• Original research

by Paul Govern | Posted on Thursday, Oct. 18, 2012 — 10:18 AM

Patient handovers matter. A lot.

That’s the conclusion from Vanderbilt researchers who reviewed three years of patient data and found that major complications occurring within 24 hours after cardiac surgery were cut in half following the adoption of an improved handover process.

“Patient handover” refers to the transfer of vital information about a patient from one team or one provider to the next. The new study from the Monroe Carell Jr. Children’s Hospital at Vanderbilt examines handovers from the operating room (OR) to the Pediatric Cardiac Intensive Care Unit (PCICU). Patient handover discussions with no fixed, definitive form were jettisoned in favor of more structured and thorough discussions with broader participation from both teams.

Use of OR safety checklists and timeouts have been shown to reduce surgical errors, but they leave patient complication rates unaffected. This study is among the first to examine patient complications and clinical outcomes following handover improvements. The study, led by Hemant Agarwal, MBBS, appears in a recent issue of Critical Care Medicine.

Investigators learned that:

• Children undergoing cardiopulmonary resuscitation within 24 hours post handover dropped from 5.4 percent to 2.6 percent.
• Twenty-four hour rates of surgical reexploration (generally triggered by suspected internal bleeding) dropped from 9 percent to 5.5 percent.
• Patients placed on extracorporeal membrane oxygenation within 24 hours dropped from 2.8 percent to 1.3 percent.
• Twenty-four hour rates of severe metabolic acidosis dropped from 6.7 percent to 2.6 percent.
• Fifty percent of patients were able to come off their ventilators within 24 hours, up from the previous rate of 43 percent.

During the period of the study there were no initiatives aimed specifically at lowering these complications for this patient group. The observation period for each patient was limited to 24 hours in an effort to screen out other influences and bring the impact of the changed process into greater relief.

“I think the reason this type of study has been absent from the literature has to do with the difficulty of instituting a structured handover process and sustaining it over the long haul,” Agarwal said.

In July 2009 Agarwal led the PCICU in implementing its new handover process, introducing participation from surgeons and cardiologists, 30-minute advance notice from the OR about the status of each arriving patient and a question period for the benefit of the full receiving team. As before, the attending cardiac anesthesiologist from the OR leads the handover discussion.

Intensive care medicine fellows use a checklist to document which topics are covered in each handover discussion, and Agarwal uses these records to guide improvements.

PCICU team members were surveyed before and after adoption of the structured handover, and in the latter survey they judged handover information to be adequate for 84 percent of the survey items, up from 57 percent in the prior survey. The new process also received high scores for improved depth, consistency and thoroughness.

Contact:
Paul Govern, (615) 343-9654
paul.govern@Vanderbilt.Edu

Sleep is one of the few things in medicine that is both a disorder and a symptom. The DSM-IV catalogue of sleep disorders includes primary insomnia, narcolepsy, and circadian rhythm sleep disorder, to name a few. Meanwhile “insomnia or hypersomnia” and “fatigue or loss of energy” are listed as symptoms for both major and mild depression, while “decreased need for sleep” is a symptom of mania and hypomania in bipolar disorder.

According to an NIMH catchment study, 46.5 percent of patients with hypersomnia had a psychiatric disorder. Another study found that 29 percent of individuals with hypersomnia had major depression.

Meanwhile, loss of sleep has been described as the fast road to mania. Not uncoincidentally, studies are linking bipolar disorder to a variation in a gene that regulates the suprachiasmatic nuclei, the brain’s “master clock.”

A 2004 Depression and Bipolar Support Alliance survey found sleep disturbance to be “one of the most common problems associated with mental illness.” Respondents cited racing thoughts, emotional stress, and restlessness. Nearly all thought lack of sleep impacted on their mood and caused sadness, anxiousness, and irritability.

A 2002 National Sleep Foundation poll found that more than one-third of Americans are so sleepy it interferes with their daily activities. Insomnia results in confusion, tension, fatigue, anger, cognitive impairment, and, of course, mood episodes. Those with sleep difficulties are more likely to be absent from work and have accidents or injuries than the general population.

Maintaining a regular sleep schedule is vital to managing one’s mental illness. It need not conform to the schedule of someone who needs to be at work at 8:00 or 9:00 AM, but it needs to be consistent. Excessive sleep is counterproductive, and napping should be resorted to only sparingly (as this can throw off one’s sleep schedule).

Many people find it useful to have a one or two-hour winding down period prior to turning out the lights. This can involve various relaxing routines, including yoga, visualizations, breathing, and meditation. Be mindful of books that are gripping page turners you can’t put down, however, and stay away from programs that are bound to set off a strong emotional response.

Many of you may be faced with making some tough choices: If you are a shift worker you may have to find a job with regular hours. If your work involves travel, you may have to find employment that keeps you close to home. You may have to change from a fast career track to one not so demanding.

Students who burn the midnight oil are particularly susceptible. All-nighters are a necessary fact of academic life, but many of them can be avoided by staying on top of course loads.

Many of us may legitimately need a caffeine pick-me-up, particularly those who find themselves waking up groggy from a meds hangover. Sparingly is the watchword. That morning caffeine is still in the system in the evening. Evening caffeine should be considered taboo (unless you work nights). Keep in mind, caffeine is no substitute for lack of sleep.

Psychiatric meds that interfere with normal sleep are only justifiable as a short-term solution (say to boot you out of a depression). Over the long term, however, any psychiatric med that disrupts sleep in any way (whether by making one feel too agitated or too drowsy) is a self-defeating strategy.

Take home message: Resolve right now to treat sleep as if your life depended on it. It does.

John McManamy is the author of “Living Well With Depression and Bipolar Disorder: What Your Doctor Doesn’t Tell You That You Need to Know” (HarperCollins). He lives with bipolar and serves on the board of NAMI San Diego.