The operating room (OR) staff at the Lexington Veterans Affairs (VA) Medical Center consistently works as a cohesive unit across multiple disciplines to improve the quality of veteran health care. Through their commitment to bettering the veteran patient experience, these team members have enhanced the quality of care provided to veterans over the last several years. Targeted initiatives required significant effort to perform audits of various OR tasks, such as case cart preparedness, preoperative paperwork completion, and intraoperative communication, in addition to the demands of their day-to-day jobs. Our team members have graciously accepted these tasks and adapted to the increased daily demands as a part of the OR quality improvement (QI) team, with the driving purpose of performing their jobs more safely and efficiently to improve patient care.

This mindset is truly the pinnacle of quality and process improvement. A desire to provide excellent care to the veteran population encourages the OR team to continue to seek out ways we can do better to both improve patient outcomes and transform our processes to be safer and more comfortable for staff members. Due to this culture cultivated over the last several years, our team members feel empowered to speak up when they witness substandard processes and procedures. The Surgical Intraoperative Handoff Initiative arose from frontline staff recognizing an opportunity to improve patient safety. A concerned surgical technician (ST) approached our team regarding the inconsistency amongst ST handoffs intraoperatively, concerned that an ST providing lunch breaks and taking over for call cases may not receive adequate handoff of critical contextual information.

As with all process improvement projects, we assessed the current state of the issue by creating an audit tool to assess the fidelity of communication for important handoff information for STs through consultation with the OR QI leadership and the concerned stakeholder. This audit tool was used to evaluate current handoffs in a single-blind fashion. These 23 audits revealed significant variation amongst handoffs regardless of service, procedure, or handoff timing. We also identified cases in which handoffs did not ever occur between techs during personnel changes intraoperatively. These preliminary data were brought back to the entire OR QI team, where we identified the lack of standard communication as a patient safety hazard, given poor intraoperative communication can lead to adverse events.

With leadership buy-in, we engaged all frontline stakeholders, including all STs as well as circulating nurses who help to provide ST breaks. We then addressed the lack of standardized handoff, which exists within many other health care roles, and displayed our pre-data along with the criteria we used to assess handoff content. We asked our frontline stakeholders what information they felt was critical to handoffs, and the original audit was edited and adjusted to reflect these critical topics. We also created a visual cognitive aid for this handoff to be posted in all of our ORs using the acronym SHRIMPS, which included sponges/sharps on the field (S), hidden and held items (H), replaced items (R), implants and critical instruments (I), medications on the field and already administered (M), procedural information (P), including the point in the procedure and an anatomy overview, and specimens collected or still needing to be collected (S; see Figure). We also included an announcement to the entire operating room, including the operating surgeon, as well as clarification if timing in the procedure was appropriate for a staff change.