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Annals of Medicine and Surgery 79 (2022) 103915
Available online 20 June 2022
2049-0801/© 2022 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Cross-sectional Study
Assessment of postoperative patient handover practice and safety at post
anesthesia care unit of Dilla University Referral Hospital, Ethiopia: A
cross-sectional study
Abebayehu Zemedkun
a
,
*
, Belete Destaw
a
, Seyoum Hailu
a
, Mesay Milkias
a
,
Hailemariam Getachew
a
, Dugo Angasa
b
a
Department of Anesthesiology, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
b
Department of Anesthesia, College of Health Sciences and Medicine, Hawassa University, Hawassa, Ethiopia
ARTICLE INFO
Keywords:
Handover
Post anesthesia care unit
Practice
Dilla
ABSTRACT
Introduction: Good handover creates a common understanding of responsibility and patients’ status. To proceed
with effective handover process, effective communication between healthcare providers plays a vital role. But, it
is commonly observed that there is ineffective communication between health care providers and it increases the
risk of medical errors and negatively affects the quality of care, patient outcome and satisfaction. In addition, the
transfer of care after surgery to the postanesthesia care unit (PACU) presents special challenges to providers on
both the delivering and receiving teams.
Methodology: A descriptive cross-sectional study was conducted at post anesthesia care unit of Dilla University
Referral Hospital from October 1 to November 30, 2020. To conduct the study, consecutively selected 208
handovers of patients from operation theatre (OT) to PACU were assessed. A checklist was developed based on a
combination of criteria adopted from the Australian Medical Association 2006 and British Doctors Committee
2004. It was pilot tested and changes were made before the actual data collection.
Result: Our study found that the postoperative patient handover practice among professionals was poor (below
50%) in the areas of patients’ full name, age, medical registration number (MRN), ASA class, allergic history,
medical history, baseline vital signs, preoperative diagnosis and surgical procedure performed. Our study also
found poor postoperative hand overing regarding the intraoperative blood loss 9.6%, intraoperative clinical
incidents 5.3%, recovery condition 7.2%, postoperative analgesia plan 18.8%, and post operative antibiotic plan
8.2%. Whereas, type of anesthesia 81.3%, intraoperative vital signs 80.8%, and intraoperative analgesia used
79.8%, intraoperative uid management 80.8% were among the indicators with >50% completion rate.
Conclusion and recommendation: Our study found a poor practice of patient handover regarding sociodemographic
and preoperative prole, anesthesia, surgery and other necessary information. We believe standardizing this
process and providing training will improve the quality of postoperative handovers and the safety of patients
during this critical period.
1. Introduction
Patient handover can be dened as the transfer of information, re-
sponsibility and accountability for all or some aspects of care of a patient
or a group of patients to another person or professional group on a
temporary or permanent basis [1,2]. Post operative handover (handoff)
involves the transfer of perioperative information from the surgical team
to the postoperative care provider [3]. To proceed with effective
handover process, effective communication between healthcare pro-
viders plays a vital role. But, it is commonly observed that there is
ineffective communication between health care providers and it in-
creases the risk of medical errors and negatively affects the quality of
care, patient outcome and satisfaction [4–6].
Good handover creates a common understanding of responsibility
and patients status, which means how the patients presented and how
the patient will be provided with the consecutive care [1,2,7,8]
* Corresponding author.
E-mail address: abe.zemedkun@gmail.com (A. Zemedkun).
Contents lists available at ScienceDirect
Annals of Medicine and Surgery
journal homepage: www.elsevier.com/locate/amsu
https://doi.org/10.1016/j.amsu.2022.103915
Received 31 March 2022; Received in revised form 27 May 2022; Accepted 2 June 2022
Annals of Medicine and Surgery 79 (2022) 103915
2
Handover failures are common and can lead to diagnostic and thera-
peutic delays and precipitate adverse events. The transfer of care after
surgery to the postanesthesia care unit (PACU) presents special chal-
lenges to providers on both the delivering and receiving teams. Upon
arrival at the receiving unit information are transferred by the OR team
in an environment that is often chaotic and busy, to a team largely un-
familiar with the patient [9,10]. This includes the transfer of informa-
tion about preoperative and intraoperative conditions and postoperative
management plans [2]. Moreover, anesthetists are expected to handover
all the relevant information to the recovery room staff [11].
Health care provider (HCP) handoff is a time when shortcomings in
communication can result in patient harm, particularly in the post-
operative period, when the patient’s physiology is changing rapidly. The
Joint Commission has reported that two-thirds of sentinel events result
from communication errors and more than 50% of these sentinel events
occur during HCP handoff [12]. Jones PM et al. also showed that among
adults undergoing major surgery, complete handover of intraoperative
anesthesia care compared with no handover was associated with a
higher risk of adverse postoperative outcomes [6].
Increases in medical errors have raised great concern regarding pa-
tient safety, and health care providers are seeking solutions to reduce
risk and increase patient safety with effective clinical handover pro-
cedures and practices [10,13]. Furthermore, it is very important to
analyse the practices and challenges in the local setting and that solu-
tions are customised to t the specic context in which the postoperative
handovers takes place. It is also important to acknowledge the role of
non-technical skills in the work process with respect to patient safety.
Thus, the main aim of this study was to assess the postoperative patient
handover practice and safety among professionals in Dilla University
Referral Hospital. Moreover, this study also aimed to improve the con-
tinuity and quality of post-operative patient handover and care.
2. Materials and methods
A descriptive cross-sectional study was conducted at Dilla University
referral hospital from October 1 to November 30, 2021. Dilla university
referral hospital is located at Dilla town, Gedeo zone, South Nation,
Nationalities and Peoples Region, in Southern Ethiopia at a distance of
360 km from Addis Ababa the capital of the country. The hospital has
more than 2 million people of catchment area that lives in Dilla town,
surrounding zones of southern nation and nationality, sidama and
Oromia region. It delivers comprehensive surgical care for admissions
from surgical ward, emergency department, gynecology and obstetrics,
pediatrics and orthopedics wards with full functioning four operating
theatres. The post anesthesia care unit (PACU) of Dilla University has 3
tables with 1 anesthetist and nurse in charge at a time. The unit is
located in close proximity to the operation theatre and equipped with
standard monitoring devices, oxygen sources and other routinely needed
equipments.
Usually, the responsible anesthetist who provided the intraoperative
care will transfer and handover the patients for the PACU staffs. All
(adult, paediatric, major-minor, and elective-emergency) patients from
different specialties (general surgery, orthopedics, obstetrics and gy-
naecology) underwent operation both under general anesthesia and
regional anesthesia who was handovered during the study period was
included.
In the study hospital, the postoperative handover is informal, un-
structured and inconsistent with often incomplete information transfer.
So that, immediately after handover the nurses in the PACU lled the
checklists based on the information provided to them either from
transferring anesthetists or the operating surgeon. Training was pro-
vided for the data collectors and ve nurses were involved in the data
collection.
To conduct the study, consecutively selected 208 handovers of pa-
tients from operation theatre (OT) to PACU were assessed. Patients
transferred to intensive care unit or to wards were excluded. A checklist
was developed based on a combination of criteria adopted from the
Australian Medical Association 2006 and British Doctors Committee
2004. It was pilot tested and changes were made before the actual data
collection. Thirty (30) handover information indicators were developed
and checked as “Yes” for complete handover, “No” for incomplete and
no handover or “Not applicable”. The expected completion rate was
100% for all indicators. Indicators with >90% completion rate were
marked as acceptable and completion rate of <50% was considered as
areas of critical need improvement. The checklist was divided into 3
main parts: sociodemographic and preoperative information; intra-
operative, anesthesia and surgery related information; and miscella-
neous information.
The methodology in this study followed the international guidelines
for strengthening the Reporting of Cohort Studies in Surgery (STROCSS)
2019 statement [14]. The study was registered at www.researchregistry.
com with Unique Identier Number (UIN): research registry7712.
Ethical approval was obtained from Dilla University institutional
review board. The data were collected after getting permission from the
Dilla university referral hospital. All relevant ethical principles and data
protection policies under the Helsinki declaration were followed. All
data were accessed, compiled, and secured by avoiding personal iden-
tications and all the data were accessed for only the authors. The data
were checked, coded, entered, and cleaned using IBM SPSS statistics
20.0 software. Descriptive analysis was performed. Narratives and tables
were used to present the data and ndings were expressed in the form of
frequencies and percentages.
3. Result
Information was collected from a total of 208 handovers taking place
during the data collection time. This included a wide range of surgical
specialties, and both general and regional anesthesia.
3.1. Information related to sociodemographic and preoperative patient
status
Our study found that the postoperative patient handover practice of
anesthetists was poor in the areas of sociodemographic and preoperative
status of the patients. The completion rate of patients’ full name, age,
medical registration number (MRN), ASA class, allergic history, medical
history, baseline vital signs, preoperative diagnosis and surgical pro-
cedure performed were 24.5%, 16.8%, 20.7%, 4.3%, 3.8%, 11.5%, 24%,
39% and 76.4%, respectively (Table 1).
Table 1
Components of postoperative handover provided to PACU nurses of Dilla Uni-
versity Referral Hospital. (Frequency and percentage (n (%)), N =208.
Sociodemographic and preoperative
information
Response [n (%)], N =208
Yes No NA
Age (in years) 35 (16.8) 173(83.2) 0
(0)
Patient full name 51(24.5) 157(75.5) 0
(0)
Medical registration number (MRN) 43 (20.7) 165(79.3) 0
(0)
Allergic history 8(3.8) 200(96.15) 0
(0)
ASA class 9(4.3) 199
(95.67)
0
(0)
Preoperative diagnosis 81(39) 127(61) 0
(0)
Any medical history 24(11.5) 184(88.5) 0
(0)
Procedure 159
(76.4)
49(23.6) 0
(0)
Baseline vital signs 50(24) 158 (76) 0
(0)
A. Zemedkun et al.
Annals of Medicine and Surgery 79 (2022) 103915
3
3.2. Information related to intraoperative care, anesthesia and surgery
Regarding the patients’ intraoperative care, anesthesia and surgery
related information; our study found poor postoperative hand overing
practice in the areas like intraoperative blood loss 9.6%, intraoperative
clinical incidents 5.3%, recovery condition 7.2%, postoperative anal-
gesia plan 18.8%, post operative antibiotic plan 8.2%, anticipated post
operative complications 5.3%. Whereas, type of anesthesia 81.3%,
intraoperative vital signs 80.8%, and intraoperative analgesia used
79.8%, intraoperative uid management 80.8% were among the in-
dicators with nearly good completion rate (Table 2).
3.3. Completion rate of miscellaneous information
The handover practice for other necessary miscellaneous informa-
tion was also found. For instance any post operative support needed for
the patient was transferred only in 15(7.2%) of the patients (Table 3).
4. Discussion
Teamwork is an essential component of achieving high reliability in
healthcare and working atmosphere. Poor surgical teamwork behaviour
concerning information sharing during intraoperative and handover
phases has been shown to be signicantly associated with more frequent
postoperative complications or death [15]. Postoperative patients are in
an “at-risk” state and require constant vigilance and assessment that can
only be achieved with effective communication between the anesthesia
provider and the PACU nurse. Even with vigilance, however, surgical
patients are more vulnerable to handover errors than are patients in
other clinical areas because of the combined acuity and transition [16,
17].
The aim of patient handover is to provide a high quality and
appropriate clinical information to the coming healthcare professionals
to allow for the safe transfer of responsibility for the care of patients.
Good handovers are essential in providing the continuity of care, patient
safety and error avoidance. This will help to ensure that after handover
all members of the team will have the same understanding [2,16,18,19].
Our study in general found poor handover practice regarding socio-
demographic and preoperative patient information, anesthesia and
surgery related issues, and miscellaneous information. A root cause
analysis reported by the Joint Commission suggests that poor commu-
nication is a major cause of anesthesia-related sentinel events [20].
The study revealed that none of the indicators of post operative
handover had a completion rate of 100%. Our study found that the
postoperative patient handover practice of anesthetists was poor in the
areas of sociodemographic and preoperative status of the patients. The
completion rate of patients’ full name, age, medical registration number
(MRN), ASA class, allergic history, medical history, baseline vital signs,
preoperative diagnosis and surgical procedure performed were 24.5%,
16.8%, 20.7%, 4.3%, 3.8%, 11.5%, 24%, 39% and 76.4%, respectively.
In line with our nding, a study in university of Gondar, Ethiopia
showed that patient handover practice of anesthetists was poor
regarding patient identity 3.2%, preoperative patient condition 0% and
type of operation 82.2% [2]. A survey by Jayaswal S et al. showed also
showed that the handoff process was inadequate with most of the cli-
nicians giving and receiving poor or incomplete handoff information
[20].
The transfer of care after surgery to the PACU involves cross-
disciplinary staff with varied experience; the delivering team members
with their diverse yet important perspectives of the course of surgery;
and the receiving team concurrently stabilizing, assessing, and making
care plans for the patient. Moreover, handover failures are common and
can lead to diagnostic and therapeutic delays and precipitate adverse
events [9].
Regarding the intraoperative care, anesthesia and surgery related
information, our study found poor postoperative hand overing practice
in the areas like intraoperative blood loss 9.6%, intraoperative clinical
incidents 5.3%, recovery condition 7.2% and postoperative analgesia
plan 18.8% and post operative antibiotic plan 8.2%. Whereas, type of
anesthesia 81.3%, intraoperative vital signs 80.8%, and intraoperative
analgesia used 79.8%, intraoperative uid management 80.8% were
among the indicators with nearly good completion rate. In line with our
nding a clinical audit among a total of 124 handovers taking place
between 30 anaesthetists and 12 nurses in the recovery room of Gondar
University referral hospital by Gebremedhn EG et al. also found that the
practice of post operative handover was below 90% for type of anes-
thesia 82.2%, intraoperative vital signs 87.1%, intraoperative analgesia
use 62.9%, intraoperative uid management 59.7%, intraoperative
blood loss 8.1%, intraoperative clinical incidents 3.1%, recovery con-
dition 45.1% and postoperative management plan 3.2% [2]. In contrary,
Table 2
Completion rate of postoperative handover practice indicators regarding anes-
thesia and surgery related Information provided to PACU nurses of Dilla Uni-
versity Referral Hospital. (Frequency and percentage (n (%)), N =208.
Anesthesia and surgery related information Response [n (%)], N =208
Yes No NA
Type of Anesthesia and medications given 169
(81.3)
39
(18.7)
0(0)
Intraoperative vital signs 168
(80.8)
40(19.2) 0(0)
Intraoperative uid management (type and
amount)
168
(80.8)
40(19.2) 0(0)
Intraoperative analgesic drugs given (name,
dose and route)
166
(79.8)
42
(20.2)
0(0)
Intraoperative complication (if any) 11 (5.3) 197
(94.7)
0(0)
Anticipated postoperative complications 11 (5.3) 197
(94.7)
0(0)
Monitoring used 15 (7.2) 193
(92.7)
0(0)
Recovery/extubation condition 15 (7.2) 133
(63.9)
60(28.8)
Postoperative analgesia plan 39
(18.8)
169
(81.2)
0(0)
Postoperative plan for uid management 18 (8.7) 190
(91.3)
0(0)
Intraoperative blood loss 20(9.6) 188
(90.4)
0(0)
Postoperative antibiotic plan (name, dose,
route and time)
17(8.2) 191
(91.8)
0(0)
Deep venosus thrombosis (DVT) prophylaxis 8(3.8) 0(0) 200
(96.2)
Post-operative plan for tubes and drains 11(5.3) 0(0) 197
(94.7)
Postoperative plan for NG tube and feeding 13(6.3) 175
(84.1)
20
(9.61)
Postoperative investigative modality 15(7.2) 193
(92.8)
0(0)
Medication plan ordered (if any drug needed
or to be continued)
13(6.3) 195
(93.7)
0(0)
Table 3
Completion rate of postoperative handover practice indicators regarding
miscellaneous Information provided to PACU nurses of Dilla University Referral
Hospital. (Frequency and percentage (n (%)), N =208.
Miscellaneous information Response [n (%)], N =208
Yes No NA
Any medication for shivering (type, dose and route) 81
(38.9)
127
(61.1)
0
(0)
Any antiemetic agent for Post operative nausea and
vomiting
23
(11.1)
185
(88.9)
0
(0)
Any additional postoperative support mentioned (if
needed)
15(7.2) 193
(92.8)
0
(0)
Contact person in case of any concerns 14(6.7) 194
(93.3)
0
(0)
A. Zemedkun et al.
Annals of Medicine and Surgery 79 (2022) 103915
4
a survey by Jayaswal S et al. among 80 anesthesia staff, residents, and
nurse anesthetists found good handover practice regarding name of
procedure (100%), relevant medications received by the patient theatre
(99%), Intraoperative anaesthetic course and any complications (98%)
and Medical history (93%). But the practice of handover was below 90%
in areas of antibiotic plan (88%), Patient name (83%), intraoperative
surgical course and any complications (75%) and Patient’s current
condition and vitals (73%) [20]. The reason for the discrepancies could
be setup and human resource variation, sample size difference and
merged variables. A prospective analysis conducted on total number of
790 handovers with duration of 73 ±49 s by Milby A et al. in Germany
regarding the quality of post-operative patient handover in the
post-anesthesia care unit also showed that few items were transferred in
most of the cases such as type of surgery (97%), regional anesthesia
(94%) and cardiac instability (93%). However, some items were rarely
transferred, such as American Society of Anesthesiologists physical
status (7%), initiation of post-operative pain management (12%), anti-
biotic therapy (14%) and uid management (15%). There was a slight
correlation between amount of information transferred and duration of
postoperative handovers (r =0.5) [21]. Nagpal K et al. also reported
similar nding [22].
A qualitative descriptive study (2017) by Randmaa M and his col-
leagues involving six focus groups with 23 healthcare professionals
involved in postoperative handovers in Sweden showed that there are
variations in different professionals’ views on the postoperative hand-
over that healthcare interventions are needed to minimise the gap be-
tween professionals’ perceptions and practices and to achieve a shared
understanding of postoperative handover [15]. So that, implementation
of a handover protocol has been suggested by experts in order to stan-
dardise patient handovers [13,21,22]. Moreover, like our hospital’s
practice, Nagpal et al. identied that the postoperative handover is
informal, unstructured and inconsistent with often incomplete infor-
mation transfer [23].
5. Limitation
The limitation of this study is it is a single centre study that it is only
representative for the study hospital. Nevertheless, it is most likely that
studies in other hospitals would lead to similar results. Limited number
of articles for discussion of the practice and safety of handover was also
other limitation of the study.
6. Conclusion and recommendation
Our study found a poor practice of patient handover regarding
sociodemographic and preoperative information, anesthesia and sur-
gery related issues and other necessary information. So that, we believe
standardizing this process can improve patient care by ensuring infor-
mation completeness and accuracy and increasing the efciency of the
patient transfer process. We also recommend providing training
regarding postoperative handover, team skills and communication.
These recommendations have the potential to improve the quality of
postoperative handovers and the safety of patients during this critical
period.
Availability of data
All data generated or analyzed during this study were included in
this published article.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Ethical approval
Ethical approval: Ethical clearance to conduct the research was ob-
tained from the institutional review board of Dilla University College of
health sciences and medicine.
Sources of funding for your research
No funding source.
Author contribution
All authors made a signicant contribution to the work reported,
whether that is in the conception, study design, execution, acquisition of
data, analysis and interpretation, or in all these areas; took part in
drafting, revising or critically reviewing the article; gave nal approval
of the version to be published; have agreed on the journal to which the
article has been submitted; and agree to be accountable for all aspects of
the work.
Registration of research studies
Trial registry number.
1. Name of the registry: research registry
Unique Identifying number or registration ID: 7712.
2. Hyperlink to your specic registration (must be publicly accessible
and will be checked): https://www.researchregistry.com/browse-th
e-registry#home/
Consent
NA.
Guarantor
Abebayehu Zemedkun.
Declaration of competing interest
Declarations of interest: none.
Abbreviations
OT Operation Theatre
PACU Post Anesthesia Care unit
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.amsu.2022.103915.
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