Intraoperative Handoff Tool for Nurses
Problem Statement: Patients are particularly vulnerable during handoffs because pertinent care
information may be incorrectly communicated or not communicated at all. More than 65% of
sentinel events in accredited healthcare organizations are caused by communication problems
with evidence suggesting that at least half of communication breakdowns occur during
handoffs.1, 8 Additionally, adverse events happen more often in surgical units than any other
clinical area, tend to be more severe, and could potentially lead to tragic patient outcomes. 7,9 In
response to these findings, the Joint Commission introduced handoffs as part of its National
Patient Safety Goals in 2006 and continued to do so through 2009 by way of Goal 2E which
encourages hospitals to “implement a standardized approach to “handoff” communications
including an opportunity to ask and respond to questions.” 2 As of 2010, the Joint Commission’s
requirement for handoffs is Element of Performance 2: “The hospital’s process for hand-off
communications provides for the opportunity for discussion between the giver and receiver of
patient information.” 2
What is an Intraoperative Handoff? A handoff is the transfer of information, authority,
accountability, and responsibility during intraoperative transitions of care and includes the
conveying of pertinent and correct information by the provider transferring care with regards to
the provider’s intraoperative management leading up to the handoff, relevant background
information regarding the particular patient, stage of the procedure, the patient’s status, any
recent or potential changes, and the recommended plan of care moving forward to the provider
receiving care responsibilities.1,3,10,19
Purpose of Tool: To provide structure and guidance to intraoperative handoffs with the purpose
of encouraging effective communication; reducing the likelihood of errors, adverse events, near
misses, and inefficiencies from occurring; preventing patients from being harmed; and improving
patient outcomes.3,9
Who Should Use this Tool? Any circulating nurse or scrub technician in the cardiovascular
operating room (CVOR) who is engaged in the process of transitioning patient care should use
this tool.
How to Use this Tool: Use this tool as a guide for every OR procedure in which there is a
transition in care.

Handoff Principles
I.
The clinician transferring care responsibilities should:
a. Provide appropriate information with regards to the patient, procedure, their
intraoperative management, recent or potential changes, and recommended
plan of care moving forward.
II.
The clinician receiving care responsibilities should:
a. Verify the information by reading or repeating back the content 1,3,5-6
b. Review and know pertinent patient historical data (e.g. relevant previous care,
treatment and services)6,18
III.
Both clinicians should:
a. Carry out the handoff in person1,5
b. Reduce the amount of time that handoffs take by allowing only the following
types of conversations to occur during handoffs:
i. Discussions that pertain to the specific patient at hand 1
ii. Urgent clinical issues1
c. Document that a transfer has taken place
d. Promote a culture that values interactive questioning and voicing of concerns
regardless of social hierarchy1,3,5
e. If possible, make every effort to limit distractions by engaging in preventive
measures such as using a designated space1,3,5-6
f. Intraoperative handoffs should be conducted in the OR
g. Engage in both verbal and written ways of communicating1,3
h. Avoid jargon and use language that is both clear and common3
i. Establish a designated time for signouts 5
j. Set aside sufficient time to avoid inaccurate communication1,3,6
k. Use computers and available technology (e.g. EMR) to encourage the efficient
exchange of pertinent, correct information 1,5
l. Monitor the effectiveness of handoffs and providers’ adherence to guidelines
concerning handoffs; ascertain feedback from staff 1
Charlene’s Recommendations
George’s Recommendations
Provider Transferring Care Responsibilities
What does the provider taking over care responsibilities need to know about?
Introduce yourself, role and job 1,11,16
Situation
Briefly state the problem: What, when, how severe?11
 Patient Information:1,12
o Name, age, gender12,16
o Medical record number13,16
o Planned procedure and attending surgeon1,12,16
o Pre-operative/Admission diagnosis and date, History of Present
Illness (HPI), reason for procedure 1,12,16
o Advance directive, code status (if appropriate)5,11-12,16
o Other concerns (e.g., spiritual, religious, cultural, learning,
primary/alternate language) 12
 Current status (e.g., procedure progress, complications, and stability) 16
 Other pertinent clinical information (16)
 CV stability issues
 Pulmonary issues
 Neurologic issues
 Renal issues
 Current procedure
o Current stage of procedure
o Response to procedure (21), anesthesia
o Significant events during surgery
 Anesthesia induction, airway,
 CV stability
 Others (eg falls)
 Current support
o Ventilator settings: special requirements
o IV access: central/peripheral, difficulties in starting lines
o Medications: IVFs, infusions, antibiotics (times given)
o Laboratory results:
 ABGs, BG, electrolytes (pre-op, intra-op), ACTs (PT,
PTT)
 Critical results, comparison to previous results(16,20-21) [Use of
trend/flowsheet or electronic record]
 Current surgical concerns
o Time into surgery
 Time to closing
 Unit and room (16, 20) [Pre-post-operative
destination?]
o Ventilator management
o IV access, fluid management, pressor management
√
N/A
o Other drug management
 Infection, antibiotic
 Allergies(12,17,18), Allergic reaction (20)
 Co-morbidities
 Seizures – DM - Cardiac Dz –Dysrhythmia –
HTN - Resp Dz – Asthma - Renal Dz - Liver Dz
- Malignant Hyperthermia (22)
o Contingency planning (9, MH’s tool)
o Safety Concerns(1,21) /Precautions (18,20)
 Infection Control(17)
 Isolation(19-20) (If yes, type – MRSA? VRE? TB? Other?)
Background 1,4,11
Background information about your patient.
 Pertinent PMH/PSH 19 vs. (Circle one if necessary) seizures – DM cardiac dz –dysrhythmia – HTN - resp dz – asthma - renal dz - liver dz
- malignant hyperthermia – additional issues: 17
 Access (A-line, central, PA etc.)
o Art line___ Site____ patent (Y/N)___
o CVL_____ Site____ patent (Y/N)___
o PIV______ Site____ patent (Y/N)___
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Pre-operative vitals 19
o Time___:__
o Temp ___ (F) HR___RR___pBP __/__ cBP __/__ SpO2____
Medications/labs
o Medications administered (e.g. steroids, anticoagulants, plavix,
asa, beta blockers) 11,15-16,6-19
o Anticoagulants:
Drug________Dose________Route_IVP/IV/ IM other____
Time Start ___:___ Time complete___:___
Next dose _______ or ___:___
o Beta blockers:
Drug________Dose________Route_IVP/IV/ IM other____
Time Start ___:___ Time complete___:___

Vasoactive agents: name, reason, dose, discussion with
surgeon
 Narcotics/benzodiazepines1,19: Time last narcotic was
given 15
 Anesthetic issues/muscle relaxant/antiemetic 15,19
 Antibiotic(s): Name, time of antibiotic administration, time
next dose due 1,15,19
o Any meds due or planned?19
 Verify labels, check concentrations, place meds in
separate locations
o Fluids, IVs, fluid status, fluid replacement and type - I and O
(e.g. fluids given, urine out, ongoing plans)1,6,11,15-16,19
o Preop/current/most recent/abnormal labs (e.g. hgb, hematology,
coagulation studies, microbiology, glucose, other pertinent),
lab/path pending/planned 6,11,15-16,19
 Available blood products, blood given/units available, ongoing plans 6,19
 Pre-operative/Admission diagnosis and date
 Other pertinent clinical information
 Significant Medical History
o Previous episodes, hospitalizations, treatments, services,
past/home medications, or family history
o History of present/chronic illness/comorbidities
 Special needs of patient
o Primary Language(17) [Highlight if speaks no English]
o Communication, intellectual, emotional, religious, social cultural,
learning (17)
o Legal status(17)
o Information about the family (12,23)
 Present/available?(yes/no)(19)
 Location/Contact Person/number(18)
o Socio-economic factors(21)
 Information about the family or others waiting for the patient
o Is the family present/available?(yes/no)
o Location?
o Contact Person/number
 Safety Concerns /Precautions
o Allergies
o Allergic reaction
o Infection Control
 Isolation (If yes, type – MRSA? VRE? TB? Other?)
o Alerts(e.g. falls)
o (Circle one if necessary) Seizures – DM - Cardiac Dz –
Dysrhythmia – HTN - Resp Dz – Asthma - Renal Dz - Liver Dz Malignant Hyperthermia
o Contingency planning
Assessment
What is your assessment of the patient’s situation
 Systems?
 Known complications
 Most recent vital signs
Recommendation
What are your recommendations to the clinician taking over care
responsibilities?
 [By systems?]
 [Prioritized task list in order of urgency and timing?]
 Required actions and brief rationale
 Level of urgency and explicit timing, prioritization of actions
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Who is responsible (nurse/doctor/team) including patient/family
responsibilities
Plan for continuing care interventions
Abnormal results and related
Nursing orders/Nursing plan of care
Additional Questions/Comments
Test or medication order?
Order change?
Continuing Treatments
Post-op room/unit confirmation
Present changes
o What will happen next?
o Any new/updated information?
o Any recent changes in (the patient’s) condition or
circumstances?
o Any anticipated or potential changes?
o Aspects of care to be aware of or closely monitored
 What is the plan? Contingency plans?
Provider Receiving Care Responsibilities
Repeat back:
 Critical actions
 Urgent actions
 Medication doses
Ascertain and review the following as needed:
 Charts
 Written information
 Reports
 Results
Additional items that a CVOR nurse may report to a CVOR nurse:
 Current stage of procedure
 Baseline patient assessment
 Position of patient during procedure
o Intraoperative issues related to positioning
 Skin prep
 ESU pad placement and removal assessment
 Equipment
o Use of special equipment
o Devices used
o Pumps needed
o Other medication delivery equipment needed
o Other equipment/devices needed
 Irrigation fluids in use
 Administration of medications or dyes from surgical field
 Medications on the sterile field
√
N/A
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Medications or drips that anesthesia would like available
Implants, transplants, explants
Dressings
Drains, stents, catheters
Instrumentation on/off field – needed
Sensory or motor limitations
Prosthesis presence
Pressure ulcer risk assessment
Anesthesia type
Allergies
o Allergic reaction:
 Blood products/Consent
 Recent changes in condition
 Vendor present/needed
 Specimens on and off field
 Counts
o Sponges
o Needle/Small items
o Instruments
 Other pertinent information
o Problems/Complications
o Special needs of patient
 Information about the family or others waiting for the patient
o Is the family present/available?(yes/no)
o Location?
o Contact Person/number
 Communication with the patient’s family regarding:
o Clinical/Change in condition
Additional Items that a CVOR Scrub Nurse/Tech may report to an
CVOR Scrub Nurse/Tech:
Anesthesia type
Medications on the sterile field
Irrigation fluids in use
Location and count of all countable items currently in use
Instrument trays in use and counts of all instruments
Extra instruments available in room
Implants on field/in room
Number and location of specimens, on and off the field
Any additional issues or concerns
References
1. Cooper A. Applying Evidence-Based Information to Improve Hand-Off Communication in
Perioperative Services. Back to Basics Ninth in a Series. The OR Connection.
2010:3(3):18-21,23-24. Accessed August 2010. Available at:
http://www.scribd.com/doc/29542046/OR-Connection-Magazine-Volume-3-Issue-3.
2. The Joint Commission: Handoff Communications: Toolkit for Implementing the National
Patient Safety Goal. Oakbrook Terrace, IL: Joint Commission Resources, 2008. In
Anderson J, Shroff D, Curtis A, The Veteran’s Affairs Shift Change Physician-toPhysician Handoff Project. Jt Comm J Qual Patient Saf. 2010;36(2):62-72.
3. Hand-off Communications: Recommendations. In Perioperative Patient Hand-Off Tool
Kit. AORN. Accessed August 2010. Available at:
http://www.aorn.org/docs_assets/55B250E0-9779-5C0D1DDC8177C9B4C8EB/44F543CC-17A4-49A8865FDDF56132C37B/HandOff_Recommendations.pdf
4. Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving
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of Hospital Medicine. 2006;1:257-266.
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http://www.aorn.org/docs_assets/55B250E0-9779-5C0D1DDC8177C9B4C8EB/44F6B4B2-17A4-49A886F218EDBF23516A/HandOff_SampleTools.pdf
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http://www.aorn.org/docs_assets/55B250E0-9779-5C0D1DDC8177C9B4C8EB/44F6B4B2-17A4-49A886F218EDBF23516A/HandOff_SampleTools.pdf
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Patient Hand-Off Tool Kit. AORN. Accessed August 2010. Available at:
http://www.aorn.org/docs_assets/55B250E0-9779-5C0D1DDC8177C9B4C8EB/44F6B4B2-17A4-49A886F218EDBF23516A/HandOff_SampleTools.pdf
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Accessed August 2010. Available at: http://www.aorn.org/docs_assets/55B250E0-97795C0D-1DDC8177C9B4C8EB/44F6B4B2-17A4-49A886F218EDBF23516A/HandOff_SampleTools.pdf
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Available at: http://www.aorn.org/docs_assets/55B250E0-9779-5C0D1DDC8177C9B4C8EB/44F6B4B2-17A4-49A886F218EDBF23516A/HandOff_SampleTools.pdf
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August 16,2010 with Elizabeth Martinez, MD,MHS (Physician, Massachusetts General
Hospital; Assistant Professor, Harvard University).
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Patient Safety Goal. Oakbrook Terrace, IL: Joint Commission Resources, 2008. In
Anderson J, Shroff D, Curtis A, The Veteran’s Affairs Shift Change Physician-toPhysician Handoff Project. Jt Comm J Qual Patient Saf. 2010;36(2):62-72.