1
|
Mathur P, Halvorson S, Cywinski JB, Machado S, Khatib R, Kurz AM, Galway U, Mascha EJ. Timing of Intraoperative Transitions of Care Among Anesthesiologists Is Not Associated With Postoperative Adverse Outcomes: Retrospective Cohort Study. Anesth Analg 2024; 139:186-194. [PMID: 38885400 DOI: 10.1213/ane.0000000000006853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND The majority of published research suggests that anesthesia handovers during major surgical procedures are associated with unintended harmful consequences. It is still unclear if the number or quality of the transition of care is the main driver of the adverse outcomes. There is even less data if the timing of the anesthesiologist handovers during the critical portion of the anesthetic continuum (induction or emergence versus surgical period) plays a role in patient outcomes. Therefore, we investigated if the anesthesiologist handovers during induction and emergence are associated with adverse patient outcomes. METHODS This retrospective investigation included noncardiac surgical procedures occurring between January 1, 2012 and December 31, 2019 that had exactly 1 attending anesthesiologist handover. We categorized transitions of care between attending anesthesiologists as being before incision, between incision and closing, and after closing. Our primary outcome was a composite of 6 categories of surgical complications and in-hospital mortality. We created logistic generalized estimating equation models to estimate the average relative effect odds ratio between each pair of the 3 transition timing groups across the components of the composite outcome. Inverse probability of treatment weights were used to mitigate confounding on a host of baseline variables. We used Bonferroni correction to adjust for multiple comparisons between the transition groups. RESULTS In total, we studied 36,937 procedures with exactly 1 attending anesthesiologist handover. Of these records, 4370 had the transition during induction, 24,999 between incision and closure, and 7568 during emergence. No differences were found between the transition periods and the composite outcome. The estimated average relative effect odds ratio (98.3% confidence interval [CI]) across the components of the composite outcome was as follows: (1.0002 [0.81-1.24], P = .99) between the induction and surgical period; (1.10 [0.87-1.40], P = .32) between the induction and emergence periods; and (0.91 [0.79-1.04], P = .08) between the emergence and surgical periods. CONCLUSIONS Timing of intraoperative handover among attending anesthesiologists during noncardiac surgery is not associated with adverse patient outcomes.
Collapse
Affiliation(s)
- Piyush Mathur
- From the Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sven Halvorson
- Prevention Science Institute, University of Oregon, Oregon
| | - Jacek B Cywinski
- From the Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sandra Machado
- From the Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Reem Khatib
- From the Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andrea M Kurz
- From the Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, University of Graz, Graz, Austria
| | - Ursula Galway
- From the Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
2
|
Dexter F, Hindman BJ, Bayman EO, Mueller RN. Patient and Operational Factors Do Not Substantively Affect the Annual Departmental Quality of Anesthesiologists' Clinical Supervision and Nurse Anesthetists' Work Habits. Cureus 2024; 16:e55346. [PMID: 38559506 PMCID: PMC10981928 DOI: 10.7759/cureus.55346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Although safety climate, teamwork, and other non-technical skills in operating rooms probably influence clinical outcomes, direct associations have not been shown, at least partially due to sample size considerations. We report data from a retrospective cohort of anesthesia evaluations that can simplify the design of prospective observational studies in this area. Associations between non-technical skills in anesthesia, specifically anesthesiologists' quality of clinical supervision and nurse anesthetists' work habits, and patient and operational factors were examined. METHODS Eight fiscal years of evaluations and surgical cases from one hospital were included. Clinical supervision by anesthesiologists was evaluated daily using a nine-item scale. Work habits of nurse anesthetists were evaluated daily using a six-item scale. The dependent variables for both groups of staff were binary, whether all items were given the maximum score or not. Associations were tested with patient and operational variables for the entire day. RESULTS There were 40,718 evaluations of faculty anesthesiologists by trainees, 53,772 evaluations of nurse anesthetists by anesthesiologists, and 296,449 cases that raters and ratees started together. Cohen's d values were small (≤0.10) for all independent variables, suggesting a lack of any clinically meaningful association between patient and operational factors and evaluations given the maximum scores. For supervision quality, the day's count of orthopedic cases was a significant predictor of scores (P = 0.0011). However, the resulting absolute marginal change in the percentage of supervision scores equal to the maximum was only 0.8% (99% confidence interval: 0.2% to 1.4%), i.e., too small to be of clinical or managerial importance. Neurosurgical cases may have been a significant predictor of work habits (P = 0.0054). However, the resulting marginal change in the percentage of work habits scores equal to the maximum, an increase of 0.8% (99% confidence interval: 0.1% to 1.6%), which was again too small to be important. CONCLUSIONS When evaluating the effect of assigning anesthesiologists and nurse anesthetists with different clinical performance quality on clinical outcomes, supervision quality and work habits scores may be included as independent variables without concern that their effects are confounded by association with the patient or case characteristics. Clinical supervision and work habits are measures of non-technical skills. Hence, these findings suggest that non-technical performance can be judged by observing the typical small sample size of cases. Then, associations can be tested with administrative data for a far greater number of patients because there is unlikely to be a confounding association between patient and case characteristics and the clinicians' non-technical performance.
Collapse
Affiliation(s)
| | | | - Emine O Bayman
- Biostatistics/Anesthesia, University of Iowa, Iowa City, USA
| | | |
Collapse
|
3
|
Saha AK, Segal S. A Quality Improvement Initiative to Reduce Adverse Effects of Transitions of Anesthesia Care on Postoperative Outcomes: A Retrospective Cohort Study. Anesthesiology 2024; 140:387-398. [PMID: 37976442 DOI: 10.1097/aln.0000000000004839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND An intraoperative transfer of care from one anesthesia provider to another, or handover, may result in information loss and contribute to adverse patient outcomes. In 2019 the authors undertook a quality improvement effort to increase the use of a structured intraoperative handover tool incorporated in the electronic medical record. The authors hypothesized that intraoperative handovers of anesthesia care would be associated with adverse patient outcomes, and that increased use of a structured tool would attenuate this effect. METHODS This study included adult patients undergoing noncardiac surgery of at least 1 h duration performed during the period 2016 to 2021. Cases with a handover were identified if either there was a change of attending anesthesiologist or change of nurse anesthetist or resident for more than 35 min. The primary outcome was the occurrence of a composite of postoperative mortality and major postoperative morbidity. The effect of the intervention was analyzed by examining the quarterly change in odds ratio for the primary outcome for cases with and without a handover. RESULTS A total of 121,077 cases, 40.4% of which had a handover, were included. After weighting, the composite outcome was statistically associated with handovers (3,517 of 48,986 [7.2%] in handover cases vs. 4,470 of 72,091 [6.2%] in nonhandover cases; odds ratio, 1.08; 95% CI, 1.04 to 1.12). Time series analysis showed a marked increase in usage of the structured tool after the initial intervention. The odds ratio for the composite outcome showed a significant decrease over time after the initial intervention (t = -3.97; P < 0.001), with the slope of the odds ratio versus time curve decreasing from 0.002 (95% CI, 0.001 to 0.004; P = 0.018) to -0.011 (95% CI, -0.01 to -0.018; P < 0.001). CONCLUSIONS Intraoperative handovers are significantly associated with adverse outcomes even after controlling for multiple confounding variables. Use of a structured handover tool during anesthesia care may attenuate the adverse effect. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Amit K Saha
- Department of Anesthesiology, and Perioperative Outcomes and Informatics Collaborative, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Scott Segal
- Department of Anesthesiology, and Perioperative Outcomes and Informatics Collaborative, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
4
|
Samost-Williams A, Bernstein SL, Thomas AT, Piersa AP, Hawkins JE, Pian-Smith MCM. A Qualitative Study of the Work Systems and Culture Around End-of-Day Intraoperative Anesthesia Handoffs in a Tertiary Care Center. Anesth Analg 2023:00000539-990000000-00662. [PMID: 38009849 DOI: 10.1213/ane.0000000000006751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Intraoperative handoffs have been implicated as a contributing factor in many perioperative adverse events. Despite conflicting data around their impact on perioperative outcomes, they remain a vulnerable point in the perioperative system with significant attention focused on improving them. This study aimed to understand the processes in place surrounding the point of information transfer in intraoperative handoffs. METHODS We used semistructured interviews with anesthesia clinicians to understand the processes and systems surrounding intraoperative handoffs. Interview data were coded deductively using the Systems Engineering Initiative for Patient Safety model as a framework, with subthemes developed inductively. RESULTS Clinicians do a significant amount of work before and after the point of information transfer to ensure a smooth handoff and safe patient care. Despite not having standardization of handoffs, most clinicians have a typical handoff organization and largely agree on content that should be included. However, there is variability based on clinician and patient characteristics, including clinician discipline and patient acuity. These handoffs are additionally impacted by the overall culture in the operating room, including the teamwork and hierarchies present among the surgical and anesthesia teams. Finally, the broader operating room logistics, including scheduling practices for surgical cases and anesthesia teams, impact the quality of intraoperative handoffs and the ability of clinicians to prepare for these handoffs. CONCLUSIONS Handoffs involve processes beyond the point of information transfer and are embedded in the systems and culture of the operating rooms. These considerations are important when seeking to improve the quality of intraoperative handoffs.
Collapse
Affiliation(s)
- Aubrey Samost-Williams
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital
| | - Samantha L Bernstein
- School of Nursing, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts
| | - A Taylor Thomas
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital
| | - Anastasia P Piersa
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital
| | - Jessica E Hawkins
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital
| | - May C M Pian-Smith
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital
| |
Collapse
|
5
|
Armstrong M, Groner JI, Samora J, Olbrecht VA, Tram NK, Noffsinger D, Boyer EW, Xiang H. Impact of opioid law on prescriptions and satisfaction of pediatric burn and orthopedic patients: An epidemiologic study. PLoS One 2023; 18:e0294279. [PMID: 37972014 PMCID: PMC10653505 DOI: 10.1371/journal.pone.0294279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES The objective of this study was to determine the reduction in prescribed opioid pain dosage units to pediatric patients experiencing acute pain and to assess patient satisfaction with pain control 90-day post discharge following the 2017 Ohio opioid prescribing cap law. METHODS The retrospective chart review included 960 pediatric (age 0-18 years) burn injury and knee arthroscopy patients treated between August 1, 2015-August 31, 2019. Prospectively, legal guardians completed a survey for a convenience sample of 50 patients. Opioid medications (days and morphine milligram equivalents (MMEs)/kg) prescribed at discharge before and after the Ohio law implementation were collected. Guardians reported experience and satisfaction with their child's opioid prescription at 90-days post discharge. RESULTS From pre-law to post-law, there was a significant decrease (p<0.001) within the burn and knee cohorts in the median days (1.7 to 1.0 and 5.0 to 3.8, respectively) and median total MMEs prescribed (15.0 to 2.5 and 150.0 to 90.0, respectively). An interrupted time series analysis revealed a statistically significant decrease in MMEs/kg and days prescribed at discharge when the 2017 Ohio opioid prescription law went into effect, with an abrupt level change. Prospectively, more than half of participants were satisfied (72% burn and 68% knee) with their pain control and felt they received the right amount of medication (84% burn and 56% knee). Inpatient opioid use was not changed pre- and post-law. CONCLUSIONS Discharge opioids prescribed for pediatric burn and knee arthroscopy procedures has decreased from 2015-2019. Caregivers varied greatly in their satisfaction with pain control and the amount of opioid prescribed.
Collapse
Affiliation(s)
- Megan Armstrong
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States of America
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Jonathan I. Groner
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States of America
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States of America
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, United States of America
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Julie Samora
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States of America
- Department of Orthopedics, Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Vanessa A. Olbrecht
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States of America
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Nguyen K. Tram
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Dana Noffsinger
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States of America
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Edward W. Boyer
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States of America
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States of America
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States of America
| |
Collapse
|
6
|
Abella MKIL, Angeles JPM, Finlay AK, Amanatullah DF. Does Operative Time Modify Obesity-related Outcomes in THA? Clin Orthop Relat Res 2023; 481:1917-1925. [PMID: 37083564 PMCID: PMC10499082 DOI: 10.1097/corr.0000000000002659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/22/2023] [Accepted: 03/17/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Most orthopaedic surgeons refuse to perform arthroplasty on patients with morbid obesity, citing the higher rate of postoperative complications. However, that recommendation does not account for the relationship of operative time (which is often longer in patients with obesity) to obesity-related arthroplasty outcomes, such as readmission, reoperation, and postoperative complications. If operative time is associated with these obesity-related outcomes, it should be accounted for and addressed to properly assess the risk of patients with obesity undergoing THA. QUESTIONS/PURPOSES We therefore asked: (1) Is the increased risk seen in overweight and obese patients, compared with patients in a normal BMI class, associated with increased operative time? (2) Is increased operative time independent of BMI class a risk factor for readmission, reoperation, and postoperative medical complications? (3) Does operative time modify the direction or strength of obesity-related adverse outcomes? METHODS This retrospective, comparative study examined 247,108 patients who underwent THA between January 2014 and December 2020 in the National Surgical Quality Improvement Project (NSQIP). Of those, emergency cases (1% [2404]), bilateral procedures (1% [1605]), missing and/or null data (1% [3280]), extreme BMI and operative time outliers (1% [2032]), and patients with comorbidities that are not typical of an elective procedure, such as disseminated cancer, open wounds, sepsis, and ventilator dependence (1% [2726]), were excluded, leaving 95% (235,061) of elective, unilateral THA cases for analysis. The NSQIP was selected due to its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight, normal weight, overweight, Class I obesity, Class II obesity, and Class III obesity. Of the patients with a normal weight, 69% (30,932 of 44,556) were female and 36% (16,032 of 44,556) had at least one comorbidity, with a mean operative time of 86 ± 32 minutes and a mean age of 68 ± 12 years. Patients with obesity tend to be younger, male, more likely to have preoperative comorbidities, with longer operative times. Multivariable logistic regression models examined the effects of obesity on 30-day readmission, reoperation, and medical complications, while adjusting for age, sex, race, smoking status, and number of preoperative comorbidities. After we repeated this analysis after adjusting for operative time, an interaction model was conducted to test whether operative time changes the direction or strength of the association of BMI class and adverse outcomes. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were calculated, and the interaction effects were plotted. RESULTS A comparison of patients with Class III obesity to patients with normal weight showed that the odds of readmission went from 45% (AOR 1.45 [95% CI 1.32 to 1.59]; p < 0.001) to 27% after adjusting for operative time (AOR 1.27 [95% CI 1.01 to 1.62]; p = 0.04), the odds of reoperation went from 93% (AOR 1.93 [95% CI 1.72 to 2.17]; p < 0.001) to 81% after adjusting for operative time (AOR 1.81 [95% CI 1.61 to 2.04]; p < 0.001), and the odds of a postoperative complication went from 96% (AOR 1.96 [95% CI 1.58 to 2.43]; p < 0.001) to 84% after adjusting for operative time (AOR 1.84 [95% CI 1.48 to 2.28]; p < 0.001). Each 15-minute increase in operative time was associated with a 7% increase in the odds of a readmission (AOR 1.07 [95% CI 1.06 to 1.08]; p < 0.001), a 10% increase in the odds of a reoperation (AOR 1.10 [95% CI 1.09 to 1.12]; p < 0.001), and 10% increase in the odds of a postoperative complication (AOR 1.10 [95% CI 1.08 to 1.13]; p < 0.001). There was a positive interaction effect of operative time and BMI for readmission and reoperation, which suggests that longer operations accentuate the risk that patients with obesity have for readmission and reoperation. CONCLUSION Operative time is likely a proxy for surgical complexity and contributes modestly to the adverse outcomes previously attributed to obesity alone. Hence, focusing on modulating the accentuated risk associated with lengthened operative times rather than obesity is imperative to increasing the accessibility and safety of THA. Surgeons may do this with specific surgical techniques, training, and practice. Future studies looking at THA outcomes related to obesity should consider the association with operative time to focus on independent associations with obesity to facilitate more equitable access. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Maveric K. I. L. Abella
- Stanford University Department of Orthopaedic Surgery, Stanford, CA, USA
- University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | - John P. M. Angeles
- Stanford University Department of Orthopaedic Surgery, Stanford, CA, USA
- Wright State University Boonshoft School of Medicine, Fairborn, OH, USA
| | - Andrea K. Finlay
- Stanford University Department of Orthopaedic Surgery, Stanford, CA, USA
| | | |
Collapse
|
7
|
Schiavi A, Hong Mershon B, Gottschalk A, Miller CR. Measurement of Information Transfer During Simulated Sequential Complete Shift-to-Shift Intraoperative Handoffs. Mayo Clin Proc Innov Qual Outcomes 2022; 7:9-19. [PMID: 36545440 PMCID: PMC9762072 DOI: 10.1016/j.mayocpiqo.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective To determine information transfer during simulated shift-to-shift intraoperative anesthesia handoffs and the benefits of using a handoff tool. Patients and Methods Anesthesiology residents and faculty participating in simulation-based education in a simulation center on April 6 and 20, 2017, and April 11 and 25, 2019. We used a fixed clinical scenario to compare information transfer in multiple sequential simulated handoff chains conducted from memory or guided by an electronic medical record generated tool. For each handoff, 25 informational elements were assessed on a discrete 0-2 scale generating a possible information retention score of 50. Time to handoff completion and number of clarifications requested by the receiver were also determined. Results We assessed 32 handoff chains with up to 4 handoffs per chain. When both groups were combined, the mean information retention score was 31 of 50 (P<.001) for the first clinician and declined by an average of 4 points per handoff (P<.001). The handoff tool improved information retention by almost 7 points (P=.002), but did not affect the rate of information degradation (P=.38). Handoff time remained constant for the intervention group (P=.67), but declined by 2 minutes/handoff (P<.001) in the control group, which required 7 more clarifications/handoff (P=.003). In the control group, 7 of 16 (44%) handoff chains contained one or more information retention scores below the lowest score of the entire intervention group (P=.007). Conclusion Clinical handoffs are accompanied by degradation of information that is only partially reduced by use of a handoff tool, which appears to prevent extremes of information degradation.
Collapse
Affiliation(s)
- Adam Schiavi
- Correspondence: Address to Adam Schiavi, PhD, MD, Department of Anesthesiology and Critical Care Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD 21287.
| | | | | | | |
Collapse
|
8
|
Meersch M, Sessler DI, Zarbock A. Outcomes From Intraoperative Handovers of Anesthesia Care-Reply. JAMA 2022; 328:1870-1871. [PMID: 36346415 DOI: 10.1001/jama.2022.16545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Outcomes Research Consortium, Cleveland, Ohio
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| |
Collapse
|
9
|
Lazzara EH, Simonson RJ, Gisick LM, Griggs AC, Rickel EA, Wahr J, Lane-Fall MB, Keebler JR. Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes. ERGONOMICS 2022; 65:1138-1153. [PMID: 35438045 DOI: 10.1080/00140139.2021.2020341] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/12/2021] [Indexed: 06/14/2023]
Abstract
Anaesthesia handoffs are associated with negative outcomes (e.g. inappropriate treatments, post-operative complications, and in-hospital mortality). To minimise these adverse outcomes, federal bodies (e.g. Joint Commission) have mandated handoff standardisation. Due to the proliferation of handoff interventions and research, there is a need to meta-analyze anaesthesia handoffs. Therefore, we performed meta-analyses on the provider, patient, organisational, and handoff outcomes related to post-operative anaesthesia handoff protocols. We meta-analysed 41 articles with post-operative anaesthesia handoffs that implemented a standardised handoff protocol. Compared to no standardisation, a standardised post-operative anaesthesia handoff changed provider outcomes with an OR of 4.03 (95% CI 3.20-5.08), patient outcomes with an OR of 1.49 (95% CI 1.32-1.69), organisational outcomes with an OR of 4.25 (95% CI 2.51-7.19), handoff outcomes with an OR of 8.52 (95% CI 7.05-10.31). Our meta-analyses demonstrate that standardised post-operative anaesthesia handoffs altered patient, provider, organisational, and handoff outcomes. Practitioner Summary: We conducted meta-analyses to assess the effects of post-operative anaesthesia handoff standardisation on provider, patient, organisational, and handoff outcomes. Our findings suggest that standardised post-operative anaesthesia handoffs changed all listed outcomes in a positive direction. We discuss the implications of these findings as well as notable limitations in this literature base.
Collapse
Affiliation(s)
- Elizabeth H Lazzara
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Richard J Simonson
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Logan M Gisick
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Andrew C Griggs
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Emily A Rickel
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Joyce Wahr
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Meghan B Lane-Fall
- David E. Longnecker Associate Professor of Anesthesiology and Critical Care, Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph R Keebler
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| |
Collapse
|
10
|
Lane S, Gross M, Arzola C, Malavade A, Szadkowski L, Huszti E, Friedman Z. What are we missing? The quality of intraoperative handover before and after introduction of a checklist. Can J Anaesth 2022; 69:832-840. [PMID: 35314994 DOI: 10.1007/s12630-022-02238-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Intraoperative handovers are common in anesthesia practice and are associated with increased patient morbidity and mortality. Checklists may improve transfer of information during handovers. This before-and-after study sought to examine the effect of a checklist on intraoperative handover. We hypothesized that introducing a handover checklist would improve our primary outcome of completeness of data transfer. METHODS From February to August 2016, anesthesia providers (residents, fellows, and consultants) at a single tertiary academic center participated in a handover study. Baseline handovers between anesthesia care providers were videotaped, analyzed, and compared with anesthetic records. An intraoperative handover checklist was then introduced, and handovers completed with it were videotaped. The completeness of handovers was compared between the baseline routine and checklist groups. The primary outcome was completeness of information transfer. RESULTS Sixty-seven anesthesia providers participated in the study. Use of the intraoperative handover checklist improved completeness of handover by 6% (95% confidence interval [CI], 2 to 10; P < 0.01). There was no relationship observed between the provider (consultants/fellows vs resident) of the handovers and the degree of completeness (95% CI, 3 to 8; P = 0.33). Complexity had a significant impact on the handover completeness with low or high complexity cases more completely handed over than those of medium complexity both before and after the intervention-a 6% increase for low complexity (95% CI, 1 to 11; P = 0.02) and a 9% increase for high complexity (95% CI, 3 to 14; P < 0.01). CONCLUSION Use of a checklist during intraoperative handovers improved completeness of data transfer. Handover checklists should be considered to improve handover completeness.
Collapse
Affiliation(s)
- Sophia Lane
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Marketa Gross
- Perioperative Services, Sinai Health System, Toronto, ON, Canada
- Department of Nursing, Ryerson University, Toronto, ON, Canada
| | - Cristian Arzola
- Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue Toronto, Toronto, ON, M5G1X5, Canada
| | - Archana Malavade
- Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue Toronto, Toronto, ON, M5G1X5, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit (BRU), University Health Network, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit (BRU), University Health Network, Toronto, ON, Canada
| | - Zeev Friedman
- Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue Toronto, Toronto, ON, M5G1X5, Canada.
| |
Collapse
|
11
|
Meersch M, Weiss R, Küllmar M, Bergmann L, Thompson A, Griep L, Kusmierz D, Buchholz A, Wolf A, Nowak H, Rahmel T, Adamzik M, Haaker JG, Goettker C, Gruendel M, Hemping-Bovenkerk A, Goebel U, Braumann J, Wisudanto I, Wenk M, Flores-Bergmann D, Böhmer A, Cleophas S, Hohn A, Houben A, Ellerkmann RK, Larmann J, Sander J, Weigand MA, Eick N, Ziemann S, Bormann E, Gerß J, Sessler DI, Wempe C, Massoth C, Zarbock A. Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications Among Adults: The HandiCAP Randomized Clinical Trial. JAMA 2022; 327:2403-2412. [PMID: 35665794 PMCID: PMC9167439 DOI: 10.1001/jama.2022.9451] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Intraoperative handovers of anesthesia care are common. Handovers might improve care by reducing physician fatigue, but there is also an inherent risk of losing critical information. Large observational analyses report associations between handover of anesthesia care and adverse events, including higher mortality. OBJECTIVE To determine the effect of handovers of anesthesia care on postoperative morbidity and mortality. DESIGN, SETTING, AND PARTICIPANTS This was a parallel-group, randomized clinical trial conducted in 12 German centers with patients enrolled between June 2019 and June 2021 (final follow-up, July 31, 2021). Eligible participants had an American Society of Anesthesiologists physical status 3 or 4 and were scheduled for major inpatient surgery expected to last at least 2 hours. INTERVENTIONS A total of 1817 participants were randomized to receive either a complete handover to receive anesthesia care by another clinician (n = 908) or no handover of anesthesia care (n = 909). None of the participating institutions used a standardized handover protocol. MAIN OUTCOMES AND MEASURES The primary outcome was a 30-day composite of all-cause mortality, hospital readmission, or serious postoperative complications. There were 19 secondary outcomes, including the components of the primary composite, along with intensive care unit and hospital lengths of stay. RESULTS Among 1817 randomized patients, 1772 (98%; mean age, 66 [SD, 12] years; 997 men [56%]; and 1717 [97%] with an American Society of Anesthesiologists physical status of 3) completed the trial. The median total duration of anesthesia was 267 minutes (IQR, 206-351 minutes), and the median time from start of anesthesia to first handover was 144 minutes in the handover group (IQR, 105-213 minutes). The composite primary outcome occurred in 268 of 891 patients (30%) in the handover group and in 284 of 881 (33%) in the no handover group (absolute risk difference [RD], -2.5%; 95% CI, -6.8% to 1.9%; odds ratio [OR], 0.89; 95% CI, 0.72 to 1.10; P = .27). Nineteen of 889 patients (2.1%) in the handover group and 30 of 873 (3.4%) in the no handover group experienced all-cause 30-day mortality (absolute RD, -1.3%; 95% CI, -2.8% to 0.2%; OR, 0.61; 95% CI, 0.34 to 1.10; P = .11); 115 of 888 (13%) vs 136 of 872 (16%) were readmitted to the hospital (absolute RD, -2.7%; 95% CI, -5.9% to 0.6%; OR, 0.80; 95% CI, 0.61 to 1.05; P = .12); and 195 of 890 (22%) vs 189 of 874 (22%) experienced serious postoperative complications (absolute RD, 0.3%; 95% CI, -3.6% to 4.1%; odds ratio, 1.02; 95% CI, 0.81 to 1.28; P = .91). None of the 19 prespecified secondary end points differed significantly. CONCLUSIONS AND RELEVANCE Among adults undergoing extended surgical procedures, there was no significant difference between the patients randomized to receive handover of anesthesia care from one clinician to another, compared with the no handover group, in the composite primary outcome of mortality, readmission, or serious postoperative complications within 30 days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04016454.
Collapse
Affiliation(s)
- Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Raphael Weiss
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Mira Küllmar
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Lars Bergmann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Astrid Thompson
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Leonore Griep
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Desiree Kusmierz
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Annika Buchholz
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Alexander Wolf
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Hartmuth Nowak
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Tim Rahmel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Michael Adamzik
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Jan Gerrit Haaker
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Carina Goettker
- Department of Anesthesiology, Department of Anesthesiology and Critical Care, Franziskus Hospital Münster, Münster, Germany
| | - Matthias Gruendel
- Department of Anesthesiology, Department of Anesthesiology and Critical Care, Franziskus Hospital Münster, Münster, Germany
| | - Andre Hemping-Bovenkerk
- Department of Anesthesiology, Department of Anesthesiology and Critical Care, Franziskus Hospital Münster, Münster, Germany
| | - Ulrich Goebel
- Department of Anesthesiology, Department of Anesthesiology and Critical Care, Franziskus Hospital Münster, Münster, Germany
| | - Julius Braumann
- Department of Anesthesiology, Intensive Care and Pain Medicine, Florence-Nightingale-Hospital, Düsseldorf, Germany
| | - Irawan Wisudanto
- Department of Anesthesiology, Intensive Care and Pain Medicine, Florence-Nightingale-Hospital, Düsseldorf, Germany
| | - Manuel Wenk
- Department of Anesthesiology, Intensive Care and Pain Medicine, Florence-Nightingale-Hospital, Düsseldorf, Germany
| | - Darius Flores-Bergmann
- Department of Anesthesiology and Operative Intensive Care Medicine, Kliniken Köln, Köln, Germany, Witten/Herdecke University, Faculty of Health, School of Medicine
| | - Andreas Böhmer
- Department of Anesthesiology and Operative Intensive Care Medicine, Kliniken Köln, Köln, Germany, Witten/Herdecke University, Faculty of Health, School of Medicine
| | - Sebastian Cleophas
- Department of Anesthesiology and Intensive Care Medicine, Kliniken Maria Hilf, Mönchengladbach, Germany
- Faculty of Medicine and University Hospital of Cologne, Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Cologne, Germany
| | - Andreas Hohn
- Department of Anesthesiology and Intensive Care Medicine, Kliniken Maria Hilf, Mönchengladbach, Germany
- Faculty of Medicine and University Hospital of Cologne, Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Cologne, Germany
| | - Anne Houben
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Dortmund, Dortmund, Germany
| | - Richard K. Ellerkmann
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Dortmund, Dortmund, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Jan Larmann
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Sander
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A. Weigand
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Nicolas Eick
- Department of Anesthesiology, Intensive Care and Pain Medicine, Dortmund-Hörde, Germany
| | - Sebastian Ziemann
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Eike Bormann
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Joachim Gerß
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Daniel I. Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Carola Wempe
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christina Massoth
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| |
Collapse
|
12
|
Daubenspeck DK, Chaney MA. INTRAOPERATIVE HANDOFF DURING CARDIAC SURGERY: A FUMBLE? J Cardiothorac Vasc Anesth 2022; 36:2851-2853. [DOI: 10.1053/j.jvca.2022.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 11/11/2022]
|
13
|
Sun LY, Jones PM, Wijeysundera DN, Mamas MA, Bader Eddeen A, O’Connor J. Association Between Handover of Anesthesiology Care and 1-Year Mortality Among Adults Undergoing Cardiac Surgery. JAMA Netw Open 2022; 5:e2148161. [PMID: 35147683 PMCID: PMC8837916 DOI: 10.1001/jamanetworkopen.2021.48161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/28/2021] [Indexed: 01/28/2023] Open
Abstract
Importance Handovers of anesthesia care from one anesthesiologist to another is an important intraoperative event. Despite its association with adverse events after noncardiac surgery, its impact in the context of cardiac surgery remains unclear. Objective To compare the outcomes of patients who were exposed to anesthesia handover vs those who were unexposed to anesthesia handover during cardiac surgery. Design, Setting, and Participants This retrospective cohort study in Ontario, Canada, included Ontario residents who were 18 years or older and had undergone coronary artery bypass grafting or aortic, mitral, tricuspid valve, or thoracic aorta surgical procedures between 2008 and 2019. Exclusion criteria were non-Ontario residency status and other concomitant procedures. Statistical analysis was conducted from April 2021 to June 2021, and data collection occurred between November 2020 to January 2021. Exposures Complete handover of anesthesia care, where the case is completed by the replacement anesthesiologist. Main Outcomes and Measures The coprimary outcomes were mortality within 30 days and 1 year after surgery. Secondary outcomes were patient-defined adverse cardiac and noncardiac events (PACE), intensive care unit (ICU), and hospital lengths of stay (LOS). Inverse probability of treatment weighting based on the propensity score was used to estimate adjusted effect measures. Mortality was assessed using a Cox proportional hazard model, PACE using a cause-specific hazard model with death as a competing risk, and LOS using Poisson regression. Results Of the 102 156 patients in the cohort, 25 207 (24.7%) were women; the mean (SD) age was 66.4 (10.8) years; and 72 843 of surgical procedures (71.3%) were performed in teaching hospitals. Handover occurred in 1926 patients (1.9%) and was associated with higher risks of 30-day mortality (hazard ratio [HR], 1.89; 95% CI, 1.41-2.54) and 1-year mortality (HR, 1.66; 95% CI, 1.31-2.12), as well as longer ICU (risk ratio [RR], 1.43; 95% CI, 1.22-1.68) and hospital (RR, 1.17; 95% CI, 1.06-1.28) LOS. There was no statistically significant association between handover and PACE (30 days: HR 1.09; 95% CI, 0.79-1.49; 1 year: HR 0.89; 95% CI, 0.70-1.13). Conclusions and Relevance Handover of anesthesia care during cardiac surgical procedures was associated with higher 30-day and 1-year mortality rates and increased health care resource use. Further research is needed to evaluate and systematically improve the handover process qualitatively.
Collapse
Affiliation(s)
- Louise Y. Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- ICES, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip M. Jones
- ICES, Ontario, Canada
- Departments of Anesthesia and Perioperative Medicine and Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Duminda N. Wijeysundera
- ICES, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University and Institute for Population Health, University of Manchester, United Kingdom
| | | | - John O’Connor
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| |
Collapse
|
14
|
Kannampallil T, Abraham J. Comment on "Adverse Outcomes Associated with Intraoperative Anesthesia Handovers: A Systematic Review and Meta-analysis". J Perianesth Nurs 2021; 36:327. [PMID: 34419218 DOI: 10.1016/j.jopan.2020.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO; Institute for Informatics, Washington University School of Medicine, St. Louis, MO
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO; Institute for Informatics, Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
15
|
Systematic Review of Intraoperative Anesthesia Handoffs and Handoff Tools. Anesth Analg 2021; 132:1563-1575. [PMID: 34032660 DOI: 10.1213/ane.0000000000005367] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Intraoperative handoffs between anesthesia clinicians are critical for care continuity. However, such handoffs pose a significant threat to patient safety. This systematic review synthesizes the empirical evidence on the (a) effect of intraoperative handoffs on outcomes and (b) effect of intraoperative handoff tools on outcomes. All studies on intraoperative handoffs and handoff tools published until September 2019, in any study setting and population, and with no prespecified criteria on the type of comparison and outcome were included. Data extracted from the included studies were aggregated to identify common patterns related to the type of surgery, clinician(s) involved, patient population, handoff tool, the tool design approach (where relevant), tool implementation strategies, and finally, all reported clinical and process outcomes. Quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Fourteen studies met the inclusion criteria. All included studies used adult patients. Eight studies were retrospective cohort studies that used administrative or electronic health record (EHR)-based databases to investigate the effects of intraoperative handoffs on morbidity and mortality. These studies included a total of 680,855 surgeries, with 139,426 of these surgeries having at least 1 handoff (20.47%). Seven of the studies found a positive association between intraoperative handoffs and considered outcomes. However, a pooled meta-analysis across these studies was not feasible across the retrospective studies due to differing surgical populations and varying definitions of the considered outcomes. Six studies used a nonrandomized prospective design to evaluate the effects of handoff tools on process-based outcomes such as clinician satisfaction, information transfer, handoff duration, and adherence. Five of the 6 handoff tools were checklist based. All prospective tool-based studies relied on small samples and reported a significant improvement on the considered process-based outcomes. The median quality score among retrospective (median [interquartile range {IQR}] = 9 [1]) was significantly higher than that of prospective (median [IQR] = 5 [1.5]) studies (U = 21, P = .0017). This systematic review provides a unique appraisal of the current state of intraoperative handoff research. To improve the quality and outcomes of handoffs, future efforts should focus on design and implementation of standardized handoff tools integrated within EHR systems, consider the use of similar metrics for evaluating handoff process and clinical outcomes, and improve the execution and reporting of studies using standard protocols and guidelines.
Collapse
|
16
|
Communication failures contributing to patient injury in anaesthesia malpractice claims☆. Br J Anaesth 2021; 127:470-478. [PMID: 34238547 DOI: 10.1016/j.bja.2021.05.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/18/2021] [Accepted: 05/27/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Communication amongst team members is critical to providing safe, effective medical care. We investigated the role of communication failures in patient injury using the Anesthesia Closed Claims Project database. METHODS Claims associated with surgical/procedural and obstetric anaesthesia and postoperative pain management for adverse events from 2004 or later were included. Communication was defined as transfer of information between two or more parties. Failure was defined as communication that was incomplete, inaccurate, absent, or not timely. We classified root causes of failures as content, audience, purpose, or occasion with inter-rater reliability assessed by kappa. Claims with communication failures contributing to injury (injury-related communication failures; n=389) were compared with claims without any communication failures (n=521) using Fisher's exact test, t-test, or Mann-Whitney U-tests. RESULTS At least one communication failure contributing to patient injury occurred in 43% (n=389) out of 910 claims (κ=0.885). Patients in claims with injury-related communication failures were similar to patients in claims without failures, except that failures were more common in outpatient settings (34% vs 26%; P=0.004). Fifty-two claims had multiple communication failures for a total of 446 injury-related failures, and 47% of failures occurred during surgery, 28% preoperatively, and 23% postoperatively. Content failures (insufficient, inaccurate, or no information transmitted) accounted for 60% of the 446 communication failures. CONCLUSIONS Communication failure contributed to patient injury in 43% of anaesthesia malpractice claims. Patient/case characteristics in claims with communication failures were similar to those without failures, except that failures were more common in outpatient settings.
Collapse
|
17
|
Lane-Fall MB, Christakos A, Russell GC, Hose BZ, Dauer ED, Greilich PE, Hong Mershon B, Potestio CP, Pukenas EW, Kimberly JR, Stephens-Shields AJ, Trotta RL, Beidas RS, Bass EJ. Handoffs and transitions in critical care-understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial. Implement Sci 2021; 16:63. [PMID: 34130725 PMCID: PMC8204062 DOI: 10.1186/s13012-021-01131-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings. METHODS The Handoffs and Transitions in Critical Care-Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU). DISCUSSION The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04571749 . Date of registration: October 1, 2020.
Collapse
Affiliation(s)
| | - Athena Christakos
- , 3400 Spruce Street 6th Floor Dulles Building, Philadelphia, PA, 19104, USA
| | - Gina C Russell
- , 3400 Civic Center Boulevard, Building 421, Philadelphia, PA, 19104, USA
| | - Bat-Zion Hose
- , 423 Guardian Drive, 333 Blockley Hall, Philadelphia, PA, 19104, USA
| | | | | | | | | | | | - John R Kimberly
- , 3620 Locust Walk, 2109 Steinberg-Dietrich Hall, Philadelphia, PA, 19104, USA
| | | | | | - Rinad S Beidas
- , 3535 Market Street, Ste 3105, Philadelphia, PA, 19104, USA
| | - Ellen J Bass
- Drexel University, 3675 Market Street, Suite 1000, Philadelphia, PA, 19104, USA
| |
Collapse
|
18
|
Massoth C, Meersch M. [Safer anesthesia and duty hour limits: are handovers of personnel allowed?]. Anaesthesist 2021; 70:439-448. [PMID: 33825936 DOI: 10.1007/s00101-021-00949-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
Restrictions of duty hours in medicine are an ambivalent matter with respect to patient safety. Continuity of treatment carries the risk of medical errors from declining performance capability and must be balanced against the risk of communication failure and information loss due to personnel changes. Complete intraoperative changes of anesthetists are frequently carried out in the clinical routine but possibly have the potential to negatively influence the postoperative morbidity and mortality. The relevance of anesthesiological care for the perioperative outcome also seems to vary depending on the specialist discipline involved. While standardized handover protocols seem to be only of limited effectiveness for the improvement of transfer of information, they are nevertheless a reasonable approach for optimization of interprofessional communication and reduction of treatment errors.
Collapse
Affiliation(s)
- Christina Massoth
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Deutschland
| | - Melanie Meersch
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Deutschland.
| |
Collapse
|
19
|
Massoth C, Saadat-Gilani K, Meersch M. [Impact of handover of anesthesia care on adverse postoperative outcomes-The HandiCAP trial]. Anaesthesist 2021; 70:320-323. [PMID: 33704505 DOI: 10.1007/s00101-021-00940-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Melanie Meersch
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Geb. A1, 48149, Münster, Deutschland.
| | | |
Collapse
|
20
|
Dexter F, Abouleish A, Marian AA, Epstein RH. The anesthetizing sites supervised to anesthesiologist ratio is an invalid surrogate for group productivity in academic anesthesia departments when used without consideration of the corresponding managerial decisions. J Clin Anesth 2021; 71:110194. [PMID: 33713934 DOI: 10.1016/j.jclinane.2021.110194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 10/21/2022]
Abstract
When the anesthesiologist does not individually perform the anesthesia care, then to make valid comparisons among US anesthesia departments, one must consider the staffing ratio (i.e., how many cases each anesthesiologist supervises when working with Certified Registered Nurse Anesthetists [CRNAs] or Certified Anesthesiologist Assistants [CAA]). The staffing ratio also must be considered when accurately measuring group productivity. In this narrative review, we consider anesthesia departments with non-physician anesthesia providers and anesthesiology residents. We investigate the validity of such departments assessing the overall ratio of anesthetizing sites supervised per anesthesiologist as a surrogate for group clinical productivity. The sites/anesthesiologist ratio can be estimated accurately using the arithmetic mean calculated by anesthesiologist, the harmonic mean calculated by case, or the harmonic mean calculated by CRNA or CAA, but not by the arithmetic mean ratio by case. However, there is lack of validity to benchmarking the percentage time that anesthesiologists are supervising the maximum possible number of CRNAs or CAAs when some of the anesthesiologists also are supervising resident physicians. Assignments can differ in the total number anesthesiologists needed while every anesthesiologist is supervising as many sites as possible. Similarly, there is lack of validity to limiting assessment to the anesthesiologists supervising only CRNAs or CAAs. There also is lack of validity to limiting assessment only to cases performed by supervised CRNAs or CAAs. When cases can be assigned to anesthesiology residents or CRNAs or CAAs, increasing sites/anesthesiologist while limiting consideration to the CRNAs or CAAs creates incentive for the CRNAs or CAAs to be assigned cases, even when lesser productivity is the outcome. Decisions also can increase sites/anesthesiologist without increasing productivity (e.g., when one anesthesiologist relieves another before the end of the regular workday). A suitable alternative approach to fallaciously treating the sites/anesthesiologist ratio as a surrogate for productivity is that, when a teaching hospital supplies financial support, a responsibility of the anesthesia department is to explain annually the principal factors affecting productivity at each facility it manages and to show annually that decisions were made that maximized productivity, subject to the facilities' constraints.
Collapse
|
21
|
Kannampallil T, Lew D, Pfeifer EE, Sharma A, Abraham J. Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes. BMJ Qual Saf 2020; 30:755-763. [PMID: 33288621 DOI: 10.1136/bmjqs-2020-012298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/10/2020] [Accepted: 11/23/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether intraoperative handover of patient care from one anaesthesia clinician to another was associated with an increased risk of adverse postoperative outcomes during paediatric surgeries. DESIGN, SETTING AND PARTICIPANTS A retrospective, population-based cohort study (1 April 2013-1 June 2018) at an academic medical centre. EXPOSURE Intraoperative handover of care between pairs of anaesthesia clinicians from one care provider to another compared with no handover of anaesthesia care. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of all-cause mortality and major postoperative morbidity within 30 days after surgery. Secondary outcomes included individual components of the primary outcome and 30-day hospital readmission. Inverse probability of exposure weighting using propensity scores for intraoperative handovers was calculated. Weighted logistic regression was used to determine the association between intraoperative anaesthesia handovers and outcomes. RESULTS 78 321 paediatric surgical cases (n=5411 with handovers) were included for analysis. Patients were predominantly male (56.5%) with a median age of 6.56 (IQR: 2.65-12.53) years and a median anaesthesia duration of 76 (IQR: 55-126) min. In the weighted sample, the odds of the primary outcome (OR: 0.92; 95% CI 0.75 to 1.13; p=0.43), any morbidity (OR: 0.93; 95% CI 0.75 to 1.16; p=0.515), all-cause mortality (OR: 0.8; 95% CI 0.37 to 1.73; p=0.565) or 30-day readmission following surgery (OR: 0.99; 95% CI 0.84 to 1.18; p=0.95) did not significantly differ among surgeries with and without handovers. CONCLUSIONS Among paediatric patients undergoing surgery, intraoperative anaesthesia handovers were not associated with adverse postoperative outcomes, after accounting for relevant covariates. These findings provide a preliminary perspective on the role of intraoperative handovers as a care-neutral event, with implications for improving safety.
Collapse
Affiliation(s)
- Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Daphne Lew
- Division of Biostatistics, Washington University in St Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ethan E Pfeifer
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Anshuman Sharma
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| |
Collapse
|
22
|
Dexter F, Epstein RH, Marian AA. Sustained management of the variability in work hours among anesthesiologists providing patient care in operating rooms and not on call to work late if necessary. J Clin Anesth 2020; 69:110151. [PMID: 33278750 DOI: 10.1016/j.jclinane.2020.110151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/09/2020] [Accepted: 11/21/2020] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE We evaluated a department's long-term (6.5-year) success of achieving an overall and individual incidence of anesthesiologists working late of approximately 20% of days when not on call to work late, if necessary, and providing care in operating rooms. DESIGN Historical cohort study, January 2014 through September 2020. SETTING Inpatient surgical suite of large teaching hospital. MAIN RESULTS The percentage of days worked past 5:00 PM was mean (standard deviation) 17.7% (5.0%) of days, 99% confidence interval (CI) 15.0% to 20.4%. There was considerable variability among quarters, the coefficient of variation being 28% (99% CI 20% to 45%). This was caused, in part, by anesthesiologists less often working late during January-March versus July-September (14.0% [4.5%] versus 21.6% [3.2%]; P = 0.0031; N = 7 years each). The N = 67 anesthesiologists not on call differed in their percentages of workdays finishing after 5:00 PM (P < 0.0001). While the mean was 18% (6%), the coefficient of variation was 37% (29% to 49%). There were no significant outliers. In contrast, not only were there differences among anesthesiologists in the relative risks of working late when receiving relief versus when not handing off a case (P < 0.0001), there were outliers. CONCLUSIONS An anesthesia department aiming for a 20% incidence of anesthesiologists having to work late when not on call can achieve this objective, long-term, within a few percent (e.g., 2%). Seasonal variation can contribute to variability among quarters in the overall departmental incidence. Individual anesthesiologists can have variability among themselves, though, and that is caused by large heterogeneity in their relative risks of working late when receiving relief versus when not handing off a case. For departments choosing to provide information to anesthesiologists to increase predictability, factors to consider should include season of the year and the individual anesthesiologist.
Collapse
|
23
|
Hannan EL, Samadashvili Z, Sundt TM, Girardi L, Chikwe J, Wechsler A, Adams DH, Smith CR, Gold JP, Lahey SJ, Jordan D. Association of Anesthesiologist Handovers With Short-term Outcomes for Patients Undergoing Cardiac Surgery. Anesth Analg 2020; 131:1883-1889. [DOI: 10.1213/ane.0000000000005221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
24
|
Hu J, Yang Y, Li X, Yu L, Zhou Y, Fallacaro MD, Wright S. Adverse Outcomes Associated With Intraoperative Anesthesia Handovers: A Systematic Review and Meta-analysis. J Perianesth Nurs 2020; 35:525-532.e1. [DOI: 10.1016/j.jopan.2020.01.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/27/2019] [Accepted: 01/09/2020] [Indexed: 12/27/2022]
|
25
|
Boet S, Djokhdem H, Leir SA, Théberge I, Mansour F, Etherington N. Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis. Br J Anaesth 2020; 125:605-613. [PMID: 32682560 DOI: 10.1016/j.bja.2020.05.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Handover of anaesthesia patient care during surgery is common; however, its association with patient outcome is unclear. This systematic review aimed to assess the impact of anaesthesia handover during surgery on patient outcome. METHODS All prospective and retrospective clinical studies specifically investigating the association of intraoperative transfer of anaesthesia care between anaesthesia providers in the operating room with patient morbidity and mortality were included. Searches were conducted from inception to April 24, 2019 in Medline, Medline in Process, CINAHL, and Embase. Reference lists of included studies were searched. Studies were assessed for eligibility and data were extracted by independent reviewers in duplicate with disagreements resolved by consensus or a third reviewer. Risk of bias was assessed in duplicate using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were summarised narratively given substantial heterogeneity. An exploratory meta-analysis was conducted using a random-effects model for a subset of comparable studies. RESULTS Eight studies met the inclusion criteria. Six studies focused on patients as the unit of analysis (npatients=605 678) and two focused on anaesthesia providers as the unit of analysis (nproviders=307). Seven studies identified a relationship between anaesthesia handovers and adverse patient outcomes, whereas one suggested that handover may be beneficial to error detection or rectification. Included studies were of fair or good quality. Meta-analysis of four studies found a 40% increased risk of patients experiencing an adverse event when an anaesthesia handover occurs during the procedure (pooled risk ratio=1.40; 95% confidence interval, 1.19 to 1.65; P<0.001; I2=98%). CONCLUSIONS Intraoperative anaesthesia handovers generally increase morbidity and mortality for surgical patients but could have the potential to improve safety in certain contexts. Future research should determine the specific handover characteristics that impact safety.
Collapse
Affiliation(s)
- Sylvain Boet
- Department of Anaesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Hadi Djokhdem
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sarah Anne Leir
- Department of Anaesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Isabel Théberge
- Department of Anaesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Fadi Mansour
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nicole Etherington
- Department of Anaesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| |
Collapse
|
26
|
Zhao R, Shammas RL, Broadwater G, Le E, Hansen-Estruch C, Kaakati R, Cason RW, Lyes M, Orr JP, Hollenbeck ST. Assessing the Influence of Attending Surgeon Continuity on Free Flap Outcomes Following Unplanned Returns to the Operating Room. J Reconstr Microsurg 2020; 36:583-591. [PMID: 32557453 DOI: 10.1055/s-0040-1713173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Unplanned returns to the operating room (OR) may be necessary at times to salvage a compromised free flap. The aim of this study was to assess the influence of attending surgeon continuity on free flap outcomes following a return to the OR. METHODS We retrospectively reviewed patients who underwent free flap reconstruction and experienced an unplanned return to the OR within 30 days from 2002 to 2017. Logistic regression modeling was used to determine factors that predict unplanned returns to the OR. RESULTS Of the 1,177 patients were identified, 267 (22.5%) had an unplanned return to the OR. Of these, 69 (5.9%) patients experienced total flap loss. Overall, 216 take-back procedures were performed by the primary surgeons (80.2%), while 50 were performed by covering surgeons (18.8%). Flap loss occurred more frequently during a weekend procedure (p = 0.013). Additionally, when the take-back procedure was performed within 5 days of the original surgery by the primary as opposed to a covering surgeon, patients experienced lower estimated blood loss (75 vs. 150 cc, p = 0.04). Overall, there was a significantly lower incidence of flap loss when the take-back procedure was performed by the primary, as opposed to the covering, surgeon (20 vs. 47%, p = 0.0001). CONCLUSION Higher rates of flap loss occur when a covering surgeon performs a take-back procedure in comparison to the primary surgeon. It is important to ensure the availability of the primary surgeon in the first few postoperative days following free flap reconstruction. When transfer of care is necessary, photographic or video documentation of the microvascular anastomosis may be helpful in addition to a verbal sign out.
Collapse
Affiliation(s)
- Ruya Zhao
- Duke University School of Medicine, Durham, North Carolina
| | - Ronnie L Shammas
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Gloria Broadwater
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Elliot Le
- Duke University School of Medicine, Durham, North Carolina
| | | | - Rayan Kaakati
- Duke University School of Medicine, Durham, North Carolina
| | - Roger W Cason
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Matthew Lyes
- Duke University School of Medicine, Durham, North Carolina
| | - Jonah P Orr
- Duke University School of Medicine, Durham, North Carolina
| | - Scott T Hollenbeck
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| |
Collapse
|
27
|
Lakha S, Levin MA, Leibowitz AB, Lin HM, Gal JS. Intraoperative Electronic Alerts Improve Compliance With National Quality Program Measure for Perioperative Temperature Management. Anesth Analg 2020; 130:1167-1175. [PMID: 32287124 DOI: 10.1213/ane.0000000000004546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Reimbursement for anesthesia services has been shifting from a fee-for-service model to a value-based model that ties payment to quality metrics. The Centers for Medicare & Medicaid Service's (CMS) value-based payment program includes a quality measure for perioperative temperature management (Measure #424, Perioperative Temperature Management). Compliance may impose new challenges in clinical practice, data collection, and reporting. We investigated the impact of an electronic decision-support tool on adherence to this emerging standard. METHODS In this retrospective observational study, perioperative temperature data were collected from cases eligible for reporting this measure to CMS from a single academic medical center before and after the implementation of an electronic decision-support tool that prompted temperature measurement and maintenance of normothermia. Proportions of measure compliance were assessed using segmented regression analysis. Proportions of intraoperative temperature measurement were also assessed, and multivariable logistic regression was performed to assess the association between patient and surgical factors and measure compliance. RESULTS A total of 24,755 cases eligible for reporting in 2017 were assessed, and 25,274 cases from 2016 were included as an extended baseline. Segmented time-series regression did not show a significant baseline trend in measure compliance. Introduction of the alerts was associated with an increase in overall compliance from 84.4% (95% confidence interval [CI], 83.6%-85.2%) to 92.4% (91.4%-93.4%), and an increase in intraoperative compliance from 26.8% (25.8%-27.8%) to 71.0% (69.6%-72.4%). The association between the alerts and overall compliance was also present on multivariable analysis. CONCLUSIONS Implementation of an intraoperative decision-support tool was associated with statistically significant improvement in the maintenance of normothermia in cases eligible for reporting to CMS. This led to improved compliance with Measure #424 and suggests that electronic alerts can help practices improve their performance and payment bonus eligibility.
Collapse
Affiliation(s)
- Sameer Lakha
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| | - Matthew A Levin
- From the Departments of Anesthesiology, Perioperative and Pain Medicine.,Genetics and Genomic Sciences
| | | | - Hung-Mo Lin
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan S Gal
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| |
Collapse
|
28
|
Krishnan S, Kumar N, Diaz E, Thornton I, Ghoddoussi F, Ellis TA. Anesthesiology Handoff Simulation Case: A Handoff From Intensive Care Unit to Operating Room for Anesthesiology Learners. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10887. [PMID: 32206703 PMCID: PMC7083603 DOI: 10.15766/mep_2374-8265.10887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 09/20/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Handoffs have been shown to be a potential cause of communication failures, leading to possible inefficiencies and patient harm. We noticed that our CA-1 residents were struggling with patient handoffs and designed this simulation to improve their handoff skills. METHODS This anesthesiology-specific simulation introduced learners to the perioperative handoff process. We designed it for anesthesiology learners, including junior residents, medical students, and student nurse anesthetists. The simulation centered upon an anesthesiology resident taking care of an ICU patient and handing that patient off to another anesthesiology provider, who took the patient to the OR. We charged learners with reviewing the patient's history and hospital course and giving a complete handoff. We evaluated learners on the completeness and quality of the handoff, as well as on their performance during the session. RESULTS Twenty-seven learners participated in this handoff simulation. The participants reported that the simulation improved their understanding of the anesthetic implications of medical conditions and gave them a better understanding of the essential elements of a handoff. Learners also indicated that the debriefing portion of the simulation was effective in filling some of their medical knowledge gaps and improving their handoff skills. DISCUSSION This simulation was found to be an effective educational experience for our CA-1 and CA-3 residents, medical students, and student nurse anesthetists. Feedback was positive from all learners. As a result, this simulation will be implemented in the early learning curriculum for all of our CA-1 residents.
Collapse
Affiliation(s)
- Sandeep Krishnan
- Associate Professor, Department of Anesthesiology, Wayne State University School of Medicine
- Program Director, Department of Anesthesiology, Wayne State University School of Medicine
- Chief of Cardiothoracic Anesthesiology, Department of Anesthesiology, Wayne State University School of Medicine
| | - Nakul Kumar
- Resident Physician, Department of Anesthesiology, The Cleveland Clinic
| | - Erik Diaz
- Resident Physician, Department of Anesthesiology, Wayne State University School of Medicine
| | - Imani Thornton
- Assistant Professor, Department of Anesthesiology, Wayne State University School of Medicine
| | - Farhad Ghoddoussi
- Research Associate, Department of Anesthesiology, Wayne State University School of Medicine
| | - Terry A. Ellis
- Associate Professor, Department of Anesthesiology, Wayne State University School of Medicine
| |
Collapse
|
29
|
Lazzara EH, Keebler JR, Simonson RJ, Agarwala A, Lane-Fall MB. Navigating the challenges of performing anesthesia handoffs and conducting anesthesia handoff research. Int Anesthesiol Clin 2019; 58:32-37. [PMID: 31800413 DOI: 10.1097/aia.0000000000000260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Elizabeth H Lazzara
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | - Joseph R Keebler
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | - Richard J Simonson
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | - Aalok Agarwala
- Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts
| | - Meghan B Lane-Fall
- Department of Anesthesiology, Perlemen School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
30
|
Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study. BMC Anesthesiol 2019; 19:182. [PMID: 31615410 PMCID: PMC6794912 DOI: 10.1186/s12871-019-0858-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/24/2019] [Indexed: 11/25/2022] Open
Abstract
Background The significance of intraoperative anesthesia handoffs on patient outcomes are unclear. One aspect differentiating the disparate results is the treatment of confounding factors, such as patient comorbidities and surgery time of day. We performed this study to quantify the significance of confounding variables on composite adverse events during intraoperative anesthesia handoffs. Methods In this retrospective study, we analyzed data from the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP). We examined the effects of intraoperative handoffs between anesthesia personnel. A total of 12,111 cases performed examined at two hospitals operated by a single healthcare system that were that included in the ACS NSQIP database performed. The presence of attending and anesthetist or resident handoffs, patient age, sex, body mass index, American Society of Anesthesiologists Physical Status (ASA-PS) classification, case length, surgical case complexity, and evening/weekend start time were measured. Results A total of 2586 of all cases in the NSQIP dataset experienced a handoff during the case. When analyzed as a single variable, attending handoffs were associated with higher rates of adverse outcomes. However, once confounding variables were added into the analysis, attending handoffs and complete care transitions were no longer statistically significant. Conclusions Inclusion of significant covariates is essential to fully understanding the impact provider handoffs have on patient outcomes. Case timing and lengthy case duration are more likely to result in both a handoff and an adverse event. The impact of handoffs on patient outcomes seen in the literature are likely due, in part, to how covariates were addressed.
Collapse
|
31
|
Dexter F, Osman BM, Epstein RH. Improving intraoperative handoffs for ambulatory anesthesia: challenges and solutions for the anesthesiologist. Local Reg Anesth 2019; 12:37-46. [PMID: 31213889 PMCID: PMC6538832 DOI: 10.2147/lra.s183188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/06/2019] [Indexed: 11/23/2022] Open
Abstract
Permanent transitions of care from one anesthesia provider to another are associated with adverse events and mortality. There are currently no available data on how to mitigate these poor patient outcomes other than to reduce the occurrence of such handoffs. We used data from an ambulatory surgery center to demonstrate the steps that can be taken to achieve this goal. First, perform statistical forecasting using many months of historical data to create optimal, as opposed to arbitrary shift durations. Second, consider assigning the anesthesia providers designated to work late, if necessary, to the ORs estimated to finish the earliest, rather than latest. We performed multiple analyses showing the quantitative advantage of this strategy for the ambulatory surgery center with multiple brief cases. Third, sequence the cases in the 1 or 2 ORs with the latest scheduled end times so that the briefest cases are finished last. If a supervising anesthesiologist needs to be relieved early for administrative duties (eg, head of the group to meet with administrators or surgeons), assign the anesthesiologist to an OR that finishes with several brief cases. The rationale for these recommendations is that such strategies provide multiple opportunities for a different anesthesia provider to assume responsibility for the patients between cases, thus avoiding a handoff altogether.
Collapse
Affiliation(s)
- Franklin Dexter
- Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, IA 52242, USA
| | - Brian Mark Osman
- Department of Anesthesiology, University of Miami, Miami, FL, USA
| | | |
Collapse
|
32
|
Agarwala AV, Lane-Fall MB, Greilich PE, Burden AR, Ambardekar AP, Banerjee A, Barbeito A, Bryson TD, Greenberg S, Lorinc AN, Lynch IP, Pukenas E, Cooper JB. Consensus Recommendations for the Conduct, Training, Implementation, and Research of Perioperative Handoffs. Anesth Analg 2019; 128:e71-e78. [DOI: 10.1213/ane.0000000000004118] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
33
|
Hanhan J, King R, Harrison TK, Kou A, Howard SK, Borg LK, Shum C, Udani AD, Mariano ER. A Pilot Project Using Eye-Tracking Technology to Design a Standardised Anaesthesia Workspace. Turk J Anaesthesiol Reanim 2018; 46:411-415. [PMID: 30505602 DOI: 10.5152/tjar.2018.67934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 07/31/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Maximising safe handoff procedures ensures patient safety. Anaesthesiology practices have primarily focused on developing better communication tools. However, these tools tend to ignore the physical layout of the anaesthesia workspace itself. Standardising the anaesthesia workspace has the potential to improve patient safety. The design process should incorporate end user feedback and objective data. Methods This pilot project aims to design a standardised anaesthesia workspace using eye-tracking technology at a single university-affiliated Veterans Affairs hospital. Twelve practising anaesthesiologists observed a series of images representing five clinical scenarios. Each of these had a question prompting them to look for certain items commonly found in the anaesthesia workspace. Using eye-tracking technology, the gaze data of participants were recorded. These data were used to generate heat maps of the specific areas of interest in the workspace that received the most fixation counts. Results The laryngoscope and propofol had the highest percentages of gaze fixations on the left-hand side of the workstation, in closest proximity to the anaesthesiologist. Atropine, although the highest percentage of gaze fixations (33%) placed it on the right-hand side of the workstation, also had 25% of gaze fixations centred over the anaesthesia cart. Conclusion Gaze fixation analyses showed that anaesthesiologists identified locations for the laryngoscope and propofol within easy reach and emergency medications further away. Because eye tracking can provide objective data to influence the design process, it may be useful when developing standardised anaesthesia workspace templates for individual practices.
Collapse
Affiliation(s)
- Jaber Hanhan
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Roderick King
- Stanford University School of Medicine, Stanford, CA, USA
| | - T Kyle Harrison
- Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Alex Kou
- Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Steven K Howard
- Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Lindsay K Borg
- Department of Anaesthesiology, Kaiser Permanente Northwest, Portland, OR, USA
| | - Cynthia Shum
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ankeet D Udani
- Department of Anaesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Edward R Mariano
- Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
34
|
Muralidharan M, Clapp JT, Pulos BP, Diraviam SP, Baranov DY, Gordon EKB, Lane-Fall MB. How does training in anesthesia residency shape residents' approaches to patient care handoffs? A single-center qualitative interview study. BMC MEDICAL EDUCATION 2018; 18:271. [PMID: 30458779 PMCID: PMC6245869 DOI: 10.1186/s12909-018-1387-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/14/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Handoffs are a complex procedure whose success relies on mutual discussion rather than simple information transfer. Particularly among trainees, handoffs present major opportunities for medical error. Previous research has explored best practices and pitfalls in general handoff education but has not discussed barriers specific to anesthesiology residents. This study characterizes the experiences of residents in anesthesiology as they learn handoff technique in order to inform strategies for teaching this important component of perioperative care. METHODS In 2016, we conducted a semi-structured interview study of 30 anesthesia residents across all three postgraduate years at a major academic hospital. Interviews were coded by two coders using a grounded theory approach and an iterative process designed to enhance reliability and validity. RESULTS Residents cited lack of consistency as a major impediment to proper handoff education. They found the impact of lectures and written materials to be limited. The level of guidance and direction they received from one-to-one attendings was described as highly variable. Residents' comfort in executing handoffs was heavily dependent on location and situation. They felt that coordination among the parties involved in the handoff was difficult to achieve, causing confusion about the importance of handoffs as well as proper protocol. Finally, residents offered opinions on when handoff education should occur during the residency and had several recommendations for its improving, including standardization of key handoff topics. CONCLUSIONS In a single center study of anesthesiology resident handoff education, residents exhibited confusion related to a perceived disconnect between the stated importance of effective handoffs and a lack of consensus on proper handoff technique. Standardization of curriculum and framing expectations has the potential to enhance resident handoff training in academic anesthesia departments.
Collapse
Affiliation(s)
- Madhavi Muralidharan
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA 19104 USA
- Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Justin T. Clapp
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA 19104 USA
- Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Bridget Perrin Pulos
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN USA
| | - Sushmitha P. Diraviam
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA 19104 USA
| | - Dimitry Y. Baranov
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA 19104 USA
| | - Emily K. B. Gordon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA 19104 USA
| | - Meghan B. Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA 19104 USA
- Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| |
Collapse
|
35
|
Training in intraoperative handover and display of a checklist improve communication during transfer of care: An interventional cohort study of anaesthesia residents and nurse anaesthetists. Eur J Anaesthesiol 2018; 34:471-476. [PMID: 28437261 PMCID: PMC5466020 DOI: 10.1097/eja.0000000000000636] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Handovers during anaesthesia are common, and failures in communication may lead to morbidity and mortality. OBJECTIVES We hypothesised that intraoperative handover training and display of a checklist would improve communication during anaesthesia care transition in the operating room. DESIGN Interventional cohort study. SETTING Single-centre tertiary care university hospital. PARTICIPANTS A total of 204 random observations of handovers between anaesthesia providers (residents and nurse anaesthetists) over a 6-month period in 2016. INTERVENTION Two geographically different hospital sites were studied simultaneously (same observations, but no training/checklist at the control site): first a 2-week 'baseline' observation period; then handover training and display of checklists in each operating room (at the intervention site only) followed by an 'immediate' second and finally a third (3 months later) observation period. MAIN OUTCOME MEASURES A 22-item checklist was created by a modified DELPHI method and a checklist score calculated for each handover by adding the individual scores for each item as follows: -1, if error in communicating item; 0, unreported item; 0.5, if partly communicated item; 1, if correctly communicated item. RESULTS Before training and display of the checklist, the scores in the interventional and the control groups were similar. There was no improvement in the control group's scores over the three observation periods. In the interventional group, the mean (95% confidence interval) score increased by 43% [baseline 7.6 (6.7 to 8.4) n = 42; 'immediate' 10.9 (9.4 to 12.4) n = 27, P < 0.001]. This improvement persisted at 3 months without an increase in the mean duration of handovers. CONCLUSION Intraoperative handover training and display of a checklist in the operating room improved the checklist score for intraoperative transfer of care in anaesthesia.
Collapse
|
36
|
Abstract
Handovers around the time of surgery are common, yet complex and error prone. Interventions aimed at improving handovers have shown increased provider satisfaction and teamwork, improved efficiency, and improved communication and have been shown to reduce errors and improve clinical outcomes in some studies. Common recommendations in the literature include a standardized institutional process that allows flexibility among different units and settings, the completion of urgent tasks before information transfer, the presence of all members of the team for the duration of the handover, a structured conversation that uses a cognitive aid, and education in team skills and communication.
Collapse
|
37
|
Jones PM, Shariff SZ, Wijeysundera DN. Anesthesia Care Handovers and Risk of Adverse Outcomes-Reply. JAMA 2018; 319:2237-2238. [PMID: 29872858 DOI: 10.1001/jama.2018.4462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Philip M Jones
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
| | - Salimah Z Shariff
- Institute of Clinical Evaluative Sciences, Western Site (ICES Western), London, Ontario, Canada
| | | |
Collapse
|
38
|
Lee SC, Atkinson ME, Minard CG, O'Brien A. Electronic tool helps anaesthesia trainee handovers. CLINICAL TEACHER 2018; 16:58-63. [DOI: 10.1111/tct.12768] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Susan C Lee
- Anesthesiology DepartmentBaylor College of Medicine Houston Texas USA
| | - Megan E Atkinson
- Anesthesiology DepartmentBaylor College of Medicine Houston Texas USA
| | - Charles G Minard
- Dan L Duncan Institute for Clinical and Translational ResearchBaylor College of Medicine Houston Texas USA
| | - Alice O'Brien
- Anesthesiology DepartmentBaylor College of Medicine Houston Texas USA
| |
Collapse
|
39
|
Jones PM, Cherry RA, Allen BN, Jenkyn KMB, Shariff SZ, Flier S, Vogt KN, Wijeysundera DN. Association Between Handover of Anesthesia Care and Adverse Postoperative Outcomes Among Patients Undergoing Major Surgery. JAMA 2018; 319:143-153. [PMID: 29318277 PMCID: PMC5833659 DOI: 10.1001/jama.2017.20040] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
IMPORTANCE Handing over the care of a patient from one anesthesiologist to another occurs during some surgeries and might increase the risk of adverse outcomes. OBJECTIVE To assess whether complete handover of intraoperative anesthesia care is associated with higher likelihood of mortality or major complications compared with no handover of care. DESIGN, SETTING, AND PARTICIPANTS A retrospective population-based cohort study (April 1, 2009-March 31, 2015 set in the Canadian province of Ontario) of adult patients aged 18 years and older undergoing major surgeries expected to last at least 2 hours and requiring a hospital stay of at least 1 night. EXPOSURE Complete intraoperative handover of anesthesia care from one physician anesthesiologist to another compared with no handover of anesthesia care. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Secondary outcomes were the individual components of the primary outcome. Inverse probability of exposure weighting based on the propensity score was used to estimate adjusted exposure effects. RESULTS Of the 313 066 patients in the cohort, 56% were women; the mean (SD) age was 60 (16) years; 49% of surgeries were performed in academic centers; 72% of surgeries were elective; and the median duration of surgery was 182 minutes (interquartile [IQR] range, 124-255). A total of 5941 (1.9%) patients underwent surgery with complete handover of anesthesia care. The percentage of patients undergoing surgery with a handover of anesthesiology care progressively increased each year of the study, reaching 2.9% in 2015. In the unweighted sample, the primary outcome occurred in 44% of the complete handover group compared with 29% of the no handover group. After adjustment, complete handovers were statistically significantly associated with an increased risk of the primary outcome (adjusted risk difference [aRD], 6.8% [95% CI, 4.5% to 9.1%]; P < .001), all-cause death (aRD, 1.2% [95% CI, 0.5% to 2%]; P = .002), and major complications (aRD, 5.8% [95% CI, 3.6% to 7.9%]; P < .001), but not with hospital readmission within 30 days of surgery (aRD, 1.2% [95% CI, -0.3% to 2.7%]; P = .11). CONCLUSIONS AND RELEVANCE Among adults undergoing major surgery, complete handover of intraoperative anesthesia care compared with no handover was associated with a higher risk of adverse postoperative outcomes. These findings may support limiting complete anesthesia handovers.
Collapse
Affiliation(s)
- Philip M. Jones
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Richard A. Cherry
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
| | - Britney N. Allen
- Institute of Clinical Evaluative Sciences, Western Site (ICES Western), London, Ontario, Canada
| | - Krista M. Bray Jenkyn
- Institute of Clinical Evaluative Sciences, Western Site (ICES Western), London, Ontario, Canada
| | - Salimah Z. Shariff
- Institute of Clinical Evaluative Sciences, Western Site (ICES Western), London, Ontario, Canada
- Arthur Labatt School of Nursing, University of Western Ontario, London, Ontario, Canada
| | - Suzanne Flier
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
| | - Kelly N. Vogt
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Duminda N. Wijeysundera
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Institute of Clinical Evaluative Sciences, Central Site (ICES Central), Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
40
|
Quality organization and risk in anaesthesia: the French perspective. Curr Opin Anaesthesiol 2017; 30:230-235. [PMID: 28118164 DOI: 10.1097/aco.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Ensuring the quality and safety of anaesthesia in the face of budgetary restrictions and changing demographics is challenging. In France, the environment is regulated by the legislation, and it is often necessary to find solutions that seize opportunities to break with the traditional organization. RECENT FINDINGS Postoperative mortality remains excessively high. The move towards ambulatory care is being adequately integrated into all the stages of patient management in the context of a single therapeutic plan that is mutually agreed upon by all caregivers. The French National Health Authority, which provides certification for healthcare establishments, encourages this 'seamless' approach between private practice and the hospital setting, based on teamwork and interdisciplinary consultation. By daring to break with traditional organizational structures, and by taking account of human factors and staged strategies, it is possible to deliver appropriate care, with a level of quality and safety that meets users' demands. SUMMARY The management of a patient undergoing surgery with anaesthesia is a seamless spectrum from the patient's home to the hospital and back to home. Decision-making must be multidisciplinary. Increased use of ambulatory care, breaks with traditional organizational structures, and efforts to reduce postoperative mortality represents opportunities to improve overall system performance. Demographic and economic constraints are potential threats to be identified.
Collapse
|
41
|
Han HH, Ko JG, Rhie JW. Factors for postoperative complications following pressure ulcer operation: stepwise multiple logistic regression analysis. Int Wound J 2017; 14:1036-1040. [PMID: 28419746 DOI: 10.1111/iwj.12754] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 03/09/2017] [Accepted: 03/28/2017] [Indexed: 02/04/2023] Open
Abstract
Patients with pressure ulcers are generally older, have a long hospital stay and often have a variety of comorbidities. The decision to perform surgery for pressure ulcer management can be difficult because of concerns about the risk of postoperative complications. The aim of this study was to analyse the relationship between comorbid conditions and surgical outcomes in order to guide patient selection for pressure ulcer surgery. In 57 patients, data on age, defect size, operating time, hospital stay, body mass index, surgical site, mobility state, cardiac ischaemic history, diabetes, renal failure, ventilator dependency, tracheostomy state, use of haemodilution therapy and cancer were evaluated using stepwise multiple logistic regression analysis to determine the relationships between variables. There were no postoperative cardiac ischaemic events. Wound complications occurred in 8 patients (14%), pneumonia in 12 patients (21·1%) and mortality in 1 patient (1·7%). The risk of postoperative pneumonia increased 1·069-fold in elderly patients (odds ratio = 1·069, P < 0·05) and increased 44·17-fold in preoperative ventilator users (odds ratio = 44·17, P < 0·05). The risk of wound complication increased 1·012-fold with the presence of a larger defect site (odds ratio = 1·012, P < 0·05) and increased 7·474-fold in patients who received haemodilution therapy (odds ratio = 7·474, P < 0·05). Our results indicate that most comorbid conditions did not significantly affect postoperative cardiopulmonary or wound complications. However, the risk of postoperative pneumonia increased in patients with ventilator use or old age, and the risk of wound complication increased in patients with a large defect size and in those who used haemodilution therapy.
Collapse
Affiliation(s)
- Hyun Ho Han
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Jun Gul Ko
- Department of Plastic Surgery, Seoul St. Mary's hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Won Rhie
- Department of Plastic Surgery, Seoul St. Mary's hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
42
|
Park LS, Yang G, Tan KS, Wong CH, Oskar S, Borchardt RA, Tollinche LE. Does Checklist Implementation Improve Quantity of Data Transfer: An Observation in Postanesthesia Care Unit (PACU). OPEN JOURNAL OF ANESTHESIOLOGY 2017; 7:69-82. [PMID: 29780662 PMCID: PMC5954829 DOI: 10.4236/ojanes.2017.74007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Omission of patient information in perioperative communication is closely linked to adverse events. Use of checklists to standardize the handoff in the post anesthesia care unit (PACU) has been shown to effectively reduce medical errors. OBJECTIVE Our study investigates the use of a checklist to improve quantity of data transfer during handoffs in the PACU. DESIGN A cross-sectional observational study. SETTING PACU at Memorial Sloan Kettering Cancer Center (MSKCC); June 13, 2016 through July 15, 2016. PATIENTS OTHER PARTICIPANTS We observed the handoff reports between the nurses, PACU midlevel providers, anesthesia staff, and surgical staff. INTERVENTION A physical checklist was provided to all anesthesia staff and recommended to adhere to the list at all observed PACU handoffs. MAIN OUTCOME MEASURE Quantity of reported handoff items during 60 pre- and 60 post-implementation of a checklist. RESULTS Composite value from both surgical and anesthesia reports showed an increase in the mean report of 8.7 items from pre-implementation period to 10.9 post-implementation. Given that surgical staff reported the mean of 5.9 items pre-implementation and 5.5 items post-implementation without intervention, improvements in anesthesia staff report with intervention improved the overall handoff data transfer. CONCLUSIONS Using a physical 12-item checklist for PACU handoff increased overall data transfer.
Collapse
Affiliation(s)
- Lauren S. Park
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Gloria Yang
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Charlotte H. Wong
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
- Cornell University, Ithaca, NY, USA
| | - Sabine Oskar
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Ruth A. Borchardt
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Luis E. Tollinche
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| |
Collapse
|
43
|
Wax DB, McCormick PJ. A Real-Time Decision Support System for Anesthesiologist End-of-Shift Relief. Anesth Analg 2017; 124:599-602. [DOI: 10.1213/ane.0000000000001515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
44
|
Abstract
Abstract
Background
Whether anesthesia care transitions and provision of short breaks affect patient outcomes remains unclear.
Methods
The authors determined the number of anesthesia handovers and breaks during each case for adults admitted between 2005 and 2014, along with age, sex, race, American Society of Anesthesiologists physical status, start time and duration of surgery, and diagnosis and procedure codes. The authors defined a collapsed composite of in-hospital mortality and major morbidities based on primary and secondary diagnoses. The relationship between the total number of anesthesia handovers during a case and the collapsed composite outcome was assessed with a multivariable logistic regression. The relationship between the total number of anesthesia handovers during a case and the components of the composite outcome was assessed using multivariate generalized estimating equation methods. Additionally, the authors analyzed major complications and/or death within 30 days of surgery based on the American College of Surgeons National Surgical Quality Improvement Program–defined events.
Results
A total of 140,754 anesthetics were identified for the primary analysis. The number of anesthesia handovers was not found to be associated (P = 0.19) with increased odds of postoperative mortality and serious complications, as measured by the collapsed composite, with odds ratio for a one unit increase in handovers of 0.957; 95% CI, 0.895 to 1.022, when controlled for potential confounding variables. A total of 8,404 anesthetics were identified for the NSQIP analysis (collapsed composite odds ratio, 0.868; 95% CI, 0.718 to 1.049 for handovers).
Conclusions
In the analysis of intraoperative handovers, anesthesia care transitions were not associated with an increased risk of postoperative adverse outcomes.
Collapse
|
45
|
Dexter F, Epstein RH, Dutton RP, Kordylewski H, Ledolter J, Rosenberg H, Hindman BJ. Diversity and Similarity of Anesthesia Procedures in the United States During and Among Regular Work Hours, Evenings, and Weekends. Anesth Analg 2016; 123:1567-1573. [PMID: 27611808 DOI: 10.1213/ane.0000000000001558] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Anesthesiologists providing care during off hours (ie, weekends or holidays, or cases started during the evening or late afternoon) are more likely to care for patients at greater risk of sustaining major adverse events than when they work during regular hours (eg, Monday through Friday, from 7:00 AM to 2:59 PM). We consider the logical inconsistency of using subspecialty teams during regular hours but not during weekends or evenings. METHODS We analyzed data from the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry (NACOR). Among the hospitals in the United States, we estimated the average number of common types of anesthesia procedures (ie, diversity measured as inverse of Herfindahl index), and the average difference in the number of common procedures between 2 off-hours periods (regular hours versus weekends, and regular hours versus evenings). We also used NACOR data to estimate the average similarity in the distributions of procedures between regular hours and weekends and between regular hours and evenings in US facilities. Results are reported as mean ± standard error of the mean among 399 facilities nationwide with weekend cases. RESULTS The distributions of common procedures were moderately similar (ie, not large, <.8) between regular hours and evenings (similarity index .59 ± .01) and between regular hours and weekends (similarity index, .55 ± .02). For most facilities, the number of common procedures differed by <5 procedures between regular hours and evenings (74.4% of facilities, P < .0001) and between regular hours and weekends (64.7% of facilities, P < .0001). The average number of common procedures was 13.59 ± .12 for regular hours, 13.12 ± .13 for evenings, and 9.43 ± .13 for weekends. The pairwise differences by facility were .13 ± .07 procedures (P = .090) between regular hours and evenings and 3.37 ± .12 procedures (P < .0001) between regular hours and weekends. In contrast, the differences were -5.18 ± .12 and 7.59 ± .13, respectively, when calculated using nationally pooled data. This was because the numbers of common procedures were 32.23 ± .05, 37.41 ± .11, and 24.64 ± .12 for regular hours, evenings, and weekends, respectively (ie, >2x the number of common procedures calculated by facility). CONCLUSIONS The numbers of procedures commonly performed at most facilities are fewer in number than those that are commonly performed nationally. Thus, decisions on anesthesia specialization should be based on quantitative analysis of local data rather than national recommendations using pooled data. By facility, the number of different procedures that take place during regular hours and off hours (diversity) is essentially the same, but there is only moderate similarity in the procedures performed. Thus, at many facilities, anesthesiologists who work principally within a single specialty during regular work hours will likely not have substantial contemporary experience with many procedures performed during off hours.
Collapse
Affiliation(s)
- Franklin Dexter
- From the *Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa; †Miller School of Medicine, University of Miami, Florida; ‡Anesthesia Quality Institute, Schaumburg, Illinois; §United States Anesthesia Partners, Ft Lauderdale, Florida; ‖Department of Management Sciences, University of Iowa, Iowa City, Iowa; ¶Malignant Hyperthermia Association of the United States, New York, New York; #Saint Barnabas Medical Center, Livingston, New Jersey; and **Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | | | | | | | | | | | | |
Collapse
|
46
|
Wanta BT, Glasgow AE, Habermann EB, Kor DJ, Cima RR, Berbari EF, Curry TB, Brown MJ, Hyder JA. Operating Room Traffic as a Modifiable Risk Factor for Surgical Site Infection. Surg Infect (Larchmt) 2016; 17:755-760. [PMID: 27598433 DOI: 10.1089/sur.2016.123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Surgical site infections (SSI) contribute to surgical patients' morbidity and costs. Operating room traffic may be a modifiable risk factor for SSI. We investigated the impact of additional operating room personnel on the risk of superficial SSI (sSSI). PATIENTS AND METHODS In this matched case-control study, cases included patients in whom sSSI developed in clean surgical incisions after elective, daytime operations. Control subjects were matched by age, gender, and procedure. Operating room personnel were classified as (1) surgical scrubbed, (2) surgical non-scrubbed, or (3) anesthesia. We used conditional logistic regression to test the extent to which additional personnel overall and from each work group were associated with infection. RESULTS In total, 474 patients and 803 control subjects were identified. Each additional person among total personnel and personnel from each work group was significantly associated with greater odds of infection (all personnel, odds ratio [OR] = 1.082, 95% confidence interval [CI] 1.031-1.134, p = 0.0013; surgical scrubbed OR = 1.132, 95% CI 1.029-1.245, p = 0.0105; surgical non-scrubbed OR = 1.123, 95% CI 1.008-1.251, p = 0.0357; anesthesia OR = 1.153, 95% CI 1.031-1.290, p = 0.0127). After adjusting for operative duration, body mass index, diabetes mellitus, and vascular disease, additional personnel and sSSI were no longer associated overall or for any work groups (total personnel OR = 1.033, 95% CI 0.974-1.095, p = 0.2746; surgical scrubbed OR = 1.060, 95% CI 0.952-1.179, p = 0.2893; surgical non-scrubbed OR = 1.023 95% CI 0.907-1.154, p = 0.7129; anesthesia OR = 1.051, 95% CI 0.926-1.193, p = 0.4442). CONCLUSION The presence of additional operating room personnel was not independently associated with increased odds of sSSI. Efforts dedicated to sSSI reduction should focus on other modifiable risk factors.
Collapse
Affiliation(s)
- Brendan T Wanta
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota
| | - Amy E Glasgow
- 2 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota
| | - Elizabeth B Habermann
- 2 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota.,3 Department of Health Sciences Research, Division of Health Care Research and Policy, Mayo Clinic , Rochester, Minnesota
| | - Daryl J Kor
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota
| | - Robert R Cima
- 2 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota.,4 Department of Surgery, Division of Colorectal Surgery, Mayo Clinic , Rochester, Minnesota
| | - Elie F Berbari
- 5 Department of Medicine, Division of Infectious Diseases, Mayo Clinic , Rochester, Minnesota
| | - Timothy B Curry
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota.,6 Department of Medicine, Division of Physiology, Mayo Clinic , Rochester, Minnesota
| | - Michael J Brown
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota
| | - Joseph A Hyder
- 1 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota.,2 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota
| |
Collapse
|
47
|
Char D. Anesthesia Intraoperative Handoffs: Is Decision Ownership Compatible With Transitions of Care Providers? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:19-20. [PMID: 27471931 DOI: 10.1080/15265161.2016.1197341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
|
48
|
Ledolter J, Dexter F. On the reciprocity of connections in weighted and unweighted networks. COMMUN STAT-THEOR M 2016. [DOI: 10.1080/03610926.2015.1085570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Johannes Ledolter
- Department of Management Sciences, Tippie College of Business, University of Iowa, Iowa City, IA, USA
| | - Franklin Dexter
- Department of Anesthesia, College of Medicine, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
49
|
|