Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications Among Adults

Abstract

IMPORTANCEIntraoperative 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 PARTICIPANTSThis 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 MEASURESThe 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.

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“…There are up to 300 million surgical procedures annually in the world [ 1 ]. About 10–50% of surgical patients suffer continuous postsurgical pain [ 2 ], of which, about 2–10% is severe pain that lasts for at least one year [ 3 ].…”

Outcomes From Intraoperative Handovers of Anesthesia Care

“…First, we believe that the negative findings in this study should be interpreted in light of the fact that continuity of care was preserved in most cases via the supervising anesthesiologist even after cases were handed over between anesthesia trainees . This definition of complete handover differs from those used in prior studies, in which an attending anesthesiologist transitioned patient care to another attending anesthesiologist and then was no longer available .…”

“…This definition of complete handover differs from those used in prior studies, in which an attending anesthesiologist transitioned patient care to another attending anesthesiologist and then was no longer available . The continuity of supervisory anesthesia care in this study may have served as a buffer that prevented negative outcomes. Although the primary analysis found no differences in the composite outcome, the adjusted analysis, as recommended for randomization stratification factors, showed that 1 handover of care had an odds ratio of 1.16 for the 30-day composite primary outcome of all-cause mortality, hospital readmission, or serious postoperative complications.…”

“…To the Editor A recent randomized clinical trial (RCT) from Germany investigating the effect of intraoperative handovers of anesthesia care on mortality, readmission, or postoperative complications found no difference in outcomes with handovers. This finding contrasts with prior retrospective studies that found anesthesia handovers were associated with adverse outcomes, raising questions about what constitutes a complete handover of anesthesia care, whether the findings of the RCT apply to handovers in other countries, including the US, and whether standardized handover protocols might improve outcomes.…”

“…Second, the handovers described in this trial were conducted under auspicious conditions, presumably among stable patients undergoing elective, preplanned procedures, which may limit the generalizability of the results. Specifically, 93% of surgeries in the handover group started before 1 pm , within a median duration of 140 minutes from the start of the procedure.…”