Consensus Recommendations for the Conduct, Training, Implementation, and Research of Perioperative Handoffs

A Quality Improvement Initiative to Reduce Adverse Effects of Transitions of Anesthesia Care on Postoperative Outcomes: A Retrospective Cohort Study

BACKGROUND

An intraoperative transfer of care from one anesthesia provider to another, or handover, may result in information loss and contribute to adverse patient outcomes. In 2019 the authors undertook a quality improvement effort to increase the use of a structured intraoperative handover tool incorporated in the electronic medical record. The authors hypothesized that intraoperative handovers of anesthesia care would be associated with adverse patient outcomes, and that increased use of a structured tool would attenuate this effect.

METHODS

This study included adult patients undergoing noncardiac surgery of at least 1 h duration performed during the period 2016 to 2021. Cases with a handover were identified if either there was a change of attending anesthesiologist or change of nurse anesthetist or resident for more than 35 min. The primary outcome was the occurrence of a composite of postoperative mortality and major postoperative morbidity. The effect of the intervention was analyzed by examining the quarterly change in odds ratio for the primary outcome for cases with and without a handover.

RESULTS

A total of 121,077 cases, 40.4% of which had a handover, were included. After weighting, the composite outcome was statistically associated with handovers (3,517 of 48,986 [7.2%] in handover cases vs. 4,470 of 72,091 [6.2%] in nonhandover cases; odds ratio, 1.08; 95% CI, 1.04 to 1.12). Time series analysis showed a marked increase in usage of the structured tool after the initial intervention. The odds ratio for the composite outcome showed a significant decrease over time after the initial intervention (t = -3.97; P < 0.001), with the slope of the odds ratio versus time curve decreasing from 0.002 (95% CI, 0.001 to 0.004; P = 0.018) to -0.011 (95% CI, -0.01 to -0.018; P < 0.001).

CONCLUSIONS

Intraoperative handovers are significantly associated with adverse outcomes even after controlling for multiple confounding variables. Use of a structured handover tool during anesthesia care may attenuate the adverse effect.

EDITOR’S PERSPECTIVE

A Qualitative Study of the Work Systems and Culture Around End-of-Day Intraoperative Anesthesia Handoffs in a Tertiary Care Center

BACKGROUND

Intraoperative handoffs have been implicated as a contributing factor in many perioperative adverse events. Despite conflicting data around their impact on perioperative outcomes, they remain a vulnerable point in the perioperative system with significant attention focused on improving them. This study aimed to understand the processes in place surrounding the point of information transfer in intraoperative handoffs.

METHODS

We used semistructured interviews with anesthesia clinicians to understand the processes and systems surrounding intraoperative handoffs. Interview data were coded deductively using the Systems Engineering Initiative for Patient Safety model as a framework, with subthemes developed inductively.

RESULTS

Clinicians do a significant amount of work before and after the point of information transfer to ensure a smooth handoff and safe patient care. Despite not having standardization of handoffs, most clinicians have a typical handoff organization and largely agree on content that should be included. However, there is variability based on clinician and patient characteristics, including clinician discipline and patient acuity. These handoffs are additionally impacted by the overall culture in the operating room, including the teamwork and hierarchies present among the surgical and anesthesia teams. Finally, the broader operating room logistics, including scheduling practices for surgical cases and anesthesia teams, impact the quality of intraoperative handoffs and the ability of clinicians to prepare for these handoffs.

CONCLUSIONS

Handoffs involve processes beyond the point of information transfer and are embedded in the systems and culture of the operating rooms. These considerations are important when seeking to improve the quality of intraoperative handoffs.

Handoffs and the challenges to implementing teamwork training in the perioperative environment

Perioperative handoffs are high-risk events for miscommunications and poor care coordination, which cause patient harm. Extensive research and several interventions have sought to overcome the challenges to perioperative handoff quality and safety, but few efforts have focused on teamwork training. Evidence shows that team training decreases surgical morbidity and mortality, and there remains a significant opportunity to implement teamwork training in the perioperative environment. Current perioperative handoff interventions face significant difficulty with adherence which raises concerns about the sustainability of their impact. In this perspective article, we explain why teamwork is critical to safe and reliable perioperative handoffs and discuss implementation challenges to the five core components of teamwork training programs in the perioperative environment. We outline evidence-based best practices imperative for training success and acknowledge the obstacles to implementing those best practices. Explicitly identifying and discussing these obstacles is critical to designing and implementing teamwork training programs fit for the perioperative environment. Teamwork training will equip providers with the foundational teamwork competencies needed to effectively participate in handoffs and utilize handoff interventions. This will improve team effectiveness, adherence to current perioperative handoff interventions, and ultimately, patient safety.

An evidence synthesis on perioperative Handoffs: A call for balanced sociotechnical solutions

SIGNIFICANCE

Perioperative handoffs interconnect the preoperative, intraoperative, and postoperative phases underlying surgical care to maintain care continuity -yet are prone to coordination and communication failures.

OBJECTIVE

To synthesize evidence on factors affecting the safety and quality of perioperative handoff conduct and process.

MATERIALS AND METHODS

A search of PubMed, EMBASE, and CINAHL was conducted to include observational, descriptive studies of preoperative, intraoperative, and postoperative handoffs published in English language, peer-reviewed journals. Data analysis was informed by the Systems Engineering Initiative for Patient Safety (SEIPS) framework describing the relationship between the work-system, work processes, and outcomes. Study quality was assessed using the Quality Scoring System.

RESULTS

Twenty-three studies were included. Eighteen studies focused on postoperative handoffs, with one on preoperative, three on intraoperative and only one that looked at preoperative/postoperative handoffs combined. The SEIPS framework elucidated the complex inter-related factors (enablers and barriers) related to perioperative handoff safety. While some studies found that the use of standardized handoff tools and protocols and interdisciplinary teamwork were frequently-reported enablers, other studies identified the lack of structured handoff tools and protocols, poor teamwork and communication, and improper use of documentation tools were top-cited barriers affecting handoff quality. Suggestions to ensure handoff safety and quality included implementing structured handoff checklists and protocols and building interprofessional teamwork competencies for effective communication.

DISCUSSION AND CONCLUSION

Our review highlights an urgency to develop more holistic sociotechnical solutions that can create and sustain a balance between technical innovations in tools and technologies and the non-technical interventions/training needed to improve interpersonal relations and teamwork competencies - taken together, can improve the quality and safety of perioperative handoff practice.

Holistic strategy for promoting effective handoffs

Background

Handoffs are ubiquitous in modern healthcare practice, and they can be a point of resilience and care continuity. However, they are prone to a variety of issues. Handoffs are linked to 80% of serious medical errors and are implicated in one of three malpractice suits. Furthermore, poorly performed handoffs can lead to information loss, duplication of efforts, diagnosis changes and increased mortality.

Methods

This article proposes a holistic approach for healthcare organisations to achieve effective handoffs within their units and departments.

Results

We examine the organisational considerations (ie, the facets controlled by higher-level leadership) and local drivers (ie, the aspects controlled by the individuals working in the units and providing patient care).

Conclusion

We propose advice for leaders to best enact the processes and cultural change necessary to see positive outcomes associated with handoffs and care transitions within their units and hospitals.

Learning outcomes of structured perioperative teaching based on adult learning

BACKGROUND

Self-directed learning is the cornerstone of adult learning. The aim of the study was to investigate the improvement of core competency and increase interest to be a surgeon among medical students after a perioperative training through a structured learning with written record model. The mediating role of adult learning pattern on core competency was also examined.

METHODS

A 2-week training protocol was based on a structural learning model which included a structured written record by the learner for postoperative immediate feedback. An adult learning questionnaire (ALQ) was developed to assess learners' adult learning pattern and a clinical core competency questionnaire (CCCQ) was developed to assess learning outcomes. A two-way repeated measured of ANCOVA would be used to analyze the interaction effect of adult learning pattern and learning effect on learning outcomes.

RESULTS

From Jan 2017 to Dec 2019, 412 medical students were enrolled in the study. The increase scores of CCCQ and a significant numbers of increase interest to be a surgeon were shown after the perioperative training. Two-way repeated measure ANOVA revealed that there were significant differences in change between pre- and post-CCCQ across four levels of ALQ (interaction effect F = 13.0, p <0.001). The more adult learning patterns medical students own, the more they will benefit from the training.

CONCLUSIONS

The structural learning with written record model provides an effective perioperative training represented with clinical core competency and increase the interest to be a surgeon in the future. Medical students with tendency of adult learning pattern would learn better.

The PATH to patient safety

Communication is critical to safe patient care. In this issue of the British Journal of Anaesthesia, Jaulin and colleagues show that use of a Post-Anaesthesia Team Handover (PATH) checklist is associated with fewer hypoxaemia events in the PACU, reduced handover interruptions, and other important metrics related to improved communication. The PATH checklist provides a link within a broader chain of safety checklists and other interventions that comprise a perioperative chain of survival.

A Collaborative Partnership between the Multicenter Handoff Collaborative and an Electronic Health Record Vendor

OBJECTIVES

 The operating room is a specialized, complex environment with many factors that can impede effective communication during transitions of care between anesthesia clinicians. We postulated that an efficient, accessible, standardized tool for intraoperative handoffs built into standard workflow would improve communication and handoff safety. Most institutions now use an electronic health record (EHR) system for patient care and have independently designed intraoperative handoff tools, but these home-grown tools are not scalable to other organizations and lack vendor-supported features. The goal of this project was to create a standardized, intraoperative handoff tool supported by EHR functionality.

METHODS

 The Multicenter Handoff Collaborative, with support from the Anesthesia Patient Safety Foundation, created a working group of frontline anesthesia experts to collaborate with a development team from the EHR vendor (Epic Systems) to design a standardized intraoperative handoff tool. Over 2 years, the working group identified the critical elements for the tool and software usability, and the EHR team designed a standardized intraoperative handoff tool that is accessible to any institution using this EHR.

RESULTS

 The first iteration of the intraoperative handoff tool was released in August 2019, with a second version in February 2020. The tool is standardized but customizable by individual institutions.

CONCLUSION

 We demonstrate that work on complex health care processes critical to patient safety, such as handoffs, can be performed on a national scale through cross-industry collaboration. Frontline experts can partner with health care industry vendors to design, build, and release a product on an accelerated timeline.

Exploring postoperative handover quality in relation to patient condition: A mixed methods study

AIMS AND OBJECTIVES

To describe postoperative handover reporting and tasks in relation to patient condition and situational circumstances, in order to identify facilitators for best practices.

BACKGROUND

High-quality handovers in postoperative settings are important for patient safety and continuity of care. There is a need to explore handover quality in relation to patient condition and other affecting factors.

DESIGN

Observational mixed methods convergent design.

METHODS

Postoperative patient handovers were observed collecting quantitative (n = 109) and qualitative data (n = 48). Quantitative data were collected using the postoperative handover assessment tool (PoHAT), and a scoring system assessing patient condition. Qualitative data were collected using free-text field notes and an observational guide. The study adheres to the GRAMMS guideline for reporting mixed methods research.

RESULTS

Information omissions in the handovers observed ranged from 1-13 (median 7). Handovers of vitally stable and comfortable patients were associated with more information omissions in the report. A total of 50 handovers (46%) were subjected to interruptions, and checklist compliance was low (13%, n = 14). Thematic analysis of the qualitative data identified three themes: "adaptation of handover," "strategies for information transfer" and "contextual and individual factors." Factors facilitating best practices were related to adaptation of the handover to patient condition and situational circumstances, structured verbal reporting, providing patient assessments and dialogue within the handover team.

CONCLUSIONS

The variations in items reported and tasks performed during the handovers observed were related to patient conditions, situational circumstances and low checklist compliance. Adaptation of the handover to patient condition and situation, structured reporting, dialogue within the team and patient assessments contributed to quality.

RELEVANCE TO CLINICAL PRACTICE

It is important to acknowledge that handover quality is related to more than transfer of information. The present study has described how factors related to the patient and situation affect handover quality.