Research

JAMA | Original Investigation

Effect of Intraoperative Handovers of Anesthesia Care on Mortality,

Readmission, or Postoperative Complications Among Adults
The HandiCAP Randomized Clinical Trial
Melanie Meersch, MD; Raphael Weiss, MD; Mira Küllmar, MD; Lars Bergmann, MD; Astrid Thompson, MD; Leonore Griep, MD; Desiree Kusmierz, MD;
Annika Buchholz, MD; Alexander Wolf, MD; Hartmuth Nowak, MD; Tim Rahmel, MD; Michael Adamzik, MD; Jan Gerrit Haaker, MD; Carina Goettker, MD;
Matthias Gruendel, MD; Andre Hemping-Bovenkerk, MD; Ulrich Goebel, MD; Julius Braumann, MD; Irawan Wisudanto, MD; Manuel Wenk, MD;
Darius Flores-Bergmann, MD; Andreas Böhmer, MD; Sebastian Cleophas, MD; Andreas Hohn, MD; Anne Houben, MD; Richard K. Ellerkmann, MD;
Jan Larmann, MD; Julia Sander, MD; Markus A. Weigand, MD; Nicolas Eick, MD; Sebastian Ziemann, MD; Eike Bormann, MSc; Joachim Gerß, PhD;
Daniel I. Sessler, MD; Carola Wempe, PhD; Christina Massoth, MD; Alexander Zarbock, MD

Visual Abstract
IMPORTANCE Intraoperative handovers of anesthesia care are common. Handovers might Supplemental content
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, Author Affiliations: Author
there was no significant difference between the patients randomized to receive handover of affiliations are listed at the end of this
anesthesia care from one clinician to another, compared with the no handover group, in the article.

composite primary outcome of mortality, readmission, or serious postoperative Corresponding Author: Melanie
Meersch, MD, Department of
complications within 30 days.
Anesthesiology, Intensive Care and
TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04016454 Pain Medicine, University Hospital
Münster, Albert-Schweitzer-Campus
JAMA. doi:10.1001/jama.2022.9451 1, Bldg A1, 48149 Münster, Germany
Published online June 4, 2022. (meersch@uni-muenster.de).

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 Research Original Investigation Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications
I
n 2012, an estimated 310 million surgical procedures with
anesthesia were performed, with greater frequency since
then.1,2 Nine million patients had surgery that included a
complete anesthesia handover, usually secondary to profes-
sional or personal commitments and duty-hour restrictions but
also due to physician illness or fatigue.1,3,4 The potential con-
sequences of care transitions include loss of critical informa-
tion, which may result in suboptimal care and patient harm.3,5,6
Information transfer in a noisy and distracting environment
while continuing patient care entails considerable risk of com-
munication failure.7,8 Conversely, continued care by a fa-
tigued clinician also imposes risk.9
Retrospective analyses in large cohorts of patients who had
cardiac and major noncardiac procedures reported discrep-
ant findings.3,10 Although some failed to identify associa-
tions between intraoperative transition of anesthesia care and
complications, others reported that handovers were associ-
ated with an increased risk of short-term mortality and seri-
ous postoperative complications including surgical revision,
hemorrhage, organ dysfunction, and thromboembolic
complications.3,5,11-15
Observational analyses of handovers cannot fully control
for confounding. Therefore, a multicenter randomized trial
testing the primary hypothesis that intraoperative handovers
of anesthesia have an effect on a composite of all-cause mor-
tality, hospital readmission, and serious postoperative com-
plications was conducted.
Methods
Study Design and Ethics
A detailed description of the HandiCAP trial procedures was
published16 (see also the study protocol in Supplement 1 and
the statistical analysis plan in Supplement 2). Approval was ob-
tained from the Ethics Committee of the Chamber of Physi-
cians Westfalen-Lippe and the Westphalian-Wilhelms Univer-
sity Muenster (2018-470-f-S) and from the corresponding
boards at each site. Patient enrollment began after starting the
trial registration process. Due to several requests, official reg-
istration was delayed until after 3 patients were enrolled. These
patients were included in the full analysis set.
Written informed consent was obtained from participat-
ing patients before surgery. An independent data and safety
monitoring board provided trial oversight and reviewed blinded
safety data. Study design and manuscript preparation
followed Consolidated Standards of Reporting Trials
(CONSORT) recommendations.
Patient Recruitment
Adults aged 18 years or older who were designated American
Society of Anesthesiologists (ASA)17 physical status 3 or 4 and
were scheduled for major inpatient surgery with an antici-
pated duration of 2 or more hours were enrolled. Major sur-
geries were targeted within the broad range of general, neu-
rological, vascular, orthopedic, gynecologic, thoracic,
urological, trauma, plastic, and cardiac surgery and were iden-
tified by experienced anesthesiologists and/or surgeons. Pa-
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Key Points
Question Among adults undergoing extended surgical
procedures, what is the effect of an intraoperative handover of
anesthesia care on clinical outcomes?
Findings In this randomized clinical trial that included 1772
patients, the composite primary outcome of mortality,
readmission, or serious postoperative complications within 30
days did not differ significantly among participants randomized to
receive handover of anesthesia care vs no handover of care (30%
vs 33%, respectively).
Meaning Among adults undergoing extended surgical
procedures, there was no significant difference between handover
of anesthesia care compared with no handover of care in the risk
of postoperative morbidity and mortality.
tients were excluded if they had previous surgery by the same
specialty within 6 months, were pregnant or breastfeeding, or
participated in another interventional trial within the last
3 months.
Randomization
Patients were randomly assigned to 1 of the 2 treatment groups
in a 1:1 ratio in permuted blocks of 4 and 6 and stratification
by site and anesthesiologist training level (≤2 years, >2-5 years,
or >5 years) through a central web-based system. Supervisors
who allocated handovers were unblinded, whereas patients
and outcome assessors were not informed of the treatment as-
signments. Because handovers of anesthesia care or lack
thereof are routine, treating anesthesiologists were unaware
whether a particular handover was per clinical routine or due
to trial participation. Neither supervisors nor treating anes-
thesiologists were informed of the trial hypothesis.
Procedures
Anesthesia care was provided by anesthesia interns or resi-
dents (≥5 years’ training is required to become a specialist) or
by specialists (without responsibility of supervising resi-
dents). Patients assigned to the no handover strategy were
treated by the same anesthesiologist from the point of anes-
thesia induction to the end of the surgical procedure. Pa-
tients allocated to the handover group were to have at least 1
complete transition of care from one anesthesiologist to an-
other during surgery (the exact time point of the handover was
not prespecified).
The change of the treating anesthesiologist was orga-
nized such that the experience level of incoming clinicians was
similar to that of outgoing clinicians. After the handover was
completed, the outgoing anesthesiologist was no longer avail-
able for further consultation. Handovers were restricted to the
in-room anesthesiologist. In cases in which an intern or resi-
dent was involved, the supervising attending physicians re-
mained unchanged. Short breaks up to 45 minutes provided
by the supervising attending were not considered handovers.
None of the participating centers used a structured handover
protocol. Handovers were therefore conducted according to
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 Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications
institutional standards, which include conveying informa-
tion about important organ systems and special patient-
specific conditions.
Depending on their experience, treating interns or resi-
dents were supervised by an attending physician. Supervi-
sors were generally present during anesthetic induction but
then only intermittently because they were responsible for 3
to 4 operating rooms. Experienced residents provided care in-
dependently, but could always call an attending.
Outcomes
The primary end point was a composite of all-cause mortal-
ity, readmission to any hospital, or serious postoperative com-
plication within 30 days after the index surgery. Serious com-
plications included postoperative ventilation for 48 hours or
more, major disruption of a surgical wound requiring surgi-
cal revision, major bleeding with transfusion, pneumonia, new-
onset of atrial fibrillation, moderate and severe acute kidney
injury (Kidney Disease: Improving Global Outcomes stage 2 or
3),18 new onset of kidney replacement therapy, cardiac ar-
rest, myocardial infarction, sepsis per Third International
Consensus19 definition, stroke, pulmonary embolism and deep
venous thromboembolism, shock (cardiogenic, hypovole-
mic, distributive, or obstructive shock), and unplanned reop-
eration within 30 days. Secondary end points were the com-
ponents of the primary composite and intensive care unit (ICU)
and hospital lengths of stay.
Sample Size Calculation
The sample size estimate was performed with the PASS-
software version 14 based on a meta-analysis of 4 published
trials using a similar primary end point. Primary composite end
point rates were assumed to be 20.8% in the handover and
15.6% in the no handover group (difference, 5.2%).3,5,11,12 A total
of 864 patients per group provided 80% power at a 2-sided α
of 5%. Assuming a 5% dropout rate, the resulting total sample
size was 1814 patients (eMethods in Supplement 3).
Statistical Analysis
Statistical analyses were planned prior to unblinding the study
statistician and reviewing the data.20 A full description is pre-
sented in Supplement 2. Standardized differences between
study groups were calculated using SAS macro stddiff.21
The primary analysis included all randomized and evalu-
able patients (full analysis set). Patients were analyzed accord-
ing to their randomized assignment, disregarding protocol vio-
lations. Missing data were not imputed. In sensitivity analyses,
patients with major protocol deviations were excluded. The
primary analysis was performed using the 2-sided Cochran-
Mantel-Haenszel χ2 test, stratified by trial site and anesthesi-
ologist experience. Categorical secondary outcomes were ana-
lyzed with Fisher exact tests, and in additional sensitivity
analyses with the Cochran-Mantel-Haenszel test. Censored
lengths of hospital and ICU stays were analyzed with Cox re-
gression (specified post hoc) after confirming the propor-
tional hazards assumption using Grambsch-Therneau tests. Pri-
mary and secondary outcomes were considered significant at
a 2-sided P ≤ .05. Secondary outcomes were not corrected for
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Original Investigation Research
multiplicity, and the findings for secondary outcomes should
be interpreted as exploratory.
Results are presented as odds ratios (ORs) and absolute risk
differences (RDs) with 95% CIs for categorical variables and
Hodges-Lehmann estimator of location shift for continuous
variables.22 In stratified analyses, both ORs and absolute RDs
were first calculated within each stratum and then pooled over
all strata to determine a common OR and absolute RD.
Multivariable logistic regression for the primary end point
was conducted using site as a random effect and adjusting for
relevant baseline characteristics was conducted (type of sur-
gery and revised cardiac risk index). Additionally, the num-
ber of handovers and experience level of the initial anesthe-
siologist were included.
Safety end points were the components of the primary
composite within 30 days and were evaluated on an as-
treated basis.
The following post hoc analyses were performed. The pri-
mary end point was compared between randomized groups
using logistic regression, adjusting for stratification factors (site
as a random effect and experience level as a fixed effect). Num-
ber of anesthesia procedures with supervision and anesthe-
sia complications were compared between exposure groups
using the Fisher exact test. In subgroups by duration of sur-
gery, primary and secondary outcomes were compared be-
tween randomized groups using the Cochran-Mantel-
Haenszel test. Occurrence of secondary end points within 7
days and in-hospital mortality were compared between ran-
domized groups using the Cochran-Mantel-Haenszel test. For
patients with 1 handover, the primary outcome was com-
pared between different experience levels of the first and sec-
ond anesthesiologist using the Fisher exact test. Association
between the primary and secondary end points and the num-
ber of handovers was presented descriptively. Death within 24
hours and in-hospital mortality were analyzed as post hoc out-
comes. The results of post hoc analyses were considered sig-
nificant at a 2-sided P ≤ .05 without correction for multiplic-
ity and should be interpreted as hypothesis generating.
Statistical analyses were performed using SAS version 9.4
(SAS Institute Inc).
Results
Patients
From June 2019 to June 2021, 6626 patients were screened for
eligibility, of whom 1817 were randomized (final date of follow-
up, July 31, 2021). Forty-five patients were excluded from the
primary analysis because they were lost to follow-up for the
primary end point. Ultimately, there were 1772 patients in the
full analysis set, with 891 patients (50.3%) randomly as-
signed to the handover group, anesthesia car from another cli-
nician, and 881 (49.7%) to the no handover group (Figure 1).
Baseline characteristics and surgical details of patients in
the primary analysis did not differ meaningfully between the
2 groups (Table 1 and eTables 1 and 2 in Supplement 3). The
mean age of those in the primary analysis was 66 (SD, 12) years,
997 (56%) were men, 1440 (82%) had social health insurance,
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 Research Original Investigation Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications
Figure 1. Recruitment, Randomization, and Outcome Ascertainment of Patients
in the HandiCAP Randomized Clinical Trial
6626 Patients scheduled for major surgery
of ≥2 h were assessed for eligibility
1817 Randomized
908 Randomized to handover anesthesia care
774 Received intervention as randomized
117 Did not receive intervention as
randomized
17 Lost to follow-upa
891 Included in the primary analysis (mean
No. of anesthesiologists, 2.7 [SD, 0.8])
181 Excluded from per-protocol analysisb
the median Charlson Comorbidity Index was 5 (IQR, 4-7), and
1717 (97%) were designated ASA grade 3.
Overall, 1721 patients (97%) had elective surgery (Table 1).
The most common procedures were general surgery (26%),
neurosurgery (25%), vascular surgery (19%), and orthopedic
procedures (17%) (eTable 2 in Supplement 3). The median du-
ration of surgery was 180 minutes (IQR, 128-258 minutes). Most
patients had balanced anesthesia or combined general and re-
gional anesthesia. The median duration of anesthesia induc-
tion was 28 minutes (IQR, 19-41 minutes), and the total anes-
thesia duration was 267 minutes (IQR, 206-351 minutes;
Table 2).
Details of Anesthesia Care
A total of 774 patients (87.0%) in the handover group had a tran-
sition of anesthesia care, with 635 (71.4%) having 1 transition,
and 127 (14.3%) having 2 transitions (Table 2). Of the patients
in no handover group, 795 (91.0%) were continuously cared
for by a single anesthesiologist whereas 69 patients (7.9%) had
1 handover (Table 2). Consequently, 116 patients (13.0%) as-
signed to a handover and 79 (9.0%) assigned to the no han-
dover group did not receive the designated management
(Table 2; eTable 3 in Supplement 3).
Most handovers were performed in the morning (Table 2).
The anesthesiologists’ time on duty before surgical proce-
dures was similar between groups: the mean time was 126 (SD,
120) minutes in the handover group and was 108 (SD, 113) min-
utes in the no handover group. The median time from start of
anesthesia to first handover was 140 minutes (IQR, 102-196
minutes) in the handover group and 272 minutes (IQR, 163-
484 minutes) in the no handover group. Most anesthetic in-
ductions were supervised by attendings in both groups but less
often among patients assigned to the handover group (67% vs
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4809 Excluded
3315 Did not meet inclusion criteria
966 Met exclusion criteria
914 Underwent surgery by the
same specialty <6 mo
52 Were participants in another
interventional trial
295 Declined participation
233 Other reasons
a
Patients lost to follow-up could not
be reached, so no data were
909 Randomized to no handover care available.
795 Received usual care as randomized b
Patients with protocol deviations
86 Did not receive intervention as (deviation from inclusion and
randomized
28 Lost to follow-upa exclusion criteria, deviation from
the randomized study group,
cancellation of the surgical
881 Included in the primary analysis (mean procedure, and premature
No. of anesthesiologists, 1.8 [SD, 0.6]) termination of study participation)
200 Excluded from per-protocol analysisb
were excluded from the
per-protocol analysis.
74%; P < .001, Table 2). Educational level of the initial anes-
thesiologist was similar in both groups (Table 2 and eTable 4
in Supplement 3). The most common complications during an-
esthetic induction were bradycardia, severe hypotension, and
hypertension (Table 2 and eTable 3 in Supplement 3).
Primary Outcome
The primary composite end point did not differ significantly
between the 2 groups, with 268 events (30.1%) among pa-
tients in the handover group and 284 (32.5%) among patients
in the no handover group (absolute RD, −2.5%; 95% CI, −6.8%
to 1.9%; OR, 0.89; 95% CI, 0.72 to 1.10; P = .27; Table 3 and
eTable 5 in Supplement 3).
Secondary Outcomes
Mortality, readmissions, and serious postoperative complica-
tions did not significantly differ by group (Table 3). The most
frequent complications were unplanned return to the operat-
ing room (12.3%), major disruption of surgical wound (6.8%),
and bleeding (6.5%). There were 463 patients (52.0%) in the
handover group and 419 (48.0%) in the no handover group who
required ICU admission (P = .10). The durations of ICU stays
were not significantly different with a median of 1 day (IQR,
1-3 days) in the handover group vs 1 day (IQR, 1- 3 days) in the
no handover group (P = .36). Hospital length of stay also did
not differ significantly (median, 8 days; IQR, 6-15 days in the
handover group and 8 days; IQR, 6-14 days in the no han-
dover group; P = .25, Table 3).
Additional Analyses
Type of surgery, revised cardiac risk index, number of han-
dovers, and training level were not significantly associated with
serious postoperative complications (Figure 2 and eTable 6 in
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 Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications Original Investigation Research

Table 1. Baseline Characteristics of Patients in the Primary Analysis of the HandiCAP Randomized Clinical Trial

No. (%) of patients

No handover
Handover (n = 891) (n = 881)
Patient demographics
Age, mean (SD), y 65.9 (11.9) 66.4 (12.0)
Weight, mean (SD), kg 82.7 (19.7) 81.6 (19.0)
Height, mean (SD), m 1.7 (0.1) 1.7 (0.1)
BMI, median (IQR) 27.1 (23.7-31.1) 26.8 (23.7-30.4)
Sex
Men 499 (56.1) 498 (56.8)
Women 391 (43.9) 379 (43.2)
Insurancea
Abbreviations: ASA, American
Private 151 (17.0) 175 (20.0) Society of Anesthesiology; BMI, body
Social 738 (83.0) 702 (80.1) mass index, calculated as weight in
kilograms divided by height in meters
Comorbidities
squared; CKD, chronic kidney
ASA scoreb disease; NSQIP, National Surgical
3 (severe general illness) 862 (97.2) 855 (97.5) Quality Improvement Program;
SURPAS, Surgical Risk Preoperative
4 (life-threatening general illness) 25 (2.8) 22 (2.5)
Assessment.
Charlson Comorbidity Index, median (IQR)c 5 (4-7) 5 (4-7) a
Patients with private insurance were
Surgical morbidity risk assessment, median (IQR), % cared for by department chairs or
Modified NSQIPd 13.2 (8.7-20.0) 12.6 (8.3-19.4) their representatives, at least for
anesthetic induction. Other patients
SURPASe 28.9 (21.5-36.7) 28.5 (21.4-35.7)
were cared for by any available
Hypertension 639 (71.8) 656 (75.0) anesthesiologists.
Cancer 464 (52.1) 430 (49.1) b
American Society of Anesthesiology
Peripheral vascular disease 232 (26.1) 222 (25.4) classifications are defined as follows
(grades 1, 2, and 5 patients were not
Chronic pulmonary disease 218 (24.5) 216 (24.7)
eligible for inclusion): 3, a patient
Coronary artery disease 207 (23.3) 217 (24.8) with severe systemic disease that
Diabetes 186 (20.9) 180 (20.6) limits physical activity; and 4, a
patient with severe systemic
Congestive heart failure 135 (15.2) 120 (13.7)
disease that is a constant threat to
Cerebrovascular disease 131 (14.7) 126 (14.4) life.
c
Myocardial infarction 115 (12.9) 114 (13.1) The Charlson Comorbidity Index is a
Moderate or severe CKD 106 (11.9) 88 (10.1) list of 17 comorbidities identified by
the International Classification of
Anesthesiologist characteristics Diseases, each of which is assigned
Level of training of initial anesthesiologist, resident-y a weight from 1 to 6 (0 indicates
1 175 (19.7) 189 (21.6) healthy patients [no comorbidities
identified]; higher scores indicate
2-3 215 (24.2) 220 (25.2) the presence of additional
4-5 243 (27.3) 208 (23.8) comorbidities).
d
>5 y 59 (6.6) 87 (10.0) NSQIP is a surgical prediction tool
Specialist 110 (12.4) 104 (11.9) using 24 variables to predict
multiple adverse events, here we
Attending physician 88 (9.9) 66 (7.6) show a modified NSQIP (missing
Surgery variables were ascites within 30
Duration of surgery, minf days prior to surgery, steroid use for
chronic condition, smoking status,
Mean (SD) 219 (121) 196 (109) dyspnea).
Median (IQR) 189 (136-275) 168 (120-250) e
SURPAS is a surgical prediction tool
Admission category of 8 adverse outcomes using 8
predictor variables.
Elective 866 (97.3) 855 (97.6)
f
Duration of surgery is the time from
Emergency 24 (2.7) 21 (2.4)
skin incision to skin suture.

Supplement 3). Results of the safety analysis are reported in
eTable 7 in Supplement 3.
Post Hoc Analysis and Outcomes
Results of the primary analysis were confirmed in a mixed
model, adjusting for stratification factors with site as a ran-
dom effect and training level as a fixed effect (OR, 0.89; 95%
CI, 0.73 to 1.09; P = .27). There was no significant heteroge-
neity across trial sites (eFigure in Supplement 3). The overall
incidence of the primary composite end point was 30.2% (275
of 911) among patients without handovers, 33.5% (236 of 704)
among those with 1 handover, and 25.2% (34 of 135) among

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 Research Original Investigation Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications

Table 2. Anesthesia Details

No. (%) of patients Absolute difference

Handover No handover (handover vs no Standardized
(n = 891) (n = 881) handover), % differencea
No. of complete handovers, median 1 (1 to 1) 0 1 (1 to 1)
(IQR)b
0 116 (13.0) 795 (91.0) −77.9 (−80.8 to
−75.0)
1 635 (71.4) 69 (7.9) 63.5 (60.0 to 66.9)
2 127 (14.3) 8 (0.9) 13.4 (11.0 to 15.7) 2.50

3 9 (1.0) 1 (0.1) 0.9 (0.2 to 1.6)

4 3 (0.3) 1 (0.1) 0.2 (0.2 to 0.7)
Start of anesthesia to first handover, 140 (102 to 196) 272 (163 to 484) −125 (−171 to −89) −0.82
median (IQR), minc
Time on duty before index operation, 126 (120) 108 (113) 7 (3 to 13) 0.15
mean (SD), min
Start time of anesthesia for index
surgeryb
7-9 AM 460 (51.7) 496 (56.8) −5.1 (−9.7 to 0.4)
9-11 AM 213 (23.9) 204 (23.3) 0.6 (−3.4 to 4.6)
11 AM-1 PM 155 (17.4) 129 (14.8) 0.3 (−0.8 to 6.1)
0.17
1-3 PM 55 (6.2) 40 (4.6) 1.6 (−0.5 to 3.7)
3-5 PM 5 (0.6) 4 (0.5) 0.1 (−0.6 to 0.8)
5-9 PM 2 (0.2) 1 (0.1) 0.1 (−0.3 to 0.5)
Supervision by attending physiciand 592 (66.5) 646 (74.1) −7.6 (−11.8 to 3.3) −0.17
Type of anesthesia a
Standardized differences were
Balanced 637 (54.9) 673 (58.5) −3.7 (−7.7 to 0.4) calculated according to Yang and
Total intravenous 246 (21.2) 186 (16.2) 5.0 (1.8 to 8.2) Dalton.21 The standardized
difference shows the clinical
Epidural 218 (18.8) 222 (19.3) −0.6 (−3.8 to 2.6)
0.21 relevance of the difference between
Peripheral regional 41 (3.5) 41 (3.6) 0.1 (−1.5 to 1.6) groups (0.2, small; 0.5, medium;
Spinal 14 (1.2) 23 (2.0) −0.8 (−1.8 to 0.2) ⱖ0.8 large).
b
Change of anesthetic procedure 5 (0.4) 6 (0.5) −0.0 (−0.5 to 0.5) One missing value in the handover
e
and 7 in the no handover group
Duration of anesthesia induction, min
because patients were randomized
Mean (SD) 32 (26) 33 (23) 0 (−2 to 1) but surgical procedure was not
−0.01 performed.
Median (IQR) 27 (19 to 41) 29 (19 to 41)
c
Total duration of anesthesia, min f Only patients with handovers
included.
Mean (SD) 304 (127) 283 (121) 20 (10 to 30) d
0.17 Depending on their experience,
Median (IQR) 278 (216 to 369) 259 (195 to 342) treating interns or residents were
Complications during anesthesia 273 (30.7) 288 (33.0) −2.6 (−7.6 to 2.4) −0.05 supervised by an attending
induction physician. Supervisors were
Bradycardia 132 (37.8) 135 (36.2) 1.6 (−5.4 to 8.7) generally present during anesthetic
Severe hypotension 91 (26.1) 93 (24.9) 1.1 (−5.2 to 7.5) induction, but then only
intermittently.
Hypertension 70 (20.1) 80 (21.5) −1.4 (−7.3 to 4.5) e
Anesthesia induction is defined as
Multiple punctures 25 (7.2) 35 (9.4) −2.2 (−6.2 to 1.8) start of any anesthesia induction
Tachycardia 9 (2.6) 10 (2.7) −0.1 (−2.4 to 2.2) process (eg, hypnotic
0.27 administration or epidural catheter
Catheter malposition 4 (1.2) 3 (0.8) 0.3 (−1.1 to 1.8)
insertion) and patients being ready
Broncholaryngospasm 3 (0.9) 0 0.9 (−0.1 to 1.8) for surgery.
Aspiration 1 (0.3) 0 0.3 (−0.3 to 0.9) f
Total duration of anesthesia is
Tooth demolition 1 (0.3) 0 0.3 (−0.3 to 0.9) defined as start of any anesthesia
induction process up to the end of
Unsuccessful intubation 1 (0.3) 6 (1.6) −1.3 (−2.7 to 0.1)
anesthesia (eg, extubation).

those with 2 handovers (eTable 8A and B in Supplement 3). The
incidence of the composite end point did not differ signifi-
cantly depending on the educational level of the relieving an-
esthesiologist (eTable 9A and B in Supplement 3).
A sensitivity analysis restricted to complications occur-
ring within the first 7 days demonstrated that, with the excep-
tion of moderate to severe acute kidney injury being higher
in the handover group (27 patients [3.0%] in the handover
group vs 14 [1.6%] in the no handover group; absolute RD, 1.5%;
95% CI, 0.1%-to 2.9%; OR, 2.03; 95% CI, 1.00 to 4.29; P = .04),
serious postoperative complications did not differ signifi-
cantly by group (eTable 10 in Supplement 3). In analyses by du-
ration of surgery, the primary outcome was significantly more
common in patients in the fourth duration quartile (>180 min)

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 Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications Original Investigation Research

Table 3. Clinical Outcomes

Absolute risk
Handover No handover difference, Handover vs no handover,
(n = 891)a (n = 881)a (95% CI), %b OR (95% CI)c P value
Primary outcome
Composite end point consisting of all-cause mortality, 268 (30.1) 284 (32.5) −2.5 (−6.8 to 1.9) 0.89 (0.72 to 1.10) .27d
readmission to a hospital, and serious postoperative
complications within 30 d, No. (%)
Secondary outcomes
Breakdown of the composite end point, No./total (%)
All-cause mortality within 30 d 19/889 (2.1) 30/873 (3.4) −1.3 (−2.8 to 0.2) 0.61 (0.34 to 1.10) .11e
Readmission within 30 d 115/888 (13.0) 136/872 −2.7 (−5.9 to 0.6) 0.80 (0.61 to 1.05) .12e
(15.6)
Serious postoperative complications within 30 d 195/890 (21.9) 189/874 0.3 (−3.6 to 4.1) 1.02 (0.81 to 1.28) .91e
(21.6)
Serious postoperative complications in detail,
No. (%)
Prolonged ventilation ≥48 h 27 (3.0) 20 (2.3) 0.8 (−0.8 to 2.3) 1.34 (0.74 to 2.40) .38e
Major disruption surgical wound 62 (7.0) 57 (6.5) 0.4 (−1.9 to 2.8) 1.07 (0.74 to 1.56) .78e
Bleeding 54 (6.1) 60 (6.9) −0.8 (−3.1 to 1.5) 0.88 (0.60 to 1.28) .50e
Pneumonia 34 (3.8) 37 (4.2) −0.4 (−2.3 to 1.4) 0.90 (0.56 to 1.44) .72e
New onset atrial fibrillation 10 (1.1) 9 (1.0) 0.1 (−0.9 to 1.1) 1.09 (0.44 to 2.70) >.99e
Moderate and severe AKI 30 (3.4) 22 (2.5) 0.9 (− 0.7 to 2.4) 1.35 (0.77 to 2.36) .33e
New onset KRT 11 (1.2) 8 (0.9) 0.3 (−0.6 to 1.3) 1.35 (0.54 to 3.38) .65e
Cardiac arrest 9 (1.0) 17 (2.0) −0.9 (−2.1 to 0.2) 0.51 (0.23 to 1.16) .12e
Myocardial infarction 8 (0.9) 4 (0.5) 0.4 (−0.3 to 1.2) 1.97 (0.59 to 6.58) .39e
Sepsis 30 (3.4) 42 (4.8) −1.4 (−3.3 to 0.4) 0.69 (0.43 to 1.11) .15e
Stroke 4 (0.5) 8 (0.9) −0.5 (−1.2 to 0.3) 0.49 (0.15 to 1.63) .26e
Pulmonary embolism or deep venous thrombosis 10 (1.1) 15 (1.7) −0.6 (−1.7 to 0.5) 0.65 (0.29 to 1.46) .32e
Shock 34 (3.8) 33 (3.8) 0.0 (−1.7 to 1.8) 1.01 (0.62 to 1.65) >.99e
Unplanned return to operating room 116 (13.0) 101 (11.6) 1.5 (−1.6 to 4.5) 1.15 (0.86 to 1.52) .35e
Length of stay, median (IQR), d
Hospital 8.0 (6.0-15.0) 8.0 (6.0- 0 (0 to 1) HR, 0.95 (0.86 to .25g
14.0) 1.04)f,h
ICU 1.0 (1.0-3.0) 1.0 (1.0-3.0) 0 (0 to 0) HR, 0.96 (0.87 to .36g
1.05)f,h
d
Abbreviations: AKI, acute kidney injury; ICU, intensive care unit; HR, hazard Cochran-Mantel-Haenszel χ2 test.
ratio; KRT, kidney replacement therapy; OR, odds ratio. e
Fisher exact test.
a
Total numbers are included when they differ from those in the overall study f
HR less than 1 indicates an effect in favor of handover compared with no
group. handover.
b
Absolute risk difference <0 indicates an effect in favor of handover compared g
Wald χ2 test.
to no handover. h
Censored at the day of death during hospital stay.
c
OR less than 1 indicates an effect in favor of handover compared with no
handover.

than those in the first duration quartile (≤128 min). However,
the odds for the composite outcomes for the handover vs no
handover groups were not significantly different within each
quartile (eTable 11 in Supplement 3). Neither the number of
deaths within 24 hours (1 patient [0.1%] in the handover group
vs 0 in the no handover group) nor the in-hospital mortality
(22 patients [2.5%] in the handover group vs 31 [3.6%] in the
no handover group) differed significantly (OR, 0.70; 95% CI,
0.38-1.27; P = .25).
Discussion
Among adults undergoing prolonged surgery, there was no sig-
nificant difference between handovers of anesthesia care com-
pared with no handovers of anesthesia care on the composite
primary outcome of mortality, readmission, or serious post-
operative complications within 30 days.
To our knowledge, there have not been prior randomized
clinical trials of intraoperative care transitions but many co-
hort analyses have reported associations between care tran-
sitions and harms including mortality, prolonged ICU and hos-
pital stays, bleeding and infectious complications, and longer
ventilation times.3,5,11,12,14 Others, though, have reported no
significant association between handovers and harm.10,15 Apart
from being limited by their retrospective designs, most in-
cluded relatively healthy patients although the risk of inad-
equate information transfer is presumably greatest in sicker
patients.3,5,10,12 Nearly all patients in this trial were desig-
nated ASA grade 3, indicating that patients were at risk for com-

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 Research Original Investigation Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications

Figure 2. Multivariable Regression Analysis for the Primary End Point

Composite end point

No. of
patients Total Odds ratio Composite end Composite end
(n = 1772) No. (%) (95% CI) point less likely point more likely P value
Type of surgery .26
Revised cardiac risk index .48
0 86 317 (27.1) 0.83 (0.55-1.27) .39
1 213 740 (28.8) 0.82 (0.58-1.15) .25
2 154 433 (35.6) 0.99 (0.71-1.40) .97
≥3 88 239 (36.8) 1 [Reference]
Training level, y .33
≤2 158 498 (31.7) 1.00 (0.74-1.37) .98
>2 258 869 (29.7) 0.85 (0.64-1.12) .25
Specialist in anesthesiology 125 362 (34.5) 1 [Reference]
No. of handovers .26
In the model, site was included as
0 221 846 (26.1) 1 [Reference]
random effect and type of surgery,
1 229 685 (33.4) 1.16 (0.93-1.45) .18
revised cardiac risk index, number of
≥2 41 148 (27.7) 0.89 (0.60-1.33) .57
handovers, and training level as fixed
effects. Type of surgery was not
0.5 1 2 significant (P = .26) and was not
Odds ratio (95% CI) included in the figure in detail
(eTable 6 in Supplement 3).

plications. Nevertheless, handovers of anesthesia care did not
significantly increase the incidence of the primary composite
outcome of mortality, readmission, or serious postoperative
complications within 30 days.
Clear communication reduces error during personnel
transitions.23,24 For example, in a study of 134 pediatric inten-
sive care patients, 94% of the handovers included more than
1 communication error.25 Techniques to improve the quality
of communication including tools to ensure that transmitted
information is received and understood are common outside
health care such as in air traffic control and in the military. Stan-
dardized communication tools have been developed for an-
esthesia, but are rarely used.26-28 None of the trial sites used
structured handover protocols. But given that unstructured
handovers did not worsen complications, it seems unlikely that
results would differ substantively had a formal transition pro-
cess been used.
Observational analyses are susceptible to unmeasured con-
founding, and this may be a particular concern for analyses of
care transitions because many potentially important factors
are not recorded in electronic records, including the trajec-
tory of a particular case and whether replacement clinicians
were selected for special relevant skills or even personal cir-
cumstances such as a disagreement between the anesthesi-
ologist and surgeon. Randomization minimizes the likeli-
hood of confounding and selection bias. This trial thus
enhances available understanding of the putative relation-
ship between intraoperative care transitions and serious post-
operative complications and readmission, and indicates that
if there is such a relationship, its magnitude is small.
The sample-size estimate was based on a 21% incidence
of serious postoperative complications.3,5,11,12 The observed in-
cidence was higher (31%) and similar to that reported in the
largest retrospective report (32%).3 The relatively high inci-
dence may reflect restricting the enrollment to patients clas-
sified as ASA grades 3 and 4. Most patients in the handover
group had 1 or 2 anesthesia care transitions (86%) whereas only
1% had 3 or 4. This trial was not powered to analyze results by
the number of handovers, but 1 or 2 handovers did not signifi-
cantly increase the risk of complications.
Limitations
This study has several limitations. First, 11% of the patients in
each group did not receive the designated management strat-
egy for various reasons including lack of personnel and un-
planned changes in surgical duration. However, per protocol
analyses confirmed the primary findings. Second, patients who
had nighttime or weekend surgery were not included be-
cause insufficient staffing precluded adherence with the ran-
domization. Thus, this study could not address whether han-
dovers are harmful during off-hours when patients often have
greater illness severity and clinicians are stressed and fa-
tigued.
Third, it was not possible to account for structure and con-
duct of handovers as well as for the experience of surgeons,
anesthesiologists, and surgical nurses. Consequently, the ef-
fect of the experience of the surgeons and other involved per-
sonnel remains unknown. Fourth, some types of surgery, no-
tably cardiac surgery, were underrepresented. Because cardiac
surgery differs substantially from noncardiac surgery, the re-
sults may not generalize to that population.
Fifth, it was not possible to fully mask those who partici-
pated in this study because personnel assignments, includ-
ing handovers, needed to be made by an unmasked coordina-
tor. The potential for bias thus remains because the assigner
could influence the timing of handovers, and which clini-
cians replaced the initial team. Nevertheless, patients, clini-
cians, and investigators were not informed of the treatment
assignments. Treating anesthesiologists were thus masked to
which patients were included in the trial.
Sixth, intraoperative complications were not recorded.
Therefore, it cannot be assessed whether handovers pro-

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 Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications Original Investigation Research

voked intraoperative events. However, there was no differ-

ence in short-term outcomes. Seventh, nearly all patients were
categorized ASA grade 3. Lack of harm from anesthesia care
transitions presumably applied to healthier patients but may
not apply to patients with greater severity of illness who may
be categorized as ASA grade 4. Future trials are warranted to
evaluate whether the results are generalizable to different
patients, various health care systems, and regional delivery
models.
Conclusions
Among adults undergoing extended surgical procedures, there
was no significant difference between the patients random-
ized to receive handover of anesthesia care from one clini-
cian to another, compared with the no handover group, in the
composite primary outcome of mortality, readmission, or se-
rious postoperative complications within 30 days.

ARTICLE INFORMATION Gerß, Massoth, Zarbock. REFERENCES

Accepted for Publication: May 20, 2022.
Published Online: June 4, 2022.
doi:10.1001/jama.2022.9451
Author Affiliations: Department of
Anesthesiology, Intensive Care and Pain Medicine,
University Hospital Münster, Münster, Germany
(Meersch, Weiss, Küllmar, Wempe, Massoth,
Zarbock); Department of Anesthesiology, Intensive
Care and Pain Medicine, University Hospital
Knappschaftskrankenhaus Bochum, Bochum,
Germany (Bergmann, Thompson, Griep, Kusmierz,
Buchholz, Wolf, Nowak, Rahmel, Adamzik, Haaker);
Department of Anesthesiology, Department of
Anesthesiology and Critical Care, Franziskus
Hospital Münster, Münster, Germany (Goettker,
Gruendel, Hemping-Bovenkerk, Goebel);
Department of Anesthesiology, Intensive Care and
Pain Medicine, Florence-Nightingale-Hospital,
Düsseldorf, Germany (Braumann, Wisudanto,
Wenk); Department of Anesthesiology and
Operative Intensive Care Medicine, Kliniken Köln,
Köln, Germany, Witten/Herdecke University, Faculty
of Health, School of Medicine (Flores-Bergmann,
Böhmer); Department of Anesthesiology and
Intensive Care Medicine, Kliniken Maria Hilf,
Mönchengladbach, Germany (Cleophas, Hohn);
Faculty of Medicine and University Hospital of
Cologne, Department of Anesthesiology and
Intensive Care Medicine, University of Cologne,
Cologne, Germany (Cleophas, Hohn); Department
of Anesthesiology, Intensive Care and Pain
Medicine, Klinikum Dortmund, Dortmund,
Germany (Houben, Ellerkmann); Department of
Anesthesiology and Intensive Care Medicine,
University Hospital Bonn, Bonn, Germany
(Ellerkmann); Department of Anesthesiology,
University Hospital Heidelberg, Heidelberg,
Germany (Larmann, Sander, Weigand); Department
of Anesthesiology, Intensive Care and Pain
Medicine, Dortmund-Hörde, Germany (Eick);
Department of Anesthesiology, Medical Faculty,
RWTH Aachen University, Aachen, Germany
(Ziemann); Institute of Biostatistics and Clinical
Research, University of Münster, Münster, Germany
(Bormann, Gerß ); Department of Outcomes
Research, Anesthesiology Institute, Cleveland
Clinic, Cleveland, Ohio (Sessler).
Author Contributions: Drs Meersch and Zarbock
had full access to all of the data in the study and
take responsibility for the integrity of the data and
the accuracy of the data analysis. Drs Massoth and
Zarbock contributed equally.
Concept and design: Meersch, Thompson, Rahmel,
Gerß, Wempe, Zarbock.
Acquisition, analysis, or interpretation of data:
All authors.
Drafting of the manuscript: Meersch, Weiss,
Küllmar, Kusmierz, Buchholz, Wisudanto, Bormann,
Critical revision of the manuscript for important
intellectual content: Meersch, Weiss, Bergmann,
Thompson, Griep, Wolf, Nowak, Rahmel, Adamzik,
Haaker, Goettker, Gruendel, Hemping-Bovenkerk,
Goebel, Braumann, Wenk, Flores-Bergmann,
Böhmer, Cleophas, Hohn, Houben, Ellerkmann,
Larmann, Sander, Weigand, Eick, Ziemann, Gerß,
Sessler, Wempe, Massoth.
Statistical analysis: Meersch, Bormann,
Gerß, Zarbock.
Obtained funding: Meersch, Bergmann.
Administrative, technical, or material support:
Weiss, Küllmar, Bergmann, Griep, Kusmierz,
Buchholz, Nowak, Rahmel, Adamzik, Haaker,
Gruendel, Goebel, Wisudanto, Böhmer, Ellerkmann,
Ziemann, Wempe, Massoth.
Supervision: Thompson, Adamzik, Wisudanto,
Wenk, Ellerkmann, Weigand, Gerß, Zarbock.
Conflict of Interest Disclosures: Dr Meersch
reported receiving fees from bioMérieux, FMC, and
Baxter outside the submitted work. Dr Zarbock
reported receiving grants from Baxter, Fresenius,
BioMérieux, the German Research Foundation, the
German Israel Foundation, and Astellas outside the
submitted work and personal fees from Novartis,
Bayer, Guard Therapeutics, AM Pharma,
bioMérieux, Fresenius, Baxter, and Paion outside
the submitted work; and serving as a section editor
for Anesthesia & Analgesia and for Anästhesist. No
other disclosures were reported.
Funding/Support: The trial was funded by
Else-Kröner-Fresenius Stiftung German Research
Foundation (grants 2018_A96, KFO342-1, ZA428/
18-1, ZA428/21-1, and ME5413/1-1).
Role of the Funder/Sponsor: The
Else-Kröner-Fresenius Stiftung and the German
Research Foundation had no role in the design and
conduct of the study; collection, management,
analysis, and interpretation of the data;
preparation, review, or approval of the manuscript;
and decision to submit the manuscript for
publication.
Data and Safety Monitoring Board: Department
of Anesthesiology, University Hospital Düsseldorf,
Germany: Peter Kienbaum, MD; Department of
Anesthesiology, Intensive Care and Pain Medicine,
Schwarzwald-Baar Klinikum, University of Witten
Herdecke, Germany: Sebastian Russo, MD; and
Institute for Mathematics and Techniques,
University of Applied Sciences Koblenz, Germany,
Markus Neuhäuser, MD.
Data Sharing Statement: See Supplement 4.
Additional Contributions: We would like to thank
all the study nurses of all participating centers for
data entry and the staff in the participating ICUs.
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