Acta Anaesthesiol Scand 2014; 58: 192197

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2013 The Acta Anaesthesiologica Scandinavica Foundation.

Published by John Wiley & Sons Ltd
ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/aas.12249

Quality of post-operative patient handover in the

post-anaesthesia care unit: a prospective analysis
A. Milby1, A. Bhmer2, M. U. Gerbershagen2, R. Joppich2 and F. Wappler2

1
Medical School, University Witten/Herdecke, Witten, Germany and 2Department of Anaesthesiology and Intensive Care Medicine, Hospital
Merheim, Cologne, Germany

Background: Anaesthesiology plays a key role in promoting

safe perioperative care. This includes the perioperative phase in
the post-anaesthesia care unit (PACU) where problems with
incomplete information transfer may have a negative impact on
patient safety and can lead to patient harm. The objective of this
study was to analyse information transfer during post-operative
handovers in the PACU.
Methods: With a self-developed checklist including 59 items
the information transfer during post-operative handovers was
documented and subsequently compared with patient information in anaesthesia records during a 2-month period.
Results: A total number of 790 handovers with duration of
73 49 s was analysed. Few items were transferred in most of the
cases such as type of surgery (97% of the cases), regional anaesthesia (94% of the cases) and cardiac instability (93% of the
cases). However, some items were rarely transferred, such as

atient handovers are an inherent part of

medical practice. Medical staff uses handovers
to report patients medical conditions as well as
completed investigations, and treatment. Problems
with information transfer may lead to uncertainties
about patient care and possible patient harm.1 This is
particularly important in the perioperative phase
where different medical staff is involved in the care
of patients. Communication failures may also occur
resulting in loss of relevant information.2 Using
checklists is an opportunity to minimise this risk.3,4
In 2007, the World Health Organization (WHO)
started a campaign named Safe surgery saves lives,
including the development of the WHO Surgical
Safety checklist.5 Several studies suggest that the
implementation of surgical safety checklists led to a
reduction of complications and mortality,6 and an
improvement in information transfer.7,8
Improving patient safety has become a widely
discussed topic in anaesthesiology. The European
Society of Anaesthesiology adopted The Helsinki
Declaration on Patient Safety in Anaesthesiology in

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American Society of Anesthesiologists physical status (7% of the

cases), initiation of post-operative pain management (12% of the
cases), antibiotic therapy (14% of the cases) and fluid management (15% of the cases). There was a slight correlation between
amount of information transferred and duration of postoperative handovers (r = 0.5).
Conclusion: The study shows that post-operative handovers in
the PACU are in most cases incomplete. It appears useful to
optimise the post-operative handover process, for example by
implementing a standardised handover checklist.
Accepted for publication 17 November 2013
2013 The Acta Anaesthesiologica Scandinavica Foundation.
Published by John Wiley & Sons Ltd

2010 aiming to improve patient safety by implementing standardised anaesthesia concepts.9

Post-operative handovers in the post-anaesthesia
care unit (PACU) seem to be informal,10,11 unstructured and incomplete.12 This involves a risk of losing
relevant information and may result in increased
rates of complications.13 A Canadian study that
focused on pre- and intra-operative information has
also shown that information transfer during postoperative handovers is incomplete.14
The purpose of this study was to analyse information transfer during post-operative handovers in a
large number of patients in the PACU of a university
hospital. The study focused on the patients preoperative status along with intraoperative and postoperative information.

Methods
This prospective observational study was conducted
in the PACU of a teaching hospital of the University
Witten/Herdecke in Cologne, Germany. The study

Post-operative patient handover in the PACU

Fig. 1. Pre-operative data documented and

transferred during patient handover.

was approved by the ethics committee of Witten/

Herdecke University in 2011 (Protocol number:
108/2011; Date of approval: 17 October 2011).
Patient informed consent was obtained prior to the
investigation during perioperative risk evaluation.
During a 2-month period, post-operative
handovers between anaesthesiologists and staff in
the PACU (anaesthesiologist or anaesthesia nurse)
were observed prospectively by a single researcher.
All patients who were transferred from the operating room to the PACU were included in this study.
Exclusion criteria for this study were age < 18 years,
patients who had surgery under local anaesthesia or
in standby and patients who were transferred from
the operating room directly to the surgical intensive
care unit.
On the basis of a literature review about information transfer and quality of post-operative
handovers and based on standardised anaesthesia
records used in our hospital as well as the established national patient questionnaire for preoperative data, a checklist (Appendix S1) with 59
items was designed. The content of the checklist
was structured in three sections: pre-operative,
intraoperative and post-operative items (Fig. 1).
Pre-operative information included patient data
(patients name and age) and the American Society
of Anesthesiologists (ASA) Physical Status. Further
components were underlying diseases and preexisting conditions (divided into neurology, cardiol-

ogy, pulmonology, myopathies, liver diseases,

kidney diseases, metabolic disorders and infectious
diseases) according to the standard questionnaire
used in German Departments of Anaesthesiology.
Allergies, medication and anaesthesia risks were
also a feature of this checklist section. Particularities
in patients anatomy and whether there was a drug
or alcohol abuse known was also documented.
Intraoperative data included the type of anaesthesia, whether post-operative nausea and vomiting
prophylaxis was administered and airway management. Any kind of catheter insertion was
documented. Furthermore, the second part included occurrences in haemodynamics, volume
management, antibiotic therapy, type of surgery,
anaesthesia-related special occurrences (e.g. allergic
reaction, hypotension, tooth damage), blood loss,
drainages and initiation of pain management during
surgery.
The third section of the checklist includes relevant
post-operative information PACU. Additionally, it
was documented whether there were any important
particularities (relevant information for postoperative care which is not represented in the checklist, for example: language barriers, patient with a
legal guardian who needs to be contacted postoperatively).
After the development of the checklist, there was
a trial period where the researcher tested the applicability of the checklist.

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A. Milby et al.

Fig. 2. Pre-existing conditions documented

and transferred during patient handover.

The observations took place during regular day

shifts from Monday to Friday. Handovers during
nightshifts or on weekends were excluded.
In order to avoid bias, all anaesthesiologists and
nurses, who participated in this study, were not
informed about the checklists content, yet they
were aware that a study about post-operative
handovers in the PACU was conducted. All patients
and PACU staffs names were anonymised.
Additionally, the duration of handovers was
measured with a stop watch and documented on the
protocol.
Subsequent to the observation of handovers each
checklist with the information communicated
during post-operative handovers were compared
with the information documented in anaesthesia
records.
The analysis of the data was descriptively and
entered into a spread sheet (Microsoft Excel 2010
version 14, Redmond, WA, USA). Afterwards, data
were analysed with IBM SPSS Statistics Version 21
and are presented in percentages and absolute terms
together with mean value and standard deviation.
Correlations are presented as Pearson correlation
coefficient (r).

Results
A total number of 798 post-operative handovers
were observed of which 790 were included in this
study. Eight handovers were excluded because of
missing information. The length of handovers was
73 48 s (minimum 1 and maximum 330 s).

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All results are presented as the percentage of

cases in which transfer of information occurred for
patients with a specific condition. Thus, 88% of those
patients with Parkinsons and 72% of those with
diabetes mellitus were identified to the PACU staff,
in contrast to 37% with liver diseases, 36% with
other metabolic diseases, 33% with a change in level
of consciousness and only 20% of those with
myopathies. These pre-existing conditions are presented in Fig. 2.
Pre-operative information transferred during
post-operative handovers is presented in Fig. 1.
Accordingly, 92% of those patients who had a pacemaker or implantable cardioverter defibrillator, 88%
of those patients with infectious diseases and 81% of
patients names were reported to staff in the PACU.
In contrast, 44% of those patients who had allergies,
and 16% of those patients with regular use of medication were identified to staff in the PACU. The ASA
physical status was only described in 7% of all
patients.
Figure 3 illustrates intraoperative information
transmitted during handovers. The type of surgery
was reported in 97% of the cases, and 93% of those
patients with intraoperative cardiac instability were
reported to PACU staff. Fluid management was only
communicated in 15% of the cases. Furthermore,
antibiotic therapy and post-operative pain management was only mentioned during handovers in 14%
and 12% of cases, respectively.
The quantity of post-operative information
transferred during handovers was also highly heterogeneous (Fig. 4): 92% of particularities, which

Post-operative patient handover in the PACU

Fig. 3. Intraoperative data documented and transferred during patient handover.

*anaesthesia-related special occurences: airway, cardiovascular, general reactions, labs, central nervous system, problems with regional
anaesthesia, technical problems).

Fig. 4. Post-operative data documented

and transferred during patient handover.

occurred during the perioperative phase, and 73%

of antagonist administration was transmitted in the
PACU. Compared with 67% of those patients who
needed further diagnostics after surgery, and 20%
of those patients who received post-operative pain
management.

Discussion
The present study demonstrates that information
transfer during post-operative handovers from
anaesthesiologists to the staff in the PACU is incomplete in most cases.

Some information was transferred frequently, such

as patients name or type of surgery while other items
were mentioned less often, for example initiation of
pain management and placement of peripheral
venous catheters. Some of the items that were rarely
transmitted, such as post-operative pain management, are important for post-operative care. The
reason why information transfer is so variable during
post-operative handovers remains unclear but there
are probably numerous contributing factors. A prior
study about information transfer during postoperative handovers in the PACU demonstrated that
there is a difference between actually reported infor-

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A. Milby et al.

mation and what anaesthesiologists believe should

be communicated during handovers.14 The reason
for this is not entirely clear, but the authors speculate
that they are multifactorial and may depend on type
of surgery and the culture of patient handover
within the hospital.
It would certainly be ideal to have a complete
transmission of all relevant information. However,
in reality, this seems to be unlikely. Still, omitting
certain issues entirely may result in life-threatening
events. For example, relevant allergies were only
communicated in 44% of the cases. An important
goal of patient care is the transfer of sufficient relevant information to ensure patient safety. A
further study analysed surgical adverse events.15
Surgeons were interviewed and provided reports
for these incidents. The results suggested, among
others, that incomplete information transmission
especially during handoffs or changes in staff can
lead to adverse events. This can have diverse
impacts on patients, ranging from unnecessary
procedures up to permanent disability or even
death.
The implementation of a handover protocol has
been suggested by experts in order to standardise
patient handovers.16 This may lead to a minimisation
of loss in information transfer; a fact also demonstrated in several smaller studies.12,17
A recent study compared post-operative
handovers in the PACU before and after the implementation of a checklist. It suggests an improvement
in quality of post-operative handovers because of
better information transfer.18
The duration of post-operative handovers in
this study ranged from 1 to 330 s. It appears reasonable to have an adequate time span to communicate
all relevant information during post-operative
handovers. An adequate time span is however difficult to define and should be part of further surveys.
Overall, in a time pressured setting like the postoperative phase, it would be ideal to have a short
duration of handover and a high transmission of
important information. A study, using Formula 1 pit
stop and aviation models for quality and safety,
implemented a handover protocol for handovers
from the operating room to the intensive care unit:
This protocol led to reduction of technical errors
and handover omissions as well as duration of
handovers.19
This study has several limitations. The staff was
informed that a study about post-operative
handovers would be conducted in the PACU. Furthermore, the researcher was physically present

196

during each handover. Both facts may have led to an

increased effort of personnel to conduct more complete handover.
Furthermore, this study only analysed whether
items were applicable for a patient. The study did
not consider whether anaesthesiologists mentioned
that items were not applicable for a patient (for
example: The patient has no allergies).
In addition, it is questionable, from a practical
point of view, whether a checklist with 59 items is
suitable for daily use in the PACU. Where time is a
limiting factor, it appears necessary to design a short
checklist with the most important information. The
importance of using short and plain checklists has
been mentioned before.20
The analysis of post-operative handovers took
only place during weekdays. Handovers during
night shifts and weekends were not assessed.
Further studies should analyse information transfer
of handovers during night and weekend shifts, in
order to prove whether the amount of information
transfer is influenced by specific time frames.
Finally, only one handover at a time was observed
because only a single researcher was responsible for
measurements. Consequently, in those cases of more
than one admission at the same time, only one
handover could be assessed.
This study is only representative for the researchers hospital. Nevertheless, it is most likely that
studies in other hospitals would lead to similar
results. This study may encourage other Departments of Anaesthesiology to embark on self-analysis.
In conclusion, this study shows that information
transfer during post-operative handovers in the
PACU are in most cases incomplete. Thus, it seems
sensible to optimise the post-operative handover
process by developing and implementing a structured handover checklist, and thus improve patient
safety. Further studies should then be done to document the effect of an improved handover process.
Conflict of interest: No external funding and no
competing interests declared.
Funding: None.

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Address:
Annika Milby
Ellerstr. 76
53119 Bonn
Germany
e-mail: annika.milby@uni-wh.de

Supporting information
Additional Supporting Information may be found in
the online version of this article at the publishers
web-site:
Appendix S1. Handover checklist.

197

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