Smooth Transitions: Expert Committee Reveals How to Improve the Perioperative Handoff Process

Jordan Francke, MD MPH

Approximately 80% of serious medical errors involve miscommunication during handoffs between medical providers for reasons including delayed and missed diagnoses, miscommunication between trainees of various levels, and omission of clinically important information, according to the Joint Commission Center for Transforming Healthcare. On Saturday, May 18, at the 2024 Annual Meeting, presented by IARS and SOCCA, experts within the Multi-Center Handoff Collaborative (MHC) provided evidence on ways to streamline the process and improve its efficacy of transfer of critical information during the cosponsored by Society of Critical Care Anesthesiologists session, “Perioperative Handoffs: How Can We Make Them Better?”

Kunal Karamchandani, MD, associate professor of anesthesiology and pain management, UT Southwestern Medical Center, moderated the session.

First speaker Aalok V. Agarwala, MD, MBA, clinical professor of anesthesiology, associate chief medical officer and vice president of quality and safety at Massachusetts General Hospital, and chair of the MHC, began by reminding the audience that every patient interaction in anesthesiology involves a handoff. Even if a provider manages an anesthetic from the start to finish of a case, they ultimately will transport the patient to a recovery area where a new team will assume care. Some cases will also involve intraoperative handoffs, and these handoffs vary not just based on who is transferring the information (e.g., ICU nurse to anesthesia attending, anesthesia resident to PACU nurse). The level of complication depends on the type of patient (e.g., ambulatory) and what physical lines and monitors a patient has (e.g., VA-ECMO, endotracheal tubes, external ventricular drains). The operating room also represents a transfer of patients who are particularly vulnerable: the unconscious, anesthetized patient cannot participate in the transfer of information, and thus fully relies on the exchange being accurate and comprehensive.

Dr. Agarwala discussed how the intraoperative handoff has countless challenges that might not be present in other environments, including background music and conversations, audible vitals and alarms, and asymmetry of roles (e.g., a resident signing out to an attending, or vice versa). This might explain why in a review of 927 colorectal surgery patients, 30-day postoperative complications or deaths increased as the number of attending anesthesiologists covering a case increased (https://pubmed.ncbi.nlm.nih.gov/25794111/). Dr. Agarwala argued that while handoffs in anesthesia are necessary, their safety can be improved through the handoff provider preparing to transfer the most critical clinical information, the receiving provider reading about the patient prior to the handoff whenever possible, for the handoff to be done in-person with closed-loop communication if feasible, and for the use of cognitive aids and checklists.

Building upon Dr. Agarwala’s insights, Andrea Vannucci, MD, clinical professor and vice-chair for quality and safety at the University of Iowa, discussed the intraoperative handoff tool within the Epic electronic health record (EHR), which is utilized by roughly 50% of American hospitals. The MHC has worked closely with the Epic team to streamline the process. For example, once you click “handoff” in the intraoperative record, a sidebar appears showing information MHC has identified as being the most critical data to exchange between providers. The tool then automatically moves to update the staffing of the anesthesia provider within the case. Dr. Vannucci argued that by incorporating this into the EHR, it also allows residents to be able to quantify how many intraoperative handoffs have been performed during residency, a competency expected by the accrediting body for American residency programs, the Accreditation Council for Graduate Medical Education (AGCME).

Christopher Potestio, MD, assistant professor of anesthesiology and critical care at Cooper Medical School of Rowan University, asserted that despite many believing handoffs lead to inefficiencies, data show that handoffs do not delay first start cases or worsen room turnover times (https://pubmed.ncbi.nlm.nih.gov/28470134/). Dr. Potestio also illustrated that while structured checklists for handoffs do roughly double the time spent doing handoffs it also reduces omission of critical information (https://pubmed.ncbi.nlm.nih.gov/30499797/). He ended by positing that structured, multidisciplinary handoffs have implications in both the provider experience of higher satisfaction once they assume care, and also in the patient’s experience through improved advocacy, pain management, and unit-level outcomes.