Anesthesia & Analgesia:
Patient Safety: Review Article
Can We Make Postoperative Patient Handovers Safer? A Systematic Review of the Literature
Segall, Noa PhD*; Bonifacio, Alberto S. BSN†; Schroeder, Rebecca A. MD*,†; Barbeito, Atilio MD*,†; Rogers, Dawn BSN†; Thornlow, Deirdre K. RN, PhD‡; Emery, James PhD§; Kellum, Sally RN-BC, MSN∥; Wright, Melanie C. PhD¶; Mark, Jonathan B. MD*†; On behalf of the Durham VA Patient Safety Center of Inquiry
From the *Department of Anesthesiology, Duke University Medical Center, Durham; †Anesthesiology Service and ∥Clinical Informatics, Veterans Affairs Medical Center, Durham; ‡School of Nursing and §Fuqua School of Business, Duke University, Durham, North Carolina; and ¶Patient Safety Research, Saint Alphonsus Health System, a member of Trinity Health, Boise, Idaho.
Supported by the VA National Center for Patient Safety.
The Durham VA Patient Safety Center of Inquiry is a multidisciplinary team focused on optimizing the safety of patient care through research, high-fidelity point-of-care simulation training, and the diverse perspectives of clinicians, human factors engineers, and organizational behavior experts. Its members are B. Atkins, A. Barbeito, A. Bonifacio, R. Burton, J. Emery, G. Hobbs, M. Holtschneider, O. Jennings, S. Kellum, J. Mark, S. Perfect, D. Rogers, R. Schroeder, T. Schwartz, N. Segall, S. Sitkin, J. Taekman, D. Thornlow, and M. Wright.
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Noa Segall, PhD, Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to email@example.com.
Accepted February 3, 2012
Published ahead of print April 27, 2012
Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.
Patient handovers, defined as “the transfer of information and professional responsibility and accountability between individuals and teams,”1 are high-risk, error-prone patient care episodes.2,3 Handover failures are common and can lead to diagnostic and therapeutic delays and precipitate adverse events.4–8 The transfer of care after surgery to the postanesthesia care unit (PACU) or intensive care unit (ICU) presents special challenges to providers on both the delivering and receiving teams. The operating room (OR) anesthesia and surgical team is charged with transporting the patient, along with clinical and monitoring equipment, from the OR to the receiving unit, while simultaneously monitoring and performing additional therapeutic tasks such as manual ventilation. Upon arrival at the receiving unit, the technology and support are transferred to local systems while knowledge of the patient gained by the OR team during the procedure is transmitted, in an environment that is often chaotic and busy, to a team largely unfamiliar with the patient. This knowledge transfer involves cross-disciplinary staff with varied experience; the delivering team members with their diverse yet important perspectives of the course of surgery; and the receiving team concurrently stabilizing, assessing, and making care plans for the patient.
It is not surprising, under these circumstances, that postoperative handovers are rife with technical and communication errors.7,9,10 Several studies also point to a relationship between handovers and patient outcomes.11–13 As recognition of the risks inherent to patient handovers has grown, increasing attention has focused on this process of care. In light of this interest, it is important to characterize current practices in postoperative handovers and to identify evidence-based methods to improve them. The goal of this study was to present a review of the literature on this topic and to summarize process and communication recommendations based on its findings.
A search was conducted using the PubMed and ProQuest databases with the terms handover, handoff, and patient transfer and combinations of each term with the terms postoperative, anesthesia, postanesthesia, surgery, operating room, ICU, critical care, intensive care, surgical intensive care, admission, communication, and team. Other information sources included the Agency for Healthcare Research and Quality Collection on Discontinuities, Gaps, and Hand-Off Problemsa and handover-related literature reviews.14–18 More than 500 papers were identified. All titles were reviewed for possible inclusion and, for those that were deemed relevant, the abstracts were examined to ensure relevance. Reference sections of papers that met inclusion criteria were scrutinized for additional sources. All papers that addressed patient transfers from the OR to the PACU or ICU were included in the literature review. Papers on other handover types, e.g., work shift changes, and those discussing transfers not originating in the OR were excluded.
Papers included in this review were classified into 1 of 4 categories as proposed by Wong et al.16:
* Category 1: Comprehensive intervention-based study—Clear articulation of entire approach to improve clinical handover covering data collection, intervention design, implementation and evaluation, and insights into lessons learned. High level of potential transferability.
* Category 2: Intervention-based study—Approach to clinical handover improvement intervention that is not comprehensive or is limited in depth/clarity. Medium to low level of potential transferability.
* Category 3: Preintervention study—Studies variously engaging in data collection, analysis, and evaluation to investigate different aspects of clinical handover. Focused on enhancing understanding, identifying gaps and challenges, or the utility of particular research approaches. Some studies provide recommendations for change management, handover improvement interventions, or system reform. High to low level of potential transferability.
* Category 4: Published opinions or reviews—Publications not involving any primary research and often not peer reviewed. Can provide potentially useful perspectives on different aspects of clinical handover including high-risk scenarios, evidence gaps, and factors imposing limitations on sustainability or transferability of handover initiatives.
Thirty-one articles met the inclusion criteria. Twenty-four included recommendations for structuring the handover process or information transfer. Of these, 14 supported the proposed solutions with some level of evidence. Only 4 papers described comprehensive intervention-based studies (category 1). Five additional studies described handover training initiatives and the creation of printed or electronic postoperative reports, with limited evaluation of their efforts (category 2). There are 18 cross-sectional studies characterizing current postsurgery handover practices (category 3). All papers were published in 2000 or later with the exception of a 1989 paper listing information needed by the PACU nurse receiving new patients.19 Fourteen were published in 2010 or later (Fig. 1). The papers are presented in Table 1.
As stated earlier, 4 of the studies developed an intervention and formally assessed its impact on process measures during handovers.10,20–22 The interventions involved various combinations of a handover protocol to structure tasks and processes, an information transfer checklist to standardize communication, and team training. Different methods were used to develop them. A Six Sigma approach was adopted in 1 study in which 3 barriers to safe handovers were identified: (1) inconsistent participation of clinicians from the delivering team in information exchange; (2) poor standardization of content and processes; and (3) the presence of interruptions and distractions. A protocol was developed to address these and other issues that were found to lead to frequent communication errors.22 In another study, a protocol for handover of surgical patients was developed based on analogs drawn between postoperative patient handovers and other multiprofessional safety-critical processes, namely, racing team pit stops and aviation training. A checklist was created for the surgeon, anesthesiologist, and receiving ICU team to ensure that important patient information was communicated.10 Two additional studies relied on outcomes of a Failure Modes and Effects Analysis and small-scale root cause analyses21 and on interviews with expert care providers20 to develop handover protocols and checklists. Interestingly, all 4 comprehensive intervention-based papers analyzed the same study population, pediatric cardiac patients. They all improved metrics of effectiveness (decreased technical errors and information omissions), efficiency (reduced handover duration or time to complete specific tasks), and perceived teamwork. However, the interventions did not significantly reduce high-risk events20 or realized errors.21 Their effects on patient outcomes were not evaluated.
Most of the papers provided quantitative or qualitative descriptions of current postsurgical care transfers. These cross-sectional studies present evidence of the many errors and deficiencies associated with handovers, their impact on patient safety, and the effect of handover practices on the work of care providers. Although most papers examined only 1 or 2 care settings, it is striking to note that many of their findings are consistently observed across multiple sites. Common barriers to safe, effective postoperative handovers include the incomplete transfer of information,7,9,10,20,22–30 other communication issues (e.g., inaccurate information, lack of consistency and organization, information overload),4,6,7,11,22,25,28 distractions (including performing clinical activities during the transfer of information),9,22,24–26,30,31 inconsistent or incomplete teams,22,25 absent or inefficient execution of clinical tasks,4,9,10,21 and poor standardization.22,25,26
These barriers, and poor communication in particular, may affect patient outcomes. A study of surgical malpractice claims involving communication failures that resulted in patient harm found the transfer of care to be particularly vulnerable to breakdowns. At least 43% of communication breakdowns were associated with handovers, and 39% were associated with physical patient transfers.12 In an analysis of incidents related to the intrahospital transfer of ICU patients, 36% of events involved the OR as the origin or destination of transport.13 In PACUs, the second most common factor contributing to reported incidents was poor communication, associated with 14% of incidents.11 Finally, postoperative patients were found to be at higher risk for complications or death when their surgical teams exhibited less briefing and information sharing during handover.6 Although these findings do not establish a cause-and-effect relationship between poor handovers and decreased patient safety, they imply an association that warrants a more in-depth examination of postoperative transfer of care.
A number of authors developed tools to measure handover quality, e.g., for the purpose of evaluating the effectiveness of interventions. These tools are largely focused on information transfer,9,10,20,21,23,27,32 but some also assess clinical task performance,9,10,21,23 nontechnical skills,6,9,32 and nursing satisfaction with handover quality.23 Most tools are observational and involve assessing whether certain pieces of information have been transferred or tasks have been executed. The extent to which their validity and reliability have been evaluated is variable.
Many of the papers included in this literature review recommend strategies for facilitating the different phases of postsurgical handovers and for quality improvement. A complete list is shown in Appendix 1. Some of these strategies are supported by quantitative and/or qualitative data and are repeatedly identified as important by several authors. They are presented in Table 2. Similarly, suggestions for patient information to be included in verbal or written handovers are outlined in Appendix 2, and those that are supported most extensively are summarized in Table 3.
Our review of the literature on patient and knowledge transfers after surgery reveals that research in this area is still in its infancy. Although many studies examine current handover practices from various perspectives, few have tested approaches for improving them. These intervention-based studies suffer from small sample sizes (between 31 and 171 handovers, pre- and postintervention combined) and insufficient details about the solutions or methods used to evaluate them. Furthermore, they all focus on 1 study population, pediatric patients undergoing cardiac surgery. The perioperative and recovery teams caring for this patient population are typically small, consistent, and highly specialized, while the patients are often characterized by high complexity regarding invasive monitoring, IV vasoactive infusions, assisted ventilation, etc. Thus, the generalizability of the approach described in these studies is limited. In addition, no rigorous experimental designs (e.g., with randomized group assignments) have been performed to isolate the effects of interventions from extraneous factors. Perhaps more importantly, we identified only 1 study that attempted to assess the impact of an intervention (handover protocol and checklist) on patient outcomes,33 and this study was not sufficiently powered or adequately designed and analyzed to conclusively document an improvement in outcomes. However, checklists and team training, tools that have been shown to improve handover quality, have face validity, and their effectiveness in reducing patient morbidity and mortality has been demonstrated in other health care activities.34–37 Rigorous study designs, adequate sample sizes, diverse study sites, and assessments of patient outcomes are needed to effectively evaluate approaches to improving postoperative handovers.
Other interesting questions arise regarding patient outcomes. For example, do patients with poor handovers do worse or, conversely, do unstable patients get poor handovers? This question is difficult to answer, and we found no studies that attempted to do so. Those most closely related include an observational study that showed that patients whose surgical teams exhibited less briefing and information sharing were at a higher risk for poor outcomes, even after adjusting for patients' risk category.6 However, although it is possible that poor information exchange led to complications, the reverse is also possible (e.g., that providers concentrated on emergent patient care needs, rather than communication, during handovers). In another study, Catchpole et al.10 found a positive relationship between patients' operative risk and information omissions. It is possible that when patients are medically compromised, less information is shared about them. But other factors may also be responsible for omitting important information when handing over high-risk patients (e.g., if a particularly laconic surgeon performs specific procedures in complex patients). One reason why it is important to consider the patient safety implications of deficient handovers is the notion of opportunity cost, or the cost of the handover to providers (time expended), measured in terms of the value of other activities that are foregone to complete it. If we cannot demonstrate that inadequate handovers contribute to poor patient outcomes (or proxy measures of outcomes, such as medication errors), care providers may not recognize the benefit of such resource-intensive recommendations as ensuring the presence of all relevant team members, foregoing other activities during handover communication, and using checklists to guide discussions (Table 2).
Additional research questions regarding the characteristics of a good handover are worthy of attention. For example, what role does provider experience have in communicating important information? It may be that providers who are more experienced (or more familiar with each other's work practices) are able to communicate more succinctly than, for example, junior trainees, even though the same information is conveyed. Conversely, it is possible that experienced providers, who handover or receive patients on a daily basis, may incorrectly assume certain information (“this anesthesiologist always reverses neuromuscular blocking drugs, even if the reversal drug is not documented in the anesthesia record”) or forget to share or request information. It would be interesting to test the utility of information transfer checklists for providers with different experience levels, with a special focus on the implications of assumptions and unspoken understandings.
In addition, it would be valuable to compare different information delivery methods, e.g., face-to-face, telephone, recorded, written, or electronic. Although verbal, face-to-face postoperative handovers are the norm in the studies we reviewed, simulation-based studies of shift-change handovers have shown that information retention was worst during verbal handovers compared with verbal with note taking and handovers using a printed handout.38,39 It is also possible that multiple interactions, e.g., a review of the electronic record followed by a documented conversation with the delivering team, would provide the receiving team with a more comprehensive picture of the recovering patient. However, the impact on workflow entailed by such double-task handovers would need to be considered.
Related to these issues, research on electronic tools to support postoperative handovers is also needed. Such tools can facilitate handovers by extracting information from databases, thereby ensuring data accuracy, completeness, and timeliness.40,41 Standardizing knowledge transfers using electronic health record–based systems can decrease the incidence of information errors and omissions and reduce adverse events.41–44 However, our literature review identified only 2 studies that used information technology to facilitate handovers from the OR. In 1 study, the authors created various printed reports generated from the Anesthesia Information Management System records and distributed them to different patient destinations (ICU, general ward, etc.). This report was not formally evaluated.45 In another study, a document was created as part of the patient's electronic health record using provider-entered data, but its evaluation was similarly limited.33 Another idea for future research is to assess the utility of providing PACU and ICU clinicians with access to intraoperative information (e.g., labs, anesthesia chart) via the electronic health record in real time. Such functionality would allow the clinicians to prepare for the patient's arrival and could increase handover efficiency, but the impact of such changes on workflow must also be considered.
Finally, further research is needed on the topic of sustainability. This topic has not been examined in the context of other types of patient handovers.16 Only 1 of the papers we reviewed studied the feasibility and long-term effects of changes in postoperative handover practice.30 This study found only partial compliance with a handover protocol initiated 3 years prior. Although attendance of team members was high, distractions were common and information delivery did not adhere to the protocol. Indeed, some elements of the protocol were inconsistently reported whereas other elements, also of clinical importance, but not included in the original protocol, were frequently discussed during the handover. (This positive change was labeled by the manuscript's authors as user-centered innovation.) In other quality improvement research, some studies have shown that compliance rates decrease after the initial period of implementation, whereas others have demonstrated successful change management.46–48 Sustainable change is critical to high-quality patient care. It is important to understand how sustainability can be achieved, including overcoming economic, structural, and cultural barriers to success.
Many of the research questions discussed herein cannot be ethically or practically answered using randomized controlled trials, the “gold standard” of clinical investigation. Other, more feasible experimental designs may be required, such as the pragmatic trial. These trials compare 2 or more interventions in terms of their effectiveness in real-world practice, using broad eligibility criteria without blinding to treatment assignment. Thus, they sacrifice internal validity but gain generalizability.49 A pragmatic trial might be possible by randomizing patients to different handover methods by hospital or surgical service. With a pilot study to estimate effect size, feasibility, and cost implications, such a trial could assess the impact of different interventions on patient outcomes and process measures. Simulation-based studies can be used to determine the characteristics of a good handover. Simulated patients can range from high-fidelity mannequins to written descriptions and have been used to compare information transfer methods, train in teamwork and communication, and study information loss in handovers.38,39,50,51 Finally, both quantitative and qualitative observational studies can be valuable in describing current practice and many have been published on the topic of postoperative handovers.6,23,27,52
There are several limitations associated with our review of the literature. First, we elected to include all research on postoperative handovers, regardless of the patient population or destination unit. Thus, patients and settings ran the gamut from adults admitted to the PACU to infants admitted to the pediatric cardiac ICU. The level of complexity associated with the different types of handovers varied considerably, as did the members of the delivering and receiving teams. However, all postsurgical handovers have some common characteristics, which, we believe, warranted their shared analysis: (1) they all involve the physical transfer of a patient in a vulnerable state, along with monitoring and clinical equipment; (2) upon arrival, the transfer of knowledge and care responsibility occurs between multiprofessional clinicians with different levels of experience, which contributes to a communication gap53; and (3) many of the information items to be transferred and tasks to be completed are common to all surgical patients.
Second, based on the body of literature, we compiled a list of recommendations for improving the physical and communication aspects of postoperative handovers. However, not all recommendations are supported empirically; and for those that are, the levels of evidence vary. This is attributable to the paucity of relevant studies and to limited efforts to validate findings, and points again to the need for more research to support recommendations and identify best practices in postoperative patient handovers.
Associated with this limitation is the challenge of adapting the recommendations to clinical practice. With respect to the knowledge transfer, for example, there are 74 elements listed in Appendix 2. Clearly, it is impractical to convey so much information in a brief handover, and some elements may be irrelevant for certain settings, operations, or patient populations. In addition, excessive information can act as a distracter and keep providers from other work, while providing little value to the receiving team. However, Table 3, which lists the best substantiated and most frequently recommended information requirements, is clearly not a blanket solution. For instance, some of the information requirements included in papers authored by nurses19,54 were not included in most other papers, such as the patient's English comprehension, preoperative level of consciousness, or contact information for members of the OR team in case of problems. Thus, they were not added to Table 3. However, to the extent that this information allows nurses to better prepare and care for their patients, it should be included in postoperative handovers. Thus, each clinical practice must identify a minimal dataset that is essential for safe, effective patient care, and a methodology that promotes flexible standardization of the information content.
Finally, our search strategy may have led us to omit articles, for example, by not including all relevant terms in our list of keywords. We improved our search by using complementary strategies, including scanning literature reviews and bibliographies of pertinent articles. Although this approach minimized the likelihood of missing suitable articles, it did not eliminate the possibility. Related to this, a publication bias may have affected our findings. Because of the tendency to favor studies with positive results, studies with negative results may not have been published.
More than 40 million patients undergo surgery in the United States annuallyb and are subsequently transferred to a PACU or ICU for recovery. According to our review of the literature, these transfers are characterized by poor teamwork and communication, patients arriving in a compromised state, unclear procedures, technical errors, unstructured processes, interruptions and distractions, lack of central information repositories, and nurse inattention because of multitasking. An association between poor-quality handovers and adverse events is also demonstrated, although causality cannot be proven.
Although the quality of research on postoperative handovers is variable and strong evidence is lacking, several recommendations are broadly supported. First, standardizing this process can improve patient care by ensuring information completeness and accuracy and increasing the efficiency of the patient transfer process. Handover standardization also addresses a Joint Commission national patient safety goal.c As part of this recommendation, the use of checklists to guide communication and protocols to structure clinical activities is advocated. To ensure the attention of all team members, many authors advise completing urgent tasks before the information transfer, limiting conversations while performing tasks, and adopting the “sterile cockpit” approach, i.e., allowing only patient-specific discussions during the verbal handover. All relevant team members should be present during the handover, and each should have an opportunity to speak or ask questions. Finally, training in team skills and communication is also promoted in some publications. These recommendations have the potential to improve the quality of postoperative handovers and the safety of patients during this critical period.
Name: Noa Segall, PhD.
Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.
Attestation: Noa Segall approved the final manuscript.
Name: Alberto S. Bonifacio, BSN.
Contribution: This author helped design the study, conduct the study, and analyze the data.
Attestation: Alberto S. Bonifacio approved the final manuscript.
Name: Rebecca A. Schroeder, MD.
Contribution: This author helped design the study and analyze the data.
Attestation: Rebecca A. Schroeder approved the final manuscript.
Name: Atilio Barbeito, MD.
Contribution: This author helped analyze the data and write the manuscript.
Attestation: Atilio Barbeito approved the final manuscript.
Name: Dawn Rogers, BSN.
Contribution: This author helped analyze the data.
Attestation: Dawn Rogers approved the final manuscript.
Name: Deirdre K. Thornlow, RN, PhD.
Contribution: This author helped analyze the data and write the manuscript.
Attestation: Deirdre K. Thornlow approved the final manuscript.
Name: James Emery, PhD.
Contribution: This author helped analyze the data.
Attestation: James Emery approved the final manuscript.
Name: Sally Kellum, RN-BC, MSN.
Contribution: This author helped analyze the data.
Attestation: Sally Kellum approved the final manuscript.
Name: Melanie C. Wright, PhD.
Contribution: This author helped design the study and write the manuscript.
Attestation: Melanie C. Wright approved the final manuscript.
Name: Jonathan B. Mark, MD.
Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.
Attestation: Jonathan B. Mark approved the final manuscript.
This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).
We thank Kathy Gage for her critical review of the manuscript.
a Agency for Healthcare Research and Quality: Discontinuities, Gaps, and Hand-Off Problems. Available at: http://www.psnet.ahrq.gov/collectionBrowse.aspx?taxonomyID=412. Accessed November 21, 2011. Cited Here...
b Anesthesia in the United States 2009. Available at: aqihq.org/Anesthesia%20in%20the%20US%202_19_10.pdf. Accessed January 19, 2012. Cited Here...
c The Joint Commission Accreditation Program: Hospital—National Patient Safety Goals. Available at http://www.healthlawyers.org/SiteCollectionDocuments/Content/ContentGroups/Publications2/Health_Lawyers_Weekly2/Volume_3/Issue_25/JCAHO_guidance.pdf. (p. 6; although this is not the original document). Accessed August 24, 2009. Cited Here...
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