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Handoff improvement and adverse event reduction programme implementation in paediatric intensive care units in Argentina: a stepped-wedge trial
  1. Facundo Jorro-Barón1,2,
  2. Inés Suarez-Anzorena1,
  3. Rodrigo Burgos-Pratx3,
  4. Noelia De Maio4,
  5. Matías Penazzi5,
  6. Ana Paula Rodriguez2,
  7. Gisela Rodriguez6,
  8. Daniel Velardez4,
  9. Luz Gibbons7,
  10. Silvina Ábalos3,
  11. Silvina Lardone5,
  12. Rosario Gallagher4,
  13. Joaquín Olivieri6,
  14. Rocío Rodriguez7,
  15. Juan Carlos Vassallo8,
  16. Luis Martín Landry4,
  17. Ezequiel García-Elorrio1
  1. 1Quality of Care, Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
  2. 2PICU, Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
  3. 3PICU, Hospital Materno Infantil ‘Héctor Quintana’, San Salvador de Jujuy, Jujuy, Argentina
  4. 4PICU, Hospital de Pediatría Prof Dr Juan P Garrahan, Buenos Aires, Argentina
  5. 5PICU, Hospital de Niños de San Justo, San Justo, Provincia de Buenos Aires, Argentina
  6. 6PICU, El Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
  7. 7Statistics, Data Management and Information Systems, Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
  8. 8Teaching and Research, Hospital de Pediatría Prof Dr Juan P Garrahan, Buenos Aires, Argentina
  1. Correspondence to Dr Facundo Jorro-Barón, Quality of Care, Instituto de Efectividad Clinica y Sanitaria, Buenos Aires C1414CPV, Argentina; fjorro{at}


Background There are only a few studies on handoff quality and adverse events (AEs) rigorously evaluating handoff improvement programmes’ effectiveness. None of them have been conducted in low and middle-income countries. We aimed to evaluate the effect of a handoff programme implementation in reducing AE frequency in paediatric intensive care units (PICUs).

Methods Facility-based, cluster-randomised, stepped-wedge trial in six Argentine PICUs in five hospitals, with >20 admissions per month. The study was conducted from July 2018 to May 2019, and all units at least were involved for 3 months in the control period and 4 months in the intervention period. The intervention comprised a Spanish version of the I-PASS handoff bundle consisting of a written and verbal handoff using mnemonics, an introductory workshop with teamwork training, an advertising campaign, simulation exercises, observation and standardised feedback of handoffs. Medical records (MR) were reviewed using trigger tool methodology to identify AEs (primary outcome). Handoff compliance and duration were evaluated by direct observation.

Results We reviewed 1465 MRs: 767 in the control period and 698 in the intervention period. We did not observe differences in the rates of preventable AE per 1000 days of hospitalisation (control 60.4 (37.5–97.4) vs intervention 60.4 (33.2–109.9), p=0.99, risk ratio: 1.0 (0.74–1.34)), and no changes in the categories or AE types. We evaluated 841 handoffs: 396 in the control period and 445 in the intervention period. Compliance with all items in the verbal and written handoffs was significantly higher in the intervention group. We observed no difference in the handoff time in both periods (control 35.7 min (29.6–41.8) vs intervention 34.7 min (26.5–42.1); difference 1.43 min (95% CI −2.63 to 5.49, p=0.49)). The providers’ perception of improved communication did not change.

Conclusions After the implementation of the I-PASS bundle, compliance with handoff items improved. Nevertheless, no differences were observed in the AEs’ frequency or the perception of enhanced communication.

Trial registration number NCT03924570

  • quality improvement
  • hand-off
  • adverse events
  • epidemiology and detection
  • critical care
  • paediatrics

Data availability statement

Data are available in a public, open-access repository:

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  • Contributors FJB, EGE, LML and JCV conceived the original idea and study design. FJB and EGE contributed to the design and implementation of the research. RBP, NDM, MP, RG, APR, DV, SA, LG, SL, JO and GR contributed to the implementation of the research. FJB, EGE, ISA, LG and RR contributed to the analysis and interpretation of the results and to the writing of the manuscript. All authors discussed the results and commented on the manuscript.

  • Funding Salud Investiga ‘Dr Abraam Sonis’ grant, category Multicentric Study, funded by the National Ministry of Health, through the Directorate of Research for Health, Argentine.

  • Disclaimer The funders of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report.

  • Competing interests FJB, LML, MP, GR, NDM, RBP and ISA report grants from the Ministry of Health of the Nation, through the Directorate of Research for Health, Argentine, during the conduct of the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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