Handovers in anesthesia are extremely critical events in the perioperative phase, however, their importance is frequently overlooked. Handovers occur for a number of reasons, usually due to shift-changes, reallocation of staff, illness, personal/professional obligations, or prevention of complications related to sleep deprivation. Care transitions have been designated by the World Health Organization as one of its top five areas of focus for “patient safety solutions.” During handovers, key details about the patient’s history, physical/functional status, or critical events in the case may be omitted or poorly communicated, a potential predisposing factor for complications. Lack of completeness or accuracy during handovers is common and has led many institutions to standardize the handover process by incorporating tools that ensure providers cover all important aspects of the patient’s perioperative course. This has become critical during the recent effort to limit junior doctors’ consecutive training hours.  

In review of the available literature, Jones and O’Reilly-Shah reported that most studies found a negative effect related to complete transitions of care.^5,6 Anesthesia handovers during cardiac surgery were found to exhibit worse short-term mortality in one study, however, Shah et al. conducted a retrospective analysis of anesthesia handovers in 2019 and found no statistically significant difference in outcomes when confounders were controlled.^2,6 A prior study by Terekhov et al. found similar lack of effect, however, Saager et al. did find a significant association and direct proportionality between the number of handovers and in-hospital morbidity/mortality regardless of whether the handover was between attendings, residents, or nurse anesthetists.^7,8 In an observational study of complications following colorectal surgery, Hyder et al. similarly found an association between the number anesthesia care transitions and postoperative complications. These findings persisted in spite of adjustments in sensitivity and matching for case duration.⁴ 

In 2014, Arora et al. described the concept of “continuity-enhanced turnovers.” They recommend improving transitions in care by raising the quality of information shared, increasing professional responsibility for sender & recipient, and an alternative philosophy of “coverage.” Improvements such as staffing models that allow for intra-team handovers versus team-team handovers, using handovers as learning opportunities, and performance monitoring during handovers were discussed. The authors also recommended that the recipient receive information about the patient before the handover. The initial provider should also expect to hear about the patient following handover, as the handover should not be seen as a hard stop in their care for the patient. Finally, they strongly recommend against double handovers, as the “sender” should be able to give primary first-hand knowledge of the patient to the handover recipient.¹ 

It should be noted that handovers in many cases are necessary or warranted and cannot be completely eliminated. Based on currently available literature, the anesthesia handover process should be optimized to prevent complications related to transition in care. More research is needed to assess which components are most critical to prevent poor outcomes, however, current data should be used to guide senior providers and educate junior providers in optimizing patient care in spite of these unavoidable transitions in care. 

References 

1. Arora VM, Reed DA, Fletcher KE. Building continuity in handovers with shorter residency duty hours. BMC Medical Education. 2014;14 Suppl 1(S1):S16. https://www.ncbi.nlm.nih.gov/pubmed/25560954. doi: 10.1186/1472-6920-14-S1-S16.
2. Hannan EL, Samadashvili Z, Sundt TMI, et al. Association of anesthesiologist handovers with short-term outcomes for patients undergoing cardiac surgery. Anesthesia & Analgesia. 2020;131(6):1883–1889. https://journals.lww.com/anesthesia-analgesia/Fulltext/2020/12000/Association_of_Anesthesiologist_Handovers_With.28.aspx. doi: 10.1213/ANE.0000000000005221.
3. Howard SK, Rosekind MR, Katz JD, Berry AJ. Fatigue in anesthesia: Implications and strategies for patient and provider safety. Anesthesiology. 2002;97(5):1281-1294. doi: 10.1097/00000542-200211000-00035.
4. Hyder JA, Bohman JK, Kor DJ, et al. Anesthesia care transitions and risk of postoperative complications. Anesthesia & Analgesia. 2016;122(1):134-144. doi: 10.1213/ANE.0000000000000692.
5. Jones PM, Cherry RA, Allen BN, et al. Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery. JAMA. 2018;319(2):143-153. doi: 10.1001/jama.2017.20040.
6. O’Reilly-Shah VN, Melanson VG, Sullivan CL, Jabaley CS, Lynde GC. Lack of association between intraoperative handoff of care and postoperative complications: A retrospective observational study. BMC Anesthesiology. 2019;19(1):182. doi: 10.1186/s12871-019-0858-8.
7. Saager L, Hesler BD, You J, et al. Intraoperative transitions of anesthesia care and postoperative adverse outcomes. Anesthesiology. 2014;121(4):695-706. doi: 10.1097/ALN.0000000000000401.
8. Terekhov MA, Ehrenfeld JM, Dutton RP, Guillamondegui OD, Martin BJ, Wanderer JP. Intraoperative care transitions are not associated with postoperative adverse outcomes. Anesthesiology. 2016;125(4):690-699. doi: 10.1097/ALN.0000000000001246.