Improving Patient Safety During Postoperative Handoffs
Abstract & Commentary
By David J. Pierson, MD, Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle.
This article originally appeared in the June 2012 issue of Critical Care Alert. It was peer reviewed by William Thompson, MD. Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
Synopsis: This comprehensive review on postoperative patient handoffs confirms that they are high-risk events associated with adverse patient outcomes, and permits the identification of several strategies likely to improve the process despite the incompleteness and other limitations of the existing literature.
Source: Segall N, et al, on behalf of the Durham VA Patient Safety Center of Inquiry. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg 2012; Apr 27. [Epub ahead of print.]
A patient handover, or handoff, in health care can be defined as the transfer of information, professional responsibility, and accountability between individuals and teams. Handoffs represent a time of particular patient vulnerability to complications and medical errors, and with the current focus on safety an increasing amount of attention has been devoted to characterizing and improving them. One context in which handoffs are especially frequent, and patients especially susceptible to adverse events, is transfer to the post-anesthesia unit or ICU after anesthesia and surgery. This study by Segall and colleagues of the Durham VA Patient Safety Center of Inquiry in North Carolina sought to better characterize current practices in patient handoffs in this setting, and to identify strategies for improving the process.
The authors conducted an extensive literature search via PubMed and other databases using search terms intended to discover all studies and other publications related to postoperative handoffs. They classified candidate articles into four categories of study design and potential transferability of findings and recommendations, with Category 1 being comprehensive, intervention-based studies having strong design and potentially generalizable results, and Category 4 being published opinions and reviews, potentially useful for identifying evidence gaps, limitations, and perspectives. Segall et al thoroughly reviewed all appropriate articles and summarized them in a series of comprehensive tables included in the article and its appendices.
From more than 500 publications, 31 articles dealing with postoperative handoffs were reviewed in detail. Of these, 24 provided recommendations for structuring the handoff process, in 14 instances basing this on some sort of evidence. Only four studies were comprehensive, intervention-based investigations qualifying for Category 1 status. Five more included some level of evaluation and were classified in Category 2; 18 were cross-sectional studies (Category 3) characterizing current post-surgery handoff practices. With one exception, all the studies were published since 2000, and 14 of them in 2010 and 2011.
Despite the wide variation in study design and article quality, Segall et al report that they identified a number of common barriers to safe, effective postoperative handoffs. The latter fell into six general categories: incomplete information transfer; other communication issues such as inaccurate information, inconsistency, poor organization, and information overload; the intrusion of clinical activities and other distractions into the handoff process; inconsistency and incompleteness of the transferring and/or receiving teams; failure of effective execution of clinical tasks; and lack of standardization. Based on their review, the authors listed a number of strategies for improving the safety and effectiveness of postoperative handoffs that were strongly supported by the existing evidence and authoritative opinion. Further, based on their findings they created an extensive list of patient information that should be included in verbal and written handoffs; the complete list is included in the article's appendix.
This article confirms the findings of numerous previous publications about postoperative patient handoffs: they are characterized by poor teamwork and communication, processes of care are poorly structured and described, nurses and staff are often distracted by other work, and vital information is often unavailable or poorly organized. The literature review also documents a strong association between poor-quality handoffs and adverse events affecting patients, although as the authors point out it is not possible to be sure here about causation.
There are numerous potential limitations in this study, as the authors also discuss. Curiously, the four Category 1 (best designed) studies all dealt with pediatric cardiac surgery patients. Despite the limitations, however, the marked agreement about what is wrong with postoperative patient handoffs and what should ideally be done about it, gleaned from a diverse and extensive literature, represents a great deal of practical experience and collective clinical wisdom. The recommendations are not all based on best-quality evidence, but their broad implementation would surely improve both patient care and the work environment for many clinicians who participate in postoperative ICU management.