We appreciate the interest expressed in the letter by Kulhari et al.  for our recent article on structured handoffs among anesthesia providers. The authors raise two salient points regarding the investigation. First, they point out the importance of education in handoff improvement initiatives and asked for further details regarding our intervention. As noted in the “Intervention” section of the Materials and Methods, we introduced the initiative to the faculty in a meeting, which included education regarding the evidence that handoffs of care were associated with adverse outcomes in our own data, as well as in the literature, that our use of a structured tool lagged those of comparison institutions in the Multicenter Perioperative Outcomes Group data, and that use of such a tool was correlated with better transfer of information between professionals. While participation was not mandated, monthly updates on use of the tool were a regular part of faculty meetings. Similar, though less frequent reminders were given in resident and certified registered nurse anesthetist meetings. E-mail messages were sent to all department clinicians encouraging use approximately 6 months into the project. Additionally, we believe there was a solid foundation of undertaking annual quality improvement initiatives and of culture of safety in the department, though we did not conduct any qualitative research to verify whether this impacted the rapid uptake of the tool in practice.

Second, the authors asked for details of the development of the tool itself, which was already incorporated into the Epic electronic health record system used in all anesthetizing locations. The process was an iterative consensus-building exercise among a group of anesthesiologists forming the Multicenter Handoff Collaborative, with support from the Anesthesia Patient Safety Foundation and Epic Systems.3  The method, which resembled a modified Delphi procedure, attempted to balance flexibility, workflow convenience, and ease of programming and implementation, and has been described in detail.3  While we, as well as the original authors of the tool, agree that it may not have been fully optimized, we feel that our provocatively positive results in patient outcomes justify further encouragement of use of such tools in anesthesia practice.