Staff breaks are associated with improved surgical outcomes, a study has concluded. However, the study failed to find an association between handoffs and outcomes.
Elucidating the relationship between transitions of care and outcomes is critical for determining best practices for safe patient care. “We read with great interest the Cleveland Clinic study, which demonstrated that intraoperative handoffs could be a place where care may be improved,” said Jonathan P. Wanderer, MD, assistant professor of anesthesiology at Vanderbilt University Medical Center, in Nashville, Tenn. “They found, at least at their institution, that handoffs were associated with increasing complication rates. So, we wanted to see if we could replicate their findings here at Vanderbilt.
“In addition, they had not looked at breaks. So we thought—just because of the way our data were structured—that it would be interesting to examine breaks as distinct from handoffs. And to be honest, we weren’t expecting to find a strong effect for either one.”
To help shed light on these relationships, Dr. Wanderer and his colleagues probed the institution’s database to identify adult patients admitted after noncardiac surgery between 2005 and 2014; the number of anesthesia handovers and breaks was determined for each case. A variety of data were extracted including age, sex, race, American Society of Anesthesiologists (ASA) physical status, surgery start time, duration of surgery, principal diagnosis and procedure codes. Assessed outcomes included in-hospital mortality, as well as serious cardiac, respiratory, gastrointestinal, urinary, bleeding and infectious complications.
Using definitions of adverse events as defined by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the investigators also analyzed death within 30 days of surgery and/or major complications, including acute renal failure, bleeding requiring transfusion of at least four units of packed red blood cells, cardiac arrest, coma, myocardial infarction, unplanned intubation, prolonged ventilation, pneumonia, stroke, wound disruption, surgical-site infection, sepsis and systemic inflammatory response syndrome.
As reported at the 2015 annual meeting of the ASA (abstract A1007), 183,517 anesthetics were identified for the primary analysis. Factors associated with increased risk for postoperative adverse outcomes included ASA physical status (odds ratio [OR], 1.941; 95% CI, 1.894-1.990), severity of diagnosis (OR, 1.381; 95% CI, 1.372-1.389), severity of procedure (OR, 1.133; 95% CI, 1.125-1.141), age (OR, 1.075; 95% CI, 1.064-1.087) and sex (OR, 1.120, male vs. female; 95% CI, 1.083-1.159).
Why Are Breaks Helpful?
On the other hand, a one-unit increase in the number of anesthesia handovers (OR, 1.008) was not found to be predictive of increased risk for postoperative mortality and serious complications when controlled for potential confounding variables (P=0.60). Meanwhile, staff breaks were associated with a 12.6% reduction in risk for the composite outcome (OR, 0.874; P<0.0001). A total of 9,361 anesthetics were identified for the ACS NSQIP analysis, which demonstrated ORs of 0.991 for handovers and 0.739 for breaks.
“We did a little pontificating on why breaks could be helpful,” Dr. Wanderer told Anesthesiology News. “We assume that well-rested individuals could be expected to perform better, or perhaps the break gives clinicians an opportunity to reassess what they were doing and how things were going when they left.
“Another potential explanatory effect—which is, to be fair, complete speculation—is the impact of the people covering the break,” he added. “Some of our more experienced anesthesia providers typically provide the bulk of the breaks. As part of that, they’re reviewing details on the patient, the procedure, the airway and access. So perhaps that experienced third party might, in the aggregate, find some things that are important for patient outcomes.” An analysis of the certified registered nurse anesthetists covering breaks found that they averaged seven years’ experience.
Although the association between breaks and outcomes proved surprising to the investigators, they have not changed their clinical practice patterns as a result. “We always want to be sure that the information we’re looking at is correct, thus the importance of validation studies,” he explained. “Plus, from a staffing feasibility standpoint, we really don’t have the opportunity to increase the frequency of breaks.”
That didn’t stop Dr. Wanderer from reminding other institutions about the importance of regular staff breaks. “I think it’s absolutely the right message to make sure anesthesia providers are getting breaks … because it’s important,” he added.
Ashish C. Sinha, MD, PhD, DABA, MBA, vice chair (research) of anesthesiology and perioperative medicine at Drexel University College of Medicine, in Philadelphia, found the study interesting, and was encouraged by the large number of patients included. “I believe the ‘fresh look’ that colleagues provide when they come to the OR [operating room] helps create an atmosphere for catching inadvertent mistakes,” Dr. Sinha said.
“Breaks are what keep our perspective fresh,” he added. “In the world of anesthesia, problems can happen in the ‘cruise control’ part of the case, which can be predictably boring, and the level of vigilance may drop off just a bit. Not surprisingly, many anesthesia errors and negative outcomes occur during the middle of the case, not the beginning or end, as some might believe.”