LONDON -- After surgeons completed a six-hour operation to fix the hole in a boy's heart, Angus McEwan supervised one of the more dangerous phases of the procedure: transferring the fragile three-year-old from surgery to the intensive care unit.
Thousands of such "handoffs" occur in hospitals every day, and devastating mistakes can happen during them. This one went off without a hitch, thanks to pit-stop techniques of the Ferrari race-car team.
"It was smooth. We didn't miss anything," said Dr. McEwan, a senior anesthesiologist at Great Ormond Street Hospital for Children. His role as leader of the handoff was partly modeled after Ferrari's "lollipop man," who uses a large paddle to direct drivers to the pit.
In one of the more unlikely collaborations of modern medicine, Britain's largest children's hospital has revamped its patient handoff techniques by copying the choreographed pit stops of Italy's Formula One Ferrari racing team. The hospital project has been in place for two years and has already helped reduce the number of mishaps.
The challenge of moving a patient to another unit, or to a new team during a shift change, is an old one. In 1995, one man in Florida had the wrong leg amputated after a flubbed handoff. "If you transfer a patient to the ICU after surgery and the ventilator isn't ready, you're really riding on the edge" of patient safety, says Allan Goldman, head of the pediatric intensive care unit at Great Ormond Street Hospital and a chief architect of the hospital's collaboration with Ferrari.
A 2005 study found that nearly 70 percent of preventable hospital mishaps occurred because of communication problems, and other studies have shown that at least half of such breakdowns occur during handoffs.
American hospitals are starting to improve the way they transfer patients. As in Britain, they are borrowing ideas from fields more skilled in the art of high-risk handoffs, including aviation, spaceflight and the military. Last week the Royal College of Surgeons of England and Dr. Goldman's hospital held an international conference on the subject. One of the speakers was a British submarine commander who spoke about lessons from the Kursk, the Russian submarine that sank in 2000.
Kaiser Permanente of California, a health system with 37 medical centers and 8.6 million members, has a handoff method based on a change-of-command system developed for nuclear submarines. At Trinity Medical Center in Rock Island, Ill., nurses and doctors actually "pass the baton": They place documents with key patient information inside a plastic baton and pass it on during a patient handoff.
A facility in St. Joseph's Health System in Orange, Calif., uses a method it calls "Ticket to Ride" -- a series of questions about the patient's medications, infections and other medical issues, that have to be asked of a person transferring the patient between departments. Blount Memorial Hospital in Maryville, Tenn., encourages its staff to "Just Go NUTS," an acronym for a four-step handoff routine it recommends (Name, Unique issues, Tubes, Safety).
Recent trends have increased the risk during handoffs. A nurse shortage means more hospitals are hiring temporary staff. Because of new rules, medical interns are also working fewer hours, which makes shift changes -- and therefore handoffs -- more frequent. At the same time, some surgeons work in larger teams and connect patients to an ever-growing tangle of wires and tubes.
Earlier this year, the Joint Commission on Accreditation of Healthcare Organizations began requiring U.S. hospitals to standardize their approach for handoff communications or risk losing their accreditations. Without accreditation, hospitals can find it harder to get reimbursed by Medicare and private insurers.
Founded in 1852, the Great Ormond Street Hospital was one of the first children's hospitals in the English-speaking world. In 1929, J.M. Barrie gave the hospital full copyright and royalties of his children's classic, Peter Pan.
The facility treats 100,000 children each year and is known for its expertise in infant heart surgery, a field where a lot can go wrong. Two decades ago, a lot did go wrong.
Between 1987 and 1993, surgeon Marc de Leval performed 104 "arterial switches" at Great Ormond Street Hospital. The operation corrects a congenital heart defect and is often done within the first two weeks of a newborn's life. At one stage, seven of Dr. de Leval's patients died in quick succession. Horrified, he decided to retrain at another institution before returning to Great Ormond Street Hospital. He didn't have such an alarming run of failures again.
Soon after, in 1994, Dr. de Leval published an unusually forthright paper about what had gone wrong. His key insight was that the infant deaths couldn't entirely be explained by the riskiness of the procedure or blatant failures such as a machine breaking down. Instead, he pointed to general "suboptimal performance" by himself and his team.
Dr. de Leval then persuaded 21 surgeons across Britain to allow "human-factor" specialists to observe their arterial-switch operations. The specialists use scientific techniques to study how people interact in a particular environment, including areas where technology is heavily used.
The study found, not surprisingly, that big mistakes can lead to bad outcomes. Its unexpected finding was about small mistakes: The study revealed that they often went unnoticed and unrectified. What's more, "if you added them up they correlated strongly" with bad outcomes, says Dr. de Leval.
The paper caused a stir when it appeared in the Journal of Thoracic and Cardiovascular Surgery, in 2000. At Great Ormond Street Hospital, it prompted doctors to take a harder look at how their teams were working together and transferring patients. "Our handovers were haphazard," says Dr. Goldman, the pediatric ICU chief.
Sometimes a patient, still in a precarious condition after an operation, was moved before the ventilator in the ICU had been properly set up. Or a key component of the blood-pressure monitor went missing and a nurse had to scramble to find it -- a loss of valuable minutes.
One Sunday in 2003, after a particularly tough day in the operating theater, Dr. Goldman and surgeon Martin Elliot slumped before a TV set and watched a Formula One race unfold. Both were racing fans, and they noticed striking similarities between patient handovers at their hospital and the interchange of tasks at a racing pit stop. But while a 20-member crew could switch a car's tires, adjust its front wing, clean the air vents and send the car roaring off in seven seconds, hospital handovers seemed downright clunky by comparison.
The duo invited members of McLaren, a British team that fields race cars in Formula One contests, to provide insights into pit-stop maneuvers. Armed with videos and slides, the racing team described how they used a human-factors expert to study the way their pit crews performed. They also explained how their system for recording errors stressed the small ones that might go unnoticed, not the big ones that everyone knew about.
That point struck a chord with Dr. de Leval. He immediately saw that pit-stop handovers were successful precisely because of an obsession with tiny mistakes, a conclusion similar to the one he had reached in his 2000 paper about arterial-switch operations.
Dr. de Leval then hired Ken Catchpole, a human-factors expert, to do a more detailed study of patient safety in the hospital's cardiac-surgery unit. The hospital also got in touch with Ferrari, which invited a team of doctors from the hospital to attend practice sessions at the British Grand Prix in order to get a closer look at pit stops. The Ferrari Formula One team is operated by the same company, Ferrari SpA, that makes sports cars for the general public.
There were skeptics. "I did think that the whole idea was a bit kooky," says Dr. McEwan, the anesthesiologist.
In early 2005, Dr. Elliot, Dr. Goldman and Mr. Catchpole traveled to Ferrari's headquarters in Maranello, Italy, and sat down with Nigel Stepney, the racing team's technical director. As a test car roared around a nearby track, the visitors played a video of a hospital handover and described the process in pictures.
The Ferrari man wasn't impressed. "In fact, he was amazed" at how clumsy and informal the hospital handover process appeared to be, recalls Mr. Catchpole, now a researcher at Oxford University.
In that meeting, Mr. Stepney described how each member of the Ferrari crew is required to do a specific job, in a specific sequence, and usually in silence. By contrast, he noted, the hospital handover was often chaotic. Several conversations between nurses and doctors went on at once. Meanwhile, different members of the team disconnected or reconnected equipment to a patient, but in no particular order.
In a Formula One race, the "lollipop man" with a paddle ushers the car in and signals the driver when it's safe to go. But in the hospital setting, it wasn't always clear who was in charge. Though the anesthesiologist had nominal responsibility to take the lead during a handover, sometimes the surgeon assumed that role -- or no one at all.
The crew at Ferrari trained for the worst contingencies. "If Michael Schumacher comes in five laps early because it's raining and he wants wet-weather tires, they're prepared," says Mr. Catchpole, referring to the Ferrari driver and seven-time world champion, who recently retired. The hospital team dealt with problems as they came up.
Back in London, Dr. Goldman and his colleagues began to incorporate Ferrari's lessons, along with advice from two jumbo-jet pilots, into the hospital handover process. They wrote up a seven-page protocol describing every step in the procedure. Between December 2003 and December 2005, they also did a careful study to see if those changes made any real difference to patient safety.
Dr. Goldman and his colleagues recently submitted a paper to a peer-reviewed journal that describes 50 patient handovers at Great Ormond Street Hospital over that two-year period. The study looked at 23 handovers before the Ferrari-inspired changes were put in place, and 27 after.
After the changes, the average number of technical errors per handover fell 42 percent and "information handover omissions" fell 49 percent. It also took slightly less time to execute each handover, though, unlike the Ferrari team, the doctors weren't trying to speed up their process. The study didn't attempt to measure whether the changes reduced deaths.
Not everything has gone smoothly. Mr. Catchpole says that some cardiac doctors at Great Ormond Street Hospital chose not to adopt the new handover process, arguing that there was nothing wrong with the old method.
At one point, Drs. Goldman and Elliot considered having their surgical team stand in prearranged places around the patient, just as Ferrari organizes technicians around a pit stop. "But I thought it was a step too far," says Dr. McEwan. The idea was dropped.
Nonetheless, cardiac-surgery handovers at the hospital are now systematic. One recent afternoon, three-year-old Faizaan Hussain lay sedated on an operating table, his chest open and his tiny heart pumping solidly. The six-hour operation to save his life was coming to a close.
Faizaan suffered from tetralogy of Fallot, a congenital condition that includes a hole in the heart and thickened heart muscle that reduces the normal flow of blood. Such infants are often blue. Each year in the U.S., about 3,000 babies are born with the condition. If untreated, about 25 percent of patients die within the first year of life and about 40 percent by age 10.
As a pair of surgeons closed the boy's chest, Dr. McEwan took the lead role in preparing for the handover, mimicking the job done by Ferrari's lollipop man. Dr. McEwan dispatched a member of the team to the ICU with a document describing the state of the patient and what equipment was needed at the ICU end -- a contingency-planning idea learned from the Italian racing team. The patient was then moved from the operating table to a mobile bed. Dr. McEwan and his colleagues systematically disconnected a mess of tubes and wires from a large refrigerator-size unit in the operating room and replugged them into smaller devices on the mobile bed.
"We call it the spaghetti effect," said Dr. McEwan, as he untangled a pair of tubes draining blood and fluid from the boy's chest. Other wires led to monitors measuring the boy's blood pressure, heart rate, oxygen saturation level, temperature and respiration. The process lasted several minutes; it was completed in near silence.
At the ICU, where a new group of doctors and nurses awaited the patient, the surgical team went through a three-step procedure to complete the handover. First, key instruments were replugged into the ICU's wall units. Dr. McEwan noticed that the boy's blood pressure had jumped, so he asked a nurse to increase the anesthetic.
Because of the efficient transfer, "we could pick that up immediately instead of 10 minutes later," said Dr. McEwan.
Next, the anesthesiologist went through a two-page handover checklist, including the patient's name, age, weight and medical history. "Before he came to us, he was very blue," he said. When a pair of doctors at the back of the room started up a conversation, Dr. McEwan shushed them.
The senior ICU doctor listened carefully, while an ICU nurse wrote down everything. Finally, a surgeon described the operation. Only 15 minutes had elapsed since Faizaan was wheeled in. Even so, the new ICU team now knew almost as much about the boy's medical condition as did the surgeons, who had been with him for six hours. The surgical team's work was done.
Faizaan made a quick recovery and, less than a week later, his parents took him home.