Handoffs of surgical patients

INTRODUCTION — Handoffs, also termed handovers, are defined as points in a patient's care when responsibility for well-being is transferred between individual providers and/or care teams. Such transitions of care occur at multiple stages in the perioperative process, including handoff to another anesthesia provider in the operating room (OR) and eventual patient transport with monitoring to a separate physical location for handoff to personnel in the post-anesthesia care unit (PACU) or intensive care unit (ICU).

This topic describes handoffs that typically occur in the perioperative period. A general discussion of formal handoff processes for transitions of care in other hospital settings is available in another topic (see "Patient handoffs"). Transition of care during hospital discharge is also discussed separately. (See "Hospital discharge and readmission".)

USE OF A FORMAL HANDOFF PROCEDURE — For all phases of perioperative care, we employ a formal handoff protocol that emphasizes standardization of this process, including both verbal and written communication. (See "Patient handoffs", section on 'The handoff process' and "Patient handoffs", section on 'Strategies for effective handoffs'.)

A standardized, comprehensive, easy to follow handoff protocol may improve quality of data transfer and outcomes by reducing preventable complications [1,2]. For example, a standardized process should exist for confirming medications and allergies during each perioperative handoff. A poor handoff process coupled with a documentation error can be particularly dangerous (eg, failure to document administration of a drug or to review medications during the handoff may result in readministration with overdose after the handoff) (see "Prevention of perioperative medication errors", section on 'Standardized handoffs'). Published handoff protocols can be modified to fit a specific setting and local institutional practice.

In a 2021 systematic review, analysis of eight retrospective studies covering nearly 140,000 handoffs across more than 680,000 surgeries found an association between handoffs and poor patient outcomes in seven of these studies [3]. However, analysis of six prospective studies in this review noted that use of a handoff tool resulted in improvements in process-based outcomes such as clinician satisfaction, information transfer, and handoff duration with use of a formal handoff tool.

Perioperative handoffs have particular risks and challenges:

●General risks during handoffs – Handoffs have been identified as particularly critical points in all stages of patient care and have been associated with patient harm [4-8], as well as malpractice claims [9,10].

Handoff failures have been identified as a source of communication and technical errors as well as adverse outcomes in the operating room (OR), similar to other hospital settings [5,11-20]. Communication failures were cited as a contributing cause for bad outcome in 60 of 258 litigated surgical malpractice cases, with 43 of these failures occurring during a handoff [21]. The Joint Commission reports that up to 80 percent of serious medical errors involve communication failures between care providers during the transfer of patients [4]. Poor communication during handoffs has been implicated in various medical errors included diagnostic testing errors, delays in diagnosis and treatment, and failure to continue needed therapies [5,15,22,23]. Also, distractions are common during handoffs, occurring at a rate of 2.3 per minute [11]. Omissions of critical data or tasks are common, and transmission of information further degrades during the next handoff [16]. (See "Patient handoffs".)

●Specific challenges during perioperative handoffs – Perioperative transfers of care can be especially challenging, as they often occur in complex, noise-filled environments such as the OR, post-anesthesia care unit (PACU), intensive care unit (ICU), or emergency department (ED), and care must be continuously delivered throughout the handoff process [24]. In addition, care transitions may involve several different types of providers, such as attending and resident clinicians in various specialties; PACU, ICU, or ED nurses; respiratory therapists; and other medical professionals. Furthermore, critically ill patients are typically connected to hemodynamic monitoring equipment that must also be transferred to different monitors.

The structure and function of perioperative handoffs vary significantly depending on a variety of factors, including the acuity of the patient's condition, the types of providers involved, and the phase of care. While there are a number of ways to categorize handoffs during the continuum of care for a surgical patient, the most commonly employed context is the phase of care in the specific locations involved, as outlined in this topic [25,26].

PREOPERATIVE HANDOFFS — Preoperative handoffs occur when a patient is brought to the operating room (OR) or other procedural area from a preoperative location. Typically, patients undergoing outpatient surgery or those coming to the hospital for admission on the day of surgery are placed in a holding area before transfer to the OR. Some preoperative patients come directly from a hospital floor, an intensive care unit (ICU), or the emergency department (ED). Aspects of handoffs from each of these preoperative locations differ depending on the acuity of the patient's condition and the nature and urgency of the planned procedure.

Outpatients: Holding area to operating room — Most outpatient surgical patients begin their preoperative experience in a holding area or room, where a routine intake process is begun by a perioperative nurse. Here, patients and their family members also typically meet members of the surgical, anesthetic care, and intraoperative nursing teams before entering the OR. Very little data exist about this day-of-surgery preoperative interaction in which information is communicated from the patient and family members to medical professionals involved in the perioperative care. In some institutions, this information is entered into an electronic health record by the intake nurse and/or others. It is not known whether this information is routinely accessed by health care providers subsequently involved in the patient's perioperative care, or to what extent the information is useful for prevention of medical error.

Inpatients: Floor to operating room — For inpatients requiring surgery, handoff processes from a hospital floor to the holding area vary among institutions. Information transfer may occur via progress notes and other data in the patient chart. Also, the surgical team may communicate additional critical information. However, this is a time- and production-pressured setting where nursing or clinician personnel caring for the patient on the floor who are most familiar with clinical and other issues are typically not physically present. Direct communication among such personnel and the holding area nursing personnel or the OR care team may or may not occur.

One small study of inpatients followed across the perioperative course found that the most frequent communication and information transfer failures occurred during the preoperative phase of care [16]. Only one-quarter of the necessary information was known by the perioperative nursing team. Although both the anesthesia and surgical teams had access to >80 percent of the information, it is unclear whether adequate time was allotted for review of this information. A formal verbal handoff process between the hospital floor team and the OR team occurred for less than one-half of the patients [16].

In a larger qualitative follow-up study, the types of preoperative communication and information transfer failures were characterized as missing consents, incomplete information regarding allergies and preoperative medications, inadequate documentation of preoperative assessment, failure to follow established policies and checklists, failure to follow specialists' recommendations, lack of communication between floor and OR personnel, and lack of communication between the surgical and anesthetic care teams [27].

Some institutions have implemented a formal checklist to provide a structure for intrahospital transfer of surgical patients. Such instruments help to standardize processes thereby ensuring that clinicians have critical information when patient care is transferred to a new team (form 1) [28].

Inpatients: Intensive care unit to operating room — We employ a standardized protocol for ICU to OR handoffs that includes a structured process for verbal bedside communication among the anesthesia clinician, the patient's bedside nurse, the ICU clinician team, and the respiratory therapist when indicated. The process includes a cognitive aid to assist clinicians with this information transfer (table 1) [29]. Such handoffs may occur as an emergency situation and typically include the transfer of hemodynamic monitors and multiple high-risk medications. These additional complexities increase the risk of the handoff process.

Scant data exist concerning adequacy of handoffs from the ICU to the OR (see 'Operating room to intensive care unit' below). One study that examined handoffs from a neonatal ICU to the OR found multiple barriers to adequate information exchange [30]. These included lack of preparation for transfer by the neonatal ICU team, lack of a standardized report to the receiving OR team, and lack of clarity about provider roles during the transition of care between team members, with numerous distractions or interruptions occurring during handoffs. In a study of a standardized protocol for handoffs of adult patients from ICU to OR, improved communication and improved anesthesia provider satisfaction occurred without causing surgical delays compared with the data collected before implementation of the protocol [31].

Emergency department to operating room — Transfers of care from the emergency department (ED) directly to the OR are emergency events. Despite the widely-held perception that arrival of a patient in the OR directly from the ED is typically disorganized, little has been published about potential improvements. A simple sequential three-step process has been described that may improve efficiency and situational awareness of all care team members [32]. First, a surgical team member announces the patient and procedure upon entry into the OR; second, the patient is transferred onto the OR bed and appropriate OR monitors and equipment are attached; and third, the anesthesia team calls for quiet as the ED nurse gives a brief report appropriate to the urgency of the surgical situation. It is unknown whether such a simple process or a more detailed checklist would be preferable in this setting, but some standardization of this complex process is likely to be beneficial by allowing shared understanding among team members of an individual patient's urgent needs.

INTRAOPERATIVE HANDOFFS — Intraoperative transitions of care between anesthesia clinicians occur both for short breaks (eg, a lunch break during a long case) as well as for complete transfer of care (eg, at the end of a shift). We employed a structured process that included an electronic checklist within the anesthesia information management system that resulted in a significant improvement in critical information transfer and retention (figure 1) [33]. A thorough intraoperative handoff should include review of pertinent medical history; allergies; the surgical procedure that is underway; airway management and any difficulties; total dose and last timing for opioids, muscle relaxants, and antibiotics; estimated blood loss; total fluids administered including colloids and blood products; critical laboratory values (eg, hemoglobin or hematocrit, glucose and potassium levels, last activated whole blood clotting time if heparin was administered); untoward intraoperative events; and the plan for disposition at the conclusion of surgery [34].

●Risks for intraoperative handoffs – Improvements in processes to optimize handoffs in the operating room are important, particularly for intraoperative handoffs that involve complete transfer of anesthesia care (whereby a case started by one anesthesiologist is handed off to another anesthesiologist who completes the case). Such complete handovers have been associated with adverse outcomes in several retrospective reviews [14,18,19,35-37]:

•Cardiac surgical cases:

-In a 2022 retrospective study of 102,156 patients undergoing cardiac surgery in the Canadian province of Ontario, complete handover of anesthetic care occurred in 1.9 percent of the cases [37]. Complete handover was associated with increased risk of 30-day mortality (hazard ratio [HR] 1.89, 95% CI 1.41-2.54) and one-year mortality (HR 1.66, 95% CI 1.31-2.12), as well as longer durations of ICU stay (risk ratio [RR] 1.43, 95% CI 1.22-1.68) and hospital stay (RR 1.17, 95% CI 1.06-1.28), compared with cases without a handover.

-In a 2020 retrospective study of 103,102 patients in the New York State cardiac surgery registry, complete handover occurred in 8.5 percent of the cases, and was associated with higher in-hospital/30 day mortality (2.86 vs 2.48 percent; adjusted RR 1.15, 95% CI1.01-1.31), compared with no handover [36].

-In a 2015 propensity-matched retrospective study of 14,421 patients undergoing cardiac surgery at a single institution, a handover occurred in 6.7 percent of the cases, and was associated with higher in-hospital/30 day mortality (5.4 versus 4.0 percent; adjusted odds ratio [OR] 1.43, 95% CI 1.01-2.06) compared with no handover [14].

•Noncardiac surgical cases:

-In a 2018 retrospective study of 313,166 patients undergoing major noncardiac surgery in Ontario, complete handover of anesthetic care occurred in 1.9 percent of the cases, and was associated with increased risk for a composite outcome of all-cause death, hospital readmission, or major postoperative complications (adjusted risk difference [aRD] 6.8 percent, 95% CI 4.5-9.1 percent) compared with cases without a handover [35].

-In a 2013 propensity-matched retrospective study of 138,932 patients undergoing various surgical procedures at a single institution (the Cleveland Clinic), each additional intraoperative handoff was associated with increased risk of complications (in-hospital mortality or postoperative morbidity) [19]. These complications were noted in 8.8, 11.6, 14.2, 17.0, and 21.2% of patients with 0, 1, 2, 3, and ≥ 4 transitions (OR 1.08, 95% CI 1.05 to 1.10 for each additional transition).

-In a 2016 retrospective single-institution study of 927 patients undergoing colorectal surgery at a single institution, the number of anesthesia team members involved was associated with increased risk for postoperative complications (OR 1.52, 95% CI 1.18-1.96) [18].

Limitations of these observational studies include the inability to determine the reason that complete handover occurred in certain cases. Despite adjustments for confounding factors in several of the studies, it is possible that these cases were longer, more complex, or more often performed during evening or weekend hours. Furthermore, outcome data for intraoperative handoffs are not consistent, particularly for temporary breaks in care rather than complete handovers for the remainder of a case. In a landmark 1982 study, 96/1000 preventable adverse events related to anesthetic management involved an intraoperative handoff and a relief anesthesiologist; however, the investigators concluded that the relief process might have a net positive effect since many errors were discovered due to the introduction of a new provider [38]. Subsequently, these investigators outlined a protocol and checklist for intraoperative handoffs for temporary breaks [39]. Another retrospective single-institution study of >140,000 cases also noted that short breaks were not associated with increased odds of postoperative mortality and serious complications [40]. Nevertheless, adherence to a structured thorough handoff process is critical for all types of intraoperative handoffs.

●Unique challenges for intraoperative handoffs – It is unclear why intraoperative handoffs for complete transfer of care may lead to postoperative adverse outcome [41]. Advantages of intraoperative handoffs are several, including a lower level of complexity compared with other perioperative transitions of care from the operating room (OR) to the post-anesthesia care unit (PACU), or from the OR to the intensive care unit (ICU) where handoffs occur between providers from different disciplines and care priorities. Also, intraoperative handoffs occur between anesthesia clinicians who are each focused on that phase of the patient's care, albeit with potentially differing levels of training or expertise. Furthermore, intraoperative handoffs do not include transport of the patient or the transfer of equipment and monitoring to another physical location.

However, intraoperative handoffs do have some unique challenges:

•One or more handoffs for transfer of care are typically necessary during prolonged surgery that often involves technically complex or multiple procedures [41].

•The start time of the operation may be a contributing factor. Handoffs are more likely to occur during cases that are started late in the day by personnel who may be finishing a long shift. Such situations may involve increased risk due to fatigue, waning attention, or limited availability of support personnel [41].

•Variability in the type and quality of transferred information is common due to absence of structure for an intraoperative handoff process for complete transfer of care.

•Intraoperative handoffs are often performed in a noisy and/or dark environment for patients who require continuous clinical care as the handoff is occurring.

•The process may be interrupted by immediately necessary interventions, such as administration of anesthetic or other pharmacologic agents or changes in the bed position requested by the surgeon.

•Even when there is a thorough transfer of perceived knowledge, there is likely subliminal information of a patient's physiology that an anesthesiologist gains over the case that is not perceived consciously, and which cannot be transferred to the next anesthesiologist, but which provides for better care.

●Interventions to improve intraoperative handoffs – Risks associated with intraoperative handoffs may be lessened by employing standardized communication for transmission of critical information during any intraoperative handoff process, including use of tools such as checklists or other cognitive aids to enhance information transfer [17].

A few studies have focused on attempts to standardize or otherwise improve intraoperative handoffs [34,42,43]. A checklist for such use was published in 1989, but without formal study of its implementation or effectiveness [39]. Subsequent studies employing a pre/post interventional design demonstrated that use of a checklist improves reliability of handoffs [33,44,45]. For example, implementation of a structured process that included an electronic checklist within the anesthesia information management system resulted in a significant improvement in critical information transfer and retention (figure 1) [33]. An interventional cohort study demonstrated that training and subsequent display of an intraoperative handoff checklist improved the quality of observed handoffs compared with a control group [45]. The effect of such interventions on postoperative outcome has not been studied.

POSTOPERATIVE HANDOFFS

Operating room to post-anesthesia care unit — We use a standardized process for the initial handoff from the anesthesia care team to personnel in the post-anesthesia care unit (PACU) [44,46-48]. An example of a simple and easily-displayed cognitive aid to facilitate initial handoff from the anesthesiologist to the PACU nurse is shown in the figure (figure 2). An example of a comprehensive standardized PACU admission form is shown in the table (table 2).

The operating room to PACU handoff should include:

●Review of pertinent medical history, allergies, and the surgical procedure performed

●Total dose and last timing for opioids, muscle relaxants, and antibiotics

●Total fluids administered including colloids and blood products

●Critical intraoperative laboratory values if these were obtained (eg, hemoglobin or hematocrit; glucose and potassium levels; last activated whole blood clotting time if heparin was administered)

●Airway management and any difficulties

●Prophylactic medications previously administered for postoperative nausea and vomiting

●Any untoward intraoperative events

●The plan for postoperative analgesia

●Discussion of disposition after PACU discharge (eg, to home, a hospital ward, or an intensive care unit [ICU] bed).

Despite the fact that all patients undergoing surgical care have a transition of care to a postoperative setting, studies have noted significant variability in the amount and quality of information transferred between care providers, often with omission of critical information (eg, patient allergies, medications administered, fluid management, American Society of Anesthesiologists status) [49,50]. Some studies have also noted poor satisfaction of the receiving providers [42,51-53].

Several studies have demonstrated that implementation of a structured handoff process improves the transition of care to the PACU setting, with a decrease in communication errors and omission of information, and improved reliability and effectiveness of communication as well as staff satisfaction [44,46-48]. Standardized processes typically include a definition of team members' roles, responsibilities, and expectations, in combination with introduction of a structured checklist or similar cognitive aid (table 2 and figure 2).

Operating room to intensive care unit — We employ a protocol for handoffs from the operating room (OR) to the intensive care unit (ICU) that addresses the following key elements (also shown in the example in the table (table 3)) [12,48,54-64]:

●Critical needs (eg, vasoactive infusions, type of ventilation, active bleeding, monitors, ventilation) and estimated time of arrival are communicated to the ICU by telephone to allow adequate time for ICU staff preparations.

●All key personnel (eg, surgeon, anesthesiologist, ICU attending, ICU nurses, respiratory therapist) should be present before beginning transfer of technology and information, and each individual should attend to their assigned task.

●Technology transfer occurs in distinct and separate steps that are in sequential order, with monitors transferred first, then ventilation, then infusions, then drains. Conversation during this transfer is strictly limited to the task being accomplished.

●Information transfer likewise occurs after hemodynamic stability is achieved after the technology transfer, and occurs in sequential order, with only one person speaking at any time. The anesthesiologist presents patient information and current condition (similar to the intraoperative handoff (figure 1)), and includes plans for postoperative analgesia and sedation (if appropriate). Next, the surgeon presents pertinent surgical details, events, and aspects of the anticipated plan of care while the patient is in the ICU. Finally, the intensivist presents plans for immediate further care, including administration of antibiotics, prophylaxis for deep vein thrombosis, orders for laboratory and other testing, plans for nutrition, and key goals for the next 12 hours.

●All personnel are invited to ask questions.

Uncertainty regarding the patient's condition (ie, known and potential but unknown aspects of current condition) influences specific content and the level of detail included in the handoff, questions that may be asked by receiving personnel, and total time allotted for the handoff process [65].

Since critically ill patients may be hemodynamically unstable with a need for vasoactive infusions, mechanical ventilation, and advanced monitoring devices, the handoff process is often complex. An environment that includes multiple caregivers from different disciplines (eg, surgeons, anesthesia team members, ICU clinicians, and OR and ICU nurses, respiratory therapists, perfusionists) also increases the complexity of handoffs from or to the ICU [12,55]. Thus, the verbal report should be delivered in a focused manner with minimal conversation or other distractions that are not pertinent to the care of the individual patient. During this report, any movement of the patient or monitoring equipment should be performed by individuals who are not receiving the report. During any transfer of care in either the OR or the ICU, the anesthesiologist should remain with the patient until hemodynamic and overall stability are assured.

Handoffs from OR to ICU have documented inadequacy of critical information transfer, diagnostic and treatment delays, and technical errors related to the processes of physically transferring a patient to a different set of monitors in the ICU (eg, lack of necessary equipment, unintended lapses in monitoring) [12,24,66]. The impact of introducing structured handoff processes to improve information transfer and reduce technical errors during OR to ICU handoffs has been studied (primarily in cardiac surgical patients). In a 2018 literature review of 21 studies (4568 patients), a structured interdisciplinary handover from the OR to the ICU after cardiac surgery was associated with prevention of adverse events (seven studies), improved handoff completeness (18 studies), provider satisfaction and perception of good teamwork (13 studies), and compliance with process measures including efficiency in transfer of information, equipment, and technology, as compared with unstructured handoffs [61]. Examples of improvements in clinical outcomes include more timely administration of antibiotics, reduction in time to extubation, reduced need for respiratory and cardiovascular interventions, and reduced overall risk of postoperative complications [1,2,61-63].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Patient safety in the operating room".)

SUMMARY AND RECOMMENDATIONS

●Use of a formal handoff procedure – For all phases of perioperative care, we employ a formal handoff protocol that emphasizes standardization of this process, including both verbal and written communication. Perioperative transfers of care can be especially challenging, as they often occur in a chaotic, noise-filled environment such as the operating room (OR), post-anesthesia care unit (PACU), intensive care unit (ICU), or emergency department (ED), and care must be continuously delivered throughout the handoff process. In addition, care transitions may involve providers from multiple disciplines, and critically ill patients are typically connected to hemodynamic monitoring equipment that must also be transferred to different monitors. (See 'Use of a formal handoff procedure' above.)

●Preoperative handoffs – Preoperative handoffs occur when a patient is brought to the OR from a preoperative location:

•Outpatients – Most outpatient surgical patients begin their preoperative experience in a holding area or room, where a routine intake is completed by a perioperative nurse and they typically meet members of the surgical, anesthetic care, and intraoperative nursing team before entering the OR. (See 'Outpatients: Holding area to operating room' above.)

•Inpatients – Handoff processes for inpatients include examination of progress notes and other data in the patient chart, and the surgical team may communicate additional critical information. Direct communication between nursing or clinician personnel caring for the patient on the floor may or may not occur with holding area nursing personnel or the OR care team. (See 'Inpatients: Floor to operating room' above.)

•ICU patients – We employ a standardized protocol for ICU to OR handoffs that includes a structured process for verbal bedside communication among the anesthesia clinician, the patient's bedside nurse, the ICU clinician team, and the respiratory therapist when indicated, with a cognitive aid to assist clinicians with this information transfer (table 1). Such handoffs typically include transfer of hemodynamic monitors and multiple high-risk medications, and may occur in an emergency situation. (See 'Inpatients: Intensive care unit to operating room' above.)

•ED patients – A simple sequential three-step process may improve efficiency and situational awareness during transfers of care from the ED directly to the OR. First, a surgical team member announces the patient and procedure upon entry into the OR; second, the patient is transferred onto the OR bed and appropriate OR monitors and equipment are attached; and third, the anesthesia team calls for quiet as the ED nurse gives a brief report appropriate to the urgency of the surgical situation. (See 'Emergency department to operating room' above.)

●Intraoperative handoffs – Intraoperative transitions of care between anesthesia clinicians occur both for short breaks (eg, a lunch break during a long case) as well as for complete transfer of care (eg, at the end of a shift). We employ a structured process that included an electronic checklist within the anesthesia information management system that resulted in a significant improvement in critical information transfer and retention (figure 1). (See 'Intraoperative handoffs' above.)

●Postoperative handoffs

•Handoff in the PACU – We employ a standardized process for the initial handoff from the anesthesia care team and other intraoperative personnel (eg, circulating nurse and surgeon) to personnel in the PACU. An example of a simple cognitive aid to facilitate this handoff is shown in the figure (figure 2). An example of a comprehensive standardized PACU admission form is shown in the table (table 2). (See 'Operating room to post-anesthesia care unit' above.)

•Handoff in the ICU – We employ a standardized protocol for OR to ICU handoffs. As shown in the example (table 3), the following elements are addressed (see 'Operating room to intensive care unit' above):

-Critical needs (eg, vasoactive infusions, type of ventilation, active bleeding, monitors, ventilation) and estimated time of arrival are communicated to the ICU by telephone to allow adequate time for ICU staff preparations.

-All key personnel (eg, surgeon, anesthesiologist, ICU attending, ICU nurses, respiratory therapist) should be present before beginning transfer of technology and information, and each individual should attend to their assigned task.

-Technology transfer occurs in distinct and separate steps that are in sequential order, with monitors transferred first, then ventilation, then infusions, then drains. Conversation during this transfer is strictly limited to the task being accomplished.

-Information transfer likewise occurs after hemodynamic stability is achieved after the technology transfer, and occurs in sequential order, with only one person speaking at any time.

-All personnel are invited to ask questions.