Evaluation of the association between quality of handover and length of stay in the post anaesthesia care unit: a pilot study

The length of stay in the post-anaesthesia care unit (PACU) impacts patient throughput through the operating theatres. [1, 2]. Anecdotally, poor quality of handover between the operating room team and the PACU staff is associated with excessive PACU length of stay. Following institutional review board approval, we evaluated the effect of unsatisfactory handovers on PACU length of stay. We assessed 360 consecutive handovers of patients from anaesthesia providers (residents, nurse anaesthetists and staff anaesthesiologists) to PACU nurses. After arrival of a patient in the PACU, the anaesthesia provider transferred care of the patient to a PACU nurse. The handover quality was rated by a PACU nurse using the Anwari instrument [3] to assess the following variables: i) content of sign-out; ii) condition of patient on arrival; iii) professional behaviour; and iv) nurse satisfaction. We also evaluated whether the use of a modified handover score, that excluded variables assessing patient physiological condition, was associated with PACU length of stay. To examine the strength of the association between score on the handover instrument and PACU length of stay, the handover score was plotted against length of stay and a Spearman correlation coefficient was calculated (Fig. 4). A LOWESS (locally weighted scatter plot smoothing) curve fit to the scatter plot data shows a nonlinear relationship between the two variables. Results of the correlation analysis show an association between handover score and PACU length of stay (Spearman ρ 0.258, p < 0.0001). This association persisted after controlling for pain severity. Since alterations in a patient’s vital signs on arrival in the PACU may reflect increased severity of illness rather than unsatisfactory handover, the analysis was repeated using the handover instrument with vital signs excluded, revealing similar results. Possible sources of bias in our study include lack of full blinding of the handover assessor, use of multiple assessors that could have added variability, and the potential influence of PACU volume and acuity on patient discharge time. Scatter plot of quality of handover score vs PACU length of stay. Length of stay in PACU depends on multiple peri-operative operative factors [4]; we concentrated on the handover process itself. The clinical handover process has recently become the centrepiece of educational efforts to improve patient care [5–8]. Handover problems are global and affect most medical disciplines [9]. Our results suggest that additional effort needs to be taken to educate anaesthesia providers on how to optimise the quality of their PACU handover. This pilot study is the first to examine the relationship between handover quality and PACU length of stay. The next step would be to confirm these findings in a blinded multicentre study controlled for peri-operative variables known to influence PACU length of stay.