Effectiveness of the Practice of Standardized Handover Process Using a Checklist in the Postanesthesia Care Unit: An Observational Study

Abstract

Context:

Patient handovers without any structured checklist may omit essential information that might have undesirable consequences for patients.

Aim:

We sought to determine the effectiveness of a structured postanesthesia care handover (PACH) checklist in the postanesthesia care unit (PACU) to reduce adverse clinical outcomes.

Setting and Design:

A single-center, prospective, pre–postimplementation study was conducted.

Materials and Methods:

Moreover, post-PACH checklist implementation data were collected from 130 participants (n = 65 in each group) by an independent observer. Data analysis was performed using the SPSS (25.0) version (IBM SPSS statistics). The Chi-square test was used to compare the dichotomous response.

Results:

A statistically significant reduction in hypoxemia (21.5% vs. 0; P < 0.001) was observed in the postimplementation group. There were significant improvements in patient information (P < 0.01), reduction in variations in hemodynamic parameters (P < 0.01), and improvement in the quality of information transferred concerning surgical procedures (P < 0.01). The number of phone calls to consultants was significantly lower in the PACH group.

Conclusion:

Implementation of the PACH checklist was associated with no hypoxemic events in PACU by improving the quality of communication. The implementation of a structured checklist in PACU should be mandatory in the postoperative intensive care unit.

INTRODUCTION

Transferring patients after surgery to the postanesthesia care unit (PACU) poses a major challenge to staff on both delivering and receiving teams. The transfer often happens in a busy environment and the team who receives the patient will be unfamiliar with the patient condition.[1,2] Postoperative handover is the critical transfer of perioperative information from the surgical team to the postoperative team that mandates effective communication between health-care providers.[3,4]

In an attempt to address the above-mentioned problems, various authors have recommended the utilization of checklists to improve both the quality and quantity of information to be transferred. Our objective was to evaluate whether a standardized checklist in the postoperative intensive care unit (ICU) can reduce the risks of hypoxemia and adverse events in the ICU.

MATERIALS AND METHODS

The study was initiated after approval from the ethics and scientific committee approval. The study was registered with clinical trial registry. This was an observational study where the total sample size was 130, with 65 in each group. Written informed consent was obtained from all patients. The sample size was calculated using the formula

n = (2[p]) [1− p’] [Zα/2+ Zβ] [Zα/2+ Zβ])/(p1− p2) (p1− p2)

where p1 = 38.6%

p2 = 20.7%

p’ =0.2965

which gives the sample size as 65 in both the case and control groups.

Total sample size =130.

Zα/2 = 1.96 is ρ NV at a 5% level of significance

Z1 – β =0.84 is ρ NV at 80% power

P1= Population in a case group, P2= Population in a control group.

A convenience sampling method was used. After obtaining informed consent, adult patients aged ≥18 years with American Society of Anesthesiologists (ASA) grades of I, II, and III admitted to PACU were recruited as study participants. Exclusion criteria included patients undergoing daycare surgery not requiring postanesthesia care and those with type I and II respiratory failure.

The study had three consecutive stages. Stage 1 included a baseline evaluation that was performed before the implementation of the postanesthesia care handover (PACH) checklist [Table 1]. An independent observer evaluated the process of handover from the anesthesia unit to the PACU nurse and collected the data. The anesthesia team was informed about the observer’s presence however to prevent any bias they were not informed about the purpose of the observer’s presence.

Table 1.

Postanesthesia care handover checklist

General clinical condition of the patient	Stable/unstable (vitals)
Patient	Name and ID check - yes/no Any allergy - yes/no Type of surgery Type of anaesthesia
Procedure	Position Airway management/O2 supply Fluid management
Medications	Analgesia PONV Done/to do
Other	Laboratory investigations and results if required Any concerns
Any queries

PONV=Postoperative nausea vomiting

In this stage, the observer will note the patients for any variations in heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure, and oxygen saturation (SpO₂). Any incidence of hypoxia (SpO₂ < 94%), hypotension (SBP < 90 and DBP < 60 or fall in BP > 30% from baseline), bradycardia (HR < 60), tachycardia (HR > 100), and arrhythmias will be recorded. In addition, postoperative nausea vomiting (PONV), decreased urine output, total fluid administration, oxygen supplementation, length of stay in PACU and the number of phone calls to the concerned consultants also will be noted. Postoperative pain will be assessed by a 10-point Visual Analog Scale (VAS) score. Visual Analog Score is usually a horizontal line 100 mm in length, anchored by word descriptors at each end. The patient marks on the line the point that they feel represents their perception of their current state. Any score of > 3 will be noted. There should be clear identification of the PACU nurse that will handle the patient, by the person responsible for shifting the patient to post-PACU. The duration of handover and interruptions during handover also will be recorded.

Stage 2 consisted of time dedicated to training the entire anesthesia-PACU team on the PACH checklist. It primarily focused on the proper usage of the PACH checklist, writing documents and ensuring that everyone had a clear understanding of the checklist.

Stage 3 was carried out similarly to stage 1 and included an independent evaluation of the checklist.

The primary outcome measured was the occurrence of a hypoxemic event in PACU defined as SpO₂ < 94% for at least 30 s. The secondary outcomes included were postoperative variations in hemodynamic parameters till the patient was in the PACU. This included PONV, pain (VAS > 3), length of stay in PACU, duration of handover, any interruptions during handover, nurse’s satisfaction and number of phone calls made to various consultants.

The data were analyzed using SPSS for Windows (SPSS ver. 25.0, IBM Corp – Java™ Platform SE binary-IBM Corp; London UK). Continuous data were compared using an unpaired t-test between the groups, and categorical data were compared using a Chi-square test. The level of significance was set at P ≤ 0.05.

RESULTS

A total of 130 participants (n = 65 in each group) were enrolled before and after the implementation of the checklist. All the participants underwent surgery and were monitored in the PACU. The distribution of gender and ASA physical status was comparable in both groups (P > 0.05) [Table 2].

Table 2.

Demographic data

	Precheck list, n (%)	Postcheck list, n (%)	P
Age (mean±SD)	39.2±11.8	40.4±11.9	0.76 (NS)
Gender
Female	29 (44.6)	28 (43.1)	0.86 (NS)
Male	36 (55.4)	37 (56.9)
Total	65 (100)	65 (100)
ASA
I	30 (46.2)	34 (52.3)	0.39 (NS)
II	34 (52.3)	28 (43.1)
III	1 (1.5)	3 (4.6)
Total	65 (100)	65 (100)

NS=Not significant using Chi-square test, SD=Standard deviation, ASA=American Society of Anesthesiologists

It was found that the quality of information related to patients increased significantly in most parameters in the PACH group compared to the control group. Allergy details were communicated in 100% versus 50.8% in the control group with statistical significance < 0.001. Other parameters communicated were general condition 100% versus 44.6%; identifying lead receiver 100% versus 40%; medical history 40% versus 100% and type of surgery 49.2% versus 100% in the PACH group compared to the control group. The above values were statistically significant, with a P < 0.001. Other parameters such as oxygenation and monitoring were set up in both the groups and were statistically insignificant (P > 0.05) [Table 3].

Table 3.

Comparison of various parameters between postanesthesia care handover and control groups

	Control group, n (%)	PACH group, n (%)	P
Allergy details
Yes	33 (50.8)	65 (100)	<0.001*
No	32 (49.2)	0
ASA physical status
Yes	0	65 (100)	<0.001*
No	65 (100)	0
General condition statement
Yes	29 (44.6)	65 (100)	<0.001*
No	36 (55.4)	0
Identifying nurse leader in PACU
Yes	26 (40)	65 (100)	<0.001*
No	39 (60)	0
Monitoring (before verbal transfer)
Yes	65 (100)	65 (100)	-
No	0	0
Oxygen
Yes	42 (64.6)	43 (66.2)	0.85 (NS)
No	23 (35.4)	22 (33.8)
Patient identity
Yes	65 (100)	65 (100)	-
No	0	0
Significant medical history
Yes	26 (40)	65 (100)	0.001*
No	39 (60)	0
Type of anesthesia
Yes	65 (100)	65 (100)	-
Total	65	65
Type of surgery
Yes	32 (49.2)	65 (100)	0.001*
No	33 (50.8)	0

*Statistically significant at P <0.01 and NS using Chi-square test. NS=Not significant, ASA=American Society of Anesthesiologists, PACU=Postanesthesia care unit, PACH=Postanesthesia care handover

It was also observed that participants in the PACH checklist group had no significant hypoxemic events than those in the control group (21.5% vs. 100%; P = 0.001). A significantly lower percentage of participants in the PACH group experienced PONV with a P = 0.005, hypertension (P < 0.001), and tachycardia (P < 0.023). None of the participants in the PACH group experienced pain with P < 0.001. Episodes of bradycardia were fewer in participants from the PACH group (P = 0.07). The handover process in the PACH group had significantly fewer phone calls to the anesthesia unit with P < 0.001, and all the nurses were satisfied with the handover process in the PACH group (P < 0.001). The duration of handover was >5 min in the PACH group, which was significant (P < 0.001) [Table 4].

Table 4.

Comparison of variables between postanesthesia care handover and control groups

	Control group, n (%)	PACH control, n (%)	P
Bradycardia
Yes	9 (18.8)	4 (7)	0.07 (NS)
No	39 (81.3)	53 (93)
Duration of handover (min)
<5	65 (100)	0	<0.001*
>5	0	65 (100)
Number of interruptions during handover
No	65 (100)	65 (100)	-
Yes	0	0
Number of nurse’s phone calls to consultants
Yes	23 (35.4)	6 (9.2)	<0.001*
No	42 (64.6)	59 (90.8)
Nurse’s satisfaction
Yes	23 (35.4)	65 (100)	<0.001*
No	42 (64.6)	0
PONV
Yes	12 (18.5)	2 (3.1)	0.005*
No	53 (81.5)	63 (96.9)
SBP (>140 or <90)
Yes	32 (49.2)	6 (9.2)	<0.001*
No	33 (0.8)	59 (90.8)
SpO2 (< 94%)
Yes	14 (21.5)	0	<0.001*
No	51 (78.5)	65 (100)
Tachycardia
Yes	17 (30.4)	8 (13.1)	<0.023#
No	39 (69.6)	53 (86.9)
VAS score >3
Yes	14 (21.5)	0	<0.001*
No	51 (78.5)	65 (100)

*Statistically significant at P<0.01, ^#P<0.05. NS=Not significant using Chi-square test, PACH=Postanesthesia care handover, PONV=Postoperative nausea vomiting, SBP=Systolic blood pressure, VAS=Visual Analog Scale, SpO₂=Oxygen saturation

The surgical procedures were more precisely documented in the PACH group than the control group for vascular access (49.2% vs. 100%), fluid management (49.2% vs. 100%), reporting of adverse events (60% vs. 100%), and position of participant (0 vs. 100%), respectively. In addition, the information on airway management and medication already delivered were comparable in both groups [Table 5].

Table 5.

Comparison of procedural information between postanesthesia care handover and control groups

	Control group, n (%)	PACH control, n (%)	P
Adverse event during surgery (information)
Yes	39 (60)	65 (100)	<0.001*
No	26 (40)	0
Airway management
Yes	65 (100)	65 (100)	-
No	0	0
Antiemetic
Yes	65 (100)	65 (100)	-
No	0	0
Fluid management
Yes	32 (49.2)	65 (100)	<0.001*
No	33 (50.8)	0
Position
Yes	0	65 (100)	<0.001*
No	65 (100)	0
Vascular access
Yes	32 (49.2)	65 (100)	<0.001*
No	33 (50.8)	0

*Statistically significant at P <0.01 using Chi-square test. PACH=Postanesthesia care handover

DISCUSSION

Good postoperative care is essential for the rapid recovery of patients which is dependent on clear transmission of information from the operating team to PACU. Effective communication between the teams plays an important role that can be enhanced by following a clear set of instructions. In this observational study, we tested the effectiveness of a standardized checklist for handover between the anesthesiologist and the nursing staff in preventing hypoxia and hemodynamic events in PACU by providing necessary preoperative and intraoperative information about the patient. We found that having a PACH checklist and following it favored the transfer of high-quality and appropriate clinical information to the PACU team.

Implementation of the PACH checklist was associated with a significant improvement in the quality of patient-related information in terms of allergies, general condition of the patient, medical histories, and type of surgeries all ranging from 49.2% to 60%, respectively. Boat and Spaeth, Jaulin et al., and Starmer et al. reported similar improvements in the quality of patient handoff after implementation of a checklist. However, it was also observed that certain aspects of handover, like patient identity, the type of anesthesia, and monitoring of patients before any verbal transfer of information, were similar in both groups and did not warrant the implementation of a checklist.[5,6]

Agarwal et al. reported a reduction in postoperative complications and improvements in outcomes by introducing a standardized checklist for pediatric patients, which was similar to our study.[7] In our study we observed that the number of phone calls by nurse to the consultants regarding patient care was less. A possible explanation could be the transfer of accurate information that bypasses the need to navigate through the busy and at times, chaotic atmosphere of hospitals.[8]

The usual expectation postimplementation of the checklist would be a reduction in the time taken for handover. However, in the present study, we observed that the duration of handover in the PACH groups was > 5 min. This was in line with findings from studies conducted by Salzwedel et al. and Park et al., who reported a significant delay in the handover process.[4,9] We hypothesize that lack of training in using this checklist and/or encountering unseen terms disrupting the “usual flow” as the possible reason. We found that nurses’ satisfaction improved by 64% after the implementation of the PACH checklist. Similar improvements in nurses’ satisfaction highlighting the success of introducing checklists were also observed in studies conducted by Petrovic et al., and Johnson et al.[10,11]

The goal of a checklist is to avoid any adverse events arising from miscommunication. This is achieved by a physical checklist that constantly reminds members of the anesthesia team not to omit any information. The checklist fulfilled the objective in the present study with a significant improvement in the quality of procedural information such as adverse events during surgery, fluid management, vascular access, and position of the patients transferred to PACU. In the present study, it was surprising to observe that there was no information on the position of the patient during the handover process before implementing the checklist and that improved to 100% after implementing the checklist. It is important to understand that ineffective handovers can give rise to substantial gaps in patient care ranging from medical errors, to morbidity, and mortality.[12,13,14]

Handover checklists in the anesthesia care unit help structure the complex information that is provided to the nurses in the anesthesia care unit, by the anesthesiologist. Nevertheless, it is often observed that anesthesia to PACU handovers is incomplete, imprecise, and highly variable regarding information transfer and therefore does not ensure patient safety. An attempt was made to overcome this barrier by Halladay et al. and Pandya et al., who observed that there was a significant improvement in the transfer of quality information and reduction in medication error by implementing and evaluating an electronic medical record-based checklist.[15,16]

Many checklists are employed at different stages between professionals in an operating set-up, including but not limited to; SBAR (S: Status; B: Background; A: Assessment; R: Recommendation) for the surgical team, SWITCH (S: Surgical procedure; W: Wet [i.e., fluids]; I: Instruments; T: Tissue [i.e., specimens]; C: Counts and H: Have you any questions) for change of shift handover during surgery, the handoff Clinical Examination Exercise for shift-to-shift physician handoff.[17,18,19]

Through our study and many others discussed above, it is evident that the usage of a handover checklist between the anesthesiologist and the nursing staff significantly minimizes the loss of valuable content and miscommunication. Hence, usage of these checklists is of vital importance and should be practiced in all health-care facilities providing postoperative care.

Our study had a few limitations; the study was limited to a single hospital; therefore, the results cannot be generalized. Results from a multi-center study could have been more valid and generalized, thereby providing us with a better assessment of the response to PACH checklist handover in different setups. We did not take any feedback regarding the effectiveness of training of the checklist from the entire team of PACU; due to the cross-sectional design of the study, we could not determine if the checklist was integrated into their routine practice and the experience of the nurses in PACU was not standardized and their experience might have influenced the overall outcome.

CONCLUSION

In summary, we can conclude that the implementation of the PACH checklist during patient handover is a useful, valuable, and effective tool that helps prevent loss of information, thereby drastically reducing life-threatening outcomes such as hypoxemia and other associated hemodynamic disturbances.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.