Handoffs: The latest buzzword in patient safety

They’re part of the game in football and relay races—but are handoffs safe for anesthetized patients?

As resident work hours decreased over the last few years, everyone hoped that hospitals would become safer. That hasn’t happened. No decreases in medical errors or improvements in safety have been demonstrated since residents quit working 36-hour stretches.

Many people think that more frequent handoffs—or handovers, as they’re called in Canada and Europe—may be a big part of the problem. As patient care is transferred between doctors at the end of each shift, vital information must be communicated. In a New York Times Magazine article about resident work hours published on August 7, Dr. Darshak Sanghavi warned that this process often turns into “a real-life game of telephone, where a message is passed from doctor to doctor—and frequently garbled in the process.”

Surely we in anesthesiology do better. Some anesthesiology practices hand off patients more often than others—academic and HMO groups often work according to a schedule with planned relief at the end of the day; private practice anesthesiologists tend to finish their own cases. But there has been little suspicion that handoffs of anesthetized patients were hazardous to their health.

We’ve always believed that care is transferred in the operating room under controlled conditions with ample time to communicate information.  An abstract presented at the 2011 meeting of the Society for Cardiovascular Anesthesiologists challenged this assumption with some startling data about the safety of handoffs. Dr. Christopher Hudson and his colleagues at the University of Ottawa Heart Institute collected data on over 14,000 patients who underwent cardiac surgery between 1999 and 2009. Anesthetic handover was defined as “transfer of responsibility of a patient from one attending anesthesiologist to another at any point during the surgery.” In-hospital mortality was significantly higher among the patients in the handover group (7.6% vs. 3.3%), and major morbidity endpoints such as MI, stroke, prolonged ventilation, and acute kidney injury were also higher (22% vs. 12%).

This isn’t the first study to suggest that handoff during anesthesia is a risk factor. In a case-control study with a cohort of over 800,000 patients, Dr. M. Sesmu Arbous reported in the February 2005 issue of Anesthesiology that when the same attending anesthesiologist stayed with a patient throughout the case with no handoff, there was a decreased risk of severe morbidity and mortality. This finding was not affected by the way information was exchanged during handoff—whether not at all, by telephone, or in the operating room.

So where does this leave us in the practice of anesthesiology?  Some physicians hope that a better handoff protocol is the answer.  Dr. Michelle Petrovic and her colleagues at Johns Hopkins have implemented a pilot protocol for handoffs between the operating room and postoperative care.  All key members of the team must be present during the handoff, including the surgeon and the anesthesiologist. Their report is guided by an information checklist and formal agreement among all present when the handoff is complete.  With this protocol, the incidence of missed information in the surgery report decreased from 26% to 16%, but missed information in the anesthesia report remained essentially the same, about 18%.

Does a better handoff really help, or are there subtle things about the patient under anesthesia that no report will adequately convey?  Not long ago, I relieved a colleague for the last portion of a long case.  The report I received was thorough and the patient woke up without incident.  However, when the PACU nurse called me later to say that the patient’s affect appeared odd, and asking about his baseline mental status, I was at a loss to reply.  I hadn’t seen him when he was awake, so I couldn’t answer the question.

Could it be that you just can’t know a patient under anesthesia well if you haven’t seen him prior to surgery?  We all know there are subtle findings that don’t get communicated well even in the best H & P.  A patient can have a problem list with multiple entries and still appear basically healthy.  In contrast, a patient with few known risk factors can appear frail or just unwell to an experienced physician.  Even the best checklist can fail to communicate those warning signs.

Are patient handoffs during anesthesia safe?  Does a change of anesthesiologist uncover potential problems or lead to danger?  Is a tired anesthesiologist who knows the patient safer than a fresh one who doesn’t? Would a better handoff with a checklist solve the problem?  Clearly, the jury is still out on this question.

This article first appeared on CSA Online First, August 22, 2011

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