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Anesthesiology handover during cardiac surgery associated with increased mortality

JAMA Network Open
Reuters Health - 22/02/2022 - A handover of anesthesia care during cardiac surgery - at least in certain circumstances - is associated with higher risks of patient death at both 30 days and one year later, researchers in Canada report.

Specifically, handovers during complex procedures such as coronary-artery-bypass graft (CABG) with valve surgery, cases started during regular work hours, and care transitions during or after bypass were all associated with worse outcomes.

Handovers were associated with longer hospital and ICU stays, the team reports in JAMA Network Open.

The central issue with anesthesia handovers, the authors explained, is the tradeoff between possibly excessive fatigue in the anesthesia clinician and "unintended information loss during the handover."

Their multicenter, retrospective study involved more than 102,000 adul patients in Ontario who underwent CABG, cardiac-valve surgery, or thoracic aorta surgical procedures between 2008 and 2019. This cohort was about one-quarter women, and the mean age was 66.

Overall, 1,926 patients (1.9%) experienced complete handover of anesthesia care (replacement of one anesthesiologist by another). The report notes that handovers became more common over the term of the study, rising from 0.7% in 2008 to 2.9% in 2019.

Handovers were associated with an 89% increase in mortality risk at 30 days (hazard ratio, 1.89; 95% CI, 1.41 to 2.54) and a 66% increase at one year (HR, 1.66; 95% CI, 1.31 to 2.12). The higher risk was estimated to have resulted in 38 additional deaths at 30 days and in 62 at one year.

Regarding the higher mortality seen with cases starting on regular workdays, lead author Dr. Louise Sun of the Ottawa Heart Institute's Division of Cardiac Anesthesiology told Reuters Health by email, "I think that cases started early in the day and requiring handover in the evening are the very long and complicated ones."

"These already high-risk cases are then handed over to a replacement anesthesiologist who may be tired from a long day of work," she continued. "In contrast, cases started overnight are handed over in the morning to a 'fresh' anesthesiologist."

In an accompanying editorial, Dr. Laurent G. Glance of the University of Rochester School of Medicine, in New York, and colleagues cite a much smaller 2020 study from New York State that showed complete anesthesia handovers were tied to a 15% higher 30-day mortality risk (https://bit.ly/3Hdspv7).

"The most striking difference between the studies," the editorialists write, "is that the rate of complete anesthesia handovers was 1.9% in Canadian patients and 8.5% in US patients."

Given that both studies were methodologically sound, Dr. Glance and colleagues conclude, "It is difficult to speculate what could account for the large difference in risk with the possible exception that because handovers are more routine in US practice, they may be less likely to lead to adverse outcomes."

The lead author of that New York study, Dr. Edward L. Hannan of the University at Albany School of Public Health, told Reuters Health by email that "it would be interesting to understand why handovers are both less frequent and more dangerous in Ontario than in New York, although a full understanding would probably require more information than what currently exists in the respective registries."

He seconded the editorialists' recommendations, which include standardizing the handover process and involving both surgeons and anesthesiologists and could be adopted without further research.

Dr. Randall M. Clark, president of the American Society of Anesthesiologists, told Reuters Health by email. "Higher mortality with regular workday cases is not what most anesthesiologists would expect," adding that the study design might have been subject to residual confounding or possibly an issue with billing codes.

Dr. Clark, who was not involved in the new study, said that although it is observational, "the findings can be used to suggest changes in how care is delivered."

SOURCE: https://bit.ly/36puJ5B and https://bit.ly/3h7hIzO JAMA Network Open, online February 11, 2022.

By Scott Baltic

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