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Handover of Anesthesiology Care and Cardiac Surgery Patient Mortality
Quick Takes
- Complete handover of care from one anesthesiologist to another showed a statistically significant association with 30-day mortality, 1-year mortality, and greater ICU and hospital length-of-stay among patients undergoing cardiovascular surgery.
- When the handover occurred during or after cardiopulmonary bypass, a stronger association with 30-day mortality and greater rate of 30-day patient-defined adverse cardiac and noncardiac events were observed.
- Adverse outcomes were associated with complete handover only in cases started during regular work hours.
Study Questions:
Handover of care by anesthesiologists may involve loss of pertinent clinical information. However, concerns also exist about the impact of fatigue on clinician vigilance. What is the relationship between complete handover of anesthesic care and 30-day and 1-year postoperative mortality, and what is its impact on length-of-stay and a variety of adverse clinical outcomes?
Methods:
Residents of Ontario aged ≥18 years who underwent coronary artery bypass grafting (CABG), valve surgery, or aortic surgery between 2008–2019 were studied retrospectively. Primary endpoints were 30-day and 1-year postoperative mortality. Secondary outcomes were patient-defined adverse cardiac and noncardiac events (PACE), and postoperative length-of-stay in the intensive care unit (ICU) and hospital. PACE events included stroke with severe clinical sequelae, new-onset heart failure, chronic ventilator dependence, new-onset dialysis dependence, and long-term care admission. The main exposure was complete handover of anesthesia care during surgery, where the primary anesthesiologist transferred responsibility for anesthetic management to a separate anesthesiologist who had not been involved with the case from the start. Covariates included patient comorbidities, procedure duration, and characteristics of surgeon and anesthesiologist, and adjustments were made using inverse probability of treatment weighting.
Results:
Among 102,156 patients meeting inclusion criteria, 1,926 (1.9%) had complete handover of anesthetic care, with prevalence of handover increasing over time, from 0.7% in 2008 versus 2.9% in 2019. Handover was more common at teaching hospitals, during emergency surgery, during longer surgery (≥300 minutes), aortic surgery, in patients experiencing cardiogenic shock or more severe anginal or heart failure symptoms, with surgeons having lower surgical volume, and with female anesthesiologists.
After adjustment for covariates using inverse probability of treatment-weighting, complete handover of anesthetic care was associated with greater mortality at 30 days (hazard ratio [HR], 1.89 [1.41, 2.54]) and 1 year (HR, 1.66 [1.31, 2.12]), and statistically longer ICU and hospital length-of-stay. The relationship between handover and mortality was more pronounced during procedures with greater complexity. Handover showed no overall significant association with PACE events at 30 days or 1 year in the adjusted cohort.
Conclusions:
Among patients undergoing cardiac surgery, complete handover of anesthetic care was associated with greater risk of 30-day and 1-year postoperative mortality, and longer ICU and hospital length-of-stay.
Perspective:
The anesthesiologist who initiates the care of a surgical patient gains direct familiarity with the patient’s underlying clinical condition based on a thorough preoperative assessment, and during the course of anesthetic induction and initiation of surgery, acquires additional insight on the patient’s status and unique hemodynamic responses during a variety of clinical events. That understanding is enhanced by communication with the surgeon, and it informs clinical decision making during subsequent critical junctures, including safe separation from cardiopulmonary bypass, assessment of hemostasis, addressing need for circulatory support, and transition to ICU care. At times when handover of anesthetic care cannot be avoided, development of protocols stipulating a minimum period of overlapping care prior to handoff and more formal signout encompassing key topics may be considered in an effort to counteract disadvantages inherent to handoff events.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure
Keywords: Anesthesia, Anesthesiologists, Anesthesiology, Cardiac Surgical Procedures, Coronary Artery Bypass, Fatigue, Heart Failure, Hemodynamics, Intensive Care Units, Long-Term Care, Patient Handoff, Patient Transfer, Renal Dialysis, Shock, Cardiogenic, Stroke, Surgeons, Ventilators, Mechanical
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