Once again: a unique specialty

In the last years, since I became ESAIC Newsletter chief editor, I have had more than one opportunity to refer to the fact that anaesthesiology is a medical domain which, for many reasons, does not resemble any other.

We are special because of the many demands the profession has towards its physicians, because of the high responsibility for the patient’s life, and because of the vast amount of theoretical knowledge needed to practice it, doubled by the clear request for highly manual skills.

Lately, one more feature came to my mind.

It is about the usual habit/demand for periodical handover and transfer of the patient, temporary or complete, to another professional.

Almost half a century ago, when I moved to Israel from a much colder country, I was surprised during my first days of work in the operating room (OR) , when I used to be asked by my senior(s) if I needed a relief for a couple of minutes. When I kindly refused it, I was recommended to go to the OR kitchen and have a glass of cold water: “we have a warm climate, you do need it!”.

Years later, I asked myself what is behind this usual behavior, that of relieving the anaesthesiologist for a short time during a long workday.

I looked around and I tried to understand this process.

What I found out was that we, once again, are a unique specialty.

I apologise for bringing here some aspects too well known to any of my peers, but I feel the need to put them together, just to make my case.

In comparison to any other medical profession, we are obliged to spend most of our working day near a patient who needs continuous surveillance, meaning the permanent presence of the anaesthesiologist in the OR. We are the first to go in and the last to get out. While the surgeon(s) and the nurse(s) have long minutes of break between two cases, we are requested to accompany the (still) asleep patient to the recovery area, to transmit to the staff there the most important data about his/her condition, to be sure that the patient did not need us anymore and then to go back to the OR, where the next patient was already waiting for us.

Most of the surgeons work just a short number of days in the OR, but most of us are busy there almost every single working day.

Other professionals can afford breaks after their department morning rounds and the outpatient patients are usually scheduled with short breaks every couple of hours.

So, volens-nolens, we are supposed to deal with the reality which includes the handovers as part of our daily activity.

It is true, this habit is practiced in other medical domains, too (1), but it seems that anaesthesia in the OR occupies the first place regarding the frequency with which it is encountered.

The handoff or handover is defined as the process of transferring primary authority and responsibility for providing clinical care to a patient from one  departing caregiver to an incoming caregiver.

To the best of my knowledge, until recently this special aspect of our profession has not been investigated from the scientific point of view, and it seems that the handovers have been taken for granted and nobody thought to go into depth and analyse it in a more serious manner.

Even if the topic of handoverswas present in the literature and discussed some 25 years ago (2), the subject showed up on anaesthesia literature much later (3).

In most cases the handovers are done for a short period of time, minutes up to half an hour. But not too rarely we are witnessing an aspect called in the literature “complete handover” or “complete handoffs” (4,5), meaning that the first anaesthesiologist transfers the case to another one up to the end of the procedure.

Rather than being a peripheral topic related to our practice, literature specifies that the handover consists of three key aspects: transfer of information, responsibility and accountability (6), in other words a much more complicated process. It demands time, a lot of mutual confidence and understanding, and the ability to take over in the middle of a procedure.

The case for a debate is clear. One is supposed, first, to weigh the advantages vs drawbacks of the system and then to try and find the solution for minimising its negative effects.

Nobody questions the need for temporary relieving of an anaesthesiologist who is busy in the OR hour after hour. Once back to his/her patient the physician in charge with the patient could go on performing the usual tasks in a better physical shape and in a better mood.

More than this, it is obvious that the transfer of the patient, even temporarily, to a colleague’s responsibility offers a chance to correct errors and might prevent an inadvertent oversight of a required action. The receiving anaesthesiologist provides “fresh eyes” (5) and offers a new insight regarding the patient condition. It means that a serious and complete transfer of information could reduce the rate of adverse incidents during anaesthesia.

But the handover practice brings with it some clear drawbacks. Much too often the transfer of information to the relieving physician is incomplete, superficial, ineffective and it lacks a standardised way of informing the replacing physician about the patient’s full situation (co-morbidity, adverse incidents during induction, technical difficulties encountered by the surgeon, etc.).

Jones’s paper (4) reported a retrospective study of more than 300,000 adults who underwent major surgery, 6,000 of them undergoing the procedure with complete intraoperative handover of anaesthesia care. The study found out a much higher rate of adverse outcome (all-cause deaths, hospital readmission, postoperative complications) in the group of the patients with complete handover in comparison with those in the non-handover group (49% vs 29%, p<.001).

In a very recent study (7) on 700 patients who underwent major noncardiac surgery the authors reported that intraoperative complete handover between anesthesiologists was associated with an increased risk of postoperative delirium (p=0.046). More than this,patients with intraoperative complete handover had a higher incidence of non-delirium complications (P = 0.003) and stayed longer in hospital after surgery (P= 0.002).

So, it seems that one needs to look into the handoff/handover process as to a serious subject and try to propose an attitude which would minimise its negative effects, without compromising its clear practical value.

Bagian and Pauli (5) addressed this subject by declaring that “significant advancement in patient safety and transition in health care will require acceptance of standard methodologies, tools and techniques that improve communication…..”.

Lee et al (8) are of the opinion that handovers are highly susceptible to communication failure. They developed an electronic handover checklist as an educational tool to teach trainees a standardised method of handing over an anaesthesia case. Their study showed that the use of that device clearly improved the process of transferring the patient information among the anaesthesia team.

In spite of theseinteresting results, I am of an opinion that the name of the game is human communication. Failure to adequately communicate important data is the root of the incidents and accidents produced by the process of handover.

By the way, this process is not unknown to industry. There the solution was found by improving the quality of communication, by giving enough time to the receiver to get the information and to check the situation in-depth before taking over.

My message is a simple one. The process of handover/handoff is too important not to be seriously taken into consideration in the OR. The underlying problem is the lack of communication. In an era where the lack of time and production pressure are felt all over the world and influence our professional results, each of us are obliged to pay attention to the transfer of information from one professional to another during an anaesthetic procedure. This is important in every field of activity. In ours it is crucial.

References.

1. Davis J et al J Grad Med Educ 2017;9:18

2.Sherlok C. Nursing standard 1995;52:33

3.Hudson CC et al. J Cardiothorac Vasc Anesth.2015;29:11–6

4.Jones PM et al JAMA 2018;319:143

5.Bagain JP and Pauli DE JAMA 2018;319:125

6.Randmaa M,et al. BMJ Open 2017;7:e015038. doi:10.1136/bmjopen-2016-015038

7.Liu GY et al J Anesth 2019; 33:295

8.Lee Sc et al. Xlin Teach 2019;16:58