Melanie Meersch1, Raphael Weiss1, Mira Küllmar1, Lars Bergmann2, Astrid Thompson2, Leonore Griep2, Desiree Kusmierz2, Annika Buchholz2, Alexander Wolf2, Hartmuth Nowak2, Tim Rahmel2, Michael Adamzik2, Jan Gerrit Haaker2, Carina Goettker3, Matthias Gruendel3, Andre Hemping-Bovenkerk3, Ulrich Goebel3, Julius Braumann4, Irawan Wisudanto4, Manuel Wenk4, Darius Flores-Bergmann5, Andreas Böhmer5, Sebastian Cleophas6,7, Andreas Hohn6,7, Anne Houben8, Richard K Ellerkmann8,9, Jan Larmann10, Julia Sander10, Markus A Weigand10, Nicolas Eick11, Sebastian Ziemann12, Eike Bormann13, Joachim Gerß13, Daniel I Sessler14, Carola Wempe1, Christina Massoth1, Alexander Zarbock1. 1. Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany. 2. Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany. 3. Department of Anesthesiology, Department of Anesthesiology and Critical Care, Franziskus Hospital Münster, Münster, Germany. 4. Department of Anesthesiology, Intensive Care and Pain Medicine, Florence-Nightingale-Hospital, Düsseldorf, Germany. 5. Department of Anesthesiology and Operative Intensive Care Medicine, Kliniken Köln, Köln, Germany, Witten/Herdecke University, Faculty of Health, School of Medicine. 6. Department of Anesthesiology and Intensive Care Medicine, Kliniken Maria Hilf, Mönchengladbach, Germany. 7. Faculty of Medicine and University Hospital of Cologne, Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Cologne, Germany. 8. Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Dortmund, Dortmund, Germany. 9. Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany. 10. Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany. 11. Department of Anesthesiology, Intensive Care and Pain Medicine, Dortmund-Hörde, Germany. 12. Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany. 13. Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany. 14. Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.
Abstract
Importance: Intraoperative handovers of anesthesia care are common. Handovers might improve care by reducing physician fatigue, but there is also an inherent risk of losing critical information. Large observational analyses report associations between handover of anesthesia care and adverse events, including higher mortality. Objective: To determine the effect of handovers of anesthesia care on postoperative morbidity and mortality. Design, Setting, and Participants: This was a parallel-group, randomized clinical trial conducted in 12 German centers with patients enrolled between June 2019 and June 2021 (final follow-up, July 31, 2021). Eligible participants had an American Society of Anesthesiologists physical status 3 or 4 and were scheduled for major inpatient surgery expected to last at least 2 hours. Interventions: A total of 1817 participants were randomized to receive either a complete handover to receive anesthesia care by another clinician (n = 908) or no handover of anesthesia care (n = 909). None of the participating institutions used a standardized handover protocol. Main Outcomes and Measures: The primary outcome was a 30-day composite of all-cause mortality, hospital readmission, or serious postoperative complications. There were 19 secondary outcomes, including the components of the primary composite, along with intensive care unit and hospital lengths of stay. Results: Among 1817 randomized patients, 1772 (98%; mean age, 66 [SD, 12] years; 997 men [56%]; and 1717 [97%] with an American Society of Anesthesiologists physical status of 3) completed the trial. The median total duration of anesthesia was 267 minutes (IQR, 206-351 minutes), and the median time from start of anesthesia to first handover was 144 minutes in the handover group (IQR, 105-213 minutes). The composite primary outcome occurred in 268 of 891 patients (30%) in the handover group and in 284 of 881 (33%) in the no handover group (absolute risk difference [RD], -2.5%; 95% CI, -6.8% to 1.9%; odds ratio [OR], 0.89; 95% CI, 0.72 to 1.10; P = .27). Nineteen of 889 patients (2.1%) in the handover group and 30 of 873 (3.4%) in the no handover group experienced all-cause 30-day mortality (absolute RD, -1.3%; 95% CI, -2.8% to 0.2%; OR, 0.61; 95% CI, 0.34 to 1.10; P = .11); 115 of 888 (13%) vs 136 of 872 (16%) were readmitted to the hospital (absolute RD, -2.7%; 95% CI, -5.9% to 0.6%; OR, 0.80; 95% CI, 0.61 to 1.05; P = .12); and 195 of 890 (22%) vs 189 of 874 (22%) experienced serious postoperative complications (absolute RD, 0.3%; 95% CI, -3.6% to 4.1%; odds ratio, 1.02; 95% CI, 0.81 to 1.28; P = .91). None of the 19 prespecified secondary end points differed significantly. Conclusions and Relevance: Among adults undergoing extended surgical procedures, there was no significant difference between the patients randomized to receive handover of anesthesia care from one clinician to another, compared with the no handover group, in the composite primary outcome of mortality, readmission, or serious postoperative complications within 30 days. Trial Registration: ClinicalTrials.gov Identifier: NCT04016454.
Importance: Intraoperative handovers of anesthesia care are common. Handovers might improve care by reducing physician fatigue, but there is also an inherent risk of losing critical information. Large observational analyses report associations between handover of anesthesia care and adverse events, including higher mortality. Objective: To determine the effect of handovers of anesthesia care on postoperative morbidity and mortality. Design, Setting, and Participants: This was a parallel-group, randomized clinical trial conducted in 12 German centers with patients enrolled between June 2019 and June 2021 (final follow-up, July 31, 2021). Eligible participants had an American Society of Anesthesiologists physical status 3 or 4 and were scheduled for major inpatient surgery expected to last at least 2 hours. Interventions: A total of 1817 participants were randomized to receive either a complete handover to receive anesthesia care by another clinician (n = 908) or no handover of anesthesia care (n = 909). None of the participating institutions used a standardized handover protocol. Main Outcomes and Measures: The primary outcome was a 30-day composite of all-cause mortality, hospital readmission, or serious postoperative complications. There were 19 secondary outcomes, including the components of the primary composite, along with intensive care unit and hospital lengths of stay. Results: Among 1817 randomized patients, 1772 (98%; mean age, 66 [SD, 12] years; 997 men [56%]; and 1717 [97%] with an American Society of Anesthesiologists physical status of 3) completed the trial. The median total duration of anesthesia was 267 minutes (IQR, 206-351 minutes), and the median time from start of anesthesia to first handover was 144 minutes in the handover group (IQR, 105-213 minutes). The composite primary outcome occurred in 268 of 891 patients (30%) in the handover group and in 284 of 881 (33%) in the no handover group (absolute risk difference [RD], -2.5%; 95% CI, -6.8% to 1.9%; odds ratio [OR], 0.89; 95% CI, 0.72 to 1.10; P = .27). Nineteen of 889 patients (2.1%) in the handover group and 30 of 873 (3.4%) in the no handover group experienced all-cause 30-day mortality (absolute RD, -1.3%; 95% CI, -2.8% to 0.2%; OR, 0.61; 95% CI, 0.34 to 1.10; P = .11); 115 of 888 (13%) vs 136 of 872 (16%) were readmitted to the hospital (absolute RD, -2.7%; 95% CI, -5.9% to 0.6%; OR, 0.80; 95% CI, 0.61 to 1.05; P = .12); and 195 of 890 (22%) vs 189 of 874 (22%) experienced serious postoperative complications (absolute RD, 0.3%; 95% CI, -3.6% to 4.1%; odds ratio, 1.02; 95% CI, 0.81 to 1.28; P = .91). None of the 19 prespecified secondary end points differed significantly. Conclusions and Relevance: Among adults undergoing extended surgical procedures, there was no significant difference between the patients randomized to receive handover of anesthesia care from one clinician to another, compared with the no handover group, in the composite primary outcome of mortality, readmission, or serious postoperative complications within 30 days. Trial Registration: ClinicalTrials.gov Identifier: NCT04016454.
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