anesthesiologist handoffs and morbidity

[Euripides]

This is going to be an interesting discussion.

"Conclusions and Relevance 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. These findings may support limiting complete anesthesia handovers."

Handovers During Anesthesia Care

Intraoperative Anesthesia Handovers and Complications After Major Surgery

---

Members don't see this ad.

 

[Beach bum]

This is going to be an interesting discussion.

"Conclusions and Relevance 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. These findings may support limiting complete anesthesia handovers."

Handovers During Anesthesia Care

Intraoperative Anesthesia Handovers and Complications After Major Surgery

No surprise, been known for a long time...

 

[Psai]

Yeah no ****

 

[Noyac]

Tell me this, when it comes to efficiency in your OR are yo7 going to resist handing over your case when it has been nothing but stable? If you are in an “eat what you kill” practice then the handoff isn’t a big part of the practice I assume.

I will have more to say on this topic soon enough. As you all know.

 

[nimbus]

Not withstanding worse outcomes, it also makes us appear less professional and less committed, more like interchangeable shift working nurses than doctors. Surgeons don’t hand off cases mid-procedure. Is it because our job is so much easier than theirs? Are patients informed that somebody they have never met will be taking over their care midcourse? IMHO handoffs should be minimized and certainly not routine.

 

[sevoflurane]

lap choles, hernias, ortho, gen surg, gyn cases... yeah. I don't have a problem with that.

Ruptured AAAs, Heart cases, Cranis, massive traumas or any kind of unstable patient.... I personally finish that case- every time.

Example: A couple days ago I was called in to do a big emergent crani on a 30 y/o with a huge previously unknown tumor that had bled- a lot. Midline shift, both lateral ventricles completely gone from compression, conseted for a crani/lobectomy, etc, etc... Neurosurgeon says that she is going to bleed and will go from a hgb of 10 to a hgb of 4 in seconds. Brain extremely tight and herniating once we removed the skull and prepared to make incision. Hooked up a cordis, AC ric and an aline + a belmont on standby.

I would never ever hand over a case like this. I was 5th call and was the last person to leave the hospital that night (around midnight).
I was offered relief, but it just didn't seem right and just had to suck it up. No big deal and felt good about my decision to stay and finish the case.

 

[wickedskillz]

yeah def elected to stay and finish some cases during residency. Didn't feel right walking out of the big ones. A more routine case I would still leave, or even a big case that will close forever but exciting parts are done.

That said, handoff is a reality of our specialty, same as it is with ER, ICU, and even now lots of hospitalists. Thats essentially all the big resuscitation people in the hospital. I think that along with trying to minimize sign outs (like esp when the post-late person goes home, then someone takes over for a bit, then they go home and call person takes over), the key is good hand-off about pt, procedure, etc. That's probably where alot of the mishaps happen.

 

[2Fast2Des]

lap choles, hernias, ortho, gen surg, gyn cases... yeah. I don't have a problem with that.

Ruptured AAAs, Heart cases, Cranis, massive traumas or any kind of unstable patient.... I personally finish that case- every time.

Example: A couple days ago I was called in to do a big emergent crani on a 30 y/o with a huge previously unknown tumor that had bled- a lot. Midline shift, both lateral ventricles completely gone from compression, conseted for a crani/lobectomy, etc, etc... Neurosurgeon says that she is going to bleed and will go from a hgb of 10 to a hgb of 4 in seconds. Brain extremely tight and herniating once we removed the skull and prepared to make incision. Hooked up a cordis, AC ric and an aline + a belmont on standby.

I would never ever hand over a case like this. I was 5th call and was the last person to leave the hospital that night (around midnight).
I was offered relief, but it just didn't seem right and just had to suck it up. No big deal and felt good about my decision to stay and finish the case.

Sounds like a boss case!

 

[AdmiralChz]

lap choles, hernias, ortho, gen surg, gyn cases... yeah. I don't have a problem with that.

Ruptured AAAs, Heart cases, Cranis, massive traumas or any kind of unstable patient.... I personally finish that case- every time.

Example: A couple days ago I was called in to do a big emergent crani on a 30 y/o with a huge previously unknown tumor that had bled- a lot. Midline shift, both lateral ventricles completely gone from compression, conseted for a crani/lobectomy, etc, etc... Neurosurgeon says that she is going to bleed and will go from a hgb of 10 to a hgb of 4 in seconds. Brain extremely tight and herniating once we removed the skull and prepared to make incision. Hooked up a cordis, AC ric and an aline + a belmont on standby.

I would never ever hand over a case like this. I was 5th call and was the last person to leave the hospital that night (around midnight).
I was offered relief, but it just didn't seem right and just had to suck it up. No big deal and felt good about my decision to stay and finish the case.

That’s fair and laudable, but probably an outlier to typical day to day practice. This week a stable robotic case started at 2 PM and went past midnight, handovers are simple unavoidable in cases like that.

This isn’t “new” research, just a couple of years ago this very topic made the cover of A&A. Obviously they aren’t ideal, and we should minimize to some extent as possible - residency was infuriating, we would relieve the CRNA at 530 until the night resident could come in around 630 for a long case. Those handoffs could and should be frowned upon.

 

[aneftp]

There are a lot of dynamics into play here

1. Fee for service or billing per hours on the seat with private group model....even more incentive to stay late

2. Lowly w2 employee no overtime potential....we can say all we want....attitudes change. We’ve seen academic state hospitals shift change in middle of cardiac cases at 3pm before. Let’s not kid ourselves on this.

 

[2Fast2Des]

That’s fair and laudable, but probably an outlier to typical day to day practice. This week a stable robotic case started at 2 PM and went past midnight, handovers are simple unavoidable in cases like that.

This isn’t “new” research, just a couple of years ago this very topic made the cover of A&A. Obviously they aren’t ideal, and we should minimize to some extent as possible - residency was infuriating, we would relieve the CRNA at 530 until the night resident could come in around 630 for a long case. Those handoffs could and should be frowned upon.

I've seen and been part of the hand off chain when 4 attendings and 4 to 5 CRNAs have been signed in the chart and then the last crna to come in comes to take over when pt is on the ICU bed to transport upstairs and give report for a case he's never been part of really since it's been one of those all day debulking messes

 

[GravelRider]

Handoffs are as much a part of modern medicine as are "volume" and "turnover." Twenty years ago a patient admitted for pneumonia sat in the hospital for a week and today that same patient is expected to be discharged in 24 hours. The ORs are no different. There are some obvious exceptions mentioned in this thread, but handoffs are a part of our practice so we may as well figure out a way to get good at them.

 

[Dejavu]

Does this mean that ICU guys cannot ever go home, if there is a sick pt in their care, come relief time? Ever?

What about hospitalists?

Does this mean that ER doctors don’t get to go home? Ever?

Of course not. Same with Anesthesiologists.

We aren’t the only specialists who go home. There is no stigma placed on physicians for turning over patients in the ICU or ER. They aren’t seen as glorified nurses. Our specialty is just like that. No difference. If the medical community comes at Anesthesia for this, they have to come at all doctors who go home while patients are still being cared for.

Actually, the outliers are the surgeons.

But I agree, stabilizing a critical event during a case, I stay.

 

[Mman]

lap choles, hernias, ortho, gen surg, gyn cases... yeah. I don't have a problem with that.

Ruptured AAAs, Heart cases, Cranis, massive traumas or any kind of unstable patient.... I personally finish that case- every time.

While that is possible some of the time, I don't think it is realistic all of the time. What happens when that type A dissection comes in when you've already been there 17 hours? You going to stick around for another 12+ to finish it? At some point, handing over care to somebody who is fresher is better for the patient.

Now obviously walking away during an unstable part of things is not the way to go, but at some point you have to be able to hand over care to a colleague in a safe fashion.

 

[pgg]

Turnovers for relief at the end of the day don't bother me so much as the 8:30 AM mandatory coffee breaks. 45 minute case turnovers followed by a page asking about a lunch break. Afternoon breaks.

Every time I make the schedule I have to waste 2-4 people by assigning them to breaks. Most of them hate that assignment (who wants to spend the day cruising around giving breaks?) and it's inefficient.

I can't imagine doing that at a private group that runs with even a casual nod to efficiency. But hey, we're the government and all on salary.

Not to mention, it creates an extra 30 or 50 handoffs during the day because people can't manage their urinary or granola bar needs between cases.

But 3 mid-case breaks per day is just understood to be part of our specialty and there'd be a revolt if nobody got their breaks.

 

[nimbus]

Does this mean that ICU guys cannot ever go home, if there is a sick pt in their care, come relief time? Ever?

What about hospitalists?

Does this mean that ER doctors don’t get to go home? Ever?

Of course not. Same with Anesthesiologists.

We aren’t the only specialists who go home. There is no stigma placed on physicians for turning over patients in the ICU or ER. They aren’t seen as glorified nurses. Our specialty is just like that. No difference. If the medical community comes at Anesthesia for this, they have to come at all doctors who go home while patients are still being cared for.

Actually, the outliers are the surgeons.

But I agree, stabilizing a critical event during a case, I stay.

Patients are in the icu and wards for days. Surgery lasts a few hours. Surgeons stay the whole case.

 

[nimbus]

While that is possible some of the time, I don't think it is realistic all of the time. What happens when that type A dissection comes in when you've already been there 17 hours? You going to stick around for another 12+ to finish it? At some point, handing over care to somebody who is fresher is better for the patient.

Now obviously walking away during an unstable part of things is not the way to go, but at some point you have to be able to hand over care to a colleague in a safe fashion.

If you’ve been there for 17hrs, call someone else to start the aortic dissection.

I can't imagine doing that at a private group that runs with even a casual nod to efficiency.

We don’t. And I witness bad handoffs at the most inappropriate times with our circulators and scrub techs on a daily basis. It is one of my pet peeves. The extent of the conversation is “go take your lunch now, I have to get 2 more people.”

 

[pgg]

I think it's a rare case where the circ or scrub actually matter. As long as their swaps don't actually halt the case, and as long as the scrub is familiar with the instruments specific to that case/specialty, meh.

One of my peeves is when the circ will do an exhaustive MS2-level H&P while I'm waiting to meet the patient. They take a lot of time to do a lot of things that just dont matter and don't need a nurse's level of training. They're mostly timeout specialists, Foley drivers, and gofers, outside some of the subspecialist cases.

I almost feel a little bad saying that, because I like almost all of our periop nurses. There are maybe three I can think of who'd be useful in a crisis. I just have never felt that position actually needs a nurse. They really ARE interchangeable cogs in the OR machine, so I think their breaks and relief make no difference.

 

[deleted162650]

I just have never felt that position actually needs a nurse.

I've been thinking the same thing recently. In fact, I was discussing this one of our GI nurses who was a circulator for a long time before switching. She totally agreed with the sentiment that circulator is not really a nursing level job.

 

[GravelRider]

If you’ve been there for 17hrs, call someone else to start the aortic dissection.



We don’t. And I witness bad handoffs at the most inappropriate times with our circulators and scrub techs on a daily basis. It is one of my pet peeves. The extent of the conversation is “go take your lunch now, I have to get 2 more people.”

So you're the call guy and you're going to call the non-call guy in early or in the middle of the night? Or you are going to refuse relief after you've been there over 24 hours?

Other people's bad handoffs should not be an excuse to neglect our own handoff mechanisms. Frankly, the decision-making of a circulator is nowhere near as consequential as our decision-making. Anyone who says that their mind is as focused during hour 22 of a shift as they were during hour 2 is kidding themselves. There are many instances where the safest thing to do for a patient is to bring in a fresh set of eyes.

Handoffs are an essential skill in our practice...both giving and receiving. Are there times when people should just stay an extra hour or two to finish a case? Absolutely. However, there are also times when it is more than appropriate to turn over a case.

 

[nimbus]

I think it's a rare case where the circ or scrub actually matter. As long as their swaps don't actually halt the case, and as long as the scrub is familiar with the instruments specific to that case/specialty, meh.

One of my peeves is when the circ will do an exhaustive MS2-level H&P while I'm waiting to meet the patient. They take a lot of time to do a lot of things that just dont matter and don't need a nurse's level of training. They're mostly timeout specialists, Foley drivers, and gofers, outside some of the subspecialist cases.

I almost feel a little bad saying that, because I like almost all of our periop nurses. There are maybe three I can think of who'd be useful in a crisis. I just have never felt that position actually needs a nurse. They really ARE interchangeable cogs in the OR machine, so I think their breaks and relief make no difference.

It matters to me because they inevitably ask me a second time what the ASA score is and what size LMA I used.

 

[Mman]

If you’ve been there for 17hrs, call someone else to start the aortic dissection.

But you are the call person. That's why you've been there all day. Now it's midnight and your still up. With any real job you are going to have occasional call responsibilities that last longer than 12 hours. And if something comes in while you are on call, you gotta start it. Which means you have to hand it off at some point.

 

[nimbus]

But you are the call person. That's why you've been there all day. Now it's midnight and your still up. With any real job you are going to have occasional call responsibilities that last longer than 12 hours. And if something comes in while you are on call, you gotta start it. Which means you have to hand it off at some point.

Sometimes we take heart call for 4-5 consecutive days and if we are exhausted we’d ask one of our partners to do the case.

 

[Mman]

Sometimes we take heart call for 4-5 consecutive days and if we are exhausted we’d ask one of our partners to do the case.

4-5 days is insane if you ask me, but then again when we take heart call we are the only person on call for those cases for 24 hours. There is no calling somebody else. 4-5 days straight on call at a major level 1 trauma center would be killer.

 

[nimbus]

But you are the call person. That's why you've been there all day. Now it's midnight and your still up. With any real job you are going to have occasional call responsibilities that last longer than 12 hours. And if something comes in while you are on call, you gotta start it. Which means you have to hand it off at some point.

In reality at midnight I would just do the whole case. But if I worked 18hrs the previous day and a case came in at at 4 or 5 am I would call the person who is on the following day and ask them if they would do the case. I would never start an aortic dissection if I didn’t expect to finish it and I’ve never handed one off. We never hand off any hearts.

 

[nimbus]

4-5 days is insane if you ask me, but then again when we take heart call we are the only person on call for those cases for 24 hours. There is no calling somebody else. 4-5 days straight on call at a major level 1 trauma center would be killer.

We have separate heart call and trauma call.

 

[Mman]

We have separate heart call and trauma call.

so do we but we do hearts every day of the week and half the nights, and trauma is every night

 

[Monty Python]

It matters to me because they inevitably ask me a second time what the ASA score is and what size LMA I used.

Or even more inanely, they MUST chart how much IV fluid I gave, usually asked right as I'm extubating. Why does the circulator need to know/chart how much IV fluid I (not they) gave. Or the ASA score? Or EBL, U/O, etc? Or anesthetic technique? What in the world does that have to do with the RN circulator's responsibilities? Do I chart their Foley insertion technique? Do I chart how many 3-0 vicryl sutures the surgeon used, or number of frozens send down? No. And of course the surgeon will ask for IV and EBL totals for their op note. I have concern for numbers which are simultaneously charted on three different documents (my record, the surgeon's op note, and the circulator's chart). Human nature being what it is, a simple clerical error between those three documents might have consequences should a malpractice claim arise.

 

[nimbus]

so do we but we do hearts every day of the week and half the nights, and trauma is every night

We have hearts most days but only 2-3x/month at night. And sometimes we have a second heart room and a noncall person will do that. If you’re in town and sober anything could happen.....

 

[nimbus]

Or even more inanely, they MUST chart how much IV fluid I gave, usually asked right as I'm extubating. Why does the circulator need to know/chart how much IV fluid I (not they) gave. Or the ASA score? Or EBL, U/O, etc? Or anesthetic technique? What in the world does that have to do with the RN circulator's responsibilities? Do I chart their Foley insertion technique? Do I chart how many 3-0 vicryl sutures the surgeon used, or number of frozens send down? No. And of course the surgeon will ask for IV and EBL totals for their op note. I have concern for numbers which are simultaneously charted on three different documents (my record, the surgeon's op note, and the circulator's chart). Human nature being what it is, a simple clerical error between those three documents might have consequences should a malpractice claim arise.

We don’t have anesthesia EMR yet but I am hopeful those values will automatically be populated in the appropriate places.

 

[Monty Python]

We don’t have anesthesia EMR yet but hopefully those values will automatically be populated in the appropriate places.

Hopefully you won't be burdened with the Defense Department's inglorious systems which don't cross-populate. I chart in Innovian, the stand-alone anesthesia record. The circulator charts in Essentris. In PACU, I have to copy my Innovian record as a .pdf onto the computer desktop, then upload it into Essentris. What used to take maybe 60 seconds with paper and pen now takes upwards of 5 minutes of computer keyboarding.

(Ten pedi T&A records) x (4 extra minutes of PACU time/record) = almost a wasted hour of potential OR usage.

 

[Robotic Wis-Hipple]

I agree you shouldn’t hand off big cases just to go home at 3, or 5pm but I also think the way ORs are run handoffs are quite simply a facet of our practice that isn’t going anywhere.

And I don’t buy the argument that Surgeons don’t hand off so we shouldn’t either, that may fly if every day I have a room with one and only one surgeon, but I don’t. I mean as rooms come down a lot of times cases are consolidated or the standby cases get moved to your room with an entirely new surgeon that is now prepared to work till midnight.

Every place I’ve been in my young career has shifted people for OR efficiency sake, which is going to increase handoffs.

 

[Hoya11]

This is going to be an interesting discussion.

"Conclusions and Relevance 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. These findings may support limiting complete anesthesia handovers."

Handovers During Anesthesia Care

Intraoperative Anesthesia Handovers and Complications After Major Surgery

But isnt there bias in this study, meaning that: Long cases are long for a reason, they are big cases or challenging in some way, so yes of course they have more handoffs and yes of course they have more complications.. they probably have more opiate requirement and fluid requirement and post op pain etc... im not getting it..

 

[pgg]

I've been thinking the same thing recently. In fact, I was discussing this one of our GI nurses who was a circulator for a long time before switching. She totally agreed with the sentiment that circulator is not really a nursing level job.

Someday if I find myself the supreme dictator of a healthcare facility with operating rooms, I'm going to lay off all the periop RNs, fabricate some kind of periop tech training program (complete with inkjet Certificate of Accomplishment), and the local standard of care is going to be Certified Periop Techs to lead the timeout and double check NPO status and strap on the SCDs and paint chlorhexidine and fetch sutures and transmit SBAR irrelevancies to the PACU.

Joking aside, I don't want to come off as disrespectful to periop nurses, but if we're going to have meaningful discussions of cost containment and appropriate use of resources, maybe we should be seriously asking ourselves why we need a RN in that position. Maybe an understaffed PACU or ward or clinic could make better use of a bachelor or master degree'd, licensed RN than we can.

 

[AdmiralChz]

Someday if I find myself the supreme dictator of a healthcare facility with operating rooms, I'm going to lay off all the periop RNs, fabricate some kind of periop tech training program (complete with inkjet Certificate of Accomplishment), and the local standard of care is going to be Certified Periop Techs to lead the timeout and double check NPO status and strap on the SCDs and paint chlorhexidine and fetch sutures and transmit SBAR irrelevancies to the PACU.

Joking aside, I don't want to come off as disrespectful to periop nurses, but if we're going to have meaningful discussions of cost containment and appropriate use of resources, maybe we should be seriously asking ourselves why we need a RN in that position. Maybe an understaffed PACU or ward or clinic could make better use of a bachelor or master degree'd, licensed RN than we can.

Oh that’s not fair, you forgot their very good ability to enforce “AORN” (or whatever the alphabet soup is for OR nurses) standards like no home scrub caps and no long-sleeved t-shirts

 

[pgg]

Oh that’s not fair, you forgot their very good ability to enforce “AORN” (or whatever the alphabet soup is for OR nurses) standards like no home scrub caps and no long-sleeved t-shirts

That's a point in favor of firing / reassigning them all.

 

[Monty Python]

Someday if I find myself the supreme dictator of a healthcare facility with operating rooms, I'm going to lay off all the periop RNs, fabricate some kind of periop tech training program (complete with inkjet Certificate of Accomplishment), and the local standard of care is going to be Certified Periop Techs to lead the timeout and double check NPO status and strap on the SCDs and paint chlorhexidine and fetch sutures and transmit SBAR irrelevancies to the PACU.

Joking aside, I don't want to come off as disrespectful to periop nurses, but if we're going to have meaningful discussions of cost containment and appropriate use of resources, maybe we should be seriously asking ourselves why we need a RN in that position. Maybe an understaffed PACU or ward or clinic could make better use of a bachelor or master degree'd, licensed RN than we can.

This is just a SWAG, but it might involve Joint Commission requirements ??? Could also run into challenges with the circulating tech's inability to obtain extra meds (especially narcs) from the center core pyxis, or obtain/countersign blood products, etc, in comparison to the RN's ability. Although I like the idea of somehow neutering AORN, and their "evidence-based" best practices.

 

[pgg]

This is just a SWAG, but it might involve Joint Commission requirements ??? Could also run into challenges with the circulating tech's inability to obtain extra meds (especially narcs) from the center core pyxis, or obtain/countersign blood products, etc, in comparison to the RN's ability. Although I like the idea of somehow neutering AORN, and their "evidence-based" best practices.

My second act as dictator will be to kick JC to the curb, and use an alternate accrediting agency. CMS might be tougher to get away from. You may have identified a snag in my clever plan.

Narcotic access is the anesthesiologist's problem, not the periop RN's. We're not permitted to ask nurses to get controlled substances for us.

Our anesthesia techs fetch blood for us. Reading off and verifying that the numbers are the same on the patient's wristband, blood bag, and blood paperwork doesn't strike me as something that needs a nursing degree. I'll include training for that in my Certified Perioperative Tech curriculum. (Honestly, it's not like a periop RN is presently expected to do more than compare numbers, i.e. catch incompatibilities of RBCs or other blood products).

I still need to polish the sharp edges of the PR angles. They'll surely respond with an ad campaign decrying the fact that without periop RNs in the room, there'll only be doctors treating the disease, but no one treating the whole patient.

 

[MoMoGesiologist]

Sometimes in that 3-5 o clock period, you get multiple CRNAs/residents and even attendings relieving each other for a case. It doesn't look good and I don't think it looks very doctorly but hey what are you gonna do. It even happens for very sick patients with very active issues. Some of our faculty stay and decline relief in these cases (it's rare) but I respect them a lot when they do it. Having 3 people relieve a case in the span of one hour definitely makes me feel like I'm a replaceable cog so why wouldn't other specialties in the hospital think that.

Also, the ED or ICU never has nurses relieve their doctors unlike in anesthesia where CRNAs can relieve residents. When the nurses and surgeon in the room spend the day with the resident then see a CRNA take over, I am not surprised they think we are all equivalent. The attendings are often just too busy to make their presence felt in the OR.

 

[sevoflurane]

While that is possible some of the time, I don't think it is realistic all of the time. What happens when that type A dissection comes in when you've already been there 17 hours? You going to stick around for another 12+ to finish it? At some point, handing over care to somebody who is fresher is better for the patient.

Now obviously walking away during an unstable part of things is not the way to go, but at some point you have to be able to hand over care to a colleague in a safe fashion.

I appreciate your point of view, but in the 10 years of private practice I have never handed over one of these cases. I've also never staffed a 12+ hour dissection... even if we cool to 18-20 degrees. I have been on overnight call for trauma for instance, and staffed an emergent heart that came in at 10am. It's definitely a long day, but if I take a critical patient into the OR I take ownership of that patient and stick it out to the end from patent interview to ICU report to the intensivist/ICU nurse. I am sure that in an ACT model it's more common to hand off critical cases, but it's not the way I do my cases in a physician only group.

"We had to crash onto bypass, it's a complex dissection with multiple dissection flaps--> this lumen being the true lumen, we had to reposition the inflow cannula, we had a blast of air that went into the RCA and we had to give X amount of epi and shock him out of vfib 6 times, blah, blah blah..."

Again, simple cases including a redo-redo-redo hip I'll hand off, but if the patient is critical I find it in the best interest of the patient to stick it out start to finish as your global understanding of that patient will be better than another physician who takes over midway through a case.

 

[sevoflurane]

As nimbus mentioned, it's always better to staff someone who is fresh to do the entire case. In big groups, this is a fairly easy task.

 

[abolt18]

They'll surely respond with an ad campaign decrying the fact that without periop RNs in the room, there'll only be doctors treating the disease, but no one treating the whole patient.

But what if the doctor in the room is a DO?!??! Problem solved. They're LEADERS in whole patient healthcare...

(Disclaimer, I'm a DO, so no one take offense to my sarcasm. I hate that marketing campaign)

 

[Mman]

I appreciate your point of view, but in the 10 years of private practice I have never handed over one of these cases.

I think it's in the best interest of the patient to have a mentally and physically fresh physician caring for them if possible. And sometimes the person that has to start the case isn't that person so when somebody in better condition can take over during a stable portion of the procedure, they should. The fun part about heart cases is they go on bypass. That's pretty damn stable from an anesthesia point of view.

 

[anbuitachi]

The surgeon stays because the patient chose that surgeon

 

[dhb]

The surgeon stays because the patient chose that surgeon

The surgeon stays because he's in the OR only once or twice a week, that he can cancel clinic the next day and that no other surgeon in going to take over his case.
Anyway we know the drill on sdn: 100% blocks done in under 2min with 100% succes rate, 100% first pass alines, 100% satisfaction on labor epudurals and 0% hand overs.

I'll hand over a case if it can be handed over (95% of the time), if you want to play hardo if front on the surgeon that's fine but don't forget they all resent you because you make to much money on the patients they bring in, drink coffee, leave early and are not immediately available to do an emergency at 5pm even when they called it in a 12.

 

[aneftp]

More concrete evidence bad things happen during shift changes! Improper handoff lead to Hawaii missile incident this morning

‘Wrong button’ pushed during ‘shift change’ blamed for false Hawaii missile alert

 

[cchoukal]

Like in other areas of medicine where hand-offs have become more common, the tired physician who knows the patient and the rested physician who doesn’t will both make mistakes; it remains an unanswered empirical question who will make more/worse decisions. Of course, most handoffs aren’t about being tired, they are about maximizing the efficiency of resources for medical direction, and facilitating giving people a more predictable schedule and exit time.

 

[narcusprince]

Turnovers for relief at the end of the day don't bother me so much as the 8:30 AM mandatory coffee breaks. 45 minute case turnovers followed by a page asking about a lunch break. Afternoon breaks.

Every time I make the schedule I have to waste 2-4 people by assigning them to breaks. Most of them hate that assignment (who wants to spend the day cruising around giving breaks?) and it's inefficient.

I can't imagine doing that at a private group that runs with even a casual nod to efficiency. But hey, we're the government and all on salary.

Not to mention, it creates an extra 30 or 50 handoffs during the day because people can't manage their urinary or granola bar needs between cases.

But 3 mid-case breaks per day is just understood to be part of our specialty and there'd be a revolt if nobody got their breaks.

3 mid day breaks... wow sounds like government waste. I dont take breaks regularly unless I really have to go to the restroom. I will take a lunch. When moonlighting I do not take a lunch or breaks. Eat between cases. Im extra paranoid about handing off patients.

 

[pjl]

Or even more inanely, they MUST chart how much IV fluid I gave, usually asked right as I'm extubating. Why does the circulator need to know/chart how much IV fluid I (not they) gave. Or the ASA score? Or EBL, U/O, etc? Or anesthetic technique? What in the world does that have to do with the RN circulator's responsibilities? Do I chart their Foley insertion technique? Do I chart how many 3-0 vicryl sutures the surgeon used, or number of frozens send down? No. And of course the surgeon will ask for IV and EBL totals for their op note. I have concern for numbers which are simultaneously charted on three different documents (my record, the surgeon's op note, and the circulator's chart). Human nature being what it is, a simple clerical error between those three documents might have consequences should a malpractice claim arise.

I normally tell them to write exceptional when they ask me what anesthetic technique...is there a different answer they want and can’t figure out for themselves?

 

[sevoflurane]

Turnovers for relief at the end of the day don't bother me so much as the 8:30 AM mandatory coffee breaks. 45 minute case turnovers followed by a page asking about a lunch break. Afternoon breaks.

Every time I make the schedule I have to waste 2-4 people by assigning them to breaks. Most of them hate that assignment (who wants to spend the day cruising around giving breaks?) and it's inefficient.

I can't imagine doing that at a private group that runs with even a casual nod to efficiency. But hey, we're the government and all on salary.

Not to mention, it creates an extra 30 or 50 handoffs during the day because people can't manage their urinary or granola bar needs between cases.

But 3 mid-case breaks per day is just understood to be part of our specialty and there'd be a revolt if nobody got their breaks.

Never been in a group where breaks are expected or given. Using 2-4 people to “break out” other Anesthesiologists seems like a waste to me. I’d rather eat between cases as I do now and have 2-4 extra people off on vacation or increase everyone else’s base salary. I can easily do my business and graze between cases as the day goes on. I don’t know any other type of day.