Complete Handoffs by Anesthesiologists Tied to Poor Outcomes

Nicola M. Parry, DVM

January 10, 2018

Intraoperative transitions of anesthesia care are associated with worse postoperative patient outcomes, according to a new study published online January 9 in JAMA.

"[C]omplete intraoperative handover of anesthesia care compared with no handover was significantly associated with a higher risk of a composite of all-cause death, hospital readmission, or major postoperative complications over 30 days," write Philip M. Jones, MD, from the University Hospital-London Health Sciences Centre, Ontario, Canada, and colleagues.

"On average, for every 15 patients exposed to a complete anesthesia handover, 1 additional patient would be expected to experience the primary outcome."

According to the authors, handover of anesthesia care among anesthesiologists is a point of vulnerability during which inaccurate transfer of valuable patient information can negatively affect patient care.

To evaluate the association, Dr Jones and colleagues conducted a retrospective cohort study of 313,066 adults who underwent major surgery in Ontario hospitals between April 1, 2009, and March 31, 2015. They included patients undergoing neurosurgical, cardiac, vascular, thoracic, abdominal, pelvic, and urologic operations.

Of the 313,066 patients included in the study, 5941 (1.9%) underwent surgery with complete intraoperative handover of anesthesia care.

The researchers found that the primary outcome, a composite of all-cause death, hospital readmission, or major postoperative complications over the course of 30 days, occurred in 2583 (43.5%) patients in the complete-handover group compared with 90,306 (29.4%) of those in the no-handover group (risk difference [RD], 14.1%; 95% confidence interval [CI], 12.8% - 15.3%; P < .001).

Complete handover of anesthesia care was also linked to worse outcomes for each individual component of the primary outcome: all-cause death (5.3% vs 2.7%; P < .001), readmission to hospital (9.2% vs 6.9%; P < .001), and major postoperative complications within 30 days of surgery (36.1% vs 23.6%; P < .001).

After adjustment for patient-related factors (eg, age, comorbidities, duration of surgery) and anesthesiologist-related factors (eg, years since medical school graduation for the primary anesthesiologist), the researchers found that complete handovers were significantly associated with a greater risk for the primary outcome (adjusted RD [aRD], 6.8%; 95% CI, 4.5% - 9.1%; P < .001), as well as with all-cause death (aRD, 1.2%; 95% CI, 0.5% - 2%; P = .002) and major complications (aRD, 5.8%; 95% CI, 3.6% - 7.9%; P < .001). However, no significant association was seen with hospital readmission (aRD, 1.2%; 95% CI, −0.3% to 2.7%; P = .11).

Patients in the handover group also had longer mean hospital stays (13.2 vs 8.4 days; P < .001) and more intensive care unit admissions (39.8% vs 30.2%; P < .001).

Dr Jones and colleagues say their findings may support minimizing complete intraoperative anesthesia handovers, but acknowledge limitations of this study. For example, the study controlled for the primary anesthesiologist's career experience, but not for that of the replacement anesthesiologist or the surgeon.

Similarly, the study did not evaluate factors such as clinician fatigue or the content or methods of the anesthesia handovers.

"Although it is logical to assume that the complete handover was causally related, it is not possible to identify the specific factors or aspects of the handover that contributed to poorer outcomes," write James P. Bagian, MD, PE, from the University of Michigan, Ann Arbor, and Douglas E. Paull, MD, from the Department of Veterans Affairs National Center for Patient Safety, Ann Arbor, Michigan, in an accompanying editorial.

They stress that simply minimizing handovers may not address the likely underlying causes of the poor patient outcomes: poor communication among anesthesiologists and inadequate access to valuable clinical information.

Anesthesia handovers in this study probably took place in the traditional ad hoc and unstructured manner that did not provide communication of critical patient information, they add.

"Significant advancement in patient safety and transitions in health care will require acceptance of standardized methodologies, tools, and techniques that improve communication and adoption of newer technologies that augment human capabilities," write Dr Bagian and Dr Pauli.

"Patients deserve nothing less," they conclude.

This study was supported by the Department of Anesthesia and Perioperative Medicine at the University of Western Ontario. One author has reported receiving funding from the Canadian Institutes of Health Research and the Department of Anesthesia at the University of Toronto. The other authors and editorialists have reported no financial conflicts of interest.

JAMA. Published online January 9, 2018. Article abstract, Editorial extract

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