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... MU G ce Deli e B ine Plan Decembe 2018 E F e , Ma he Je , T e McCa e , Sa e Padge F de 3200 C d S g R ad, I d a a , IN 46222 (765) 585-8055 g ce de e @g a .c Table f C n en I. E ec i e S mma II. In .. ..... . .4-5 d ci n III. O ni ..... .6 Anal i . A. Se ice De c i i n B. Ta ge Ma ke ... ....... . 7 . .. ... . 7 . ... .. . ... . 7 C. S e & Re l .. . 8 D. SWOT E. Re .... ce & Placemen .8-11 ... .. .11 F. C m e i i e Anal i .. .11-12 G. P f f Demand H. Mac ec n mic Clima e I. O ni ... C IV. Financial Anal i .... .12-14 ... .. . . .. .. ning C. Sale F eca .14 .... .15 .. ... ..... .15 ... ....... .15-16 D. Financial S a emen .. ..... .... .16-18 E. Scena i Anal i F. Ca i al Need .. ... .. .. .15 A. Se ice P ice B. P ice Rea ........ .14 . ....... .18-19 .... .. .. .19-20 1 V. O e a i n Plan A. H .. . .. .21 he Se ice W k B. H .. W ked . .... .. .21 .. C. Gan Cha ...... .21-22 .. . . ..... . .22 D. O gani a i n ........ .22 VI. Ma ke ing Plan . .. .... .23 A. P m i n ... .... .23 B. Ad e i ing ... . .23 C. S cial Media . .24 D. Fl e ... E. Shi .. F. B ine Ca d .. .. . .25 ..... . .. .25 ... . .. .25 G. C mme cial .. .. .25-26 VII. E i S a eg ... ....... .27 VIII. C ncl IX. A endi i n ... . .28 ... . .29-37 2 3 I. E ec i e S mma MU G ce deli e ind i n han U ing he al ffe deli e emie g ce Deli e ffe c m ei f a e n Wi Edi anging f m f m l i le fla c me e n he a men a f iendl and familia face hen ecei ing ile ie . O f ill ee he final age. M ed n e a e dail like C a e able Deli e al eb i e ha e man i em . The fee ffe a le ice n he h f e aged. Pa b ic e 80 name e f each i em and n he eb i e. U ing hi age and he e ill be n hidden c m ei he deli e ffe e ice cha ge i a 20% each i em indi id all e cen age ba ed e ice fee, and a i i enc ha nded in 2018. In a h i ing , e ha e c ea ed a eb i e ha d i em cen me h d i e ice f . fee, and hi fee i al ead b il in a fee deli e f he f iendl and familia face, MU G ce en i e b and i em i a , MU G ce deli e . On e Deli e i e a d lla am f he ea n fee, a n e a e ine ine e , in ead e en i e e a e n a eekl ba i . me T e da , hich i deli e ed he da de f m 12:00 .m. Wedne da f deli e . On T e da , he g ce ie a cen ali ed l ca i n n Ma ian cam Cen e Ha che , m 105. G ce ie ill be ead f .m.-9:00 .m. T e da nigh . The e ill al and find a ime ick hei de 12:00 .m. he f ll ill be icked . Thi l ca i n i c me , ing ed, and he Pa l J N man ick be a g ace e i d in hich c indi id all . We nl ha e a fe f m 8:00 me can c n ac e i hable i em n 4 he eb i e, Ha che f h e ill all le f a g ace e i d, b en ha hi b ine can and ill be mac ec n mic clima e f deli e b D ing cce f l de ind i em ill be able i in he a fe da . We ha e and m ial n e ee e ine e a ell a c nd c ing a ial ie fi ed $62.28. Thi i a g ea ime in he deli e di ec l Ma ian Uni e i he a Ma ian Uni e i den f n d b cce f l b anal ing he n f lack f ad e i ing. We g b ine . Ma ian G ce ind Deli e n. ed $91.28 and e ill b ing hi i ead an f m hei g ce ie ! 5 II. In Mi Uni e i ha i S a e e : MU G ce change he a ill a e den a : MU G ce den . O h me age fea e den een c me e i c m i ed f d c n f he i em a e al ead ma k c me ick c en l 80 i em e- jec ed jec ed n mbe ch deli e l k e ice an hing f ali g ce deli e and ef nd lic e e ice f lana i n . The . We ill deli e nline e age n he eb i e. O nd a Walma , Meije , and Ta ge e . The e a e f he e i em ha e m l i le a ie ie a jec ial fee e e a ha ell. The c ble he am n f ell a a 20% deli e fee. e ill b eak e en af e 177 ale a an n, in hich e ecei ed 41 b eak e en i hin 3 eek . A he c ncl each eam membe en ime i T e da e ening f m 8:00-9:00 m. Ha ing Deli e e can d nce a m 105, and hei g ce ie f m ha l ca i n. The c ha e a ne inc me f $2,152.54. Taking fh g ce g ammed i h a incl ded n a able i em , a ale. Ba ed ff ale, e belie e ha ae hei f Ma ian , N man Cen e fee n each i em indi id all . Thi 20% ma k a e age f $11 e ing f den c n Ma ian cam ill likel g eb i e. Man Objec i e : MU G ce e i a eb i e ha di claime ick hei g ce ie h me age, nline Deli e a cen ali ed l ca i n n cam ill ha e an h f ame f he ffe ing a l ld be he da e and ime f deli e eek and e deli e den ha he c hel hei ime and ene g . Se ice S Ma ian Uni e i i he e he ge hei g ce ie b ime and eff el e he feel de e e Deli e d ci n de eaching 82 i n f he de a a de e nd $11 eek. We ing eme e , e a e ne inc me and di iding hi b ked, e ill be making $19.13 e h he . 6 III. O ni Anal i A. Se ice De c i i O eam ill be a c llege G ce de den Deli e f m iding a e ice i can be a diffic l a k i a eb i e ba ed b c me ine and b ing hei he den find ime f Ma ian Uni e i . We kn make i ( 1) ha , de cam he g ce f m ai ha e. MU ill ecei e he g ce e ch a : Walma , Meije , and Ta ge . B. Ta ge Ma ke The e a e ideal a ge ma ke and he famil membe f he e f MU G ce den . Bel ae Deli e , me den a i ic a ending Ma ian f Ma ian den aigh f m he Admi i n Office: S den S S S G S a Ma ian (3,595) den li ing in Ma ian d m and a a men den i h ca n cam (753) den a hle e (620) ad a e den (514) den i h n-cam j b (361). The ec nd a ge ma ke n mbe ill k ihe e hi hi la ge a ge a dience b ma ke ing e ain email in end ill a f an ne h fl e ha a en de ha ne familie being diffe en . We hem mainl e can each ill ee hen he (1008) i i cam c ia Faceb me k. We ill al b email. We al . 7 C. S e & Re MU G ce fi a en b C a f d. O Deli e c nd c ed ine den e e l e ha d ing he c e e e able e e a f ll c nnec e f he fall eme e . The ih h : Reached 86 e le Maj i f h e h e nded e e J ni . (27%) Maj i f e le h f g ce ie a Walma (37%) Maj i f he indi id al ha an e ed aid ha hei a en g ce ie (44%) Af e c nd c ing e l ial gh P fe n, e en an he e he e hel ed hem a f le ha a ici a ed and e e: Pa ici an e e highl a i fied (78%) M den b gh g ce ie ice a eek (43%) The m la da ha den ld e eb i e i T e da (45%) Sh ed ha he den ld e e ice again D. SWOT A a i S eng h : The e a e man eng h i fi ha ea h ee ea ha he membe den ). Being a f c nnec i n maj . The membe . The ne le el mean eng h i n ing and finance d f MU G ce e ling, c l Deli e g a d, 21 cia i n, ni n f black iden i ie , Re blican , Ma ian Maniac , and Knigh Deli e e . The fi he di e i h m e, and e ha e a minim m f f he eam. One a e male, and ne i n nbina . One i a managemen maj , ne i an a G ce Deli e le el ( ne j ni , ne f h ee diffe en cla n cam n ing maj , ne i an acc ack and field, f MU G ce e a e en lled in h ee diffe en cla membe i female, acc eng h eam. D ing hi a e in e Cen den f eme e ble maj , and ne i a c mm nica i n di e e ac i i ie ch la , b ling, n cam den g , e nmen f la in iden i ie , Ma ian Uni e i Life. Team fB ine ki he ne 109, he e e e ch a : C llege eng h f he MU eam k 8 challenge and MU G ce Deli e n b h f hem. S me cha ac e i ic in a e: c mm nica i n, a igning a k ba ed n indi id al leade hi . We al cam ha e a di e e k hi a S a b ck and he Lib a , a m nh ell a e ed eng h , ha m n , and ch a : a ke e ience n Ma ian ell a being a manage a a l cal R e21 f hile a ending Ma ian. An he membe a a ca hie , a ha f MU G ce Deli e ha ked a K ge m i ing Li le Leag e ba eball game in hi h me n. A hi d membe ha led c e f ain e a a men manage ge all f he S ne C eame , We Lafa e e Pa k and Rec ea i n, Li le Leag e m i ing, and P el ck Bl ebe Fa m . The f and Wa e Pa k Re a a a men c m le e a i ell a c mm nica ing i h k d ne n ime. Thi membe ha al h eam membe ha ked a C ld ked in e ail a Indiana Beach Am emen . Weakne : The e a e h ee maj The fi i b hich make f ched le . C ne g he a e eakne an e , he di e i e l ad. M e ac king in f MU G ce f life e king i h he idea de nall h i le , i make lea ning h e nc ld nde membe d and he c nce a ecific acc e fec l a a e al in l ed i h a membe a a ha e ne den . The nali ie . When king in a eng h and eakne . When aking he a en ha each ne f im king n. fif een c edi h a end Ma ian Uni e i gh a he beginning eem eam a e f hi , m d minee ing e e ience i al a gh e, be able Deli e he . Thi made i e e Deli e ic la ac i i /cl b. On Clif n S eng h finde e , i became a f ha he MU G ce en l , e a e all en lled in a lea a demanding c eam a Ma ian m ej b eakne e ing a in a diffe en ca eg ge each he k n an . La l , ince e all ha e diffe en lea ning n ing ac i i ie f na e am le e he eache e diffic l . One lained i , he ea 9 he membe f MU G ce n ime bef e he c Deli e need ld eall hel ha e ha cla ma e e he g lain i hem n hei acc m li h he a k a hand. Thi eakne made ge ing a k d ne ake a li le l nge . O ni ie : The fi e e ni ha MU G ce ne ea . An he maj ni ched le . Addi i nall , he i ide n e n Ma ian cam find a ide f hei membe e den ch l i i ha d ec a i n m e ab ake ad an age f i f c llege d c f, i e cellen f he ha e e c ha i n k. Whe he i be a lea , cl b , . A hle e ha e h n in e e in he ec i n i led Ma ke ing Plan, make an e ma ch. While MU G ce a fi i Deli e in king, h ha ha e b den c ld need Deli e . I i l ed in ne he hing aking ca e f famil ched le and all he diffe en in hi e ice, and hi ill be alked 23). The la b ec i n P m i n ( aking ad an age f Walma i den e f MU G ce find a balance be een all he diffe en ne i held ni an ha he maj i ni e ea edl , and ill f en ae Deli e a ing ca che and ing a Walma , e a e likel ice ge m ne back b ing he e e ice . Th ea : The e a e a i deli e ne e ice h ea i ha ee ha ha MU G ce ch a : In aca , P he Uni e i ' a h ea en ial f ne ) en, e cann c n l he ac i n ld ha en ca e ld face. The fi gh e ha e me ld n f he m al a he m eb i e c h ea i ff, Ube ea , G bh b, and D e ha Ma ian malf nc i n.Techn l g i n me hing c ma e , G ca acciden . Al h make Deli e i h Deb La be a fa l if i . The ne e -f iendl , malf nc i n and he da h. The ence (Ma ian me hing like hi h ea i if ee eb i e he e i he en ial e en f m ge ing 10 de f a e i d f ime. Th a ailable ha mee h ld . Unf need , n hing i na el , e a e n eb i e a h ld gh e did d e diligence bank acc e fec . The la able n . Thi i ch c n h lh e need a he bank like he e a d ing he ial maj ickl membe ha maj hei e ce ha MU G ce n ca . The ne e The lacemen f MU G ce Deli e Deli e an fe f m ill be alked m e ab i f he e all i l ca ed in he B B he d a i n f he f ll 109 c m e i i n eii eA a T fig e ef f in he Deli e ha e i ha each ei he membe ' ill m Sch ha e been c ea ed. l fB m 105) ha i de igna ed f ine . The Pa l J. he inne f he ing eme e . i ha c m e i i n, e anal ed ice h ld be maj ma e and In aca cha ge he f ll P na e m i nal fl e ( P an fe 23). N man Cen e c n ain a Ha che F. C h ea i m ne he m ne n. Thi ce MU G ce ledge f he Can a eb i e. Can a i ine ide ce & P ace e The fi kn ie f n m ne f m he ha k in he e en ec i n i led Ma ke ing Plan, S b ec i n P m i n ( E. Re e he be make a c m ei fi , and . We f ill be le nd ha e en i e han c m ei ing: ma e $10 deli e fee 9% e ice fee i enc aged Yea l Plan $95.88 ( de enc aged m be e $15) + i In aca $5.99 deli e fee 10% e ice fee i enc aged Yea l Plan $149 + i enc aged 11 We decided ha in ine de en i e and im le a men be m e a e. Thi i in each an ac i n. The ea deli e all da a cen ali ed l ca i n, f me . We al c e demand f (Dean f he b and Deb La a ine mee ing ge a e mi i n cam c e needed hei m del f e nfai e be ec ing m l i le cha ge m e i beca he e e a e m ch le . Tha all a ge ma ke e ice, and i h ch l), Dean R ge ence (Ma ian Uni e i a ed de fl e f ll me and f be le nd ha man e he eek and e en i e f hem did n en i e. f f De a d T We e did n n he e e ice m e ed fee f 20% n each i em a G. P c diffe en l ca i n . Since e a e making ne i deli e ing ee h ealing le ed. Once all he e c nd c a ial (Dean f a i h he e ecial e mi i n f m Dean Ke ha a ed ab le ed b R bin S ea in (Head f 3 in he B m Sch l f B 3 in Oldenb g 4 in he E an Cen e 5 in Cla e Hall 5 in D e Hall 5 in Uni e i Hall 5 in D le Hall 5 in Ma ian Hall 7 in he Lib a 8 in Al mni Jane (Dining e ice ) ne ), e c nd c ed a ial e, a ed ab n, e c ea ed 50 fl e e h ng hem acc ding den ), Sc he f ll eek i n n Oc be 30, 2018. (Oc be 16, 2018) in e had gi en MU G ce ( den affai ) 2), af e ge ing he , be h ng Deli e a nd Ma ian ing li : ine 12 The ne a gene a e a a ene a all he ad e i ing e c ld d and decided de ing n he eb i e a n di able membe ime , de , f a ie all he de 3). Once hi e al f 41 ecei de . Being fi limi ing he g ce n h n a $0 b dge ge and ing e li he f k half f he li membe min e . Unf eam f k he g ce ie back en he Meije ad e i ed e le c ld The ick f he b ine l emaining membe ha ing all he a ce ch icking en di ec af e f ial b ac ing man ea hei m e le d e n . The fi en e i ha e did n and each eam n fi n ne he eam f c llec he emaining de . anding a he main en ance he Ha che , m 105, hile he me , c llec ed hei bag i h hei make aling $431.68. O fi half f aking an he 10 ing hem hile he li , IN 46254 he ial ed igh a 8:00 .m. hen e n he hall a de al f e needed f a ed de and a ked hem n, e had 41 eam hl . We had ne membe k he name f he c e en ed hem i h hei ecei F Ma ian and e lan n li , IN 46254 a 6:30 c m le e i h check n 5349 W Pike Pla a Rd, Indiana i em . We, a a h le, ended n, b he ing eme e . F in ha e all f he i em me ick , af e ga he ing all he i em k 30 min e na el , Walma did n gi e ne g a ici a e in he ial Deli e f i em and e me a check c me f each c n a mee ing n 4545 Lafa e e Rd, Indiana f MU G ce he li . The ga he ing f he i em he ecei le each ime d ing he ing, e all me a he Walma .m. We in ed e in he ial de f each i em a needed ( man a c m le e, e nning. Once he n n Oc be 30, 2018 ime d ing hi , e all an ed h and a c m le e, e ai ed f gani e h . The ne cial media ee e hing a c de , ec . al e en e a $91.28, and a $62.28. We a e a i fied i h he e n mbe ha e an ad e i ing b dge . We eall nl ed 13 he e ce making cial media la f m in ea e had he n e a e a i fied i h a al f m all h hi ch a ial de ial a ed ab n. Thi being ai ed ial e in ing f fl e n i beca hi i H. Mac ec den a ici a e in e af e fi n, e had h e e a e a king he ha k a a h le i 2010 g ce ie being b he Uni ed S a e , b ial m e and f ll d n. An he eb i e and g n m ne f he h de gh i h and hen hi and ha e an e cellen f nd fi n f he gh nline nl acc Deli e i b ming. Thi i beca ing eme e . hi cha ( n ed f ab declining in he nea f e. e he 4), in , 1.8% f all g ce ie in 2019, hen e ill la nch, ha n mbe c m an i MU G ce n he i e. Acc ding 6.4%. I i e ci ing f cha ed in ill ha e m e han i led be e a ing in a g ing ind ine i an hing el e e c ha h n ign f C The ni c f b hi ca e, hen e in e ill ecei e 3 c edi he lace f a cla d ing he be aking and ill al d ing al ead ha e and ic C i a e ind I. O n e finali ed e, e nl had i da The mac ec n mic clima e f n den acc ecei e he m ne f m he eb i e. We e e able n, b deli e each ha d ing c n i f nning he b ing eme e . O f he h e ni k b c ine ld be d ing i h ime. In ine . The e c edi ill ake i he cla ha c ha ld be e ld en me hing el e. 14 IV. Financial Anal i A. Se ice P ice The c me ice f deli e a he ial n he a men n, e decided ice Indiana B. P ice Rea ni nable 41% f a eb i e c m a ed ha he did n in he e en e. T c me la deli e Anal i , S b ec i n C m e i i e Anal i ice ha man c llege ld a en i e han a eek, fee me ma e and In aca , ice f a 20% fee f den e n c e ice in he age a n age 11-12. i g We came le ice f i em f li a ea. Each f he e c m anie cha ge a fla a e, a e ice fee, and enc i , ee Sec i n O ea f mm in , e anal ed P e ea ch and alking i h cha ge he 20% fee n each i em indi id all in ead f age. The c n en eali e a diffe ence in he ih i a 20% fee. Ba ed n ill all a e illing he 20% deli e fee. We al fee a n . The fi a .O ch d den fi ma gin n he ideal ea e e e 20% beca . We a e a a di ad an age beca a an incen i e f make a g ha a 20% deli e le ea den c m ei e cha ge le ac n a l b h ed ha e i make e e nl and hei famil ha i i a f m e a e nce . A 20% de . All hing c n ide ed, e decided ice f e ice. C. Sa e F eca We a e edic ing ha The ea n eae Thi n a $0 b dge f a e ill ecei e 82 edic ing 82 de i beca de e e d ing ad e i ing and e al eek d ing he ial ing eme e . n e ecei ed 41 nl had he eb i e and de . nning f i 15 da . Wi h a $100 b dge f 19-20), f Need ( ad e i ing, ee ec i n Financial Anal i he e feel i i a ainable d ing eme e and m e a a ene ble he am n f de b ec i n Ca i al f e ice n cam e ecei ed d ing ial , n. D. Fi a cia S a e e Inc me S a emen O f n mbe en m fee ea ned in l f m gh a a ene hen e la nch a e age ag b d ma ke ing 82 de fee f 20%. 82 e a e a he O e e n e e e able n hing nea n ended i h 41 ef a eek a an a e age f $11 an de a * $11 e de * .20 deli e f he eme e , n i i h. When e e a d check. F m e ill defini el ial f ale , b ing eme e . Thi i h de n mbe l ing f ea nd ee e a ing f inc me nable d he e edic , i h ble ale f m hi b bled e ice 15 eek . $180.40 * 15 a emen i $500, hi c me a c edi ca d h gh Cha e, he ame bank end $3,000 i hin 3 m n h , e ill ecei e a $500 jec i n , e ill he eme e e all fee f $0.03 n he make eek. We ill be ead end m e han $8,736 in ill be minimal. The la ge al f e e de . F he fi fi 3m nh , al e en e e $3,206. en e ill be he a iable en e f c edi /debi ca d an ac i n . The e i a e ice fee f $0.30 e a an ec fee ea ned, e d fee = $180.40 e n gene a e alling $431.68. Thi ecei e hi $500 f e a d m ne . Thi b ing en e f ha de . We hen m l i l e an ici a e c edi ca d e a d . We a e a bank acc n. D ing de . U ing he e n mbe , e belie e i i eek = $2,706 fee ea ned. The ne f m n 5) a e c m i ed , a eg and an ad e i ing b dge , e ill be able n d ing he de d am ine . The ial $11 e he ial cce f l ial make a g a emen ( inc me an ac i n a fee f $0.30 e ell an ac i n, ai ni : 16 82 de e n he e all de 82 eek * 15 eek * $0.30 fee e e de al cha e . T find he eek, a e age * $11 e de de = $369. Then e calc la ed he $0.03 fee e all cha e al, and n mbe f eek in b de * 15 eek * $0.03 fee e e a a e c edi /debi e en e em g back ine . The e de = $405.90. N ge he and e ge h c edi /debi e man ai ni : e add he e en e f $369 + $405.90 = $774.90. O he e en e a e fi ed and m ch im le . Fi e ac l $100. The $100 i The e hi c ill be nb me in a c n e . O be handing li in f ne diffe en g ec a man Ma ian den e can. The b eb i e and c n ac inf ma i n n i . We ill al c la me . We ill d ad e i ing e f ial hi in f egmen en e i $25 f n, e ill be fl e en e ca d a ha e ill ill ha e ca h back incen i e f he c n e . O cce f l in ge ing c me f $40 + $15 +$20 + $25 =$100 in ad e i ing e en e i eb i e e en e hich i $25 e m n h hich e ill need f 4 m n h . $25 a m n h * 4 m n h = $100 eb i e e he mileage f m he ial en e. The final e $928 b e ine ca d . en e. The ne e ine he inne ee fi e hi ill be gi en 250 b ing $20 f en e. I i icking i h hem. We al ead ha e a ne fl e de igned f Jan a . All f he e ad e i ing e e be f $5 ca h back 100 fl e . O ending $40 f and he fif h hi en e i $15 f a he ad e i ing e . We ill be membe ad e i ing e i n e e ima e i en e i in e e ed f m ha k * 0.06 in e e en e added ill c e en e. O $4 e en e. We f ga e en e i minimal. U ing eek in ga * 15 eek = $60 ga nd hi n mbe b m l i l ing, * 4/12 m n h = $18.56 in e e e en e. All f ge he , $774.90 + $100 + $100 + $60 + $18.56 = $1053.46 al e en e . 17 Balance Shee The balance hee ( 6) i , e ha e ne i em in all h ee ca eg ie : a e , liabili ie and ec i n ha e al ca h, ne inc me f m liabili ie and ckh lde a able, hi n mbe i ea ning in ha The e i a emen n e ge he . O ( f ca h fl in hi $1,053.46. The e n mbe i e i .O i em in l an liabili ie ec i n i n e , $928. La l i e ained al i $1,224.54. ec i n i a ca h ecei ed f m c in hi b ac ed e ca h fl 7) , al i h ca h fl me e ne ca h fl e a ing ac i i ie , f m final ec i n f ne inc ea e in ca h. Thi n mbe i de i ed f m F he a emen el e in he b n mbe in hi ea ning f S ckh lde ine , ec i n i al and e all f e a ing. Thi gi e E en e , hich i nde hi ec i n i aigh he he b ac ing he $928 f m a ca h balance f $1,224.54. i ckh lde ed n he ame ec i n i ca h aid f f m financing ac i i ie . The n mbe financing f m he $2,152.54 f m f m hich i a able f m he ha k , $928. Since e ha e n in e ing ac i i ie , e g S a emen a e a emen , $2,152.54. Thi n mbe ec i n. The e ained ea ning fee ea ned n mbe , $3,206. Ne $2,152.54. Ne ckh lde e ice. We nl f Ca h Fl e a ing ac i i ie . Fi a i e a e a king he ha k ckh lde S a emen e inc me im le f e i ( ha e an c mm n , ck 8) e decided n efe ed in e ck. The nl e ained ea ning f m he balance hee . Thi make e ained al $1,224.54. 18 E. Sce a i A a i U ing c m i ed f n mbe ed, b e did n fi ell. O e financial .A he e en e f m he i em hi e en e i n im an beca di ec l ei i alen 82 ale e eek. O fi e ni i $1.34. O in h in . Thi ma i mid ice and mid ale ela ed h b f 177 mid ! The he e de . Wi h 82 e a i n. Thi mean all f nl ha e he a iable c f fi ill e ice ld me final deci i n ni and b eak e en in i 20%, a in he eme e a ed ea lie , and l ni in hi ca e i an $11 ale ha an n mbe in he ma i i hi hi n mbe fi ed and a iable c ha el e eek ha king a aging and i hin h ee eek ill be c eae hich i b eak e en a eek, e ill be able in ee e e make 20% fi ma gin n each ale. Thi i an enc he emaining e e a e a a high, mid, ih mid ale a e 1,230 f emel im de ine la ed a a in c ming in . O e a e making a 61% ng n mbe f ma i . The fee ea ned a e f he fac ha i e ice fee f 20%. We decided ha n. Thi mean a add he $500 c edi ca d e en e beca e in 9) ha , a emen , e c ea ed ng a he e f in ice, and ale make e ni ma i i and l ead hee ( cena i anal i e cel e ed. We ill e a ing. F. Ca i a Need MU G ce ill be c ea e Deli e en a f ll i a king he ha k : $728 f nd n d main, and $100 f fi G ce Deli e acc e he m ne eek f $928 in c m an . The m ne de , $100 a f he eb i e and ad e i ing. T gi e a li le m e de ail, d ing f n m ne beca in e ail an fe ing n e had f ne e n ake a fe da . We a e a king f de . We a i ed a hi n mbe b d bling he n mbe f e n m ne a n bank acc he $728 in de and h de d n in c he he MU e he fi bling he 19 am n f f n m ne ha i needed in de b he g ce ie f he fi ime f he ing eme e . The ne e en e ha MU G ce d a i n f he ing eme e . The $100 he eme e , b i ld al all f Deli e ha ld n a ac i a e nl ac i a e MU G ce Deli e eb i e f eb i e f he he d a i n f be in he d main in ead f ha ing i a a c m lica ed d main. The la c me e en e ha MU G ce $100 b i b ken d $40 f 5 Shi ( 1 ha e ill ea a na 250 b in he bag in de $20 f ill be f $25 f ine f he c ea il he f ll ing: 10) (4 hi m i nal i em f he hi me m e , fi de a lained in he ial 100 fl e ( , he f i a ine nd cam 11) (b a an a ad e i ing e nde en e f he c m an and a ell a ) ine ca d ell a being ca ied a e ice n cam ( hi f gene a e m e b ea ca d ( ca h back gi ea a he e ha i ad e i ing. O , ad e i ing hen he inne $15 f Deli e ill be handed nd i h he f nde ) ec ha n ec i n f hi 12). The e fl e b ilding a men i ned in he ec i n Ma ke ing Plan, en e ill in ial n and a e) ill be laced in he ame b ec i n Fl e ( 25). 20 . V. O e a i n Plan A. H Se ice W k O an e cel e cel e ice k b c ead hee f ha me a ead hee , ne de ed and he eam membe f i em and c llec hem. The Ma ian Uni e i . Af e ill ceed ed, he c .m. in he Pa l J N man Cen e , me de check ill be ill e ill en b diffe en g end a ha e f each i em. Once e ha e he he e. The ill di ide . The eam membe he ill be ill be able ed in ick he li ill c me back he indi id al hei de . de f m 8:00-9:00 m 105. membe ima el membe k n a e age e en and a half h h a he g ce ing he i em f ea l if m de ha e been icked and nea he main d ec e imila e and a half ill be en l he ne h . The fi m 105). Thi imebl ck ha b da ing he eb i e, he email ine in ing in i membe e le can c me and ick bag g ce ie , and ma lea e a li le half h ked e hen e la nch cha e, and handling an eek. The e h e ge ing all f he g ce ie . We ill hen ill be he b f he Pa l J. N man Cen e (Pa l J. N man Cen e , R e each eek de ending n a ailabili . T hei g ce ie . One membe ma c me a li le ea l e eb i e. We ill hen make ked We e ima e ha ill n an i ill d i e nl ading he g ce ie When he g ce ie a e B. H lacing hei di ec ie , affic he Ha che ell in he ime f ame f in he ne membe ial ing eme e . The final h ice , c ea ing he e cel cha e f mc n. We me . Thi ime a le f i em han 21 an h f all ial n, b a ind i h he l ng e m affec and fi an i e and make ibili e e kee fi c e , hi me ime bl ck ha and c ming back. C. Ga Cha gan cha ( O he ha k a me c n in e f ll cial media h and c m an a ha e ill be ecei ing he l an f m in be een hen Decembe 6, 2018 and Jan a n e 13) h , en ial c na gh b eak me . We i i i ed he l an f m he ha k c me kee name and e ice in he mind de ing b h ine ha c ea ing a c d main ha and liking a ee finali ing c m e n en l i i f bank acc ead f n e hen m d main ill be ne . We belie e m d main (m g ce deli e .c m) eaec fl e eb i e and ca d and hi gh. We ill make me ime be een Decembe 14 h-29 h f 2018 (Ch i ma b eak), e ge back f m b eak. Pa ing f 22, 2019. We ill ld be m e mem able han he ing ( e mcca ne 4. i i e.c m/m deli e ). Finall , e ill ca h back c n e ha he c n e an T i e . We belie e ha he e i em che bef e e can a h ld en e b ld g la beca e ee ing and e he a e he e a ing. D. O ga i a i MU G ce hei n d ing he Deli e ha a fe j b ha each membe ill be e n ible f d ing n ing eme e , he e incl de: Emil ill be c nnec ing i h a en ia Faceb k Ma he ill be making an e cel hee i h all he name f he d c needed a a he an i f hem T e ill be da ing he eb i e, handling a men and in ice , and c m an bank acc n Salem ill be managing In ag am and T i e , i h a f c n m i n and ad e i ing, a ell a c nd c ing c n e in h e gene a e ne c me ell 22 VI. Ma ke ing Plan A. P i In de ( gene a e m e a a ene 14), ha , acc n and e ee ed f e ice, e c nd c ed a T i e c n e a ed if he Ma ian Uni e i c ne ee , hei ecei e $5.00 ca h back n hei e name The being i en n a mall e name n ha m i nal idea hen b ine ell d ing he ial i in e a i n. Thi n i al f he f ee ad e i ing h n m e Deli e e h en e he c n e f he e hei T i e a and m d a de a $5.00 le h en e ed he c ne ia T i e . Since hi n, e lan n c nd c ing he ame nl ge gi e MU G ce ing a bag i h ne name being elec ed. ick n e a n ified ha he ked gaining e ee , b n, a l ng a e name ick n e, laced in a f ll ld be en e ed in de d ing he ial m e. The and m d a ing c n i ed f he eigh c ne den den a chance a e d ing f a a e f he b gain m e m i n ine de b beca e c m an . B. Ad e i i g Al ng i h he Deli e ha decided he be and hanging f nde ca d cial media acc fl e e h ad e i e Deli e de ed ff n he digi al c een ea a lained m e la e , MU G ce den a ge ma ke n he man b lle in b a d a f MU G ce h a n , hich ill be e nd cam nd cam ld be making , c ea ing hi , c ea ing and handing eb i e, and finall c ea ing a c mme cial ha n Ma ian Uni e i cam (al ead a ed b f he b ine ill be la ed he Ma ke ing and C mm nica i n ffice). 23 C. S cia Media MU G ce ( Deli e 15) and he be , A a ed in he fc like Uni e i F king a hei k age. Th MU G ce engagemen a den f MU G ce den file n Faceb k ld be n T i e and In ag am. Deli e n Faceb i in cha ge f finding he kb find hei famil membe fa , e c en l ha e 47 Faceb Deli e ih he e eh le beca ed ing he name f he name and in i ing hem k like f m c e c n e . Wi h m e and m e f ll m e e ee , e MU G ce en Ma ian Deli e inne a f h nd ed f ll half f e , ing ha ha ih a ge ma ke being e de i ee . Thi ee e ne lan n ea a e e laced d ing hi e ie ing i ed c ne he deciding en e he e ill gain e ice. 17) i ed a highligh ha f ll nf ed , e ice. We ha e en l ha e ab e e f he e ee n In ag am ( ell a all he e ee a c m an n T i e . D ing he ime f he c n e , e , eaeh l ing in m e f den a ge ma ke , ec e f he abili beca 16), , . T i e ha been kn ca hback c n e n gained en f ll c ne age ( T i e den a ge ma ke he m h T i e acc a a li le each a den , hei famil membe , and al mni. engaging i h fac each famil membe T i e and In ag am, l gging in hei name in he ea ch engine a k, and l Faceb a en Ma ian Uni e i h f ll f Faceb a e a i n lan, ne membe famil membe den decided he be ed f inf m ial n ha h n. On he highligh ha e ie ed hi . C In ag am ha bec me m e and m e en l la a i ing he eme e ha g ne n. 24 D. F e We c ea ed a fl e f c nd c ed he ial ed n n Oc be 30, 2018 (See A den acc n media. We belie e he e fl e hen e a e ead 12) ill be n (men i ned ea lie in ec i n O 12-14). The fl e i Hall f f Demand ( b ec i n P and e ial a f ee c nd c all fl e , a deli e Anal i e e een hemed beca endi , I em 2). We e e e ell a ad e i ing f cce f l and ha e n fi ni cce f l f ee n made ne in Jan a f he eme e . Thi fl e ( e , in each b ilding n Ma ian cam cial , . E. Shi C en l , e lan ha e fi e hi n hem ( ca d a ing h ecei e eme e , F. B enc i e f ad e i e e f aking ca d ha e 250 b den i h hem a The e b ine G. C e cia cl eam ill ha e ne f he e hi ine . We ill al , ha e a inne f m a ca d made ( ine h gh nd cam ca d ha e he link e and ead c mme cial i ed ing fi de f he ing e ice. We filmed a c mme cial a a a a and a h Ca d ill be gi en g b f Deli e he final hi . Thi d a ing ill be d ne af e age he We lan ca d 10). Each membe , and e ill ea hem f en made i h MU G ce ai make e k ne , 11). The b he eme e . Each eam membe and cla e eb i e a gi e ell a le la gh and emembe nning n ible c n ac inf ma i n. b ine . O h MU G ce c mme cial n he digi al c een a ill be e den a ge ma ke . be ligh -hea ed and f nn a a g eme e ine nd cam Deli e .I b gh e f he i . We ha e been ia he Ma ke ing and 25 C mm nica i n ffice. We ill al h , f nn , and ge he c mme cial n cial media. The c mme cial i name and e ice n he ma a Ma ian Uni e i . 26 VII. E i S a eg The e i m ch e head, i lef e g ce n ha e aid f b ine i a eg f e c m an , ince e d n im le. When i c me bag . We ill ei he kee he bag , icking c m an financiall beca eminde email f cann ill n de Knigh aff d b hei he e bag f h ,b ,af if he c e nal e ee i e e ma ha n in en, i ld n ecei ed hei me neglec d e ice n cam ha e e ma ha e me ec cle hem. We ill fi abili . We ma al e e ill ha e al ead a da Pan de . If hi d c and e ill n he end f he eme e ca d lef , hich ill be ec cled. The la me ne n he hi ffe a ha e me fl e d ing he eme e be ha mf l he a men . We ill end ge hei ha hel l de , e ill d na e e inc me den h g ce ie . 27 VIII. C ncl MU G ce c mmi ed e and ine ing hei g ce ie c mmi ed b dge G ce b e f g ce h ing n cam ge cam name i b Deli e ni nline f f g ce ie a Ma ian Uni e i . We a e ih Ma ian Uni e i ea - den a mall fee f 20% f hei en i e e ill la nch c ming and e lan b ine a f e h in n Jan a a e mall and be he ne c a e ime b me e ad e i ing mind . Wi h he 15, 2019 and e ill begin en ial i cce f l b e eb i e. de . We a e i h a mile and a f iendl face. We ill he e and c n an l make m ne immedia el . O ine a en i e ickl e ing l an f m he ha k b ill be he ne changing he c l We ffe a ni b Deli e i n ine emend in hi ind . The deli e . We a e MU and e ill DELIVER! 28 IX. A 1. Link eb i e and h e mcca ne 4. i 2. Fl e f he ial f he endi eb i e i e.c m/m deli e n 29 3. Li f d c name and 4. G a h f nline deli e g an i h jec i n 30 5. Inc me S a emen 6. Balance Shee 31 7. S a emen f Ca h Fl 8. S a emen f S ckh lde e i 32 9. Scena i Anal i 10. C m an hi 33 11. C m an b ine ca d 12. Ne fl e 34 13. Gan Cha 14. T i e C n e 35 15. Faceb k age 16. T i e age 36 17. In ag am age 37  ...

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... Running head: USE OF A CHECKLIST IN POSTANESTHESIA CARE TRANSITIONS Implementation and Evaluation of a Checklist in the Postanesthesia Care Transitions Kaleigh Milling Marian University Leighton School of Nursing Chair: D. Lee Summerlin-Grady, DNAP, CRNA _________________________ (Signature) Committee members: David Crook, MD __________________________ (Signature) Wendy Deaton, RN __________________________ (Signature) Caroline Dumas, RN _________________________ (Signature) Date of Submission: July 18, 2020 1 Use of a Checklist in Postanesthesia Care Transitions Table of Contents Abstract ................................................................................................................................4 Introduction .........................................................................................................................5 Background ....................................................................................................................5 Purpose...........................................................................................................................7 Problem Statement .........................................................................................................7 !"#$%&'$(&)%$* +,$-. /%$*01&1 )2 3")456( 7&(5 ..............................................................8 Review of the Literature ......................................................................................................9 Evidence-Based Practice: Verification of Chosen Option ..........................................13 Theoretical Framework......................................................................................................13 Goals/Objectives/Expected Outcomes ..............................................................................13 Project Design ...................................................................................................................14 Project Site and Population ..........................................................................................14 Methods .......................................................................................................................14 Measurement Instruments ...........................................................................................17 Implementation Plan and Procedure ............................................................................18 Data Collection Procedure ..........................................................................................19 Ethical Considerations/Protection of Human Subjects ................................................19 Data Analysis and Results .................................................................................................20 Preintervention Results and Analysis ..........................................................................20 Intervention Results and Analysis ...............................................................................24 Postintervention Results and Analysis .........................................................................25 Implications for Future Practice.........................................................................................28 Conclusion ........................................................................................................................29 References ..........................................................................................................................30 2 Use of a Checklist in Postanesthesia Care Transitions Appendix A ..................................................................................................................35 Appendix B ..................................................................................................................38 Appendix C ..................................................................................................................39 Appendix D ..................................................................................................................40 Appendix E ..................................................................................................................41 Appendix F...................................................................................................................43 Appendix G ..................................................................................................................45 Appendix H ..................................................................................................................46 Appendix I 8888888888888888888888889 .................47 Appendix J ...................................................................................................................49 Appendix K ..................................................................................................................54 Appendix L ..................................................................................................................59 Appendix M .................................................................................................................67 Appendix N ..................................................................................................................75 Appendix O ..................................................................................................................76 3 Use of a Checklist in Postanesthesia Care Transitions 4 Abstract The transition from the operating room to the postoperative care unit is a critical time in the perioperative period for patients. Patients are physically transferred from one location to another and critical information regarding -$(&5%(1: &%("$)-5"$(&;5 period must be delivered accurately to ensure patient safety. Over the past few years, many healthcare regulating agencies have advocated for a standardized care transitions by suggesting a handoff checklist should be implemented but this has failed to be universally executed. There is not one template universally implemented in post anesthesia standardized handoffs but many different models. Nonetheless, research has shown using a standardized template for this care transition has shown that more information was delivered to the receiving parties and safety events related to miscommunication in postoperative transitions were decreased. The purpose of this project is to refine care transitions through a standardized handoff which will improve communication and decrease safety-related events. Nurses and anesthesiologists were anonymously surveyed about their perception of postanesthesia transitions prior to and after introduction of the intervention. A postanesthesia handoff checklist formatted in a Situation, Background, Assessment, and Recommendation method was implemented at a level one trauma center in the Midwest based on feedback from the organization. The documented handoffs indicated there was a high compliance with using the checklist. The postsurveys presented low participation and neutral feelings regarding the use of a handoff checklist Keywords: postoperative, postanesthesia, handoff, care transitions, anesthesia, PACU, nurses, handover, report, communication, team, admission, surgery, patient transfer Use of a Checklist in Postanesthesia Care Transitions 5 Implementation and Evaluation of a Checklist in the Postanesthesia Care Transitions Introduction This project was submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice (DNP), Nurse Anesthesia track. The transfer of patient care from an anesthesia provider to a registered nurse (RN) is a critical time in the perioperative period. A comprehensive handoff report is necessary to ensure the receiving provider has an accurate account of the -$(&5%(:1 experience in the operating room to maximize safe patient care. Background The care transitions from anesthesia personnel to a Post Anesthesia Care Unit (PACU) RN permits providers to have an opportunity for face to face communication that includes an interactive discussion on the details of a -$(&5%(:1 procedures. The transition of care is a vulnerable time for the patient because of the physical transfer, collaboration from multiple providers, and many patients having similar medical histories. Without a validated method, there are often variances in the handoff report dependent on the provider and the nurse who participate in the transfer of care. This type of care transition has been described harshly as +&%2)"<$*= unstructured, and &%6)<-*5(5. compared to other medical care transitions (Milby, Bohmer, Gerbershagen, Joppich, & Wappler, 2014, p. 192). Postoperative handoff has been determined as a barrier in delivering safe patient care because it is +>&#>-risk. and +error--")%5. (Agarwala, Firth, Albrecht, Warren, & Musch, 2015, p. 96). When vital items are not included in a care transition there is a possibility of a critical piece of information not being communicated to the subsequent provider. This miscommunication can generate a medical error or increase mortality and/or morbidity for patients and produce longer PACU stays and delays in treatment (Rose, Newman, & Brown, 2019). Use of a Checklist in Postanesthesia Care Transitions 6 The attitude of many anesthesia professionals is that the report they deliver is adequate and they do not need to change anything about the delivery of their report (Lane-Fall, Brooks, Wilkins, Davis, & Riesenberg, 2014). These behaviors lead to poor morale of the organization and critical information not being delivered to the subsequent provider. Other detrimental behaviors include delivering reports when the nurse is not ready to accept information, side conversations during the reports, and noise from televisions or radios can affect the quality of the postanesthesia reports (Petrovic, et al., 2015). The Joint Commission (TJC) identified that the foremost reason for anesthesia associated sentinel events were communication errors and twice as many deaths are associated with communication errors than with inadequate care (Park, et al., 2017; Siddiqui, et al., 2012,). Breakdown in communication impacts as many as 85% of medical errors (Boat & Spaeth, 2013). The annual cost of medical errors in the United States is estimated at more than 17 billion dollars and medical errors result in up to 400,000 deaths annually (Halterman, Gaber, Janjua, Hogan, & Cartwright, 2019). Verbal report errors from physicians and nurses are responsible for 37% of errors in the handoff process (Siddiqui, et al., 2012). The World Health Organization (WHO) recognizes that communication errors are one of the top five preventable errors (Halterman, et al., 2019). In 2007, the WHO designed a checklist for surgeries called a +(&<5 )?(. or universal protocol which ensures that the right patient is having the right surgery on the right location which decreased morbidity, mortality, and surgical complications. This structured report increased information accuracy during transfer, patient safety, and teamwork in the operating room (OR) (Milby, et al., 2014). The research behind using a checklist is derived from +@>5 Checklist A$%&251(). which states that safety is improved with standardization (Bruno & Guimond, 2017). Checklists have been used since the 1930s and assist in preventing tasks from Use of a Checklist in Postanesthesia Care Transitions 7 being overlooked which leads to poor outcomes (Bruno & Guimond, 2017). In 2005, TJC +<$%B$(5B a standardized approach to >$%B)221. (Park, et al., 2017). Then again in 2009, TJC made standardized care transitions a National Patient Safety Goal (Petrovic, Martinez, Aboumater, 2012). The implementation of a postanesthesia checklist would confirm all the outlined data is being transferred from the anesthesia provider to the receiving RN and complies with the recommendations from the WHO and TJC. Purpose The purpose of this DNP project is not only to comply with the recommendations of the WHO and TJC who have been advocating for this change since 2005, but also to improve patient outcomes (Petrovic, et al., 2015). The use of standardized handoff has been shown to improve safety by decreasing patient morbidity, mortality, and surgical complications (Segall, et al, 2012). Another objective of this project is to improve satisfaction, decrease stress, and improve communication among providers. Problem Statement Miscommunication or missing information in a care transition is a problem that can lead to adverse events or suboptimal management of -$(&5%(1: care. Using standardized care transitions have been proven to advance postoperative handoff reports. A Problem, Intervention, Comparison, Outcome, and Timeline (PICOT) question was formulated to examine this issue. In anesthesia providers transferring the care of patients to nurses does utilizing a standardized handoff checklist for report improve the transfer of information compared to anesthesia providers who do not use a standardized handoff checklist during patients' PACU stay? A quality improvement project was designed around this question to examine if a standardized report would change perceptions of postoperative care transitions and improve patient outcomes. Organizational !"#$% Analysis of Project Site Use of a Checklist in Postanesthesia Care Transitions 8 The care transitions from over twenty anesthesia providers delivering a postanesthesia report on over seventy-five patients was informally observed at the hospital from May to August 2019, a variance was noted from anesthesia providers delivering reports and nurses receiving reports. The ideal future state of this postoperative handoff report is for 100% of the )"#$%&'$(&)%:1 determined items to be delivered to the receiving RN. The current state of the postanesthesia report is the anesthesia provider includes what they think is appropriate in handoff reports and depending on the nurse, they ask follow-up questions to complete reports. Many nurses are spending valuable time that could be spent delivering patient care, searching for this missing data in -$(&5%(1: charts when a complete report is not delivered to them. Prior to the intervention, many of the )"#$%&'$(&)%:1 anesthesiologists begin delivering reports while the nurse is still hooking up the patient to the vitals sign monitor and the report is frequently interrupted with side conversations. The current reports can be described as scattered and unpredictable. Anesthesia residents have stated that their education on care transitions were informal and inconsistent. These residents graduate and are employed as attending anesthesiologists who continue these erratic care transitions (Muralidharan, et al., 2018). The current state of postoperative handoff reports creates practice gaps that could potentially impact patient safety. The ideal state of this report eliminates these gaps and supplies the receiving nurse with an entire narrative of -$(&5%(1: perioperative periods. The difference between these two methods revolves highly around communication and standardization. Review of the Literature The American Society of Anesthesiologists (ASA) published both practice guidelines and standards of care in 2013 for the postanesthesia period. The practice guideline for postanesthetic care includes no information on handoff reporting but focuses on outcomes and treatment (ASA, Use of a Checklist in Postanesthesia Care Transitions 9 2013). The standards for care in the postanesthesia period, state that an anesthesia staff member (>$( &1 C%)D*5B#5$E*5 )% (>5 -$(&5%(:1 6)%B&(&)% accompanies the patient to the PACU. The patient will be continuously evaluated and monitored in the PACU. An oral report is necessary and is delivered to the PACU nurse caring for the patient by the anesthesia provider according to the standard of care. Three criteria must be met in this report: 1. @>5 -$(&5%(:1 1($(?1 )% $""&;$* () (>5 3/FG 1>$** E5 B)6?<5%(5B9 2. Information concerning the perioperative condition and the surgical/anesthetic course shall be transmitted to the PACU nurse. 3. The member of the anesthesia care team shall remain in the PACU until the PACU nurse accepts responsibility for the nursing care of the patient. (ASA, 2014). These criteria are very general and allow the presence of variability in care transitions. Other reasons for variance in PACU handoffs include a differing understanding of what should be included in the report, contradictory expectations and opinions, time pressures, and an unfamiliar environment for new or temporary employees. The PACU can be an unfamiliar environment for students, staff in training, per diem employees, float pool nurses, or staff reallocated from other areas of the hospital. Consequences of variance include patients and their familys: dissatisfaction, the receiving staff spending additional time searching for missing data which is an inefficient use of time in the fast-paced environment of the PACU, and medical errors due to miscommunication (Boat & Spaeth, 2014). The use of handoff checklists for postanesthesia care transitions have been comprehensively researched and the use of these handoffs decreases the variance in care transitions (Rose, Newman, Brown, 2019). There are many different models and interpretations on how to implement a checklist in handoff reporting to PACU nurses. Examples in the literature include mnemonics, situation background assessment recommendation (SBAR) methodology, Use of a Checklist in Postanesthesia Care Transitions 10 and checklists ranging from 11- 59 points (Rose, Newman, & Brown, 2018). The existing processes of postanesthesia care transitions were studied to evaluate the necessary criteria for handoff checklists and then a template was designed based on the designated criteria (Boat & Spaeth, 2014). Study designs included prospective cohort, observational with no intervention, quasi-experimental, and cross-sectional observational studies. In the majority of studies, data was collected before the intervention to establish a baseline percentage of complete handoff reporting. Data was amassed throughout the studies and the number of complete handoff reports were analyzed. Additional data was also collected throughout questionnaires to measure 1($22:1 presumption of safety, incident reports were used to measure safety metrics, and in some studies, the time spent delivering the report was measured (Randmaa, Martensson, Swenne, & Engstrom, 2013). The timeframe for the studies ranged from two weeks to six months. Many projects presented a teaching session on the handoff and the criteria their organization deemed necessary to include in a complete handoff. Almost every study displayed this criterion in the PACU by attaching it to the wall or to (>5 -$(&5%(:1 E5B1&B5 table. Some studies supplied providers with pocket cards they could attach to their badge. One organization designed a smartphone application, so staff members had an easy way to access the checklist (Jullia, et al., 2017). A recurrent theme in the research was nurses receiving handoff had a note sheet or template in the electronic health record (EHR) they completed which was modeled from the handoff checklist. Electronic Anesthesia Information Management System (AIMS), a smartphone application, has also been used to guide care transitions (Agarwala, et al., 2015). Valuable steps before initiating the report included completing a critical hookup of the patient to the monitor, obtaining a preliminary set of vital signs, and asking the RN if they were ready for report, and 2)"56$1(&%# &2 (>5 $%51(>51&$ -");&B5" >$B $%0 6)%65"%1 2)" (>5 -$(&5%(:1 2?(?"5 HI)$( Use of a Checklist in Postanesthesia Care Transitions 11 & Spaeth, 2014, p. 650). Assessing if the nurse is ready for report allows for the undivided attention of both providers. A preliminary set of vital signs assesses if the patient is still in a stable condition after being transported from the OR to the PACU. Assessing the anesthesia -");&B5":1 6)%65"%1= allows the nurse to be focused on patient specific indicators. The setting of all of the studies was the PACU, a department that is described as a fastpaced and +>&#>*0 B&1("$6(&%# 5%;&")%<5%(. which creates vulnerability and limitations to research (Halterman, et al., 2019). Many of the limitations of these studies were related to data collection, because the data were either self-reported, researchers were present, researchers could only observe one study at a time, and/or human error (Milby, et al., 2014; Park, et al., 2017). In studies that staff members were aware that they were being observed, it is possible they altered how they delivered their report, this modification in behavior is called the Hawthorne Effect (Milby, et al., 2014). The design of many of these studies did not allow for randomization which is a limitation of many quality improvement projects. The information was dispersed and available to all of the employees which creates an inability to randomize subjects because of a universal exposure to the intervention. Selection bias was recurrently listed as a limitation in these studies and can occur when there is only one researcher (Randmaa, et al., 2013). Implementation of an SBAR postanesthesia checklist handoff has shown a drastic increase in comprehensive reporting in every study that was reviewed (Randma, Swenne, Martensson, Hogberg, & Engstrom, 2016; Halterman, et al., 2019; Randmaa, Martensson, Sweene, & Engstrom, 2013; McKechnie, 2015). The benefits of using a checklist include creating a guide for information delivery, improvement in information transfer, and decreased errors. Outcomes of evidenced-based handoff reporting tools were decreased miscommunication, reduced safety-related events, diminished order entry errors, reduced unexpected death, and improvements in safety reporting (Randmaa, et al., 2013). Anesthesia providers and nurses Use of a Checklist in Postanesthesia Care Transitions 12 involved in these studies agreed that teamwork improved and that they were encouraged to work together. Nurses felt empowered to ask more questions to address all the criteria when there was a designated checklist that permitted more complete reporting (Boat & Spaeth, 2013). Communication errors are the most preventable adverse event in healthcare and over half of these errors occur during patient care transitions (Jullia, et al., 2017). The standardized handoff template strives to decrease and eventually eliminate medical errors due to miscommunication. One study reported that communication errors caused 14% of postoperative adverse events (Lane-Fall, et al., 2014). Providers with good communication skills have been found to more accurately identify problems with patients, have decreased stress, develop greater job satisfaction, possess a more satisfied patient population with better outcomes, and their patients are more likely to heed their advice and follow the treatment plan (McKechnie, 2015). Standardization of the handoff checklist is one of the easiest ways to decrease the loss of information and prevent miscommunication from occurring. TJC instructed that an unvarying approach to handoff reporting should be implemented over a decade ago that incorporates a universal list of criteria but this has been yet to be universally achieved (Park, et al., 2017). Evidence-Based Practice: Verification of Chosen Option The American Association of Anesthesiologists Standard of Care for postoperative care transitions is concise and just requires intraoperative anesthesia staff to be present for transport, monitoring, and verbal report (Park, et al., 2018). The evidence-based practice has shown there are many ways to deliver the postoperative reports, numerous models of designing a handoff checklist, and varying criteria to what should be included in the report. The use of a checklist as a cognitive aid has improved the completeness of postoperative reporting in the United States and abroad Randmaa, et al., 2013. Use of a Checklist in Postanesthesia Care Transitions 13 Theoretical Framework @>5 (>5)"5(&6$* 2"$<5D)"C ?15B 2)" (>&1 -")456( &1 F>5"0* 7(5(*5":1 Model of Research Utilization, which applies decision-making steps and critical thinking to examine and evaluate research. There are five phases to this model: preparation, validation, decision-making, application of the evidence, and evaluation (White, Dudley-Brown, & Terhaar, 2016). Preparation for this project includes the exploration of relevant data for implementation. Validation is the assessment of the data. Decision-making is the evaluation of the data and if it will be practical for the application of the evidence. After the evidence is implemented the intervention will be evaluated for effectiveness (White, Dudley-Brown, & Terhaar, 2016). Goals, Objectives and Expected Outcomes The goal of implementing a handoff checklist for postanesthesia care reporting is for providers to communicate to nurses a complete account of the events that occurred in the operating room especially related to anesthesia in 100% of their reports. The expected result of this goal is an improvement in delivering safe patient care, decreased medical errors due to miscommunication, enriched communication, and increased teamwork. The reporting will include specific criteria based on the handoff reporting tool. The goal will be measurable by "5;&5D&%# -$(&5%(1: 6>$"(1 2)" (>5 B)6?<5%($(&)% )2 (>5 $%51(>51&$ >$%B)22s. Anesthesia providers will deliver the reports and PACU nurses will receive the reports, complete their charting, and inquire about any handoff criteria that were not included in the reports. The objective of this project is to educate healthcare professionals on a handoff checklist and the importance of complete reporting. The expected outcome is the amount of complete reporting will change as providers incorporate using a SBAR PACU handoff checklist into their routine. Project Design Use of a Checklist in Postanesthesia Care Transitions 14 The implementation of a handoff checklist for PACU reporting is a quality improvement project, specifically a process improvement project. Quantitative methods will include the calculation of complete reports and use of the handoff tool. Qualitative data would be the opinions of PACU nurses and anesthesia providers about the quality of reporting and how the handoff checklist meets the needs of the organization. Project Site and Population The project site is a Level I Trauma Center located in the Midwest with over 20 operating rooms. The surgeons perform minimally invasive procedures, gynecological, pediatric, cardiac, robotic, ear, nose, throat, transplant, and orthopedic surgeries. All of these surgeries except pediatrics will be included in the population using the SBAR handoff tool. Anesthesia care is delivered by a private physician group, which is one of the largest in the Midwest. Methods Participants in this project are the anesthesiologists and their students, trainees, or residents and PACU nurses and their students or trainees who are delivering postoperative anesthesia report to a RN in the Orthopedics (Ortho) and Main PACUs will be included in this project. Because of the nature of this quality improvement project, all employees in these departments will be exposed to the information on handoff checklists, which makes randomization impossible. Participants will be involved in this project because of their employment with the hospital or anesthesia group. Preparation for this quality improvement includes designing a handoff specific to this hospital to fit the needs of the organization. The handoff will utilize the SBAR format. The SBAR format was selected because it is the most universal system approach tool used in healthcare and has been proven to be effective (McKechnie, 2015). SBAR is not only used in healthcare but also by other high-risk organizations (Randmaa, et al., 2013). Benefits of Use of a Checklist in Postanesthesia Care Transitions 15 designing the handoff using this tool are the simplicity of design, it requires minimal training, it is appropriate for many circumstances (including face to face, telephone, and written handoff), it is a brief and concise tool, the structure is predictable, and it can be used by all staff members. The universality of the SBAR format validates its applicability to this project. The information included in the checklist will be derived from a review of the literature and the needs of the organization. A list of criteria to be potentially included in the organization specific handoff is listed in Appendix A. The checklist will be formatted in the SBAR structure and specific to the organization and their patient population. Clinical stakeholders will be the decision makers to confirm the desired criteria for the handoff. Handoff criteria will be displayed in each bay in the PACU and set to be the lock screen on the iPads used by the anesthesiologists. The Main and Ortho SBAR postanesthesia handoff checklist is listed in Appendix B. Before the implementation of the SBAR postoperative checklist, the two cohorts: RNs and anesthesiologists, will be given a preintervention survey to gauge their perspective on the current state of postanesthesia reporting (Appendix C and D). Modifications to the SBAR checklist may be necessary based on this information. After the conclusion of the data collection from the SBAR handoffs, a similar survey will be given to each group. This survey will assess their perceptions of postanesthesia care transitions, safety, and teamwork based on their experience using the SBAR postanesthesia handoff (Appendix E and F). Staff members will be educated by the clinical stakeholders and provided with a one-page overview of the project (Appendix G). The benefits of this quality improvement project is dependent on the actions of the healthcare professionals involved. How these participants deliver and engage in the postanesthesia reporting process will affect the usefulness of the handoff checklist. This document will be scrutinized to examine if it meets the needs of the PACU nurses and Use of a Checklist in Postanesthesia Care Transitions 16 anesthesiologists at the hospital. The report will always revolve around the patients who have had surgery and anesthesia and their medical need for a visit to the PACU. The extraneous factors would include staff members not aware of the handoff checklist, non-compliant staff members, and medical emergencies that may trigger a delay in postanesthesia report being delivered. The care transition will begin with the anesthesiologists bringing their patients to the PACU along with the patients: charts and their iPad with the checklist set as their lock screens. They will begin delivering their report to the PACU nurse after the critical hookup to the vitals sign monitor is complete. The nurses will confirm they are ready to receive the report. The postanesthesia report will follow the format of the checklist (Appendix B). The PACU nurses will record this report on a modified version of their preexisting report sheet that follows the postoperative handoff (Appendix H). The nurse will document the report delivered to her/him and conclude this process by asking any questions she/he may have. These sheets are not part of the medical record and will be placed into a secure vestibule $( (>5 3/FG %?"151: 1($(&)%9 @>5 report sheets will be devoid of any confidential patient information. After the report is delivered and patient care is complete, the nurses will circle an answer to two questions and note any comments about the postanesthesia care transition. These two questions and a line for comments is located in the bottom righthand corner of this report sheet. These forms will be collected at the end of the study and descriptive statistics will be utilized to assess the completeness of the reporting. The institutional stakeholders will be updated at the end of the data collection. Measurement Instruments To measure the outcomes of this DNP Project the following will be used: preintervention data, report sheets with the survey (Appendix H), and postintervention data. Preintervention data will be collected anonymously from the preintervention survey completed by nurses and Use of a Checklist in Postanesthesia Care Transitions 17 anesthesiologists. These surveys will be distributed via email and collected through the Survey Monkey website. This information will be recorded into Qualtrics to perform descriptive statistics of the participants answers to questions 1-5 (Appendices C and D). This information will be utilized to $11511 (>5 1($22:1 ;&5Ds of postanesthesia reporting prior to the intervention. Additional data will be collected from the report sheets at the end of the two-week period. Descriptive and inferential statistics will be derived from this information to detail areas of strength and opportunities for improvement for complete handoff reporting. At the end of the study, data from the intervention will be displayed to demonstrate the effectiveness of the intervention. After the two-week trial period is complete, nurses and anesthesia providers will be surveyed with a similar anonymous assessment on Qualtrics via email. They will be able to convey their opinions of the intervention, how the intervention impacted patient care, and assess areas for future quality improvement interventions related to postanesthesia care transitions (Appendices E and F). Descriptive statistics will be performed on questions 1-7 of the postintervention survey. Implementation Plan and Procedure F>5"0* 7(5(*5":1 <)B5* )2 "515$"6> ?(&*&'$(&)% D$1 applied to implement this project. The researcher and stakeholders from the hospital prepared for the implementation of this quality improvement project. A literature review of criteria included in postanesthesia care transitions was performed and a collective list was derived (Appendix A). After several drafts and a collaborative effort from the primary researcher and the hospital stakeholders, a final Main and Ortho PACU SBAR Handoff was finished (Appendix B). Decision-making performed by the hospital stakeholders was the primary deciding influence for what criteria was included in the final SBAR checklist. Use of a Checklist in Postanesthesia Care Transitions 18 Validation of the need for this project was confirmed by the staff via an anonymous preintervention survey, input from the stakeholders, and the recommendations from the WHO and TJC to have implement standardized reporting in all postanesthesia handoffs. The necessity for this project was confirmed by the informal observations by the primary researcher from MayAugust 2019. Validation will be derived from the assessment of the data received from the nurse report sheets and the postsurveys. Decision-making will additionally include the evaluation of the intervention, the data, and whether this tool will be practical in (>&1 )"#$%&'$(&)%:1 clinical practice. Application of the evidence will be used to revise the SBAR checklist, prioritize the needs of the organization, and future research. The evaluation will be completed after two weeks of collecting the nurse report sheets and postintervention data are collected and analyzed. Data Collection Procedures Data collection from the intervention will be performed by the student in charge of the project. A presurvey will be distributed to nurses and anesthesiologists and they will be given two weeks to complete it. The SBAR Postanesthesia Checklist will go live and data will be collected at the end of the two-week collection period from the confidential surveys on the %?"151: "5-)"( 1>55(1. Postintervention data will be collected via an anonymous survey, the same as the preintervention survey and staff will have a week to complete it. Practical considerations include that the information will be in a paper format and not in the electronic health record, it will involve physical collection )2 (>5 %?"151: 1>55(1, and it will require participation from the staff members. Other considerations include motivating the staff members to take a survey on the project and encouragement from the clinical stakeholders may be required. Ethical Consideration/Protection of Human Subjects Use of a Checklist in Postanesthesia Care Transitions 19 Marian University Institutional Review Board (IRB) has granted an exemption for this project and no IRB approval is necessary from the hospital before the initiation of the project. All participants are protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which, among o(>5" #?$"$%(551= -")(56(1 (>5 -"&;$60 )2 -$(&5%(:1 >5$*(> &%2)"<$(&)% (Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules, 2013) (Office for Human Research Protections, n. d.). Additionally, the primary investigator and the practice personnel who carefully conducted this project followed the Standards of Care for the postanesthesia report published by the ASA. All information collected as part of evaluating the impact of this project was collected as aggregated data from the project participants and did not include any potential patient or staff identifiers. The risks to patients contributing to this project was no different than the risks were to the previous patients whose postanesthesia reports were delivered in an unstructured manner. The -$(&5%(1: &%;)*;5<5%( &% (>5 -")456( D$1 exclusively that they had a procedure performed and received anesthesia and an anesthesiologist had to give a postanesthesia report, nothing was modified regarding their care besides how the report was delivered. Confidentiality was assured by turning in the report sheets to a secure receptacle. The sheets were designed to not include identifying information of the person submitting them9 @>5 %?"151: "5port sheets were also devoid of information that would allow the patient to be identi2&5B9 @>5 1($C5>)*B5":1 modified (>5 %?"151: "5-)"( 1>55( () 1($(5= +7(?B5%( 3")456( J5-)"( 7>55(= %) -$(&5%( identifiers to be included per the request of the of anesthesiologists. These forms were disposed of using the h)1-&($*:1 B&1-)1$* 6)%($&%5"1 2)" -")(56(5B >5$*(> &%2)"<$(&)%9 K) B)6?<5%(1 )% (>5 "515$"6>5":1 personal computer and no information provided by staff in surveys via Qualtrics and Survey Monkey included any patient information. Marian IRB approval is presented in Appendix I. Data Analysis and Results Use of a Checklist in Postanesthesia Care Transitions 20 Data will be analyzed from the preintervention surveys, 1?";501 )% (>5 %?"151: "5-)"( sheets, and postintervention surveys. All data will be submitted to the researcher by PACU nurses and anesthesiologists. The responses to the preintervention and postintervention surveys are displayed in Appendices J, K, L, and M. @>5 1?";50 B$($ 2")< (>5 %?"151: "5-)rt sheets was logged using the tool in Appendix N. The results from the intervention data are displayed graphically in Appendix O. Preintervention Results and Analysis Anesthesiologists were given the link to the preintervention survey on March 9, 2020. From March 9 - March 16, 2020 a total of 38 anesthesiologists completed the survey. This organization employs 83 anesthesiologists to cover all of their contracts in the Midwest and some never work at this particular hospital. The anesthesiologists were in 100% agreement that they were satisfied with the postanesthesia handoff report they delivered. 68% of respondents answered they strongly agreed (value 2) with their postanesthesia handoffs 32% agreed (value 1). The minimum score was 1 (agreed) and maximum 2 (strongly agreed). The mean was 1.32, standard deviation 0.46, variance 0.22. All but one person (97% of respondents) agreed they communicated potential patient problems to the PACU nurse. 84% strongly agreed (value 1), 13% agreed (value 2), and 3% disagreed (value 4). The minimum was 1 (disagreed) and the maximum 4 (strongly agreed). The mean was 1.21, standard deviation was 0.57, and the variance was 0.32. They were divided on the topic of postanesthesia report being rushed, 8 (21% value 2) agreed it was rushed, 7 (18% value 3) responded neutral, 21 (55% value 4) disagreed, and 2 (5% value 5) strongly disagreed. The minimum was 2 (agree) and maximum was 5 (strongly disagreed). The mean was 3.45, the standard deviation was 0.88, and the variance was 0.77). The majority disagreed or strongly disagreed (79%) with receiving a phone call about something that could have been included in handoff. The minimum was 2 (agreed) and maximum was 5 Use of a Checklist in Postanesthesia Care Transitions 21 (strongly disagreed). The mean was 3.97, the standard deviation was 0.84, and the variance was 0.71. The majority (89%) agreed that there is good teamwork and communication between themselves and the PACU nurses. The minimum was 1 (strongly agreed) and the maximum was 3 (neither agreed nor disagreed). The mean was 1.66, the standard deviation was 0.66, and the variance was 0.44. @) (>5 )-5% 5%B5B L?51(&)%= +M) 0)? >$;5 any concerns about post$%51(>51&$ >$%B)22. <$%0 1$&B %)= +%)( (>5 D$0 N B) &(.= +N:< <)"5 (>)")?#> (>$% <$%0 )2 <0 -$"(%5"1., no because they were familiar with the nurses receiving the patients, or they made sure the nurse was comfortable before they left the PACU. Other feedback included that the process needed standardization, the report should begin after the first set of vitals, some nurses do not listen despite saying they are ready for handoff which caused the anesthesiologist to have to repeat report, some nurses are distracted and performing other tasks or talking to other nurses during report, and nurses take breaks and do not give report to the nurse relieving them. The five Likert scale questions are displayed graphically in Appendix J. Nurses were given the link to the preintervention survey on March 9, 2020. Between March 9 and March 14, a total of 19 nurses took the survey. This hospital employs approximately 60 PACU nurse and 5 are on leave. The majority of the PACU nurses were satisfied with the report they received (79%). The remaining nurses were divided equally between feeling neutral and disagreeing. The minimum value was 1 (strongly agreed) and the maximum was 4 (disagreed). The mean was 2.11, the standard deviation was 2.11, and the variance was 0.73. Fifteen of the nurses (79%) agreed that potential problems were communicated to them, 3 (16%) were neutral, and 1 (5%) strongly disagreed. The minimum value was 1 (strongly agree) and the maximum was 5 (strongly disagreed). The mean was 2.11, the standard deviation was 0.91, and the variance was 0.83. The most variance in responses to a survey question was noted on the question about feeling that post anesthesia report was rushed. Use of a Checklist in Postanesthesia Care Transitions 22 Six strongly agreed/agreed (32%), 6 (32%) were neutral, and 7 (34%) disagreed/strongly disagreed (36%). The minimum value was 1 (strongly agreed) and the maximum was 5 (strongly disagreed). The mean was 2.89, the standard deviation was 1.07, and the variance was 1.15, Pertaining to the question about making a phone call about something that could be included in handoff, 8 nurses strongly disagreed/disagreed (42%), 6 (32%) responded neutral, and 5 (26%) strongly agreed/agreed. The minimum value was 1 (strongly agreed) and the maximum value was 5. The mean was 3.16, the standard deviation was 0.99, and the variance was 0.98. All but one nurse (95%) agreed/strongly agreed there was good communication and teamwork between them and the anesthesiologists. The minimum value was 1 (strongly agreed) and the maximum value was 3 (neither agreed nor disagreed). The mean was 1.79, the standard deviation was 0.52, and the variance was 0.27. To the open ended question regarding concerns about postanesthesia handoff nurses responded they wanted actual doses of medications given during surgery, some anesthesiologists were fabulous and others do the bare minimum, some anesthesiologists do not care, it is all dependent on the anesthesiologist, that the anesthesiologists need to wait till the patient is hooked up to the monitor before they begin report otherwise they have to repeat (>5<15*;51= 1)<5 $%51(>51&)*)#&1(1 +$"5 "?1>5B () 6*)15 (>5 6>$"( $%B #&;5 "5-)"( E52)"5 (>5 brakes are on th5 E5B., +1)<5 ($*C );5" <0 1>)?*Ber D>&*5 N $< #5((&%# ;&($*1.= (>$( +B"&;5 E0 "5-)"(1 $"5 #&;5%.= <5B&6$(&)%1 $"5 %)( E5&%# <5%(&)%5B 51-56&$**0 2")< <5B&6$(&)%1 from acute pain service, there are issues with orders, +1)<5 $%51(>51&)*)#&1(1 B) %)( C%)D $ -$(&5%(:1 complete medical history- ;5"0 7F/JOPPPPP.= and they are searching through the record for things that were missed. The five Likert scale questions are displayed graphically (Appendix L). The results from the preintervention survey indicate a need for a process improvement. Overall the staff feel that postanesthesia report is effective, communication and teamwork are good but their comments to the final question of the survey signify areas for improvement. Both Use of a Checklist in Postanesthesia Care Transitions 23 the nurses: and anesthesiologists: concerns about standardization and attention to report are addressed with the and Ortho PACU SBAR Handoff. This checklist begins with critical hookup to the vital sign monitor and then the next step is to ask the nurse if she is ready for report. This allows both the nurse and anesthesiologist to see baseline PACU vital signs and treat critical vital signs immediately. By asking the nurse if she is ready for report, it is clear the report is beginning and both providers: attention should be focused on the delivery and acceptance of report. By using the checklist, concerns about medications and dosages, searching through the <5B&6$* "56)"B= $%B *$6C )2 C%)D*5B#5 $E)?( (>5 -$(&5%(:1 <5B&6$* >&1()"0 1>)?*d be decreased and ideally eliminated. The SBAR checklist ends with the nurse asking any questions she may have; this gives her the opportunity to ask questions about orders and clarify any missing or vague information delivered in the report. Intervention Results and Analysis The SBAR Handoff Checklist was implemented into practice on June 3, 2020. The collection )2 %?"151: "5-)"( 1>55(1 D&(> (>5 1?";50 )% >$%B)22 D$1 6)**56(5B 2")< Q?%5 R- June 17, 2020. The primary researcher entered the data from these sheets into Qualtrics on June 24, 2020. The tool used to log data from these sheets is found in Appendix N. A total of 244 surveys D5"5 (?"%5B &% () (>5 156?"5 "565-($6*59 @) (>5 L?51(&)%= +S$1 (>5 >$%B)22 6>56C*&1( ?15T. UUV HWUWX )2 (>5 %?"151 6&"6*5B +051.= YZV HUYX )2 (>5 %?"151 B&B %)( 6)<-*5(5 (>5 L?51(&)%= $%B [V HYWX 6&"6*5B +%).9 The minimum value was 1 (yes) and the maximum was 3 (no). The mean was 1.43, the standard deviation was 0.65, and the variance was 0.42. The PACU nurses indicated that 74% (180) of the reports were complete, 25% (62) nurses did not answer the question, and 1% (2) answered that they did not receive complete handoff. The minimum was 1 (yes) and the maximum value was 3 (no). The mean was 1.27, the standard deviation was 0.46, and the variance was 0.21. In the two reports that a nurse indicated the report was not complete, the Use of a Checklist in Postanesthesia Care Transitions 24 handoff checklist was not used, and they did not indicate what data was missing from the report they received. Only one comment was filled in on the 244 sheets, which was +great report W\]W\.9 The surveys turned in on SBAR Handoff demonstrated that the majority of the anesthesia providers were using the new template. An unexpected limitation of this study was that 25% of the nurses did not complete the survey. It was expected that some nurses would not turn in their report sheet with the survey, but it was unforeseen that they would neglect to answer any of the questions. This limitation may be due to the primary researcher being reliant on clinical stakeholders to provide education on the SBAR report. The primary researcher was not being allowed on the hospital campus due to COVID19 policies and all education was provided by the clinical stakeholders via email. The primary stakeholder did not have access to these employee email lists. Another consequence of the primary researcher not allowed on campus was that the previous nurses report sheet was still available. This sheet did not include the survey questions about handoff and many of the 25% of the incomplete report sheets were in this previous format. The completed report sheets displayed that the vast majority of the anesthesiologists did use the handoff tool and gave a complete handoff report. Postintervention Results and Analysis Anesthesiologists were given the link to the preintervention survey on June 29, 2020. From June 29 ^ July 9, 2020 a total of 21 anesthesiologists completed the survey. The anesthesiologists responded to the question about the handoff being more standardized 50% strongly agreeing or agreeing. Of the respondents 3/24 (12.5%) disagreed or strongly disagreed. The remainder 6/24 responded neutrally. The Likert scale was assigned numbers with strongly agree being 1 and strongly disagree being 5 to all the multiple-choice questions in this survey. The mean of the responses was 2.48. The standard deviation was 1.14. The variance was 1.30. Use of a Checklist in Postanesthesia Care Transitions 25 To the question regarding improvement of the post anesthesia care transitions. The majority was neutral with 7/21 (33.3%) of the respondents answering this way. 7/21 (33.3%) disagreed or strongly disagreed and the other 7/21 (33.3%) agreeing or strongly agreeing. The mean was 3.05, the standard deviation was 1.05, and the variance was 1.09. The anesthesiologists were almost in unanimous agreement with 20/21 (95%) of them answering they communicated potential problems to the PACU nurses. The minimum was 1, the maximum was 5, the mean was 1.67, the standard deviation was 0.56, and the variance was 0.32. The answers to the question about the postanesthesia report being less rushed using the checklist was divided with 3/21 (14%) strongly disagreeing, 7/21 (33.3%) disagreeing, 7/21 (33.3%), and 4/21 (19%). The minimum was 2 and the maximum was 5. The mean was 3.43, the standard deviation was 0.95, and the variance was 0.91. To the question about receiving a phone call from the nurse about something that could been included in report, 2/21 (10%) agreed, 4/21 (19%) were neutral, and the remainder 15/21 (71%) disagreed or strongly disagreed. The minimum was 2 and the maximum was 5. The mean was 3.81, the standard deviation was 0.85, and the variance was 0.73. To the question about the report beginning after the patient was hooked up to the monitor 17/21 (81%) agreed. One person (5%) disagreed and the remainder 3/21 (14%) were neutral. The minimum response was 1 and the maximum was 4. The mean was 1.86, the standard deviation was 0.83, and the variance was 0.69. To the question about teamwork improving the majority 11/21 (52%) were neutral. Five anesthesiologists (24%) agreed, 2 (10%) strongly disagreed, and 3 (14%) disagreed. The minimum response value was 1 and the maximum was 4. The mean was 3.10, the standard deviation was 0.87, and the variance was 0.75. To the open-ended question about any additional thoughts or concerns was that it was already what they were doing, that they encouraged others to be very thorough like they were, that they never saw or used the checklist, and that the nurses Use of a Checklist in Postanesthesia Care Transitions 26 report sheet needs updated with their input. The results from this survey are displayed graphically in Appendix L. Nurses were given the link to the postintervention survey on July 1, 2020. Between July 1 and July 16, a total of 16 nurses took the survey. The five-point Likert scale was assigned numbers with strongly agree designated at 1 and strongly disagree assigned 5. To the question about the handoff being more standardized, 4 (25%) nurses answered strongly agree, 4 (25%) agreed, 7 (44%) were neutral, and 1 (6%) disagreed. The minimum value was 1 and the maximum was 4. The standard deviation was 0.92, the variance was 0.84, and the mean was 2.31. The majority of nurses were neutral about the quality of the postanesthesia handoff report improving (11 nurses), 2 (12.5%) disagreed, 2 (12.5%) agreed, and 1 (6.3%) strongly agreed. The minimum value was 1 and the maximum value was 4. The variance was 0.48, the standard deviation was 0.7, and the mean was 2.88. Regarding potential problems being communicated to the nurse, 7 (44%) were neutral and the remaining nurses answered they agreed or strongly agreed. The minimum value was 1 and the maximum value was 3. The mean was 2.2, the standard deviation was 0.83, and the variance was 0.69. In response to the question about the report being less rushed the nurses responded they were neutral (63%), three nurses (19%) disagreed, and the other 3 nurses agreed or strongly agreed. The minimum value was 1 and the maximum was 4. The mean was 2.94, the standard deviation was 0.75, and the variance was 0.56. The response to the question about calling the anesthesiologist the nurses responded that they disagreed (44%), strongly disagreed (12.5), were neutral 3 (19%), or strongly agreed/agree 4 (25%). The minimum value was 1 and the maximum value was 5. The mean was 3.31, the standard deviation was 1.21, and the variance was 1.46. The response to the question about the report beginning after the patient being hooked up to the monitor, 7 nurses (44%), 5 nurses were neutral (31%), and 4 nurses (25%) agreed. The minimum value was 2 and the maximum value Use of a Checklist in Postanesthesia Care Transitions 27 was 4. The mean was 3.19, the standard deviation was 0.81, and the variance was 0.65. To the question about teamwork the majority of nurses 12/21 (75%) were neutral, 3 (19%) disagreed and 1 (6%) agreed. The minimum value was 2 and the maximum value was 4. The mean was 3.13, the standard deviation was 0.48, and the variance was 0.23. To the open-ended question $E)?( $BB&(&)%$* (>)?#>(1 )" 6)%65"%1 (>5 )%*0 $6(?$* 6)<<5%( D$1 +Unfortunately, the anesthesiologists who just want to drop & dash did not embrace the new report format. I B)%:( know what could have been done to increase buy in from the MDs. For those who are respectful & practice collegially with us already I did see a small improvement using the new format9. The results from this survey are displayed graphically in Appendix M. The results of this survey demonstrated that modifications and continuing education still need to be performed. There was an unexpected limitation of the primary research not being allowed on the hospital campus, impacted employee education on the SBAR checklist is strongly demonstrated by the responses from the anesthesiologists that they did not know about this quality improvement project and handoff checklist. The opinions of the anesthesiologists that completed the survey did not change and the limitation of bias may exist against the primary researcher due to their position as a student nurse anesthetist. The nurses and anesthesiologists disagreed about report starting after the patient was hooked up to the monitor and that all issues were communicated. The overwhelming result was that their opinion was neutral. This could be due to the fact that the survey was generalized to the entire population of reports and not specific to individual reports. The anesthesiologists and nurse acknowledged that some providers are better at delivering report than others. The only updates to the %?"151: report sheet came from nursing management to allow them a place to document things that were not previously being included in their report. Implications for Future Practice Use of a Checklist in Postanesthesia Care Transitions 28 The future practice of care transitions at this hospital would benefit from using a tailored PACU handoff report sheet. The current sheet could continue to be utilized or modified based on the suggestions from the nursing and anesthesia staff. Further research could be done after the report sheet was modified. Continuing education could be provided to the staff to increase their knowledge on why using standardized handoffs are important. In this project, only a single sheet was provided to the staff there was no in person communication to the staff from the primary researcher. More research could be collected using the appropriate report sheet with the survey questions completed by a greater number of nurses. The care transitions could also be observed by a researcher to provide further insight into the handoff process and areas for improvement. Additional modification may be derived from this information. There was also a high rate of non--$"(&6&-$(&)% &% (>5 1?";501 B51-&(5 5 %?"151: 1?-5";&1)" $%B (>5 $%51(>51&)*)#&1(1: E?1&%511 -$"(%5". The organization could also modify this report and use it for postanesthesia handoffs from anesthesia to intensive care nurses. A similar checklist could also be implemented for anesthesia providers who assume care of a patient during an ongoing surgical procedure. Many SBAR checklists could be implemented throughout this hospital and their other locations to improve patient care, decrease miscommunication, and increase teamwork. Conclusion Postanesthesia care transitions occur over 40 million times annually in the United States (Segall, et al., 2012). The biggest risk of medical errors occurring during the postanesthesia period is from miscommunication during this handoff (Siddiqui, et al., 2012). Using a standardized form for report has been recommended by both the WHO and TJC to decrease errors in this type of setting. In order to comply with these recommendations there must be a high level of participation to create the workplace culture that supports the quality improvement Use of a Checklist in Postanesthesia Care Transitions 29 projects. The COVID19 pandemic caused unexpected limitations to the project that were significant to its implementation including the start date of data collection. The expected outcomes from this study were not achieved. Further research and participation from the staff are necessary to achieve the goal of 100% of postanesthesia reports being delivered using the checklist for postanesthesia care transitions. Use of a Checklist in Postanesthesia Care Transitions 30 References Agarwala, A. V., Firth, P. G., Albrecht, M. A., Warren, L. & Musch, G. (2015). An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care. Anesthesia Analgesia. 120(1). 96-104. doi:10.1213/ANE.0000000000000506 American Society of Anesthesiologists [ASA]. (2014, October). Practice Guidelines for Postanesthesia Care. Retrieved from https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918686 American Society of Anesthesiologists [ASA]. (2014, October). Standards for Postanesthesia Care. Retrieved from https://www.asahq.org/standards-and-guidelines/standards-forpostanesthesia-care Boat, A. C. & Spaeth, J. P. (2013). Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Pediatric Anesthesia. 23, 647-654. doi:10.111/pan.12199 Bruno, G. M. & Guimond, M. E. (2016). Patient care handoff in the postanesthesia care unit: A quality improvement project. American Society of PeriAnesthesia Nurses. 32(2), 125133. doi.org/10.1016/j/jopan/2015.10.002 Halterman, R. S., Gaber, M., Janjua, M. S. T., Hogan, G. T., & Cartwright, S. M. I. (2019). Use of a checklist for the postanesthesia care unit patient handoff. The Journal of PeriAnesthesia Nursing. 34(4), 834-841. doi:org/10/1016/j.jogam.2018.10.007 Jullia, M., Tronet, A., Fraumar, F., Minville, V., Fourcade, O. Alacoque, X., 8 Kurrek. M. M. (2017). Training in intraoperative handover and display of a checklist improve communication during transfer of care. European Journal of Anaesthesiology. 34, 471476. doi:10.1097/EJA/000000000000636 Lane-Fall, M. B., Brooks, A. K., Wilkins, S. A., Davis, J. J., & Riesenberg, L. A. (2014). Use of a Checklist in Postanesthesia Care Transitions 31 Addressing the mandate for hand-off education. Anesthesiology. 120(1), 218-229. McKechnie, A. (2015). Clinical handover: The importance, problems, and educational interventions to improve its practice. British Journal of Hospital Medicine. 76(6), 353357. Milby, A., Bohmer, A., Gerbershagen, M. U., Joppich, R., & Wappler, F. (2014). Quality of post-operative patient handover in the post anaesthesia care unit: a prospective analysis. Acta Anesthesiologica Scandinavica. 58, 192-197. doi:1-/1111/a Muralidharan, M., Clapp, J. T., Pulos, B. P., Divaviam, S. P., Baranov, D. Y., Gordon, E. K. B., & Lane-Fall, M. B. (2018). How does training in anesthesia residency shape "51&B5%(1: approaches to patient care handoffs? A single-center qualitative interview study. BMC Medical Education. Office for Human Research Protections. (n. d.) Informed consent FAQs. Retrieved from https://www.hhs.gov/ohrp/regulations-and-policy/guidance/faq/informedconsent/index.html Park, L. S., Yang, G., Tan, K. S., Wong, C. H., Oskar, S., Borchardt, R. A., & Tollinche, L. E. (2017). Does checklist implementation improve quality of data transfer: An observation in the postanesthesia care unit (PACU). Open Journal of Anesthesiology. 7(4), 69-82. doi:10.4236/ojanes.2017.74007 Petrovic, M. A., Aboumatar, H., Scholl, A. T., Gill, R. 79= _"5%'&16>5C= M9 /9= F$<-= A9 79= 8 Martinez, E. A. (2015). The perioperative handoff protocol: Evaluating impacts of handoff defects and provider satisfaction in adult perianesthesia care units. Journal of Clinical Anesthesia. 23(7), 111-119. Petrovic, M. A., Martinez, E. A., Aboumatar, H. (2012). Implementing a perioperative handoff Use of a Checklist in Postanesthesia Care Transitions 32 tool to improve postprocedural patient transfers. The Joint Commission Journal of Quality and Patient Safety. 38(3), 135-142. Randmaa, M., Martensson, G., Swenne, C. L., Engstrom, M. (2014). SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: A prospective intervention study. BMJ Open. 4(1). doi:10.1136/bmjopen-2013-004268 Randmaa, M., Swenne, C. L., Martensson, G., Hogberg, H., & Engstrom, M. (2016). Implementing situation- background- assessment- recommendation in an anaesthetic clinic and subsequent information retention among receivers. European Journal of Anaesthesiology. 33. 172-178. doi:10.1097. EJA.0000000000000335 Rose, M. W., Newman, S., Brown, C. B. (2019). Postoperative information transfers: An integrative review. Journal of PeriAnesthesia Nursing. 34(2), 403-424. doi,org/10.1016/j.jopan.2018. 06.096 Segall, N., Sonifacio, A. S., Schroeder, R. A., Barbeito, A., Rogers, D., Thornlow, D. K., 8A$"C= Q9 I9 HY\WYX9 F$% D5 <$C5 -)1()-5"$(&;5 -$(&5%( >$%B);5"1 1$25"T / 101(5<$(&6 review of the literature. Anesthesia Analgesia. 115(1), 102-115. doi:10.1213/ANE.0b013e318254af4b. Siddiqui, N., Arzola., C., Iqbal, M., Sritharan., K., Guerina, L., Chung, F., & Friedman, Z. (2012). Deficits in information transfer between anaesthesiologist and postanaesthesia care unit staff: An analysis of patient handover. European Journal of Anaesthesiology. 29, 438-445. White, K. M., Dudley-Brown, S., & Terharr, M. F. (2016). Translation of evidence into nursing and health care. New York, New York: Springer Publishing Company. Use of a Checklist in Postanesthesia Care Transitions 33 Appendix A Potential criteria for SBAR Postanesthesia Handoff Assess for Readiness for POH (Postoperative Handoff) Patient information ! Age ! Gender ! Patient name ! Allergies ! ASA physical status ! Name band check Preoperative information ! Diagnosis ! Preoperative status ! Premedication ! Medical history ! Preoperative level of activity, METs ! Limb restrictions ! Surgical history ! ASA classification ! Baseline neurologic status, vital signs, height, weight ! Baseline physical examination ! Baseline weight ! Pertinent laboratory values ! Underlying preexisting diseases: neurology H3$"C&%1)%:1 B&15$15= @N/= 1(")C5= $"(5"&$* hypertension, disturbances of consciousness, other diseases), cardiology (CAD, cardiac arrhythmias, heart failure, other cardiac diseases), pulmonary (COPD, asthma, other lung diseases), kidney, myopathies, renal, liver, metabolic disorders (Diabetes), infectious disease ! Drug/alcohol abuse ! Anesthesia risk assessment ! Pacemaker/ICD ! Code status ! Current medications (especially beta-blockers) ! Anatomy/obesity ! History of PONV ! MH history Anesthesia information ! Type of anesthesia (GA, TIVA, regional) ! Type of analgesia ! Nerve block (w/ or w/o catheter), epidural, spinal ! Airway management ! Intubating conditions ! Medications administered (narcotic totals, anticoagulant, antibiotics, anticonvulsants, NMB) Use of a Checklist in Postanesthesia Care Transitions ! PONV prophylaxis ! Complications ! Vascular access/invasive monitoring ! Current blood type and crossmatch ! ST-segment changes Intraoperative information ! Type of anesthesia (general, gas, TIVA, sedation, MAC, regional, combination) ! Airway management (difficult/ LMA/ETT) ! Mask ventilation ! Tracheostoma ! Catheter insertion ! Hemodynamic occurrences (cardiac instability) ! Volume management (intake and output) ! Antibiotic therapy ! Anesthesia-related events, management, concerns: allergic reaction, tooth damage ! Blood loss ! Drains ! Packing ! Skin inspection ! Arterial line ! Central line ! Postoperative pain management initiated ! Blood transfusion (has needs) ! Unexpected events (ex. Arrhythmias, hypotension) ! Laboratory results and analysis ! Vasoactive medications/catecholamines ! Medications given- opioids, benzos, antiemetic (PONV prophylaxis, antibiotics, vasopressors, other ! Time last narcotic given Surgery information ! Surgeon ! Type of surgery ! Reason for surgery, diagnosis ! Actual surgical findings ! duration ! Surgical complications/events/concerns ! Antibiotic plain ! Blood loss ! Medications to be restarted ! DVT prophylaxis ! Tubes, drains, catheters, shunts (special instructions) ! NG tube ! Postoperative diet ! Fluid management (intake/output/EBL) ! Positioning Postoperative arrival to PACU 34 Use of a Checklist in Postanesthesia Care Transitions ! 3$(&5%(:1 `!F ! Hemodynamic status ! Neuromuscular blockade status ! Pertinent laboratory values ! Fluid status ! Patient position ! Vital signs ! Pain score ! Language barriers ! Patient with a legal guardian ! Oxygen status and amount ! Thermodynamic control ! Respiratory ventilator settings ! Arrival time to PACU ! Postoperative anesthesia orders present ! Medications due in PACU ! Patient disposition (home, admitted, ICU) ! Point out failed punctures ! Locat&)% )2 -$(&5%(:1 -5"1)%$* E5*)%#&%#1 ! Immediate expected events next 30 minutes Anticipatory guidance/clarification/contingency management ! Anticipated bleeding, pain, and airway problems ! Analgesia plan/PONV plan ! Plan for IV fluids ! Contact information for anesthetic problems ! Contract information for surgical complications, antibiotic plan ! Postoperative consults and investigations ! Plan for monitoring vital signs and parameters ! Plan for invasive lines and monitoring 35 Use of a Checklist in Postanesthesia Care Transitions Appendix B Main and Ortho PACU SBAR Handoff Critical Hookup performed Are you ready for the report? Situation: - Patient name - Procedure - Diagnosis Background: - Past medical history - Allergies - Significant labs (if applicable) - Notable baseline VS (if applicable) - Baseline neuro status (if abnormal) Assessment: - APS procedure and premedication - Anesthesia type - Medications administered and dosages (pain, N/V, antibiotic, etc.) - Neuromuscular blockade administered and dosages and reversal (if applicable) - Vital signs and fluid concerns throughout the case and interventions performed - Pain management plan - IVs/catheters/tubes - I&O - Surgical or anesthetic issues Recommendation: - Additional concerns - Patient destination Do you have any questions/concerns? 36 Use of a Checklist in Postanesthesia Care Transitions 37 Appendix C Anesthesiologists pre-implementation survey I am satisfied with the postanesthesia report I deliver ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree I communicated potential patient problems to the PACU nurse (ex. BP issues, fluid status, etc.) and offered a solution (ex. Call me, give a fluid bolus, etc.) ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree ! Disagree I feel the postanesthesia report is rushed ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree In the last month, I have received a phone call from a PACU nurse about something that could have been included in the handoff ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree There is good communication and teamwork between PACU nurses and me during the postanesthesia period. ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree Do you have any concerns about the postanesthesia handoff? Use of a Checklist in Postanesthesia Care Transitions 38 Appendix D Nurses pre-implementation survey I am satisfied with the postanesthesia report I receive ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree Potential patient problems were communicated to me (ex. BP issues, fluid status, etc.) and the anesthesiologist offered a solution (ex. Call me, give a fluid bolus, etc.) ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree I feel the postanesthesia report is rushed ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree In the last month, I have made a phone call about something that could have been included in the handoff. ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree There is good communication and teamwork between anesthesiologists and me during the postanesthesia period. ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree Do you have any concerns about the postanesthesia handoff? Use of a Checklist in Postanesthesia Care Transitions 39 Appendix E Anesthesiologists post-implementation survey The postanesthesia report I deliver using the handoff checklist is more standardized ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree The quality of the postanesthesia handoff I deliver has improved ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree I communicated potential patient problems to the PACU nurse (ex. BP issues, fluid status, etc.) and offered a solution (ex. Call me, give a fluid bolus, etc.) ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree I feel the postanesthesia report is less rushed after using the Postanesthesia Checklist ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree In the last month, I have received a phone call from a PACU nurse about something that could have been included in the handoff ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree Reports began after the patient was hooked up to the monitor and the nurse was ready for report ! Strongly agree ! Agree ! Neutral ! Disagree Use of a Checklist in Postanesthesia Care Transitions ! Strongly Disagree The communication and teamwork between PACU nurses and I have improved during the postanesthesia period. ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree Do you have any concerns about the postanesthesia handoff? 40 Use of a Checklist in Postanesthesia Care Transitions 41 Appendix F Nurses post-implementation survey The postanesthesia report I receive using the handoff checklist is more standardized ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree The quality of the postanesthesia handoff I receive has improved ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree Potential patient problems were communicated to me (ex. BP issues, fluid status, etc.) and the anesthesiologist offered a solution (ex. Call me, give a fluid bolus, etc.) ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree I feel the postanesthesia report is less rushed after using the Postanesthesia Checklist ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree In the last month, I have made a phone call about something that could have been included in the handoff. ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree Reports began after the patient was hooked up to the monitor and I was ready for the report ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree Use of a Checklist in Postanesthesia Care Transitions The communication and teamwork between anesthesiologists and I have improved during the postanesthesia period. ! Strongly agree ! Agree ! Neutral ! Disagree ! Strongly Disagree Do you have any concerns about the postanesthesia handoff? 42 Use of a Checklist in Postanesthesia Care Transitions Appendix G 43 Use of a Checklist in Postanesthesia Care Transitions 44 Appendix H !"#$%$& #%'(#) $*%%) with handoff questionnaire (right bottom corner) Procedure: Surgeon: ______________ Anesthesiologist: ________ APS: __________________ General/Mac: __________ PACU: Arrival____ Met___ DC____ Destination_____________ Intrathecal/block ________ Epidural: Fent/Morph____ ml/h Demand dose: ______ml q___ min Age: _______ Weight: _______ Allergies: Spinal sensation: admission_____ Discharge_________ Regional anesthesia: Code status: Isolation: APS medications: OR: Fluid_______ PRBC_______ EBL________ UO________ Meds in OR: Paralytic & Reversal: Diagnosis: H & P: Bed Cart Waffle Hovermat Pre- op vitals: BP________ HR_____ RR______ Temp______ Sat_____ Pain_____ Extubation ET/LMA@_____ Airway@_______________ Re-intubation___________ End vitals: BP________ HR_____ RR______ Temp______ Sat_____ Pain_____ A-line: R L Femoral Radial D/C@_________________ Neuro check: Bair Hugger on ________ Bair Hugger off ________ Xray__________@_____ Labs__________@______ Accucheck_______@______ Significant Labs: PCA: Dilaudid Morphine ______mg/mcg every ______ min Max_______ in 4 hours Cont. rate___________ IV #1_____________________ IV #2_____________________ IV #3_____________________ PACU meds: Drains/Foley: Dressings: Opioid Totals: Chest tube: CBI Report: RN_________________________ Room_______________________ Handoff checklist used: Yes/No Complete Handoff: Yes/No Comments: Use of a Checklist in Postanesthesia Care Transitions 45 Appendix I IRB Approval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Use of a Checklist in Postanesthesia Care Transitions 48 !5 # $ 60&&71)6%(+, /0(+1()%3 /%()+1( /2083+&' (0 (.+ 9:;< 172'+ =+>? @9 )''7+'A *37), '(%(7'A +(6?B %1, 0**+2+, % '037()01 =+>? ;%33 &+A C)4+ % *37), 8037'A +(6?B ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7 41))*(#4+.$& <1.$(.#+% <+.#$(. <31L%$)8 .1 .;$ ME5N (*38$ O$,> PM #88*$8Q 9%*#& 8.+.*8Q $.4>R +(& 199$3$& + 81%*.#1( O$,> 5+%% )$Q G#0$ + 9%*#& L1%*8Q $.4>R 6>?? B>?? 6>@6 -.& /$0#+.#1( ?>IS 2+3#+(4$ 51*(. ?>A@ AD ! E(8:$3 F 51*(. 6 8.31(G%H +G3$$ DB>@6F A@ @ EG3$$ 6A>6CF I A J$#.;$3 +G3$$ (13 +G3$$ ?>??F ? B /#8+G3$$ @>CAF 6 I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F AD Use of a Checklist in Postanesthesia Care Transitions 49 !D # $ *++3 /0'(#%1+'(.+')% 2+/02( )' 27'.+, ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7 9$$% <18.=+($8.;$8#+ 3$<13. #8 3*8;$& @>?? I>?? A>BI -.& /$0#+.#1( ?>DD 2+3#+(4$ 51*(. ?>SS AD ! E(8:$3 F 51*(. 6 8.31(G%H +G3$$ ?>??F ? @ EG3$$ @6>?IF D A J$#.;$3 +G3$$ (13 +G3$$ 6D>B@F S B /#8+G3$$ II>@CF @6 I -.31(G%H +G3$$ I>@CF @ K1.+% 6??F AD Use of a Checklist in Postanesthesia Care Transitions 50 !E # $1 (.+ 3%'( &01(.A $ .%4+ 2+6+)4+, % /.01+ 6%33 *20& % 9:;< 172'+ %807( '0&+(.)1C (.%( 6073, .%4+ 8++1 )1637,+, )1 (.+ .%1,0** ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7( .;$ %+8. )1(.;Q 7 ;+0$ 3$4$#0$& + <;1($ 4+%% 931) + ME5N (*38$ +L1*. 81)$.;#(G .;+. 41*%& ;+0$ L$$( #(4%*&$& #( .;$ ;+(&199 @>?? I>?? A>TS -.& /$0#+.#1( ?>DB 2+3#+(4$ 51*(. ?>S6 AD ! E(8:$3 F 51*(. 6 8.31(G%H +G3$$ ?>??F ? @ EG3$$ S>DTF A A J$#.;$3 +G3$$ (13 +G3$$ 6A>6CF I B /#8+G3$$ I@>CAF @? I -.31(G%H +G3$$ @C>A@F 6? K1.+% 6??F AD Use of a Checklist in Postanesthesia Care Transitions 51 !F # G.+2+ )' C00, 60&&71)6%()01 %1, (+%&-02H 8+(-++1 9:;< 172'+' %1, &+ ,72)1C (.+ /0'(%1+'(.+')% /+2)0,? ! 6 "#$%& '#(#)*) '+,#)*) '$+( K;$3$ #8 G11& 41))*(#4+.#1( +(& .$+):13U L$.:$$( ME5N (*38$8 +(& )$ &*3#(G .;$ <18.+($8.;$8#+ <$3#1&> 6>?? A>?? 6>CC -.& /$0#+.#1( ?>CC 2+3#+(4$ 51*(. ?>BB AD ! E(8:$3 F 51*(. 6 8.31(G%H +G3$$ BB>SBF 6S @ EG3$$ BB>SBF 6S A J$#.;$3 +G3$$ (13 +G3$$ 6?>IAF B B /#8+G3$$ ?>??F ? I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F AD Use of a Checklist in Postanesthesia Care Transitions 52 Appendix K Nurses preintervention survey results !" # $ %& '%()'*)+, -)(. (.+ /0'( %1+'(.+')% 2+/02( $ 2+6+)4+ ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7 +) 8+.#89#$& :#.; .;$ <18. +($8.;$8#+ 3$<13. 7 3$4$#0$ 6>?? B>?? @>66 -.& /$0#+.#1( ?>DI 2+3#+(4$ 51*(. ?>SA 6T ! E(8:$3 F 51*(. 6 8.31(G%H +G3$$ @6>?IF B @ EG3$$ IS>DTF 66 A J$#.;$3 +G3$$ (13 +G3$$ 6?>IAF @ B /#8+G3$$ 6?>IAF @ I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F 6T Use of a Checklist in Postanesthesia Care Transitions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Use of a Checklist in Postanesthesia Care Transitions 54 !D # $ *++3 /0'( %1+'(.+')% 2+/02( )' 27'.+, ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7 9$$% <18. +($8.;$8#+ 3$<13. #8 3*8;$& 6>?? I>?? @>DT -.& /$0#+.#1( 6>?S 2+3#+(4$ 51*(. 6>6I 6T ! E(8:$3 F 51*(. 6 8.31(G%H +G3$$ 6?>IAF @ @ EG3$$ @C>A@F I A J$#.;$3 +G3$$ (13 +G3$$ A6>IDF C B /#8+G3$$ @C>A@F I I -.31(G%H +G3$$ I>@CF 6 K1.+% 6??F 6T Use of a Checklist in Postanesthesia Care Transitions 55 !E # )1 (.+ 3%'( &01(.A $ .%4+ &%,+ % /.01+ 6%33 %807( '0&+(.)1C (.%( 6073, .%4+ 8++1 )1637,+, )1 .%1,0**? ! 6 "#$%& '#(#)*) '+,#)*) '$+( #( .;$ %+8. )1(.;Q 7 ;+0$ )+&$ + <;1($ 4+%% +L1*. 81)$.;#(G .;+. 41*%& ;+0$ L$$( #(4%*&$& #( ;+(&199> 6>?? I>?? A>6C -.& /$0#+.#1( ?>TT 2+3#+(4$ 51*(. ?>TD 6T ! E(8:$3 F 51*(. 6 8.31(G%H +G3$$ I>@CF 6 @ EG3$$ @6>?IF B A J$#.;$3 +G3$$ (13 +G3$$ A6>IDF C B /#8+G3$$ AC>DBF S I -.31(G%H +G3$$ I>@CF 6 K1.+% 6??F 6T Use of a Checklist in Postanesthesia Care Transitions 56 !F # G.+2+ )' C00, 60&&71)6%()01 %1, (+%&-02H 8+(-++1 %1+'(.+')030C)'(' %1, &+ ,72)1C (.+ /0'(%1+'(.+')% /+2)0,? ! 6 "#$%& '#(#)*) '+,#)*) '$+( K;$3$ #8 G11& 41))*(#4+.#1( +(& .$+):13U L$.:$$( +($8.;$8#1%1G#8.8 +(& )$ &*3#(G .;$ <18.+($8.;$8#+ <$3#1&> 6>?? A>?? 6>ST -.& /$0#+.#1( ?>I@ 2+3#+(4$ 51*(. ?>@S 6T ! E(8:$3 F 51*(. 6 8.31(G%H +G3$$ @C>A@F I @ EG3$$ CD>B@F 6A A J$#.;$3 +G3$$ (13 +G3$$ I>@CF 6 B /#8+G3$$ ?>??F ? I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F 6T Use of a Checklist in Postanesthesia Care Transitions 57 Appendix L Anesthesiologists postintervention survey results !" # G.+ /0'(%1+'(.+')% 2+/02( $ ,+3)4+2 7')1C (.+ .%1,0** 6.+6H3)'( )' &02+ '(%1,%2,)I+, ! 6 "#$%& '#(#)*) '+,#)*) '$+( = K;$ <18.+($8.;$8#+ 3$<13. 7 &$%#0$3 *8#(G .;$ ;+(&199 4;$4U%#8. #8 )13$ 8.+(&+3&#V$& 6>?? I>?? @>BD -.& /$0#+.#1( 6>6B 2+3#+(4$ 51*(. 6>A? @6 ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ 6T>?IF B @ EG3$$ AD>6?F D A J$#.;$3 +G3$$ (13 +G3$$ @D>ISF C B /#8+G3$$ B>SCF 6 I -.31(G%H +G3$$ T>I@F @ K1.+% 6??F @6 Use of a Checklist in Postanesthesia Care Transitions 58 !5 # G.+ J7%3)(K 0* (.+ /0'(%1+'(.+')% .%1,0** $ ,+3)4+2 .%' )&/204+, ! 6 "#$%& '#(#)*) '+,#)*) '$+( K;$ W*+%#.H 19 .;$ <18.+($8.;$8#+ ;+(&199 7 &$%#0$3 ;+8 #)<310$& 6>?? I>?? A>?I -.& /$0#+.#1( 6>?I 2+3#+(4$ 51*(. 6>?T @6 ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ B>SCF 6 @ EG3$$ @D>ISF C A J$#.;$3 +G3$$ (13 +G3$$ AA>AAF S B /#8+G3$$ @A>D6F I I -.31(G%H +G3$$ T>I@F @ K1.+% 6??F @6 Use of a Checklist in Postanesthesia Care Transitions 59 !D # $ 60&&71)6%(+, /0(+1()%3 /%()+1( /2083+&' (0 (.+ 9:;< 172'+ =+>? @9 )''7+'A *37), '(%(7'A +(6?B %1, 0**+2+, % '037()01 =+>? ;%33 &+A C)4+ % *37), 8037'A +(6?B ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7 41))*(#4+.$& <1.$(.#+% <+.#$(. <31L%$)8 .1 .;$ ME5N (*38$ O$,> PM #88*$8Q 9%*#& 8.+.*8Q $.4>R +(& 199$3$& + 81%*.#1( O$,> 5+%% )$Q G#0$ + 9%*#& L1%*8Q $.4>R 6>?? A>?? 6>CS -.& /$0#+.#1( ?>IC 2+3#+(4$ 51*(. ?>A@ @6 ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ AD>6?F D @ EG3$$ IS>6BF 6@ A J$#.;$3 +G3$$ (13 +G3$$ B>SCF 6 B /#8+G3$$ ?>??F ? I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F @6 Use of a Checklist in Postanesthesia Care Transitions 60 !E # $ *++3 (.+ /0'(%1+'(.+')% 2+/02( )' 3+'' 27'.+, %*(+2 7')1C (.+ 90'(%1+'(.+')% ;.+6H3)'( ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7 9$$% .;$ <18.+($8.;$8#+ 3$<13. #8 %$88 3*8;$& +9.$3 *8#(G .;$ M18.+($8.;$8#+ 5;$4U%#8. @>?? I>?? A>BA -.& /$0#+.#1( ?>TI 2+3#+(4$ 51*(. ?>T6 @6 ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ ?>??F ? @ EG3$$ 6T>?IF B A J$#.;$3 +G3$$ (13 +G3$$ AA>AAF S B /#8+G3$$ AA>AAF S I -.31(G%H +G3$$ 6B>@TF A K1.+% 6??F @6 Use of a Checklist in Postanesthesia Care Transitions 61 !F # $1 (.+ 3%'( &01(.A $ .%4+ 2+6+)4+, % /.01+ 6%33 *20& % 9:;< 172'+ %807( '0&+(.)1C (.%( 6073, .%4+ 8++1 )1637,+, )1 (.+ .%1,0** ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7( .;$ %+8. )1(.;Q 7 ;+0$ 3$4$#0$& + <;1($ 4+%% 931) + ME5N (*38$ +L1*. 81)$.;#(G .;+. 41*%& ;+0$ L$$( #(4%*&$& #( .;$ ;+(&199 @>?? I>?? A>D6 -.& /$0#+.#1( ?>DI 2+3#+(4$ 51*(. ?>SA @6 ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ ?>??F ? @ EG3$$ T>I@F @ A J$#.;$3 +G3$$ (13 +G3$$ 6T>?IF B B /#8+G3$$ I@>ADF 66 I -.31(G%H +G3$$ 6T>?IF B K1.+% 6??F @6 Use of a Checklist in Postanesthesia Care Transitions 62 !L # M+/02(' 8+C%1 %*(+2 (.+ /%()+1( -%' .00H+, 7/ (0 (.+ &01)(02 %1, (.+ 172'+ -%' 2+%,K *02 2+/02( ! 6 "#$%& '#(#)*) '+,#)*) '$+( X$<13.8 L$G+( +9.$3 .;$ <+.#$(. :+8 ;11U$& *< .1 .;$ )1(#.13 +(& .;$ (*38$ :+8 3$+&H 913 3$<13. 6>?? B>?? 6>DC -.& /$0#+.#1( ?>DA 2+3#+(4$ 51*(. ?>CT @6 ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ AD>6?F D @ EG3$$ B@>DCF T A J$#.;$3 +G3$$ (13 +G3$$ 6B>@TF A B /#8+G3$$ B>SCF 6 I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F @6 Use of a Checklist in Postanesthesia Care Transitions 63 !N # G.+ 60&&71)6%()01 %1, (+%&-02H 8+(-++1 9:;< 172'+' %1, &K'+3* .%' )&/204+, ,72)1C (.+ /0'(%1+'(.+')% /+2)0,? ! 6 "#$%& '#(#)*) '+,#)*) '$+( K;$ 41))*(#4+.#1( +(& .$+):13U L$.:$$( ME5N (*38$8 +(& )H8$%9 ;+8 #)<310$& &*3#(G .;$ <18.+($8.;$8#+ <$3#1&> @>?? I>?? A>6? -.& /$0#+.#1( ?>DS 2+3#+(4$ 51*(. ?>SI @6 ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ ?>??F ? @ EG3$$ @A>D6F I A J$#.;$3 +G3$$ (13 +G3$$ I@>ADF 66 B /#8+G3$$ 6B>@TF A I -.31(G%H +G3$$ T>I@F @ K1.+% 6??F @6 Use of a Checklist in Postanesthesia Care Transitions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Use of a Checklist in Postanesthesia Care Transitions 65 Appendix M Nurses postintervention survey results !" # G.+ /0'(%1+'(.+')% 2+/02( $ 2+6+)4+ 7')1C (.+ .%1,0** 6.+6H3)'( )' &02+ '(%1,%2,)I+, ! 6 "#$%& '#(#)*) '+,#)*) '$+( K;$ <18.+($8.;$8#+ 3$<13. 7 3$4$#0$ *8#(G .;$ ;+(&199 4;$4U%#8. #8 )13$ 8.+(&+3&#V$& 6>?? B>?? @>A6 -.& /$0#+.#1( ?>T@ 2+3#+(4$ 51*(. ?>DB 6C ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ @I>??F B @ EG3$$ @I>??F B A J$#.;$3 +G3$$ (13 +G3$$ BA>SIF S B /#8+G3$$ C>@IF 6 I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F 6C Use of a Checklist in Postanesthesia Care Transitions 66 !5 # G.+ J7%3)(K 0* (.+ /0'(%1+'(.+')% .%1,0** $ 2+6+)4+ .%' )&/204+, ! 6 "#$%& '#(#)*) '+,#)*) '$+( K;$ W*+%#.H 19 .;$ <18.+($8.;$8#+ ;+(&199 7 3$4$#0$ ;+8 #)<310$& 6>?? B>?? @>DD -.& /$0#+.#1( ?>S? 2+3#+(4$ 51*(. ?>BD 6C ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ C>@IF 6 @ EG3$$ 6@>I?F @ A J$#.;$3 +G3$$ (13 +G3$$ CD>SIF 66 B /#8+G3$$ 6@>I?F @ I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F 6C Use of a Checklist in Postanesthesia Care Transitions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Use of a Checklist in Postanesthesia Care Transitions 68 !E # $ *++3 (.+ /0'(%1+'(.+')% 2+/02( )' 3+'' 27'.+, %*(+2 7')1C (.+ 90'(%1+'(.+')% ;.+6H3)'( ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7 9$$% .;$ <18.+($8.;$8#+ 3$<13. #8 %$88 3*8;$& +9.$3 *8#(G .;$ M18.+($8.;$8#+ 5;$4U%#8. 6>?? B>?? @>TB -.& /$0#+.#1( ?>SI 2+3#+(4$ 51*(. ?>IC 6C ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ C>@IF 6 @ EG3$$ 6@>I?F @ A J$#.;$3 +G3$$ (13 +G3$$ C@>I?F 6? B /#8+G3$$ 6D>SIF A I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F 6C Use of a Checklist in Postanesthesia Care Transitions 69 !F # $1 (.+ 3%'( &01(.A $ .%4+ &%,+ % /.01+ 6%33 %807( '0&+(.)1C (.%( 6073, .%4+ 8++1 )1637,+, )1 (.+ .%1,0**? ! 6 "#$%& '#(#)*) '+,#)*) '$+( 7( .;$ %+8. )1(.;Q 7 ;+0$ )+&$ + <;1($ 4+%% +L1*. 81)$.;#(G .;+. 41*%& ;+0$ L$$( #(4%*&$& #( .;$ ;+(&199> 6>?? I>?? A>A6 -.& /$0#+.#1( 6>@6 2+3#+(4$ 51*(. 6>BC 6C ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ 6@>I?F @ @ EG3$$ 6@>I?F @ A J$#.;$3 +G3$$ (13 +G3$$ 6D>SIF A B /#8+G3$$ BA>SIF S I -.31(G%H +G3$$ 6@>I?F @ K1.+% 6??F 6C Use of a Checklist in Postanesthesia Care Transitions 70 !L # M+/02(' 8+C%1 %*(+2 (.+ /%()+1( -%' .00H+, 7/ (0 (.+ &01)(02 %1, $ -%' 2+%,K *02 (.+ 2+/02( ! 6 "#$%& '#(#)*) '+,#)*) '$+( X$<13.8 L$G+( +9.$3 .;$ <+.#$(. :+8 ;11U$& *< .1 .;$ )1(#.13 +(& 7 :+8 3$+&H 913 .;$ 3$<13. @>?? B>?? A>6T -.& /$0#+.#1( ?>D6 2+3#+(4$ 51*(. ?>CI 6C ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ ?>??F ? @ EG3$$ @I>??F B A J$#.;$3 +G3$$ (13 +G3$$ A6>@IF I B /#8+G3$$ BA>SIF S I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F 6C Use of a Checklist in Postanesthesia Care Transitions 71 !N # G.+ 60&&71)6%()01 %1, (+%&-02H 8+(-++1 %1+'(.+')030C)'(' %1, $ .%' )&/204+, ,72)1C (.+ /0'(%1+'(.+')% /+2)0,? ! 6 "#$%& '#(#)*) '+,#)*) '$+( K;$ 41))*(#4+.#1( +(& .$+):13U L$.:$$( +($8.;$8#1%1G#8.8 +(& 7 ;+8 #)<310$& &*3#(G .;$ <18.+($8.;$8#+ <$3#1&> @>?? B>?? A>6A -.& /$0#+.#1( ?>BD 2+3#+(4$ 51*(. ?>@A 6C ! E(8:$3 F 51*(. 6 -.31(G%H +G3$$ ?>??F ? @ EG3$$ C>@IF 6 A J$#.;$3 +G3$$ (13 +G3$$ SI>??F 6@ B /#8+G3$$ 6D>SIF A I -.31(G%H +G3$$ ?>??F ? K1.+% 6??F 6C Use of a Checklist in Postanesthesia Care Transitions 72 !"S # P0 K07 .%4+ %1K 6016+21'Q%,,)()01%3 (.07C.(' %807( (.+ /0'(%1+'(.+')% .%1,0**R /1 H1* ;+0$ +(H 41(4$3(8Y+&&#.#1(+% .;1*G;.8 +L1*. .;$ <18.+($8.;$8#+ ;+(&199Z *(913.*(+.$%HQ .;$ +($8.;$8#1%1G#8.8 :;1 [*8. :+(. .1 &31< \ &+8; &#& (1. $)L3+4$ .;$ ($: 3$<13. 913)+.> 7/] :;+. 41*%& ;+0$ L$$( &1($ .1 #(43$+8$ L*H #( 931) .;$ '/8> 913 .;18$ :;1 +3$ 3$8<$4.9*% \ <3+4.#4$ 41%%$G#+%%H :Y*8 +%3$+&H 7 &#& 8$$ + 8)+%% #)<310$)$(. *8#(G .;$ ($: 913)+.> J1 Use of a Checklist in Postanesthesia Care Transitions Appendix N SBAR PACU handoff reporting tool Was the handoff checklist used? ! Yes ! Not included on report sheet ! No Was a complete report delivered? ! Yes ! Not included on report sheet ! No Handoff report was missing what criteria? ! N/A complete report was delivered ! Not included on report sheet ! Situation ! Background ! Assessment ! Recommendation Comments 73 Use of a Checklist in Postanesthesia Care Transitions 74 Appendix O Data collection from SBAR handoff reports tool !" # T%' (.+ .%1,0** 6.+6H3)'( 7'+,R ! "#$%& '#(#)*) '+,#)*) '$+( -.& /$0#+.#1( 6 ^+8 .;$ ;+(&199 4;$4U%#8. *8$&Z 6>?? A>?? 6>BA ?>CI 2+3#+(4$ 51*(. ?>B@ @BB ! E(8:$3 F 51*(. 6 _$8 CI>TDF 6C6 @ J1. #(4%*&$& 1( 3$<13. 8;$$. @I>B6F C@ A J1 D>C6F @6 K1.+% 6??F @BB Use of a Checklist in Postanesthesia Care Transitions 75 !5 # T%' % 60&/3+(+ 2+/02( ,+3)4+2+,R ! 6 "#$%& '#(#)*) '+,#)*) '$+( ^+8 + 41)<%$.$ 3$<13. &$%#0$3$&Z 6>?? A>?? 6>@S -.& /$0#+.#1( 2+3#+(4$ 51*(. ?>BC ?>@6 @BB ! E(8:$3 F 51*(. 6 _$8 SA>SSF 6D? @ J1. #(4%*&$& 1( 3$<13. 8;$$. @I>B6F C@ A J1 ?>D@F @ K1.+% 6??F @BB Use of a Checklist in Postanesthesia Care Transitions 76 !D # M+/02( -%' &)'')1C -.%( 62)(+2)%R ! 6 "#$%& '#(#)*) '+,#)*) '$+( X$<13. :+8 )#88#(G :;+. 43#.$3#+Z 6>?? @>?? 6>@C -.& /$0#+.#1( 2+3#+(4$ 51*(. ?>BB ?>6T @AT ! E(8:$3 F 51*(. 6 JYE 41)<%$.$ 3$<13. :+8 &$%#0$3$& SB>BDF 6SD @ J1. #(4%*&$& 1( 3$<13. 8;$$. @I>I@F C6 A -#.*+.#1( ?>??F ? B P+4UG31*(& ?>??F ? I E88$88)$(. ?>??F ? C X$41))$(&+.#1( ?>??F ? K1.+% 6??F @AT Use of a Checklist in Postanesthesia Care Transitions !E # ;0&&+1('??? 51))$(.8>>> G3$+. ;+(&199 6?Y6? 77  ...

... PREOXYGENTATION OF OBESE PATIENTS Preoxygenation of Patients with Class Three Obesity Andrea Williams Marian University Leighton School of Nursing Chairs: Bradley Stelflug, DNAP, MBA, CRNA Mentor: Eric Prichard, DNAP, CRNA First Reader: Stacie Hitt, RN, PhD Date of Submission: Month, Day, Year 1 PREOXYGENTATION OF OBESE PATIENTS 2 Table of Contents Abstract.. Introduction Background Problem Statement Organizational Gap Analysis of Project Site.. Review of Literature (related to evidence-based practice/s to address the problem) Evidence Based Practice: Verification of Chosen Option. Theoretical Framework/Evidence Based Practice Model.. Goal & Objectives Project Design Project Site and Population Setting Facilitators and Barriers. Methods.. Measurement Instrument(s) Data Collection Procedure. Data Analysis. Results Interpretation/Discussion... Cost-Benefit Analysis/Budget Timeline. Ethical Considerations/Protection of Human Subjects.. Conclusion. 2 PREOXYGENTATION OF OBESE PATIENTS 3 References.. Appendix Appendix A Appendix B Appendix C Appendix D Appendix E 3 PREOXYGENTATION OF OBESE PATIENTS 4 Abstract Patients with class three obesity, formerly defined as morbid or extreme obesity, presenting for anesthesia come with an increased risk of experiencing complications. The oxygen storage capabilities and the functional residual capacity (FRC) in the lungs are reduced, making this patient population at risk for rapid oxygen desaturation with apnea. This patient population also has an increased risk for complications to occur while securing the patients airway during induction of anesthesia and are at risk for difficult airway management. Preoxygenation is performed before the induction of anesthesia to replace nitrogen in the lungs with oxygen, this will increase the time a patient can tolerate apnea without desaturating. Due to the increased risks which present with the class three obesity population, it is important to optimize preoxygenation prior to the induction of anesthesia and to consider providing apneic oxygenation during the intubation process to prevent desaturation. There are many studies and recommendations found in the literature concerning optimizing preoxygenation, patient positioning, and providing apneic oxygenation to the class three obesity patient population as means to prevent desaturation during induction of anesthesia. The objective of this project was to utilize the Iowa Model of Research-Based Practice to Promote Quality Care (IOWA Model) to perform a review of the literature concerning preoxygenation of obese patients and examine current preoxygenation practices at Hendricks Regional Health Hospital (HRH). Current practice at HRH was examined via retrospective chart review of three months of data. During September, October, and November of 2019, HRH had 82 patients with a BMI of 40 or greater receive anesthesia which required endotracheal tube (ETT) placement for airway management. 16 (20%) of these patients experienced a desaturation measured by a peripheral capillary oxygen saturation (SpO2) less than 90%. Data extracted from 4 PREOXYGENTATION OF OBESE PATIENTS 5 the retrospective chart review produced descriptive as well as parametric statistics. The results of the data analysis did not offer significant results identifying differences between the group of patients who experienced a desaturation and the group of patients who did not have a desaturation. Because of this, it is suggested each patient at risk for desaturation, including those with class three obesity, be treated as though they are going to experience a desaturation and measures to prevent this desaturation be taken. Techniques to decrease the percentage of patients who experiencing a desaturation during the induction of anesthesia at HRH are discussed in this paper. Keywords: preoxygenation, morbid obesity, class three obesity 5 PREOXYGENTATION OF OBESE PATIENTS 6 Preoxygenation of Patients with Class Three Obesity Providing anesthetic care to the obese patient population can be challenging due to the anatomical and physiological changes present in this patient population. The Centers for Disease Control and Prevention (CDC) defines obesity as a body mass index (BMI) greater than 30 (CDC, n.d.). The CDC further divides obesity into three categories: class one is BMI 30 to less than 35, class two is BMI 35 to less than 40, and class three is BMI greater than 40 (CDC, n.d.). This project will focus on the class three obesity category, formally known as morbid or severe obesity, which includes patients whose body mass index (BMI) is 40 or greater (CDC, n.d.). Proper preoxygenation prior to the induction of anesthesia is critical in this patient population in order to prolong the safe apneic time before desaturation while securing the patients airway via endotracheal intubation (ETI) (Schumann, 2019). This scholarly project examined current preoxygenation practices in the class three obese population at Hendricks Regional Health Hospital (HRH) and assessed whether practice change is indicated based on past patient data. Background SpO2, measured by pulse oximetry, is an indirect measurement of the amount of oxygen in the blood bound to hemoglobin available to the bodys tissues (Crawford Mechem, 2020). A clinically significant desaturation of oxygen is considered an SpO2 less than 90%, in which supplemental oxygen should be provided to the patient (Feller-Kopman & Schwartzstein, 2020). Using pulse oximetry reduces the need for direct measurement of the patients arterial oxygen saturation (SaO2) and arterial partial pressure of oxygen (PaO2) measured via an invasive arterial blood draw and blood gas analysis (Feller-Kopman & Schwartzstein, 2020). The partial pressure of oxygen (PO2) in arterial blood after oxygenation has occurred in the lungs is 80 to 100 mmHg (Collins et al., 2015). Deoxygenated venous blood returning to 6 PREOXYGENTATION OF OBESE PATIENTS 7 heart has a PO2 of 40 mmHg (Collins et al., 2015). The oxygen-hemoglobin dissociation curve is a sigmoid representation of the relationship between arterial blood saturation and the PO2 in the blood (Collins et al., 2015). A representation of the oxygen-hemoglobin dissociation curve can be found in Appendix A. The oxygen-hemoglobin dissociation curve is relatively flat when the SpO2 is greater than 90% (Collins et al., 2015). However, when the SpO2 falls below 90%, the curve displays a steep decline in the partial pressure of oxygen, the actual oxygen content available to the tissues (Collins et al., 2015). Prolonged oxygen desaturation will lead to dysrhythmias, hemodynamic instability and decompensation, hypoxic brain injury, and eventually death if not treated (Patel & Gilhooly, 2019). During the induction of anesthesia, a patient undergoes a period of apnea, or cessation of breathing, from the point which the anesthetic medications take effect until the successful insertion of an ETT by which the patient can be ventilated (Patel & Gilhooly, 2019). The administration of oxygen prior to the induction of anesthesia, known as preoxygenation, is an essential component which ideally prevents hypoxemia during induction or at least prolongs the patients safe apneic timethe time a patient can be apneic before desaturation occurs (Patel & Gilhooly, 2019). To increase the safe apneic time, preoxygenation increases the oxygen storage in the lungs, primarily in the functional residual capacity (FRC) (Patel & Gilhooly, 2019). The FRC is the lung volume that remains in the lungs and is not exchanged during normal tidal volume breathing (Patel & Gilhooly, 2019). Through increasing the oxygen storage in the FRC via preoxygenation to an end-tidal oxygen concentration (EtO2) of 90%, theoretically, a healthy patient can be apneic for eight minutes before desaturation occurs (Patel & Gilhooly, 2019). However, a number of factors including patient age, sex, posture, body habitus, and body size can reduce the FRC (Patel & Gilhooly, 2019). Therefore, it is not safe to assume a patient who is preoxygenated to an EtO2 of 7 PREOXYGENTATION OF OBESE PATIENTS 8 90%, has eight minutes of safe apneic time before desaturation occurs. Rather, it is important to note those with a decreased FRC, including class three obesity patients, are at an increased risk of rapid desaturation during the induction of anesthesia. The literature supports the use of a number of techniques in addition to standard preoxygenation to optimize oxygenation in high risk patients like those with class three obesity. These techniques include patient positioning techniques to increase the FRC and to improve glottic view during intubation, the use of non-invasive positive pressure ventilation (NIPPV) during preoxygenation, and the use of apneic oxygenation methods throughout the intubation process (Couture et al., 2018; Edmark et al., 2016; Futier et al., 2011; Georgescu et al., 2012; Harbut et al., 2014; Heard et al., 2016; Ramachandran et al., 2010; Sinha et al., 2013; Wong et al., 2019). Supplemental oxygenation techniques require additional steps be carried out by the anesthesia provider and additional time necessary for the anesthesia provider to implement the extra techniques. The use of additional supplies could increase the supply costs for the hospital, as well as costs related to increased time the patient will spend in the operating room. The findings of this scholarly project are valuable to hospitals similar to HRH, where cost savings are highly valued and the cost of routinely using extra supplies needs evidence-based justification. This project examined if current preoxygenation techniques used at HRH are sufficient in preventing desaturation in the class three obesity patient population during induction of anesthesia and if practice change to improve preoxygenation techniques should be explored and implemented. Problem Statement Adequate preoxygenation is crucial in order to prevent significant desaturation during the induction of anesthesia and to prolong the safe apneic time before desaturation in the event of an unexpected difficult intubation (Patel & Gilhooly, 2019). Adequate preoxygenation is vital in the 8 PREOXYGENTATION OF OBESE PATIENTS 9 cannot ventilate and cannot intubate emergent situation where time is necessary in order to get the patient spontaneously breathing again (Patel & Gilhooly, 2019). Therefore, the question examined in this project wasin patients with a BMI of 40 or greater, are the current preoxygenation techniques used at HRH effective in preventing a desaturation of SpO2 less than 90%? This project utilized a retrospective chart review of patient data to answer this question and assessed whether practice improvement is suggested at HRH. Organizational Gap Analysis of Project Site The prevalence of obesity, including class three obesity, is increasing across the United States (Hales et al., 2020). HRH has a large volume of patients presenting for surgery with class three obesity. It is important to ensure proper preoxygenation for this patient population to prevent desaturation during the induction of anesthesia. Literature suggests the use of additional preoxygenation techniques in this patient population, however, additional techniques may present with additional steps the anesthesia provider must complete, additional supply costs, or increased operating room time. For healthcare organizations who have small financial margins, these additional costs can make a large impact on their budget. This project examines current preoxygenation techniques used at HRH to assess whether practice improvement which may come with additional supply costs or additional operating room time is needed. The findings of this scholarly project are valuable to HRH and hospitals with similar characteristics, where cost savings are highly valued and the cost of routinely using extra supplies needs proper evidencebased justification. Review of the Literature 9 PREOXYGENTATION OF OBESE PATIENTS 10 There are a variety of preoxygenation methods which can be performed prior to the induction of anesthesia. The goal of preoxygenation is to replace the nitrogen in the FRC with oxygen, therefore, increasing the bodys oxygen store (Nimmagadda, Salem, & George, 2017). Two of the most common preoxygenation techniques are normal tidal volume breathing for three minutes or four vital capacity breaths (maximum exhalation followed by maximum inhalation) within 30 seconds (Nimmagadda, Salem, & George, 2017). Both of these preoxygenation techniques are considered standard preoxygenation with the same goal of an EtO2 of 90%-signifying adequate nitrogen washout and replacement with oxygen (Nimmagadda, Salem, & George, 2017). The American Society of Anesthesiologists Task Force on Management of Difficult Airways includes these standard preoxygenation techniques in their practice guidelines for managing difficult airways (ASA, 2013). The guidelines for managing difficult airways also recommends administering supplemental oxygen throughout the intubation process via nasal cannula, facemask, laryngeal mask airway (LMA), or oxygen insufflation (ASA, 2013). A study by Sinha et al. (2013) found utilizing an LMA to ventilate after induction of anesthesia significantly increased the oxygenation in obese patients compared to patients who were mask ventilated without the LMA. Patients with class three obesity have a greater risk of difficult intubation, complicated by less time before desaturation during periods of apnea due to the decrease in their FRC (Schumann, 2019). This makes adequate preoxygenation of upmost importance in this patient population. UpToDate is a resource for medical professionals which provides evidenced-based recommendations based on rigorous synthesis of the most recent medical information available in the literature (UpToDate, n.d.). It is a recommendation from UpToDate that the preoxygenation of obese patients should be performed in the reverse Trendelenburg position, 10 PREOXYGENTATION OF OBESE PATIENTS 11 rather than supine due to the reduction in lung volume in the supine position (Schumann, 2019). A recent study by Couture et al. (2018) found positioning the patients head above their feet by tilting the operating table 25 degrees into slight reverse Trendelenburg position significantly increases the FRC volume and oxygen storage capacity of the lungs when compared to the supine position. It is also an UpToDate recommendation to administer preoxygenation with non-invasive positive end-expiratory pressure (PEEP) in the obese population to improve oxygenation prior to and during induction (Schumann, 2019). A study by Edmark et al. (2016) found the patients who received preoxygenation with 10 cm H2O CPAP had significantly increased oxygenation compared to those who received traditional preoxygenation without CPAP. Similar studies by Futier et al. (2011), Georgescu et al. (2012), and Harbut et al. (2014) also found utilizing NIPPV techniques during preoxygenation significantly improved the oxygenation of participants when compared to those who did not receive NIPPV during preoxygenation. There are several passive apneic oxygenation techniques studied for use during laryngoscopy to prolong the safe apneic time for high risk patient populations, including patients with obesity (Schumann, 2019). Apneic oxygenation works on the premise that oxygen can flow through the airway to the alveoli allowing oxygen diffusion into the bloodstream to occur even during apnea (Patel & Gilhooly, 2019). Apneic oxygenation can be provided via face mask, nasal cannula, or a number of other devices which have been developed to insufflate oxygen into the trachea, pharyngeal, and nasal passages (Patel & Gilhooly, 2019). A study by Ramachandran et al. (2010) found prolonged safe apneic period in simulated difficult airway scenarios with apneic oxygenation provided by nasal cannula at five liters per minute. A similar studied by Heard, et al. (2016) found a prolonged safe apneic period with oxygen insufflation via buccal rae tube at 11 PREOXYGENTATION OF OBESE PATIENTS 12 10 L/min following standard preoxygenation. Likewise, a study by Wong et al. (2019) found utilizing high flow oxygen via Optiflow delivery device for preoxygenation at 40 L/min and apneic oxygen insufflation with the Optiflow at 60 L/min following induction of anesthesia significantly increased the safe apneic period compared to the control group who received standard preoxygenation and no apneic oxygenation. The literature review performed for this project includes research studies which were the result of a PubMed search of terms preoxygenation and obesity in all search fields. This search produced 82 articles which were then filtered to include only randomized controlled trials and clinical trials published within the last 10 years, narrowing the search results to 13 articles. Four of the remaining 13 articles were excluded for not involving obese patients as the study population. The remaining nine randomized controlled trials examining preoxygenation in the obese patient population have been included in this literature review and are also summarized in the literature review matrix which can be found in Appendix B. Evidence-Based Practice: Verification of Chosen Option This scholarly project does not implement practice change; therefore, no verification of chosen evidence-based practice option will be discussed. However, this literature review is included to summarize current practices which could be implemented to improve practice at HRH in the future. Theoretical Framework The Iowa Model of Research-Based Practice to Promote Quality Care (IOWA Model) is a theoretical framework which was developed in the 1990s to help clinicians evaluate current processes, research findings, and incorporate best practices into their patient care (IOWA Model Collaborative, 2017). The IOWA Model was used in this scholarly project to determine if there 12 PREOXYGENTATION OF OBESE PATIENTS 13 is sufficient evidence for HRH to implement practice improvement by utilizing a systematic review of the literature and through a retrospective chart review of patient data at HRH. The first step of the IOWA Model is to identify a triggering issue or opportunity (IOWA Model Collaborative, 2017). The triggering issue or opportunity can be identified by a number of methods including clinically identified issues, national initiatives, new evidence available in the literature, or accrediting agency requirements or regulations (IOWA Model Collaborative, 2017). The triggering opportunity for this scholarly project was identified based on the wide variety of preoxygenation techniques utilized for this patient population identified via clinical observation and the amount of evidence and recommendations concerning this topic available in the literature. The second step in the IOWA Model is to formulate a question or purpose (IOWA Model Collaborative, 2017). By formally identifying the question or purpose, the approach to gathering evidence on the topic is more focused and direct (IOWA Model Collaborative, 2017). The question examined in this project isin patients with a BMI of 40 or greater, are the current preoxygenation techniques utilized at HRH effective in preventing a desaturation of SpO2 less than 90%? After formally stating the question or purpose, the IOWA Model presents the first decision point of the modelis the chosen topic a priority (IOWA Model Collaborative, 2017)? After a discussion with faculty at Marian University and members of the anesthesia department at HRH, the topic of preoxygenation techniques recommended for class three obesity patients was determined to be a priority. After determining the topic as a priority, the next step when following the IOWA Model is to form a team (IOWA Model Collaborative, 2017). The team formed for this project consists of one student registered nurse anesthetist at Marian University, two faculty advisors at Marian 13 PREOXYGENTATION OF OBESE PATIENTS 14 University, and one clinical mentor, a certified registered nurse anesthetist at HRH. After forming a team, the next step in the IOWA Model is to assemble, appraise, and synthesize the evidence (IOWA Model Collaborative, 2017). This step was completed in this project by performing the literature review included in this paper. The second decision point in the IOWA Model follows the synthesis of evidence and literature and asks whether or not there is sufficient evidence to conduct research (IOWA Model Collaborative, 2017)? It was determined there is enough evidence available in the literature to warrant a retrospective chart review of patient data at HRH. The IOWA Model was used to guide this this scholarly project up to the third decision point of the modelis change appropriate for adoption into practice (IOWA Model Collaborative, 2017)? The outcomes of this project were made available to the anesthesia department at HRH and recommendations for potential areas of practice improvement identified by data assessment are discussed in this paper. A diagram of the IOWA Model utilized in this scholarly project can be found in Appendix C. Goals, Objectives, and Expected Outcomes The goal of this project was to assess current preoxygenation practices at HRH and determine if they are adequate in preventing SpO2 less than 90% during induction of anesthesia in class three obesity patients. A chart review was performed for all patients with class three obesity who underwent general surgery requiring endotracheal tube intubation at HRH from September 2019 through November 2019. The data and analysis from this scholarly project will be made available to the anesthesia department at HRH. The outcome of this project will provide evidence to either support current practices at HRH or it will serve as a basis for future clinical practice guideline formation at HRH to improve patient safety. Key stakeholders for this project 14 PREOXYGENTATION OF OBESE PATIENTS 15 include anesthesia providers, other healthcare disciplines with goals to increase patient safety, and individuals with obesity undergoing surgical procedures. Project Design This project consists of a retrospective chart review of patient data. A retrospective chart review is a project design which utilized pre-recorded patient data in order to answer a research question (Vassar & Holzmann, 2013). The data collected from a retrospective chart review can be gathered from a variety of patient record documents including electronic charting databases which is the method of data collection utilized in this project (Vassar & Holzmann, 2013). All data collected for this project was found in the anesthesia record located in the EPIC electronic medical record used at HRH. Project Site and Population This project was completed at HRH in Danville, IN a suburb of Indianapolis. HRH is a 160-bed county hospital offering a 24-hour emergency room, childbirth center, outpatient surgery center, rehabilitation services, women's center, and laboratory and radiology services (Avon Chamber of Commerce, n.d.). HRH has eight surgical suites at their main campus where data for this project was collected. Surgery specialties that take place at HRH include general, urological, gynecological, and orthopedic surgeries. The anesthesia department at HRH practices as a care-team model consisting of CRNAs and physician anesthesiologists. The anesthesia department at HRH consists of 12 full-time, two part-time, and three supplemental CRNAs and five full-time and two part-time physician anesthesiologists. Setting Facilitators and Barriers HRH uses an electronic medical record named EPIC which provides ease of access to the data which was collected for this project. A potential barrier to the integrity of data collection is 15 PREOXYGENTATION OF OBESE PATIENTS 16 the possibility of a discrepancy between what preoxygenation and induction actions were performed and what actions were charted. The overarching goal of this project is to assess if the current actions being performed are able to prevent desaturation less than 90%. The potential reality/chart discrepancy barrier can be overcome by examining whether or not the patient experienced desaturation despite what preoxygenation techniques were charted. Methods Measurement Instrument The data examined in this project is quantitative data found in the electronic health record. Data of interest was discussed amongst the project team, and it was determined the following data points would be collected from the electronic health record for each patient: BMI, age, gender, American Society of Anesthesiologists (ASA) physical status classification, preoperative history of lung disease, smoking status, Mallampati score, preoperative SpO2, preoxygenation techniques charted by the anesthesia provider, ease of mask ventilation, method of intubation (direct laryngoscopy or use of video laryngoscope), number of intubation attempts, and the presence of a SpO2 reading less than 90%. If desaturation less than 90% did occur, the time until SpO2 reached greater than 90% was also collected. Data Collection Procedure All data was collected during a retrospective review of patient charts. Inclusion criteria for this chart review were patients with a BMI of 40 or greater undergoing general anesthesia requiring an endotracheal tube for airway management. This project excluded patients with a BMI less than 40 and patients with a BMI of 40 or greater not requiring an endotracheal tube for airway management. 16 PREOXYGENTATION OF OBESE PATIENTS 17 To perform the retrospective chart review, the surgery schedule for the eight main operating rooms at HRH was accessed for each day in September, October, and November of 2019. Next, each patient with a BMI of 40 or greater was selected and only those requiring endotracheal tube intubation were included. The anesthesia record for the surgery performed was accessed and all data points were pulled from this record. Patient data was entered into an Excel spreadsheet, documenting each patients BMI, age, gender, ASA physical status classification, preoperative history of lung disease, smoking status, Mallampati score, preoperative SpO2, preoxygenation techniques utilized by the anesthesia provider, ease of mask ventilation, method of intubation (direct laryngoscopy or use of video laryngoscope), number of intubation attempts, and the presence of a SpO2 reading less than 90%. If desaturation less than 90% did occur, the time until the SpO2 reached greater than 90% was also recorded. Data Analysis Analysis of the data collected will provides descriptive results as well as parametric statistics. The analysis of parametric data is of a two-group design, independent t-test to test the numerical variables age, BMI, ASA classification, and pre-operative SpO2 utilizing Microsoft Excel. Results In September, October, and November of 2019, HRH had 82 patients undergo anesthesia for surgery which required an ETT for airway management. Characteristic data describing the total sample in this project is located in Appendix D. Of the 82 patients, 16 patients (20%) experienced a desaturation less than 90% during the induction of anesthesia. These 16 patients experienced desaturations ranging from 72% - 89%. Five of the patients who experienced a desaturation, experienced a desaturation for greater than one minute in durationthe longest 17 PREOXYGENTATION OF OBESE PATIENTS 18 desaturation occurring was six minutes. The lowest SpO2 reading and the duration of desaturation for the 16 patients experiencing desaturation is displayed on the scatter plot in Appendix D. A variety of preoxygenation techniques were charted for this patient sample. Techniques charted for the sample include standard preoxygenation, BMI guided preoxygenation, placing the patient in sniffing position, reverse Trendelenburg position, ramping the patient, and many combinations of these techniques. BMI guided preoxygenation is a preoxygenation technique available to chart at HRH, described as prolonged preoxygenation administration for five minutes. Graphical display of the preoxygenation techniques can be found in Appendix D. The total number of patients intubated with the use of a video laryngoscope was 34 (41%), compared to 47 (57%) patients who were intubated via direct laryngoscopy and one patient had two attempts of direct laryngoscopy followed by a successful attempt with a video laryngoscope. Of the patients experiencing desaturation, direct laryngoscopy was performed for seven patients, eight patients were intubated with the use of video laryngoscope, and one patient experienced both techniques. Descriptive statistical display of the ease of mask ventilation charted by the anesthesia provider, grade of laryngoscopic view, and number of intubation attempts can be found in Appendix D. Independent t-tests were performed for the numerical variables age, BMI, ASA classification, and pre-operative SpO2. No significance was found based on this testing as pvalues for these tests were 0.5, 0.6, 0.2, and 0.2, respectively. Interpretation/Discussion Preoxygenation, an essential component of airway management, is used to increase the oxygen reserves in order to prevent hypoxemia during the apneic period of the induction of 18 PREOXYGENTATION OF OBESE PATIENTS 19 anesthesia (Patel & Gilhooly, 2019). Standard preoxygenation is usually sufficient in preventing desaturation in patients without concern for difficulty of mask ventilation, intubation, or concern of rapid desaturation (Patel & Gilhooly, 2019). Many novel techniques have been studied and developed to improve preoxygenation and provide continued oxygenation to patients who are at risk for difficult mask ventilation, intubation, or are at risk of rapid desaturationsuch as the obese patient population (Patel & Gilhooly, 2019). While a variety of techniques are utilized to improve preoxygenation at HRH, 20% of their patient population experienced desaturation to SpO2 less than 90% in the three-month period analyzed in this project. The data collected in this project did not suggest any identifiable characteristics for which patients were going to experience desaturation. Nor could the data collected in this project suggest any combination of preoxygenation techniques which could prevent desaturation in this patient sample. Based on the data collected in this project, it is not possible to identify which patients will experience a desaturation prior to the induction of anesthesia, therefore every patient who presents with a BMI of 40 or greater should be treated as though they are going to desaturate and measures to prevent the desaturation must be taken. It is likely many patients from this sample population would have experienced a desaturation without the techniques which were taken to optimize preoxygenation and patient positioning prior to induction of anesthesia. Identification of patients at risk for rapid desaturation with apnea and patients at risk for difficult airway management is key to planning management of this patient population (ASA, 2013). To improve the percentage of patients experiencing desaturation, anesthesia providers at HRH could consider ramping each patient with a BMI greater than 40 to optimize glottic view and placing them in a reverse Trendelenburg position while they are preoxygenated per their BMI guidelines (ASA, 2013; Couture et al., 2018; Patel & Gilhooly, 2019). Implementing these 19 PREOXYGENTATION OF OBESE PATIENTS 20 preoxygenation and positioning techniques do not come with an additional supply cost to the hospital and adds only minimal time to the induction process. If these preoxygenation techniques do not improve the rate of patients experiencing desaturations, the anesthesia providers at HRH could consider implementing other techniques not utilized for the patients in this project. Other techniques not utilized by HRH include the use of NIPPV during preoxygenation or the variety of different apneic oxygenation devices designed to provide oxygenation to the apneic patient (Couture et al., 2018; Edmark et al., 2016; Futier et al., 2011; Georgescu et al., 2012; Harbut et al., 2014; Heard et al., 2016; Ramachandran et al., 2010; Sinha et al., 2013; Wong et al., 2019). Cost-Benefit Analysis/Budget This project consists solely of a retrospective chart review, therefore, there are no financial costs to completing this project. Timeline The timeframe from submitting request to Marian Universitys international review board (IRB) to finalizing this scholarly project is projected to take seven months. This allowed three weeks to gain Marian University and HRH IRB approval, three months to collect and analyze data, and an additional two months to summarize the findings and to finalize this scholarly paper. This timeline also allows for one month to receive final project approval. A detailed project timeline is included in Appendix E. Ethical Considerations/Protection of Human Subjects The Marian University IRB and HRH IRB approval was obtained prior to initiating this DNP Project. The patient data extracted from the electronic medical record was de-identified and Health Insurance Portability and Accountability Act of 1996 compliant to protect patient privacy. 20 PREOXYGENTATION OF OBESE PATIENTS 21 Conclusion Class three obesity patients present with additional risk for complications which must be considered prior to and during the administration of anesthesia. Obesity decreases the lungs FRC and oxygen storage capability, making obese patients at risk for rapid desaturation with apnea. Obesity also increases the risk of difficulty securing a patients airway during the induction of anesthesia. Therefore, it is important to optimize preoxygenation of this patient population prior to the induction of anesthesia and to consider providing apneic oxygenation in order to prevent desaturation during the apneic period of induction. The sample assessed in this project received a variety of combinations of preoxygenation techniques and techniques to optimize the oxygenation and the intubation procedure. 16 patients did experience a desaturation less than 90%. Areas which could improve the percentage of patients experiencing desaturation with the induction of anesthesia at HRH were identified from analyzing the data extracted from this retrospective chart review. Areas for improvement include treating every patient with a BMI 40 or greater as though they are going to desaturate. Each patient should be placed in the ramped position to improve glottic view and intubation conditions. Each patient should receive BMI guided preoxygenation while in the reverse Trendelenburg position. These suggestions do not come with additional supply costs and deliver minimal risk to the patient. Anesthesia providers at HRH could also consider utilizing a video laryngoscope for this specific patient population to help aid intubation conditions. If HRH would like to improve their percentage of patients experiencing desaturation, they could also use apneic oxygenation techniques to provide oxygen to the patient during the apneic period. Apneic oxygenation techniques may come with additional supply costs which may not be justified for routine use on every patient. 21 PREOXYGENTATION OF OBESE PATIENTS 22 22 PREOXYGENTATION OF OBESE PATIENTS 23 References American Society of Anesthesiologists Task Force on Management of Difficult Airway. (2013). Practice guidelines for management of the difficult airway. Anesthesiology, 188(2), 1-20. doi: https://doi.org/10.1097/ALN.0b013e31827773b2 Avon Chamber of Commerce. (n.d.). Health and wellness. Retrieved March 25, 2020, from https://www.avonchamber.org/health-and-wellness.html Centers for Disease Control and Prevention. (n.d.). Defining adult overweight and obesity. Retrieved March 25, 2020, from https://www.cdc.gov/obesity/adult/defining.html Collins, J., Rudenski, A., Gibson, J., Howard, L., & ODriscoll, R. (2015). Relating oxygen partial pressure, saturation and content: the haemoglobin-oxygen dissociation curve. Breathe, 11(3), 194-201. doi: 10.1183/20734735.001415 Couture, E., Provencher, S., Somma, J., Lellouche, F., Marceau, S., & Bussieres, J. (2018). Effect of position and positive pressure ventilation on functional residual capacity in morbidly obese patients: A randomized trial. Canadian Journal of Anaesthesia, 65(5), 522-528. doi: 10.1007/s12630-018-1050-1 Crawford Mechem, C. (2020, February). Pulse oximetry. Retrieved March 25, 2020, from www.uptodate.com Edmark, L., Ostberg, E., Scheer, H., Wallquist, W., Hedenstierna, G., & Zetterstrom, H. (2016). Preserved oxygen in obese patients receiving protective ventilation during laparoscopic surgery: A randomized controlled study. Acta anaesthesiologica Scandinavica, 60(1), 2635. doi: 10.1111/aas.12588 23 PREOXYGENTATION OF OBESE PATIENTS 24 Feller-Kopman, D., & Schwartzstein, R. (2020). Evaluation, diagnosis, and treatment of the adult patient with acute hypercapnic respiratory failure. Retrieved on April 16, 2020 from www.uptodate.com Futier, E., Constantin, J., Pelosi, P., Chanques., Massone, A., Petit, A., Kwiatkowski, F., Bazin., J., & Jaber, S. (2011). Noninvasive ventilation and alveolar recruitment maneuver improve respiratory function during and after intubation of morbidly obese patients: A randomized controlled study. Anesthesiology, 114(6), 1354-1363. doi: 10.1097/ALN.0b013e31821811ba Georgescu, M., Tanoubi, I., Fortier, L., Donati, F., & Drolet, P. (2012). Efficacy of preoxygenation with non-invasive low positive pressure ventilation in obese patients: Crossover physiological study. Annales francaises d'anesthesie et de reanimation, 31(9), 161-165. doi: 10.1016/j.annfar.2012.05.003 Hales, C., Carroll, M., Fryar, C., Ogden, C. (2020). Prevalence of obesity and severe obesity among adults: United States, 2017-2018. NCHS Data Brief, 360. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db360-h.pdf Harbut, P., Gozdzik, W., Stjernfalt, E., Marsk, R., & Hesselvik, J. (2014). Continuous positive airway pressure/pressure support pre-oxygenation of morbidly obese patients. Acta Anaesthesiologica Scandinavica, 58, 675-680. doi: 10.1111/aas.12317 Heard, A., Toner, A., Evans, J., Aranda Palacios, A., & Lauer, S. (2016). Apneic oxygenation during prolonged laryngoscopy in obese patients: A randomized, controlled trial of buccal RAE tube oxygen administration. Anesthesia Patient Safety Foundation Journal, 124(4), 1162-1167. doi: 10.1213/ANE0000000000001564 24 PREOXYGENTATION OF OBESE PATIENTS 25 Iowa Model Collaboration. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi: 10.1111/wvn.12223 Nimmagadda, U., Salem, R., Crystal., G. (2017). Preoxygenation: Physiological basis, benefits, and potential risks. Anesthesia Patient Safety Foundation Journal, 124(2), 507-517. doi: 10.1213/ANE.0000000000001589 Patel, A., & Gilhooly, M. (2019, February). Preoxygenation and apneic oxygenation for airway management for anesthesia. Retrieved from www.uptodate.com Ramachandran, S., Cosnowski, A., Shanks, A., & Turner, C. (2010). Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygenation. Journal of Clinical Anesthesia, 22(3), 164-168. doi: 10.1016/j.jclinane.2009.05.006 Schumann, R. (2019, August). Anesthesia for the obese patient. Retrieved from www.uptodate.com Sinha, A., Jayaraman, L., Punhani, D., & Panigrahi, B. (2013). Proseal laryngeal mask airway improves oxygenation when used as a conduit prior to laryngoscope guided intubation in bariatric patients. Indian Journal of Anaesthesia, 57(1), 25- 30. doi: 10.4103/00195049.108557 UpToDate. (n.d.). About us. Retrieved March 25, 2020, from https://www.uptodate.com/home/about-us Vassar, M., & Holzmann, M. (2013). The retrospective chart review: Important methodological considerations. Journal of Educational Evaluation for Health Professionals, 10(12). doi: 10.3352/jeehp.2013.10.12 25 PREOXYGENTATION OF OBESE PATIENTS 26 Wong, D., Dallaire, A., Singh, K., Madhusudan, P., Jackson, T., Singh, M., Wong, J., & Chung, F. (2019). High-flow nasal oxygen improves safe apnea time in morbidly obese patients undergoing general anesthesia: A randomized controlled trial. Anesthesia & Analgesia, 129(4), 1130-1136. doi: 10.1213/ANE.0000000000003966 26 PREOXYGENTATION OF OBESE PATIENTS Appendix A Figure 1 Oxygen-Hemoglobin Dissociation Curve 27 PREOXYGENTATION OF OBESE PATIENTS 28 Appendix B Table 1 Literature Review Matrix Citation Research Design Variables of & Sample Size Interest Couture, E., Provencher, S., Somma, J., Lellouche, F., Marceau, S., & Bussieres, J. (2018). Effect of position and positive pressure ventilation on functional residual capacity in morbidly obese patients: A randomized trial. Canadian Journal of Anaesthesia, 65(5), 522-528. doi: 10.1007/s12630-0181050-1 Crossover Randomized Controlled Trial Edmark, L., Ostberg, E., Scheer, H., Wallquist, W., Hedenstierna, G., & Zetterstrom, H. (2016). Preserved oxygen in obese patients receiving protective Randomized Controlled Trial 17 patients [BMI 40 or greater] 40 patients [BMI greater than 35 but less than 50] Methods Key Findings FRC measuremen t with helium dilution method FRC measured in each participant in three different positions (supine, back up tilt 25 degrees, whole table tilt 25 degrees) with two different ventilation methods (spontaneous breathing without positive pressure, and spontaneous breathing with 8 cm H20 inspiratory pressure and 10 cm H20 expiratory pressure) Significant increase in FRC when using positive pressure with spontaneous ventilation and increase FRC with whole table tilt 25 degrees but no difference in FRC from supine and back up 25 degrees. Oxygenatio n by estimated venous admixture calculation Control: supine position, 30 degree head up table tilt, 100% O2 for 3 min Use of CPAP during induction significantly increased oxygenation compared to no CPAP Experimental: Same as control with addition of Limitations & Clinical Relevance Increased FRC could theoretically increase safe apneic time. However, this study was performed on awake spontaneously breathing patients and does not take into consideration apnea and muscle relaxation that occurs during induction. Increased oxygenation can increase safe apneic time during induction. Positive pressure is not always 28 PREOXYGENTATION OF OBESE PATIENTS ventilation during laparoscopic surgery: A randomized controlled study. Acta anaesthesiologica Scandinavica, 60(1), 2635. doi: 10.1111/aas.12588 Futier, E., Constantin, J., Pelosi, P., Chanques., Massone, A., Petit, A., Kwiatkowski, F., Bazin., J., & Jaber, S. (2011). Noninvasive ventilation and alveolar recruitment maneuver improve respiratory function during and after intubation of morbidly obese patients: A randomized controlled study. Anesthesiology, 114(6), 1354-1363. doi: 10.1097/ALN.0b013e3 1821811ba Randomized Controlled Trial 66 patients [BMI greater than 40] **study was not only looking at positive pressure effects on preoxygenat ion but also positive pressure on emergence-not discussed here Arterial blood O2 12 min before and immediately following preoxygenat ion, immediately after intubation, and 5 min after ventilation 29 10 cm H2O CPAP with induction tolerated well in awake patients. Control: in beach chair position preoxygenation with 100% O2 via 15L facemask for 5 min TV breathing Beach chair position for ETI can be difficult for some providers. Statistically significant results of higher PaO2 following preoxygenation and following ETI. NIPPV in addition to RM Experimental: 2 groups following ETI is also in beach chair position supported in improving -NIPPV (PSV adjusted ventilation following to 8 ml/kg, Peep 6-8, ETI. PIP < 18) -NIPPV and recruitment maneuvers following ETI NIPPV is not tolerated well by all patients (claustrophobia). 29 PREOXYGENTATION OF OBESE PATIENTS Georgescu, M., Tanoubi, I., Fortier, L., Donati, F., & Drolet, P. (2012). Efficacy of preoxygenation with non-invasive low positive pressure ventilation in obese patients: Crossover physiological study. Annales francaises d'anesthesie et de reanimation, 31(9), 161-165. doi: 10.1016/j.annfar.2012. 05.003 Crossover Expired Randomized oxygen Controlled Study concentratio n (EtO2), 30 patients [BMI time to 30 or greater] reach EtO2 > 90%, and patient comfort with two different preoxygenat ion techniques Harbut, P., Gozdzik, W., Stjernfalt, E., Marsk, R., & Hesselvik, J. (2014). Continuous positive airway pressure/pressure support preoxygenation of morbidly obese patients. Acta Anaesthesiologica Scandinavica, 58, 675680. doi: 10.1111/aas.12317 Randomized Controlled Trial 44 patients [BMI greater than 35] Arterial blood O2 concentratio ns at baseline and following preoxygenat ion and intubation SpO2 monitoring during induction and intubation Each patient received both methods in randomly selected order with 20 min rest in between Control: supine position, TV breathing at 12 L/min flow for 3 minutes Experimental: supine position, NIPPV of 4 cm H2O inspiratory positive pressure and 4 cm H2O of PEEP, 100% O2 for 3 minutes Control: preoxygenation 80% O2 at 15 L/min facemask for 2 min., HOB elevated 25-30 degrees Experimental: preoxygenation with noninvasive CPAP/PSV (5 + 5 cm H2O) 80% O2 for 2 min., HOB elevated 25-30 degrees 30 Providing NIPPV improved patient EtO2, more patients at achieved EtO2 > 90 with NIPPV, no difference in patient comfort level Increased EtO2 could increase safe apneic time. Statistically significant results of higher PaO2 in experimental group after intubation and minimum SpO2 reading was significantly higher in experimental group as well This study used 80% O2 where clinically 100% O2 is used No difference in patient comfort level suggestions NIPPV can be tolerated by awake patient. This study used 2 min. of preoxygenation rather than recommended 3 min. 30 PREOXYGENTATION OF OBESE PATIENTS Heard, A., Toner, A., Evans, J., Aranda Palacios, A., & Lauer, S. (2016). Apneic oxygenation during prolonged laryngoscopy in obese patients: A randomized, controlled trial of buccal RAE tube oxygen administration. Anesthesia Patient Safety Foundation Journal, 124(4), 11621167. doi: 10.1213/ANE00000000 00001564 Randomized Controlled Trial Ramachandran, S., Cosnowski, A., Shanks, A., & Turner, C. (2010). Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygenation. Journal of Clinical Anesthesia, 22(3), 164-168. doi: 10.1016/j.jclinane.2009 .05.006 Randomized Controlled Trial 40 patients [BMI 30-40] Onset of apnea to SpO2 less than 95% Control: preoxygenation w/ HOB elevated 30 degrees, w/ 100% O2 via face mask until EtO2 80% Experimental: same, with addition of 10 L/min oxygen insufflation via buccal rae tube after preoxygenation 30 male patients [BMI 30-35] Simulated difficult intubation, grade IV glottic view maintained until SpO2 < 95% or 6 minutes passed following succinylchol ine administrati on, time *DL performed and grade III view maintained until desaturation or 750 seconds passed Control: reverse Trendelenburg position, no additional O2 via nasal prongs, preoxygenation with TV breathing via facemask until EtO2 was greater than 90% or within 10% of the inspired O2 concentration 31 Control: average time to desaturation 296 seconds Experimental: average time to desaturation 750 seconds Apnea time to SpO2 less than 95 was significantly shorter in control group, the lowest SpO2 in control group was significantly lower, both supporting the use of additional O2 via NC In difficult airway scenarios, glottic view is not maintained, therefore passive oxygenation is not guaranteed. Study excluded grade III, IV glottic views BMI 30-35 (not morbidly obese) Experimental: reverse Trendelenburg position, 5L O2 via nasal cannula, TV breathing 31 PREOXYGENTATION OF OBESE PATIENTS Sinha, A., Jayaraman, L., Punhani, D., & Panigrahi, B. (2013). Proseal laryngeal mask airway improves oxygenation when used as a conduit prior to laryngoscope guided intubation in bariatric patients. Indian Journal of Anaesthesia, 57(1), 25- 30. doi: 10.4103/00195049.108557 Wong, D., Dallaire, A., Singh, K., Madhusudan, P., Randomized Controlled Trial 40 patients [BMI greater than 35] Randomized Controlled Trial documented as well as time to recovery of O2 following ETI to a SpO2 of 100% Arterial blood oxygen concentratio n at baseline, following preoxygenat ion, and following intubation Apneic time measured until SpO2 32 preoxygenation via facemask until ETO2 was >90% or within 10% inspired O2 concentration Control: positioned in ramp position, preoxygenated with 100% O2 via CPAP 10mm H20 for 5 min., after apnea oropharyngeal airway inserted and ventilated for additional 5 minutes, then intubation Results statistically significant supporting use of PLMA to increase arterial O2 concentration in order to increase time to desaturation Experimental: positioned in ramp position, preoxygenated with 100% O2 via CPAP 10mm H2) for 5 minutes, after apnea PLMA inserted and ventilation continued for additional 5 minutes, then intubated Control: supine, 30 Safe apneic time was degree head up position significantly longer in on Troop-pillow, 100% the group receiving Results show oropharyngeal airway is also effective in increasing PaO2, just not to same extent. PLMA use comes at additional supply costs and steps for anesthesia provider. PLMA clinically useful in difficult airway scenarios, but not routine use. Simulated difficult airway, not clinically 32 PREOXYGENTATION OF OBESE PATIENTS Jackson, T., Singh, M., 40 patients [BMI Wong, J., & Chung, F. 40 or greater] (2019). High-flow nasal oxygen improves safe apnea time in morbidly obese patients undergoing general anesthesia: A randomized controlled trial. Anesthesia & Analgesia, 129(4), 1130-1136. doi: 10.1213/ANE.0000000 000003966 reached O2 via facemask at 15 95% or 6 L/min min. elapsed Experimental: preoxygenation for 3 min. at 40 L/min flow utilizing Optiflow delivery method, which was increased to 60 L/min after loss of consciousness 33 high-flow oxygenation and the lowest SpO2 was higher in the highflow group realistic to maintain grade III glottic view, passive oxygenation is not guaranteed in true difficult airway. The Optiflow device is not standard operative room equipment. 33 PREOXYGENTATION OF OBESE PATIENTS 34 Appendix C Figure 1 The Iowa Model Appendix B Note: Used/reprinted with permission from the University of Iowa Hospitals and Clinics, copyright 2015. For permission to use or reproduce, please contact the University of Iowa Hospitals and Clinics at 319-384-9098. 34 PREOXYGENTATION OF OBESE PATIENTS 35 Appendix D Table 1 Sample Characteristics NO DESATURATION SAMPLE DESATURATION SAMPLE (N=66) (N=16) BMI RANGE MEAN AGE RANGE MEAN GENDER MALE FEMALE ASA CLASSIFICATION I II III IV HISTORY OF LUNG DISEASE Y N SMOKING STATUS CURRENT FORMER NEVER MALLAMPATI I II III IV 40-57 45.3 40-55 46.3 18-80 49.0 25-72 51.0 17 (20%) 65 (80%) 4 (25%) 12 (75%) 1 (1%) 13 (20%) 46 (70%) 6 (9%) 0 (0%) 2 (13%) 11 (69%) 3 (19%) 38 (58%) 28 (42%) 9 (56%) 7 (44%) 11 (17%) 23 (35%) 32 (48%) 2 (13%) 3 (19%) 11 (69%) 7 (11%) 37 (56%) 20 (30%) 2 (3%) 1 (6%) 8 (50%) 6 (38%) 1 (6%) 35 PREOXYGENTATION OF OBESE PATIENTS 36 Table 2 Data Specific to Induction Period PREOPERATIVE SPO2 RANGE MEAN EASE OF MASK VENTILATION EASY MODERATE DIFFICULT NOT ATTEMPTED DID NOT SPECIFY LARYNGOSCOPIC GRADE VIEW I II III IV DID NOT SPECIFY INTUBATION ATTEMPTS 1 2 3 DID NOT SPECIFY NO DESATURATION SAMPLE (N=66) DESATURATION SAMPLE (N=16) 90-100 96.2 88-100 95.2 47 (71%) 8 (12%) 5 (8%) 4 (6%) 2 (3%) 9 (56%) 3 (19%) 0 (0%) 4 (25%) 0 (0%) 36 (54%) 21 (32%) 3 (5%) 3 (5%) 6 (9%) 8 (50%) 7 (44%) 0 (0%) 1 (6%) 0 (0%) 61 (92%) 3 (5%) 0 (0%) 2 (3%) 10 (63%) 5 (31%) 1 (6%) 0 (0%) 36 PREOXYGENTATION OF OBESE PATIENTS 37 Figure 1 Scatter Plot Display of Each Desaturation Value and the Duration of Desaturation Desaturation Duration (minutes) Desaturation Value and Duration 7 6 5 4 3 2 1 0 70 72 74 76 78 80 82 84 86 88 90 SpO2 (%) Figure 2 Five Major Categories of Preoxygenation Techniques Preoxygenation Techniques 50 40 30 20 10 0 BMI Guided Pre-O2 Standard BMI Guided Pre-O2 and Standard Other No Technique Charted BMI Guided Pre-O2 Alone BMI Guided Pre-O2 in Combination with Other Standard Pre-O2 Alone Standard Pre-O2 in Combination with Other BMI, Standard, and Other Other Alone None Charted 37 PREOXYGENTATION OF OBESE PATIENTS 38 Appendix E DNP Scholarly Project Timeline PLAN STAR T PLAN COMPLETI ON ACTUA L START ACTUAL COMPLETI ON 08/19 09/19 09/19 09/19 08/19 10/19 09/19 10/19 08/19 10/19 09/19 10/19 Project Team Form 09/19 10/19 09/19 12/19 Framework 10/19 11/19 11/19 11/19 SWOT Analysis 10/19 11/19 11/19 11/19 CITI Training 11/19 11/19 10/19 10/19 Proposal Draft 11/19 12/19 09/19 12/19 Marian IRB 11/19 01/20 12/19 12/19 Hendricks IRB 11/19 01/20 01/20 01/20 Collect Data 01/20 02/20 03/20 03/20 ACTIVITY Identify PICO Question Liturature Review Matrix Annotated Bibliography % COMPLE TE Plan Start Plan Completion In Process Complete Month A S O N D J F M A M J J 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 38 PREOXYGENTATION OF OBESE PATIENTS Data Analysis Interpretation/Discus sion 02/20 03/20 03/20 03/20 04/20 04/20 Completion of Project 05/20 06/20 04/20 Submission/Approval 06/20 07/20 39 75% 25% 25% 0% 39  ...