Author: Michael Vlessides
Intraoperative handovers between anesthesia providers are associated with adverse postoperative outcomes, and these effects are worsened when handovers occur among less experienced practitioners or during longer surgeries.
“A recently published study concluded that handovers are associated with adverse outcomes,” said Paul Rostin, cand.med., a medical student now at Christian-Albrechts University in Kiel, Germany (JAMA 2018;319:143-153). “When analyzing the data, however, we found a few issues, such as a relatively low overall rate of handovers and also an exclusion of procedures with a duration under two hours.
“Therefore, we wanted to verify their findings while addressing these issues,” he continued. “Additionally, since handovers play such a big role in anesthesia care, we also sought to identify variables that might strengthen this association and point to specific situations where handovers might be dangerous.”
The investigators also conducted a multivariable logistic regression analysis that adjusted for a wide variety of comorbidities and intraoperative risk factors; sensitivity analyses were performed, including one in a propensity-matched cohort. “Unique to our study was that we also had a variety of relative intraoperative confounders, which we had found to have an effect on patient outcomes after surgery as well,” Rostin said.
“We defined experience as case volume, which correlates well with the provider’s years of experience,” Rostin explained.
Long-Duration Surgeries Also a Risk
Reporting at the 2018 annual meeting of the American Society of Anesthesiologists (abstract A1012), the investigators revealed that 11.4% of patients (n=13,055) developed adverse postoperative events as defined by the study’s composite primary outcome. Intraoperative handovers were found to be significantly associated with an increased risk for all postoperative adverse events (odds ratio [OR], 1.11; 95% CI, 1.05-1.18; P=0.001); 30-day readmission (OR, 1.13; 95% CI, 1.05-1.22; P=0.001); and major complications (OR, 1.1; 95% CI, 1.01-1.2; P=0.022).
“So, we were able to confirm the finding of [the JAMA study], showing that handovers are indeed associated with adverse patient outcomes in an adjusted model,” Rostin said. A propensity-matched cohort of 21,742 patients confirmed these results (OR, 1.09; 95% CI, 1.01-1.18; P=0.029).
The analysis also found that surgeries of longer duration (>150 minutes) significantly augmented the effect of handovers on adverse-event occurrence (OR, 1.19; 95% CI, 1.02-1.38; P=0.029 for interaction). In contrast, high provider case volumes (defined as the number of provider anesthesia cases during the study period over 1,106) mitigated the effect of handovers on patient outcome (OR, 0.87; 95% CI, 0.77- 0.98; P=0.02 for interaction).
“We found a modifying effect for experience,” Rostin said. “In the group of experienced providers, there was no adverse effect of handovers. In the group of [less experienced] providers, however, we found a significantly increased effect with each additional handover.”
The investigators also found substantial variability between providers with respect to the incidence of handovers, ranging from 3.2% to 14.4% after adjustment for patient and procedure factors.
“We found that handovers matter across all professions,” he said. “We looked into handovers among CRNAs and residents, and found very similar associations. We also found that handovers are a bidirectional issue: There are two people involved, and the experience level of both people matters.”
“Do you use a formalized handover process in your institution, something that is consistent from one provider to the other? Or is it just random?” asked session co-moderator Maxime Cannesson, MD, PhD, a professor of clinical anesthesia and vice chair for perioperative medicine at the University of California, Los Angeles.
“About three years ago, we started a standardized protocol for handovers,” said senior author Matthias Eikermann, MD, PhD, the vice chair of faculty affairs in the Department of Anesthesia, Critical Care and Pain Medicine at Beth Israel Deaconess Medical Center, in Boston. “And when we looked into the effect of the standardized protocol on handovers, we couldn’t find one. It may have been a sample size issue, though.”
“Do you have any idea what might be the solution to the problem?” Dr. Cannesson asked. “I see these data and I am concerned. I’d like to see us do more than emphasize the issue, but rather to act on it.”
“I imagine an action plan could be implemented where we invest some resources to help with handovers,” Dr. Eikermann said. “For example, if you have complex surgery and a junior provider handing over to another junior provider, perhaps that triggers a mentor who helps them get the right information during the handover.”
Forging a Better Handover
One such solution may have been offered by investigators at Johns Hopkins Hospital in Baltimore (abstract A1017), who used an automatically generated handover tool from the electronic health record (EHR) to facilitate simulated handovers. As part of the trial, they created a simulated case of a patient with a complex medical history undergoing major spine surgery, with the EHR tool generating a written handover.
A group of anesthesia residents were randomly selected to receive details of the case one day prior to the simulation and to memorize the information in much the same way as they had been caring for the patient in the operating room all day. Half the participants had access to the EHR-generated tool while the other half did not.
On the day of the simulation, each resident answered multiple-choice questions on unrelated anesthesia topics for five minutes. They then handed the patient to a subsequent resident to simulate a complete transition of care. The provider receiving the handover could ask as many questions as necessary. Each handover was observed by a proctor.
After the handover, the first resident in the chain was given 25 retention questions regarding the case, while the second resident answered the multiple-choice questions; the process was repeated until the final resident handed off to the proctor, who answered the retention questions on details about the case with the received information. All conditions for the handover were similar between groups, with the exception of the handover tool. The control group was not permitted to use notes or external cognitive aids; all handovers were done from memory. Answers to retention questions were graded on a scale of 0 (incorrect), 1 (partial credit) or 2 (correct), for a maximum possible score of 50.
The study found there was a loss of information with each subsequent handover in the chain. Most importantly, use of the EHR-generated tool resulted in a 7.04-point advantage over controls at each handover stage (P<0.001). The researchers concluded that although there was substantial degradation of information with consecutive handovers, the EHR-derived tool offered an advantage over those occurring from memory alone.
“We believe,” Rostin said, “that hospitals should establish local guidelines taking into account the various risk factors to ensure that anesthesia handovers do not expose patients to potential harm.”