P23 - Identifying Transfer of Care Gaps: Electronic Health Record Capture of Perioperative Handoff Communications

Transitions in patient care are held together by interdisciplinary handoff communications intended to coordinate the patient’s ongoing care requirements. Patients with complexity in care encumber the transfer of care process requiring a higher level of care coordination between the interdisciplinary team. While the literature is abundant on the characteristics and quality of handoff communications, it is limited on the requirements of what data is necessary for ongoing care following transfer communications.

Poor communication and incomplete information transfer contribute to gaps in ongoing care following critical patient care transitions. Information loss has been reported to occur 100% of time and contributions between 15%-67% to adverse events. Incomplete information transfer following surgical interventions has contributed to delays in diagnostic and therapeutic interventions with potential deterioration in the patient’s status. With nurses often viewing EHR documentation as a universal communication source, abridged verbal interactions with other patient care providers leads to critical information loss for patient care. Despite the use of handoff tools, there has been no progress made on the data requirements to be included in EHRs for continuity in ongoing patient care.

Findings from a recent study exploring the verbal information transferred during operating room to post-anesthesia care unit nursing handoff communications and whether the data is captured in the electronic health record (EHR) to represent the necessary information for ongoing patient care and care planning. Findings examine how the data, information, knowledge, and wisdom framework supported the research and the emerging Kennedy integrated theoretical framework (KITF). The KITF integrates cognition theory, patterns of knowledge theory, and clinical communication space theory to support the human-technology characteristics within transitions in patient care (e.g., perioperative handoffs). Evidence of wisdom, in addition to elements of non-verbal communication patterns emerging from shared common ground, were identified as new contributions for the framework’s expansion.

To understand contributions by nursing terminologies (i.e., perioperative nursing data set [PNDS]) to post-surgical care transitions, the study examined nursing diagnoses, interventions, interim outcomes, and goals relationships to the handoff data communicated between OR and PACU registered nurses.

Study findings revealed a complex fragmented process of verbal communications and electronic documentation for the handoff process. While the EHR is prominent in data procurement for the handoff process, the design of handoff artifacts (e.g., paper, electronic) significantly impact the value of information received. Incomplete handoff tools or missing EHR data adds to a cycle of information decay while contributing to increase cognitive load and potentiating opportunities for information and knowledge loss. The absence of nursing diagnoses in the automation of the PNDS challenges the integrity of the language within the documentation platform and raises considerations for hierarchical representation within interface terminologies.

Study findings also reinforce current literature recommendations to reconsider user requirements in the design and functionality of healthcare information technology to enable data and information flow and preserve knowledge development. 

Learining Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.