Failures in communication and teamwork continue to be leading causes of preventable deaths and other adverse events in health care.1 Handoffs are essential in modern health care delivery and are defined by The Joint Commission as the “real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient's care.”2 Recognizing the critical importance of care transitions in improving patient safety, The Joint Commission initially made handoff communication a national patient safety goal in 2006 and part of their standards in 2010.3 In 2012, the Accreditation Council for Graduate Medical Education (ACGME) made handoff communication education a requirement for all accredited teaching programs in the United States.4 

As physicians caring for patients throughout the perioperative care continuum, anesthesiologists have a unique responsibility for handoffs. When patients transition from preoperative to intraoperative to postoperative care settings, responsibility for patient care is transferred among different clinicians and teams. With more than 310 million surgical procedures performed annually worldwide,5 improving communication during perioperative handoffs represents a significant opportunity to reduce adverse outcomes and improve patient safety.

Handoffs allow care teams to address and manage concerns, consider novel perspectives, and share contingency plans while building a shared mental model.6 However, in the often noisy, chaotic perioperative environment, it is challenging for clinicians to effectively communicate while continuing to provide patient care. These challenges are compounded because perioperative handoffs often occur between clinicians with different levels of training (e.g., attending to resident, resident to CRNA, etc.), and across roles (e.g., anesthesiologist to PACU nurse, inpatient medicine resident to anesthesiologist, etc.).7 

In this article, we will briefly synthesize the current evidence regarding the association of perioperative handoffs with adverse patient outcomes, share evidence for handoff-related interventions that may improve patient care, and peer into the future to see what technological innovations might help us with handoffs in the coming years.

Figure: Example of a handoff tool in a simulated intraoperative electronic record (©2022 Epic Systems Corporation).

Figure: Example of a handoff tool in a simulated intraoperative electronic record (©2022 Epic Systems Corporation).

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Multiple observational studies conducted in leading academic institutions have demonstrated an association between intraoperative transfers of care and adverse outcomes. A 2014 Cleveland Clinic study of nearly 139,000 patients found an 8% increase in in-hospital morbidity and mortality with each additional intraoperative handoff among anesthesia clinicians.8 A 2016 Mayo Clinic study of patients undergoing elective colorectal procedures found a direct correlation between the number of anesthesiology providers on a case and postoperative complications.9 In a study of more than 313,000 patients undergoing major surgery lasting more than two hours, complete handoffs were associated with a 6.8% absolute increased risk of postoperative complications, including death.10 A 2020 systematic review and meta-analysis further confirmed the above conclusions, linking a complete anesthesia handoff to negative outcomes; patients experienced a a 40% increased risk of an adverse event when an intraoperative handoff occurs.11 

One limitation of these retrospective studies is that the occurrence of a handoff may be a proxy for longer and more complex cases, possibly leading to after-hours surgery, clinician fatigue, and a higher risk of perioperative complications.12 A recent study13 tried to overcome the limitations of a retrospective approach with a randomized controlled trial. There was no difference between the handoffs and control groups in the rate of all-cause mortality or serious postoperative complications; however, several methodological weaknesses limit the generalizability of their conclusions.

It is important to note that several authors have challenged the notion that handoffs are associated with increased harm and have suggested that intraoperative transfers of care might even be beneficial to patient outcomes.14,15 Cooper et al. pointed out as early as 1978 that a fresh, new perspective from an incoming anesthesia professional could help identify harmful patterns that have been ignored by the current anesthesiologist. However, despite some notable exceptions, the preponderance of the published literature has concluded that multiple intraoperative handoffs are associated with adverse outcomes.

It is critical to determine what clinicians can do to improve the quality of handoffs and how high-quality handoffs can mitigate patient harm.

Several studies have demonstrated that the use of a checklist and team training led to improved accuracy and completeness of information transfer and increased clinician satisfaction. In one study, the development and implementation of a standardized handoff checklist resulted in handoff tool use improving from 20% to 100% in the OR and from 59% to greater than 90% in the PACU.16 Similarly, Salzwedl et al. reported that the use of a checklist was associated with an increased transfer of information, with only a modest prolongation of the handoff duration.17 

More recently, the electronic medical record (EMR) has been used to implement standardized checklists to improve intraoperative handoffs. Agarwala et al. showed that the adoption of an EMR-based checklist resulted in significant improvements in information transfer and its retention by receiving clinicians.18 Jelacic et al. also demonstrated that a tablet-based handoff checklist resulted in more items communicated.19 Other authors have suggested that a multimodal intervention, including the use of checklists, didactics, and simulation training, can improve the quality of transitions of care.20 

A recent review confirmed the benefits of using standardized checklists during intraoperative handoffs, concluding that the use of handoff tools can improve effectiveness (information retention, bilateral communication), efficiency (handoff duration), adoption, and clinicians' satisfaction with the handoff process.21 Another recent meta-analysis focused on OR to PACU handoffs showed that standardization of handoffs can improve provider, patient, and organization outcomes.22 

There is also early evidence to suggest that improvements in handoff communication can enable anesthesia professionals to identify concerns earlier and to provide appropriate care in a timely fashion, resulting in improved patient outcomes. In a prospective, single-center, pre/post checklist implementation study, Jaulin et. al. found a 5.6-fold reduction in hypoxic episodes in the PACU with the implementation of a checklist.23 Another retrospective single-center study in patients undergoing noncardiac surgery found that 30-day composite of all-cause mortality and postoperative morbidity was associated with anesthesia handoffs and that the odds ratio for this composite outcome significantly decreased after the introduction of a structured handoff tool.24 

More research is needed to validate whether intervention with checklists affects postoperative morbidity, hospital length of stay, and mortality. However, by reducing errors, enhancing communication, and fostering a culture of safety, it appears that improved handoff communication is ultimately leading to better patient outcomes and higher-quality care.24,25 

Intraoperative handoffs are prevalent and associated with worse clinical outcomes, especially during complex procedures and when patients have significant comorbidities. It is important that anesthesiology groups, health systems, and professional societies implement effective tactics that decrease the number of intraoperative handoffs. However, this may be challenging with limited OR capacity, staff shortages, and the often-conflicting scheduling priorities of the perioperative team, including OR nurses, surgeons, and anesthesia clinicians.

“It is important that anesthesiology groups, health systems, and professional societies implement effective tactics that decrease the number of intraoperative handoffs. However, this may be challenging with limited OR capacity, staff shortages, and the often-conflicting scheduling priorities of the perioperative team.”

Technology can assist with decreasing the risks of perioperative communication breakdown. EMR vendors have collaborated with clinicians to develop customizable intraoperative handoff tools24,26 that include cognitive checklists and allow easy retrieval and display of relevant clinical information. These tools can assist clinicians by promoting the complete and actionable transfer of information. Both clinical outcomes and regulatory compliance might be expected to improve.3 

Furthermore, the use of artificial intelligence (AI), including machine learning and predictive analytics, is increasingly being adopted in the perioperative setting27, and its integration into perioperative handoff tools is on the way. AI will likely allow the identification of patients at risk of specific perioperative complications such as acute kidney injury, delirium, pneumonia, deep vein thrombosis, pulmonary embolism, and cardiac events.28,29 These risk predictions could be integrated into an electronic “augmented handoff” tool, directing clinicians' attention toward prevention, early diagnosis, and/or treatment of higher likelihood complications.

“Precision medicine,” an emerging approach for disease treatment and prevention that considers individual variability in genes, environment, and lifestyle for each person30, will also likely find its way into augmented handoff tools. Clinicians will be able to tailor perioperative treatment by selecting drugs likely to be the most effective in individual patients; for instance, in treating postoperative pain.31 Human factors, quality improvement, and implementation science principles will assist clinicians and health care administrators with designing, rolling out, and scaling of effective initiatives to enhance the handoff processes.32 Finally, development of new standards for exchanging electronic health care data, known as Fast Healthcare Interoperability Resources, or FHIR,33 will be used in the creation of EMR handoff tools. FHIR will facilitate preserving and transferring critical clinical information across episodes of care, regardless of institution or setting, enabling more consistent care with fewer information gaps.

In conclusion, ensuring continuity and coordination of care in the perioperative setting is essential to patient safety. While perioperative handoffs may present a challenge, well conducted, structured handoffs with the use of effective tools can help us to achieve high-quality, safe patient care.

Andrea Vannucci, MD, FASA, ASA Committee on Patient Safety Education, Vice Chair for Quality, and Safety/Clinical Professor, University of Iowa, Iowa City, Iowa.

Andrea Vannucci, MD, FASA, ASA Committee on Patient Safety Education, Vice Chair for Quality, and Safety/Clinical Professor, University of Iowa, Iowa City, Iowa.

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Madina R. Gerasimov, MD, MS, ASA Committee on Patient Safety and Education, ASA Abstract Review Subcommittee on Perioperative Medicine, Presurgical Testing, Medical Director, Quality Improvement, Director, and Assistant Professor, Hofstra University School of Medicine, North Shore University Hospital, Northwell Health, Manhasset, New York.

Madina R. Gerasimov, MD, MS, ASA Committee on Patient Safety and Education, ASA Abstract Review Subcommittee on Perioperative Medicine, Presurgical Testing, Medical Director, Quality Improvement, Director, and Assistant Professor, Hofstra University School of Medicine, North Shore University Hospital, Northwell Health, Manhasset, New York.

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Fenghua Li, MD, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Neuroanesthesiology, and Professor and Vice Chair for Quality Assurance, Department of Anesthesiology, SUNY Upstate Medical University, Syracuse, New York.

Fenghua Li, MD, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Neuroanesthesiology, and Professor and Vice Chair for Quality Assurance, Department of Anesthesiology, SUNY Upstate Medical University, Syracuse, New York.

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Aalok V. Agarwala, MD, MBA, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Practice Management, Vice President, Quality and Safety, Associate CMO, Massachusetts General Hospital and Mass Eye and Ear, and Assistant Professor, Harvard Medical School, Boston, Massachusetts.

Aalok V. Agarwala, MD, MBA, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Practice Management, Vice President, Quality and Safety, Associate CMO, Massachusetts General Hospital and Mass Eye and Ear, and Assistant Professor, Harvard Medical School, Boston, Massachusetts.

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2
Joint Commission Center for Transforming Healthcare releases targeted solutions tool for hand-off communications.
Jt Comm Perspect
2012
;
32
(
8
):
1
3
. pubmed.ncbi.nlm.nih.gov/22928243/
3
The Joint Commission. Inadequate hand-off communication.
Sentinel Event Alert
2017
(
58
):
1
6
. pubmed.ncbi.nlm.nih.gov/25831561/
4
Lane-Fall
MB
,
Brooks
AK
,
Wilkins
SA
,
Davis
JJ
,
Riesenberg
LA
.
Addressing the mandate for hand-off education: a focused review and recommendations for anesthesia resident curriculum development and evaluation
.
Anesthesiology
2014
;
120
(
1
):
218
29
. doi.org/10.1097/aln.0000000000000070
5
Weiser
TG
,
Haynes
AB
,
Molina
G
,
Lipsitz
SR
,
Esquivel
MM
,
Uribe-Leitz
T
, et al
Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes
.
Lancet
2015
;
385
Suppl 2
:
S11
. doi.org/10.1016/s0140-6736(15)60806-6
6
Patterson
ES
,
Wears
RL
.
Patient handoffs: standardized and reliable measurement tools remain elusive
.
Jt Comm J Qual Patient Saf
2010
;
36
(
2
):
52
61
. doi.org/10.1016/s1553-7250(10)36011-9
7
Lorinc
AH C
. All Handoffs Are Not the Same: What Perioperative Handoffs Do We Participate in and How Are They Different? handoffs.org/all-handoffs-are-not-the-same/
8
Saager
L
,
Hesler
BD
,
You
J
,
Turan
A
,
Mascha
EJ
,
Sessler
DI
, et al
Intraoperative transitions of anesthesia care and postoperative adverse outcomes
.
Anesthesiology
2014
;
121
(
4
):
695
706
. doi.org/10.1097/aln.0000000000000401
9
Hyder
JA
,
Bohman
JK
,
Kor
DJ
,
Subramanian
A
,
Bittner
EA
,
Narr
BJ
, et al
Anesthesia Care Transitions and Risk of Postoperative Complications
.
Anesth Analg
2016
;
122
(
1
):
134
44
. doi.org/10.1213/ane.0000000000000692
10
Jones
PM
,
Cherry
RA
,
Allen
BN
,
Jenkyn
KMB
,
Shariff
SZ
,
Flier
S
, et al
Association Between Handover of Anesthesia Care and Adverse Postoperative Outcomes Among Patients Undergoing Major Surgery
.
JAMA
2018
;
319
(
2
):
143
53
. doi.org/10.1001/jama.2017.20040
11
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
(
4
):
605
13
. doi.org/10.1016/j.bja.2020.05.062
12
Yang
N
,
Elmatite
WM
,
Elgallad
A
,
Gajdos
C
,
Pourafkari
L
,
Nader
ND
.
Patient outcomes related to the daytime versus after-hours surgery: A meta-analysis
.
J Clin Anesth
2019
;
54
:
13
8
. doi.org/10.1016/j.jclinane.2018.10.019
13
Meersch
M
,
Weiss
R
,
Kullmar
M
,
Bergmann
L
,
Thompson
A
,
Griep
L
, et al
Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications Among Adults: The HandiCAP Randomized Clinical Trial
.
JAMA
2022
;
327
(
24
):
2403
12
. doi.org/10.1001/jama.2022.9451
14
O'Reilly-Shah
VN
,
Melanson
VG
,
Sullivan
CL
,
Jabaley
CS
,
Lynde
GC
.
Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study
.
BMC Aanesthesiol
2019
;
19
(
1
):
182
. doi.org/10.1186/s12871-019-0858-8
15
Terekhov
MA
,
Ehrenfeld
JM
,
Dutton
RP
,
Guillamondegui
OD
,
Martin
BJ
,
Wanderer
JP
.
Intraoperative Care Transitions Are Not Associated with Postoperative Adverse Outcomes
.
Anesthesiology
2016
;
125
(
4
):
690
9
. doi.org/10.1097/aln.0000000000001246
16
Boat
AC
,
Spaeth
JP
.
Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit
.
Paediatric Anaesth
2013
;
23
(
7
):
647
54
. doi.org/10.1111/pan.12199
17
Salzwedel
C
,
Bartz
HJ
,
Kuhnelt
I
,
Appel
D
,
Haupt
O
,
Maisch
S
, et al
The effect of a checklist on the quality of post-anaesthesia patient handover: a randomized controlled trial
.
Int J Qual Health Care
2013
;
25
(
2
):
176
81
. doi.org/10.1093/intqhc/mzt009
18
Agarwala
AV
,
Firth
PG
,
Albrecht
MA
,
Warren
L
,
Musch
G
.
An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care
.
Anesth Analg
2015
;
120
(
1
):
96
104
. doi.org/10.1213/ane.0000000000000506
19
Jelacic
S
,
Togashi
K
,
Bussey
L
,
Nair
BG
,
Wu
T
,
Boorman
DJ
, et al
Development of an aviation-style computerized checklist displayed on a tablet computer for improving handoff communication in the post-anesthesia care unit
.
J Clin Monit Comput
2021
;
35
(
3
):
607
16
. doi.org/10.1007/s10877-020-00521-y
20
Weinger
MB
,
Slagle
JM
,
Kuntz
AH
,
Schildcrout
JS
,
Banerjee
A
,
Mercaldo
ND
, et al
A Multimodal Intervention Improves Post-Anesthesia Care Unit Handovers
.
Anesth Analg
2015
;
121
(
4
):
957
71
. doi.org/10.1213/ane.0000000000000670
21
Abraham
J
,
Meng
A
,
Tripathy
S
,
Avidan
MS
,
Kannampallil
T
.
Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs
.
BMJ Qual Saf
2021
;
30
(
6
):
513
24
. doi.org/10.1136/bmjqs-2020-012474
22
Lazzara
EH
,
Simonson
RJ
,
Gisick
LM
,
Griggs
AC
,
Rickel
EA
,
Wahr
J
, et al
Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes
.
Ergonomics
2022
;
65
(
8
):
1138
53
. doi.org/10.1080/00140139.2021.2020341
23
Jaulin
F
,
Lopes
T
,
Martin
F
.
Standardised handover process with checklist improves quality and safety of care in the postanaesthesia care unit: the Postanaesthesia Team Handover trial
.
Br J Anaesth
2021
;
127
(
6
):
962
70
. doi.org/10.1016/j.bja.2021.07.002
24
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
(
3
):
387
98
. doi.org/10.1097/aln.0000000000004839
25
Lazzara
EH
,
Simonson
RJ
,
Gisick
LM
,
Griggs
AC
,
Rickel
EA
,
Wahr
J
, et al
Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes
.
Ergonomics
2022
;
65
(
8
):
1138
53
. doi.org/10.1080/00140139.2021.2020341
26
Hong Mershon
B
,
Vannucci
A
,
Bryson
T
,
Lin
F
,
Greilich
PE
,
Dear
G
, et al
A Collaborative Partnership between the Multicenter Handoff Collaborative and an Electronic Health Record Vendor
.
Appl Clin Inform
2021
;
12
(
3
):
647
54
. doi.org/10.1055/s-0041-1731714
27
Wingert
T
,
Lee
C
,
Cannesson
M
.
Machine Learning, Deep Learning, and Closed Loop Devices-Anesthesia Delivery
.
Anesthesiol Clin
2021
;
39
(
3
):
565
81
. doi.org/10.1016/j.anclin.2021.03.012
28
Abraham
J
,
Bartek
B
,
Meng
A
,
Ryan King
C
,
Xue
B
,
Lu
C
, et al
Integrating machine learning predictions for perioperative risk management: Towards an empirical design of a flexible-standardized risk assessment tool
.
J Biomed Inform
2023
;
137
:
104270
. doi.org/10.1016/j.jbi.2022.104270
29
Siontis
KC
,
Noseworthy
PA
,
Attia
ZI
,
Friedman
PA
.
Artificial intelligence-enhanced electrocardiography in cardiovascular disease management
.
Nat Rev Cardiol
2021
;
18
(
7
):
465
78
. doi.org/10.1038/s41569-020-00503-2
30
NationalLibraryOfMedicine. What is precision medicine? medlineplus.gov/genetics/understanding/precisionmedicine/definition/
31
Gabriel
RA
,
Burton
BN
,
Urman
RD
,
Waterman
RS
.
Genomics Testing and Personalized Medicine in the Preoperative Setting
.
Surg Oncol Clin N Am
2020
;
29
(
1
):
73
86
. pubmed.ncbi.nlm.nih.gov/31757315/
32
Lane-Fall
MB
.
What Anesthesiology Has to Learn from Implementation Science and Quality Improvement
.
Anesthesiology
2022
;
136
(
6
):
875
6
. doi.org/10.1097/aln.0000000000004206
33
HL7.org. Welcome to FHIR®
2023
. hl7.org/fhir/