
PACU 16 46 0
0
Steps: Action and Decision
0
0
A
3.1 Inform the receiving unit if the
patient has any condition that may
harm the staff. (Hepatitis C, VRE,
HIV, MRSA c-diff, Post-traumatic
stress disorder, emergence delirium).
Do not allow the staff to touch the
patient until proper barrier
precautions have been initiated
(A,C) 1 0 1 2
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 130
0
3.2 Ask the PACU nurse will attach
the patient to the monitoring system
(E)
3.2.1 IF the PACU nurse is not
ready, THEN the anesthesia provider
will attach the patient to the
monitoring system and evaluate the
VS (E)
0
3.3 Maintain open communication
with the PACU nurse regarding any
unexpected or suboptimal VS during
the hook up process (E)
0
A
3.4 Continuously evaluates the RR
(A,B,C) 1 1 1 3
D
3.4.1 IF adequate RR (8-10 breath
per minute (bpm)), THEN no action
required proceed to next step: 3.5
(A,B,C) 1 1 1 3
0
A
3.4.2 Initiate interventions when the
respiratory rate and pattern are
inadequate (RR < 8 bpm, shallow, or
rapid respirations) (A,B,C) 1 1 1 3
D
3.4.2.1 IF the patient has trouble
clearing the airway, THEN suction
the patient immediately (B)
0 1 0 1
D
3.4.2.2 IF RR is < 8 (bpm),
saturation < 95% despite 10 liters
O 2, patient is breathing shallowly or
is somnolent, THEN consider a
narcotic or benzodiazepine
antagonist if you suspect liberal
narcotic or benzodiazepine
administration intraoperatively and
assist the airway (A,B)
1 1 0 2
D
3.4.2.3 IF RR < 8 (bpm), THEN do
not medicate for pain (B)
1 1
D
3.4.2.4 IF the patient is wheezing,
THEN sit the patient up, and ask the
PACU nurse to call for a breathing
treatment immediately (B) 0 1 0 1
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 131
D
3.4.2.5 IF the patient has stridor,
THEN sit the patient up, increase O 2
flows, ask the PACU nurse to call
for a breathing treatment
immediately, reassess
anticholineterase reversal. Consider
terbutiline, racemic epinephrine,
draw an arterial blood gas, or
advanced airway techniques (B)
0 1 0 1
D
3.4.2.6 IF decreased RR is related to
weakness from residual paralysis
(assess train of four, hand grasp, lift
head for 5 seconds), THEN place a
nasal airway and administer the
recommended dose reversal agents
(glycopyrrolate & neostigmine) (B)
0 1 0 1
D
3.4.2.6.1 IF reversal agent was
necessary, THEN do not administer
narcotics until the RR is adequate
and saturation > 95% (B,E)
0 1 0 1
D
3.4.2.7 IF saturation < 95% and the
patient appears cyanotic, THEN
reestablish the patient airway (jaw
thrust, nasal or oral airway, consider
ventilator assistance with bag mask,
non-rebreather, and or advanced
airway technique and equipment).
Request additional assistance from
nursing and medical staff. (A,B,C)
1 1 1 3
D
3.4.2.8 IF the patient has respiratory
compromise and does not respond to
the above interventions, THEN call
for nursing and medical staff
assistance, emergency equipment,
and prepare to reestablish the airway
(C)
0 0 1 1
0
A
3.5 Remove the O 2 and attach the
pulse oximeter to the wall flow
meter for analysis (place on finger,
toe, ear lobe) (A,B,C) 1 1 1 3
0
A
3.5.1 Evaluate saturation (A,BC)
1 1 1 3
D
3.5.1.1 IF the saturation is > 95%
(B) on 10 (L) or within 2% of the
patients baseline, THEN no action
required proceed to next step: 3.8
(A,B,C)
1 1 1 3
0
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 132
A
3.5.2 Initiate interventions when the
saturation is suboptimal (A,B,C)
1 1 1 3
D
3.5.2.1 IF the saturation is 95% (B)
and not within 2% of the patient’s
baseline, THEN verify that the pulse
oximeter is correct (evaluate the
wave form, change the position of
the pulse oximeter) (A,B)
1 1 0 2
D
3.5.2.2 IF the value is correct,
THEN increase the O 2 flows,
encourage the patient to take deep
breaths, and identify the cause of
hypoxemia (low inspired FiO 2,
hypoventilation, VQ mismatch,
diffusion abnormality, right to left
cardiac shunt) (A,B,C)
1 1 1 3
0
A
3.6 Attach and analyze the surface
ECG (A,B,C) 1 1 1 3
D
3.6.1 IF the postoperative ECG is
unchanged (within 15-20%) from
the preoperative and intraoperative
period, THEN no action required
proceed to next step: 3.7 (A,B,C)
1 1 1 3
0
A
3.6.2 Assess causation of ECG rate
related abnormalities, arrhythmias,
evidence of ischemia or injury (C) 0 0 1 1
D
3.6.2.1 IF new onset arrhythmias,
THEN assess for hypotension
(A,B,C) 1 1 1 3
D
and hypercarbia (C)
0 0 1 1
D
3.6.2.2 IF the patient is bradycardic
but within 20% of the patient
baseline, THEN no action required,
proceed to next step: 3.10 (A,B,C)
1 1 1 3
D
3.6.2.3 IF bradycardic and < 20%
baseline, THEN consider excess
anticholinesterase as a potential
cause and administer glycopyrrolate
(B)
0 1 0 1
D
3.6.2.4 IF the patient is bradycardic
and symptomatic, THEN consider
glycopyrrolate, atropine (A,B,C),
1 1 1 3
D
ephedrine, or electrical pacing (C)
0 0 1 1
D
3.6.2.5 IF the patient is tachycardic
and symptomatic, THEN evaluate
for adequate pain control and
hypovolemia (C) 0 0 1 1
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 133
D
3.6.2.6 IF tachycardia and the BP is
baseline or elevated, THEN treat
with beta blockers if not
contraindicated (example: asthma or
COPD) (A)
1 0 0 1
D
3.6.2.7 IF ECG suggests ischemia
(ST elevation) or infarct (ST
depression), THEN do a 12-lead
ECG STAT and call for cardiology
evaluation and assistanc (A,B,C)
1 1 1 3
D
3.6.2.8 IF the heart rhythm is
unstable and/or a non-perfusing
rhythm THEN call for nursing and
medical assistance immediately and
initiate Advanced Cardiac Life
Support (A,B)
1 1 0 2
0
A
3.7 Attach BP cuff and evaluate the
BP (A,B,C) 1 1 1 3
D
3.7.1 IF the BP is the patient’s
baseline, THEN no action required,
proceed to next step: 3.8 (A,B) 1 1 0 2
0
D
3.7.2 IF the BP is < or > than 20% of
the preoperative baseline, THEN
recycle, reassess, and assess if the
patient is symptomatic (A,C) 1 0 1 2
0
A
3.7.3 Consider assessing the BP on
the opposite extremity to ensure
accuracy before treatment is initiated
(C) 0 0 1 1
0
A
3.7.4 Identify and evaluate the
causation of hypotension (C)
0 0 1 1
D
3.7.4.1 IF hypotension is related to
residual anesthetic, THEN assure
adequate ventilation and stimulate
the patient (C) 0 0 1 1
D
3.7.4.2 IF hypotension is related to
hypovolemia, THEN consider
lowering the head of the bed (if no
contraindication), administering
intravenous (IV) crystalloids,
vasopressors (neosynephrine or
ephedrine), consider blood bank
communication to ensure blood
product availability if necessary
(A,C)
1 0 1 2
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 134
D
3.7.4.3 IF the patient is hypotensive
with a history of stroke or
myocardial infarction, THEN
administer IV fluids with
consideration of underlying patient
condition. Consider blood bank
communication to ensure blood
product availability if necessary (C)
0 0 1 1
D
3.7.4.4 IF hypotension is related to
blood loss, THEN administer IV
fluids with consideration of
underlying patient condition.
Consider blood bank communication
to ensure blood product availability
if necessary (C)
0 0 1 1
D
3.7.4.5 IF the patient demonstrates
critical hypotension (BP systolic <
50 mmHg), THEN request
additional nursing and medical staff
to assist with resuscitation, establish
further IV access, consider arterial
or central line placement, aggressive
crystalloid or colloid resuscitation,
vasopressor support, and emergent
blood bank notification. (A,C)
1 0 1 2
0
A
3.7.5 Identify and evaluate causation
of hypertension (A,C)
1 0 1 2
D
3.7.5.1 IF systolic BP is < 170
mmHg and diastolic BP < 110
mmHg in a patient without co-
morbidities, THEN no action
required unless the patient remains
hypertensive before discharge from
the PACU (C)
0 0 1 1
D
3.7.5.2 IF the patient is in pain,
THEN administer pain medication
(A,B,C) 1 1 1 3
D
3.7.5.3 IF the patients bladder is full,
THEN drain the bladder (A)
1 0 0 1
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 135
D
3.7.5.4 IF the patient exceeds 20%
of h/her baseline with co-morbidities
such as coronary, cerebrovascular
disease or if a plastic case, THEN
administer medication to decrease
BP to an appropriate range (consider
esmolol [if heart rate is elevated >
70 beats and no history of asthma],
nitroglycerine or longer acting
agents such as labetolol or
metoprolol) (A,B,C)
1 1 1 3
D
3.7.5.5 IF BP is critically elevated
(210/115), THEN treat regardless of
the cause with short acting agents
(esmolol,) and consider
administering longer acting anti-
hypertensive agents (labetolol or
metroprolol), or IV antihypertensive
medications (nitroglycerine) (A,B)
1 1 0 2
0
A
3.8 Assess level of consciousness
(A,B) 1 1 0 2
A
3.8.1 Ask the patient to open h/her
eyes, squeeze your hand, and follow
simple commands (A) 1 0 0 1
D
3.8.1.1 IF altered orientation or
combative THEN request that the
patient be restrained (A,B)
1 1 0 2
D
3.8.1.2 IF the patient has a history of
emergence delirium, THEN consider
phsysostimine (B)
0 1 0 1
0
A
3.9 Assess the patients pain (A,B,C)
1 1 1 3
D
3.9.1 IF responsive, without
respiratory compromise, awake,
coherent, and complaining of pain,
THEN medicate for pain (A,C) 1 0 1 2
D
3.9.2 IF the patient is having pain
with respiratory compromise, THEN
consider a non-narcotic analgesic,
regional anesthesia, or a ketamine
infusion. Evaluate the cause of the
disproportional pain level (Example:
opioid dependent patient (A,B,C)
1 1 1 3
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 136
D
3.9.3 IF the patient has an increased
level of pain in the presence of
respiratory depression following
narcotic administration, THEN
discuss the problem with the
surgeon, PACU nurse, patient, an
family members (C) 0 0 1 1
D
3.9.4 IF unresponsive, adequate RR,
airway reflexes intact but appears to
be in pain (grimaces, tearing, rigid,
agitated, increased heart rate),
THEN do not medicate for pain,
consider alternate cause (B)
0 1 0 1
0
A
3.10 Assess the patients temperature
(A,B) 1 1 0 2
D
3.10.1 IF the temperature is = or <
100 degrees, THEN no action
required, proceed to next step: 4.1
(A,B) 1 1 0 2
D
3.10.2 IF the temperature is < 96
degrees, THEN initiate warming
measures and/or consider narcotics
for shivering (A,B) 1 1 0 2
D
3.10.3 IF the temperature is > 100
degrees, THEN remove the warm
blankets (A) 1 0 0 1
D
3.10.4 IF the temperature is > 102
degrees without a precipitating cause
such as infection, THEN assess RR
and muscle tone, draw an arterial
blood gas, attach a portable end tidal
monitor, call for assistance from
nursing and medical staff, and
consider dantrolene (A) 1 0 0 1
0
0
Procedure 4: Conduct the verbal
encounter of the patient handoff
report 7 20 0
0
Step: Action and Decision
0
0
A
4.1. Re-verify that the 5 vital signs
(O 2 saturation, heart rate and
rhythm, blood pressure, pain,
temperature) are stable (A) 1 0 0 1
0
A
4.2. Have charting available (paper
chart, EMR, anesthesia, and/or any
specialty forms (A) 1 0 0 1
0
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 137
4.3. Ask that the receiving nurse
identify h/herself (E)
0
4.4. Assess the readiness,
knowledge, and experience of the
receiving nurse (E)
0
A
4.5. Initiate the verbal handoff report
when patient reassessed, in stable
condition, sender and receiver are
face to face, and the environment is
quiet and uninterrupted (A,B,C)
1 1 1 3
D
4.5.1. IF the PACU nurse is at the
bedside and ready for report (states
h/she ready), THEN proceed with
the patient handover (A,B,C) 1 1 1 3
D
4.5.2. IF the PACU nurse is not
ready, if there is not a receiver (A)
1 0 0
D
if the nurse is not capable or is
uncomfortable with the patients
acuity THEN continue to monitor
until another receiver is available
(A,B)
1 1 0
4.5.3. IF there is excess talking,
THEN ask for attention (E)
4.5.4. IF there is noise, THEN wait
for a quiet reporting environment (E)
4.5.5. IF the receiving nurse is not
engaged, THEN provide a verbal
prompt “let me know when you are
ready for report” and wait until you
have the receivers attention (E)
D
4.5.6. IF the PACU nurse is writing
things down, THEN review the
nurses notes to ensure accuracy in
transfer of information (A) 1 0 0 1
0
A
4.6. Verbalize aspects of pertinent
past history and current status
(cardiac/pulmonary/hepatic/hematol
ogic/coagulopathic/malignancy/strok
e/hyper or hypotension/medication
usage). Identify the patient, age,
medical record number, ASA status,
past medical history, allergies, and
any medications taken pre-
operatively (A,B,C) 1 1 1 3
0
A
4.7. Inform the PACU nurse about
the baseline pre-operative O 2
saturation and medications (C) 0 0 1 1
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 138
D
4.7.1. IF midazolam administered
preoperatively in a short duration
surgical procedure, THEN inform
the PACU nurse of the possibility
that the drug side effect may
exacerbate respiratory depression
(C) 0 0 1 1
0
A
4.8. Inform the PACU nurse about
the intraoperative course and
transfer the information in a way
that addresses the postoperative
course (type of anesthesia, airway
analysis and issues, induction,
surgical procedure, antibiotic type
and timing, fluids, narcotic amount
and last does, anti-nausea
medications, estimated blood loss,
vasoactive medications, intake and
output, intraoperative events,
emergence, pre-operative mental
status, and plan for transitional care)
(A,B,C) 1 1 1 3
D
4.8.1. IF the patient was abnormally
anxious preoperatively or has a
history of post traumatic stress
disorder, THEN inform the PACU
nurse and order anxiolytics (A)
1 0 0 1
D
4.8.2. IF the patient was a difficult
intubation, THEN inform the PACU
nurse to page anesthesia
immediately if the patient
demonstrates airway difficulty.
Additionally communicate any
airway maneuvers that facilitated
ventilation (B) 0 1 0 1
D
4.8.3. IF the patient complained of a
history of post operative nausea and
vomiting, THEN inform the PACU
nurse and order antiemetic
medications (A)
1 0 0 1
D
4.8.4. IF the case was short (< 15
minutes), THEN inform the PACU
nurse that the induction medications
may still have an effect in the PACU
(C)
0 0 1 1
D
4.8.5. IF the patient demonstrated
increased sensitivity to narcotics
intraoperatively, THEN inform the
PACU nurse that careful
administration of narcotics is
necessary and to observe for
respiratory depression (A,B) 1 1 0 2
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 139
D
4.8.6. IF the patient demonstrated
decreased sensitivity to narcotics
intraoperatively, THEN inform the
PACU nurse that the patient may
experience high tolerance and that
more narcotic administration may be
required (A) 1 0 0 1
D
4.8.7. IF the patient was given
neuromuscular blockade, THEN
inform the PACU nurse of the
timing of the reversal dose (C) 0 0 1 1
D
4.8.8. IF the patient received
vasoactive agents, THEN inform the
PACU nurse of the timing and
dosage (A,C) 1 0 1 2
D
4.8.9. IF the urine output was low or
excessive, THEN decide on an
appropriate course of action
depending on the etiology (C) 0 0 1 1
D
4.8.10. IF the patient requires lab
draws or xrays, THEN inform the
PACU nurse of the rationale (A) 1 0 0 1
4.9. Additional considerations
0
D
4.9.1. IF airway abnormality
(tracheostomy, HALO, intra-oral
procedure), THEN address directly
with the PACU nurse on arrival (A) 1 0 0 1
D
4.9.2. IF the patient has invasive
monitoring (central, pulmonary
artery), an arterial line, or a cerebral
monitor, THEN request the PACU
nurse to attach and monitor (A,B,C)
1 1 1 3
D
4.9.3. IF the patient has chest tubes
or surgical drains, THEN inform the
PACU nurse what suction settings
and connections have been requested
by the surgeon (C)
0 0 1 1
D
4.9.4. IF any condition is present
that could be harmful to the staff,
THEN communicate the condition
immediately (A) 1 0 0 1
D
4.9.5. IF excessive bleeding, THEN
assess vital signs, contact surgeon,
draw labs, and consider crystalloid,
colloid resuscitation, or blood
component administration (A,B)
1 1 0 2
0
A
4.10. Provide specific measurements
for all monitoring devices.
Instructions regarding staff
notifications must be given for
measurements outside these
parameters as these changes may
indicate patient deteriorations 1 0 1 2
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 140
necessitating immediate intervention
(A,C)
0
Procedure 5: Conclude the patient
handoff report 3 5 0
0
Step: Action and Decision
0
0
A
5.1. Re-analyze the 5 VS (A,B)
1 1 0 2
D
5.1.1. IF VS stable and patient is
responsive, THEN reorient the
patient and proceed to 5.2 (A) 1 0 0 1
D
5.1.2. IF inadequate, THEN return to
steps 3.1-3.10 (A)
1 0 0 1
A
5.2. Ask the PACU nurse if there are
any questions or concerns (A,B)
1 1 0
D
5.2.1. IF the answer is “yes”, THEN
address the PACU nurse concerns
(A) 1 1
D
5.2.2. IF the answer if “no”, THEN
leave a contact number and inform
the nurse that you are leaving (A)
1 1
D
5.2.3. IF there is any post-operative
concern, THEN return for re-
assessment and re-evaluation (A),
1 0 0 1
contact the anesthesia provider (C)
0 0 1
A
5.3. Complete anesthesia
documentation (A,C) 1 0 1
130 Total Action and Decision Steps 85 67 73 0 43 87
43 Action Steps 33 24 30 0
87 Decision Steps 52 43 42 0
Total Action and Decision Steps 65.38% 51.54% 56.15%
Action Steps 76.74% 55.81% 69.77%
Decision Steps 59.77% 49.43% 48.28%
Action and Decision Steps Omitted 45 63 57
Action Steps Omitted 10 19 13
Decision Steps Omitted 35 44 45
Action and Decision Steps Omitted 34.62% 48.46% 43.85%
Action Steps Omitted 23.26% 44.19% 30.23%
Decision Steps Omitted 40.23% 50.57% 51.72%
Average Capture Omitted
PATIENT CARE HANDOFF TO THE POSTANESTHESIA CARE UNIT 141
d
Total Action and Decision Steps 57.69% 42.31%
Action Steps 67.44% 32.56%
Decision Steps 52.49% 47.51%
Highly Aligned 29 23.97%
Partially Aligned 29 23.97%
Slightly Aligned 63 52.07%
121
100.00
%
Abstract (if available)
Abstract
The purpose of this study was to use cognitive task analysis (CTA) methods to elicit knowledge from expert anesthesia providers in describing a patient handoff report (PHR) from the operating room to the Post Anesthesia Care Unit (PACU). Using information gained from four subject matter experts (SME) the results were synthesized and aggregated into a gold standard protocol (GSP). A fourth SME reviewed the results for completeness and accuracy. The results found that when compared to the GSP the individual SMEs in this study on average omitted 42.31% of the total action and decision steps. These results only partially support research that indicates that experts may omit up to 70% of critical information when providing instruction to a novice. Moreover, the experts demonstrated full alignment on only 23.97% of the action decision steps suggesting that either multiple experts are necessary to capture complete action and decision steps representing expertise, the interview interrogation was not as thorough as expected, or the scope of anesthesia is so broad that a more focused approach is warranted. The findings suggest that CTA techniques may be used to capture expertise for training novice anesthesia providers in the task of performing a PHR to the PACU.
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University of Southern California Dissertations and Theses
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Asset Metadata
Creator
Franco, Judith Anne
(author)
Core Title
The use of cognitive task analysis to capture expert patient care handoff to the post anesthesia care unit
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Education (Leadership)
Publication Date
04/10/2015
Defense Date
02/17/2015
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
cognitive task analysis,OAI-PMH Harvest,patient care handoff,post anesthesia
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
jafranco@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c3-544355
Unique identifier
UC11297405
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etd-FrancoJudi-3270.pdf (filename),usctheses-c3-544355 (legacy record id)
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544355
Document Type
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Format
application/pdf (imt)
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Franco, Judith Anne
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(contributing entity),
University of Southern California Dissertations and Theses
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Tags
cognitive task analysis
patient care handoff
post anesthesia