Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 4 Issue: 3

Optimal Characteristics of an Obstetric Anesthesia Paper vs. Electronic Hand-Off Tool

EL Becher III, Klumpner T*, Peralta F, Montague E, Wong CA and Toledo P
Northwestern University, Feinberg School of Medicine, USA
Corresponding author : Thomas T. Klumpner
Northwestern University Feinberg School of Medicine, NMH/Feinberg Room 5-704, 251 E Huron, Chicago, IL 60611, USA
Tel: +1-312-472-3585; Fax: +1-312-472-3590
E-mail: [email protected]
Received: January 14, 2015 Accepted: April 02, 2015 Published: April 05, 2015
Citation: Becher III, et al. (2015) Optimal Characteristics of an Obstetric Anesthesia Paper vs. Electronic Hand-Off Tool. J Womens Health, Issues Care 4:3. doi:10.4172/2325-9795.1000184


Optimal Characteristics of an Obstetric Anesthesia Paper vs. Electronic Hand-Off Tool

Approximately 61% of vaginal deliveries utilize neuraxial (epidural or spinal) analgesia for labor pain relief. Hand-offs are commonplace in obstetric anesthesia practice. Unfortunately, communication failures are consistently cited as the leading root cause of sentinel events. The purpose of this qualitative study was to explore optimal obstetric anesthesia hand-off characteristics and to evaluate the perceived effectiveness of a paper compared with an electronic hand-off template using face-to-face interviews with anesthesia team members.



Patient handoff; Obstetrical anesthesia; Electronic health records;Computerized medical records systems


A report published by the Centers for Disease Control found that61% of women in the United States delivering a single infant utilizedneuraxial (spinal or epidural) analgesia for pain relief during labor [1].This suggests that the majority of women in this country receive carefrom one or more anesthesiologists during labor. Given the variability in length of labor, transitions of care among anesthesia providers arecommonplace during the provision of obstetric anesthesia care.
Unfortunately, communication failures during transitions ofpatient care, or “hand-offs,” are frequent. In one study in which firstyearinternal medicine residents were surveyed about adverse eventsrelated to hand-offs, 100% (n=25) of adverse events or near misseswere the result of communication failures from suboptimal patienthand-offs [2]. Hand-off-related errors have been documented acrossa variety of patient care settings, including the surgical and neonatalintensive care units as well as the emergency department [3-5]. In 2006,The Joint Commission addressed hand-offs in the National PatientSafety Goals, and recommended that hospitals develop a standardizedapproach to patient hand-offs [6]. The Accreditation Council forGraduate Medical Education (ACGME) in the United States alsorequires that residency programs facilitate structured, effective handoffprocesses [7]. The growing number of recommendations for handoffimprovement underscores the need to evaluate how patient careis transferred between individuals and teams. To date, many studieshave evaluated the effectiveness of patient hand-offs in the fields ofinternal medicine, surgery, and pediatrics. To our knowledge onlytwo studies have evaluated the content or quality of hand-offs in theobstetric anesthesia setting [8,9].
At our institution, the care of an obstetric patient may betransferred to two, three, or more anesthesia care teams duringthe course of labor. Yet, provider differences in how informationis communicated and what information is communicated mayresult in non-standardized patient hand-offs. Electronic templatesfor hand-offs may afford an opportunity to improve this process.In November 2012, an electronic template was created to replacethe paper form. The purpose of this study was to explore optimalobstetric anesthesia hand-off characteristics, as well as to evaluate theperceived effectiveness of the paper-based and the electronic-basedhand-off template.


The Northwestern University IRB approved this study and allparticipants provided verbal consent prior to participation. Usingstratified purposeful sampling, anesthesiology resident physicians,obstetric anesthesiology fellows, and attending anesthesiologists wererecruited for study participation. To be eligible for study participation,resident physicians must experience taking overnight call on the laborand delivery unit and must have seen or used the paper or electronichand-off template. Only attending anesthesiologists who staff theobstetric anesthesia service were eligible to participate.
Obstetric anesthesia hand-offs
The annual delivery rate at Northwestern Memorial Hospital isapproximately 13,000. All patient records are electronic. On average,approximately 25 patients are handed-off during formal patient handoffswhich occur twice daily during an anesthesia team “sign-out”rounds. During the hand-off, the outgoing team transfers care of allthe patients on the labor and delivery unit to the oncoming anesthesiateam; each team includes between six and ten residents, fellows, andattending anesthesiologists. At our institution, the obstetric service does not participate in the obstetric anesthesiology hand-off. Thehand-off is done in a room which has an electronic “board” that listsall of the patients’ room numbers, names, and pertinent obstetricdetails. One resident physician or obstetric anesthesia fellow isassigned the role of “coordinator” and is responsible for leading theverbal hand-off to the oncoming team. A handwritten document,using a preprinted template, is used to organize patient information(Figure 1). This document is updated continuously during the shiftby the coordinator.
Figure 1: Paper Hand-Off Template. Information on this document includes patient room number, patient name, obstetric information (gravidity, parity,gestational age, type of labor), relevant medical problems, and anesthetic information (airway classification, height and weight, time of epidural catheterplacement, and issues with labor analgesia).
During a three-month period beginning in November 2012, an electronic version of the printed hand-off sheet was trialed (Figure 2).The tool was a shared, password-protected spreadsheet, available toall obstetric anesthesia providers. Data on the spreadsheet were notprepopulated with information from the electronic health record.Computers were available in the anesthesiology conference roomwhere hand-offs occurred as well as in all patient care areas. Notabledifferences between the electronic and paper hand-off sheets werethat patient identifiers (i.e. patient names) were not available in theonline document, and that the name of the attending obstetricianwas not included on the handwritten hand-off document, but wasincluded on the electronic hand-off document.
Figure 2: Similar to the paper hand-off template, this document includes patient room number, gravidity, parity, gestational age,type of labor, relevant medical problems, and anesthetic information (airway classification, body mass index (BMI), time of epidural catheter placement, and issues with labor analgesia). Unlike the paper template, no patient identifying information is included. The obstetrician’s name is also included in this template.
Survey and interview development
An interview guide was developed by three of the authors (F.P.,T.T.K., and P.T.) and was subsequently reviewed by an expert inobstetric anesthesia (C.A.W.) and an expert in health informationtechnology (E.M.). The survey was designed to explore optimal handoffcharacteristics, to compare the paper and electronic-based hand-offtemplate, and evaluate provider preferences for each hand-off mode.The survey was pilot tested with two attending anesthesiologists andone obstetric anesthesiology resident to determine whether questionswere understood and interpreted correctly, and to establish facevalidity. None of the survey questions were removed following pilottesting.
After screening to confirm eligibility, one trained interviewer(E.L.B) administered the final survey via face-to-face interviews.Participants completed a form that collected demographic data,including gender and age. Comfort level with electronic devices wasassessed with several questions using a 5-point Likert Scale. We thenconducted semi-structured interviews, as these integrate structuredand unstructured exchanges between the interviewer and theparticipant. Participant recruitment stopped when further interviewswere not expected to add more information (i.e. thematic saturation)[10]. Interviews were taped and transcribed verbatim. Responseswere analyzed using content analysis.
Statistical analysis
We conducted qualitative content analysis of open-endedquestions [11]. Specifically, we investigated the interviewees’ criteriafor an optimal patient hand-off as well as the perceived effectiveness ofthe paper-based and electronic-based hand-off systems. Transcriptsfor the open-ended responses were reviewed and coded by twoof the investigators (E.L.B. and P.T.) using NVivo software (QSRInternational Pty Ltd. Version 10).
Codes were developed using an inductive content analysismethodology [12-14]. Content analysis is a technique used inqualitative research, in which data are reviewed line by line, and codesare assigned as concepts are identified.12 Codes are labels assigned tostatements of varying size (e.g., paragraphs, sentences, or words) tohelp organize and describe key concepts without losing the contextin which they occur [13,14]. The process is iterative; each transcriptis reviewed to search for codes and themes which emerge from thedata. This coding scheme is revised to adjust for the previous set ofresponses, and this process is repeated until no new codes emergeand saturation is achieved. Two coders independently coded thetranscripts, and discrepancies were resolved through consensus toensure validity [15]. Once the final coding scheme was developed,a random transcript was chosen for coding to determine interraterreliability (93%). The final coding scheme was applied to alltranscripts by a single coder. The coders were blinded to subjects’demographic data at the time of transcript review and coding.Univariate statistics were used to summarize demographic data andquantitative responses.


Twenty-three physicians met the eligibility criteria and agreed toparticipate. Participants were recruited between June and July 2013and included 10 anesthesiology residents, 4 obstetric anesthesiologyfellows, and 9 attending anesthesiologists. Data from two of theinterviews were excluded due to failure of the recording device; therefore, transcripts from 21 interviews were analyzed (10 female,11 male; age range 28 to 56 years).
Eighty-six percent of participants rated their comfort level withcomputerized-spreadsheets as “comfortable” or “very comfortable.”All of the participants had seen or worked with the electronicsignout system on the labor and delivery unit. The majority ofparticipants (86%) agreed or strongly agreed that all patient recordsshould be electronic. The majority of participants (95%) believed thatan in-person (i.e. face-to-face) hand-off is necessary on the labor anddelivery unit. Key themes and subthemes identified are shown inTable 1.
Table 1: Key Themes and Subthemes.
Theme 1
Overall, anesthesia team members receiving hand-offs wantedinformation that fell into three broad categories: medical and obstetricinformation, anesthesia-specific information, and information thatwould cause a deviation from the usual plan of care. Study participantsconsistently mentioned the importance of hearing patients’ relevantmedical conditions, pertinent obstetrical issues, body mass index,and laboratory findings. Providers also wanted information onMallampati airway classification, contraindications to neuraxialanesthesia, and the status of indwelling epidural catheters. Finally,comorbidities that would change the anesthesiologist’s managementof the patient, as well as anticipated adverse events (e.g., high-riskfor cesarean delivery) also emerged as important components of ahand-off.
Theme 2
Participants identified many suboptimal hand-off characteristics.One such characteristic was not communicating critical information.All participants felt that some critical information was left out ofhand-offs at least 5% to 10% of the time. Even if all pertinent detailswere discussed, a hand-off was considered poor-quality if too muchirrelevant or unnecessary information was discussed. Nineteenparticipants (90%) stated that hand-offs occasionally containedsome irrelevant information. Examples included hand-offs in whichexcessive time was spent discussing healthy patients or patients withcommon pregnancy-related issues, such as gastroesophageal refluxdisease (GERD).
Irrelevant information can also be distracting. In the words ofanother resident:
“If you go over everything, it makes it hard to focus in on thepertinent things, so if you’re sitting there getting inundated by Gs(gravidity) and Ps (parity) and the weeks (of gestation), and theirBMI (body mass index), and hypothyroidism, and GERD, and allthis minutia, it’s just human nature, I feel like, you space off and stoppaying attention. When someone’s just rambling through everythingand they ramble through something that’s actually important, thenyou don’t hear it. Even though you do hear it, you don’t processit, and then you just can’t store that massive amount of worthlessinformation.”
Participants valued accuracy of information; poor-quality handoffsalso included laboratory values that were not up-to-date or painassessments that were inaccurate because the outgoing team wasunable to round in a timely fashion. Finally, many participants feltthat poor-quality hand-offs did not highlight important information.These hand-offs did not contain any verbal emphasis on critical information that could affect the anesthetic management of thepatient. According to one attending obstetric anesthesiologist:
“A bad hand-off would be where all information, say anabundance of information, was given but nothing was highlighted.If I just hear a whole bunch of numbers, I’m not necessarily going toknow, okay, start paying attention, this is a complicated patient...”
Theme 3
One drawback of the electronic hand-off template was itsaccessibility. Participants had to log into a computer to accessthe spreadsheet, whereas the printed document was immediatelyavailable at all times, as it was usually carried on a clip board by thecoordinating resident. Many participants stated that the portability ofthe printed document was an important advantage over the electronicspreadsheet. One resident stated:
“…having to find a computer and pulling up this record from[the electronic hand-off template] would be time consuming if you’reaccessing it many times a day.”
Additionally, the electronic-based hand-off template becameunavailable during the rare occasions when the Internet connectionwas lost. In these situations, participants were unable to access thehand-off spreadsheet.
Another shortcoming of the electronic template was difficultyof use. Participants stated that updating the electronic hand-off was“more cumbersome” and “more time-consuming.” As one residentstated:
“If nothing’s populated and I have to do the typing, it will probablytake longer because I’d be toggling back and forth between this opentab and then the patient’s record or their information. When I havethe [written hand-off] here I can just be clicking and writing at thesame time.”
Study participants were also unable to visually customize theelectronic template. For example, two participants noted that drawingstars or checkboxes to call attention to important complications orlaboratory values was much more difficult to do using the electronicspreadsheet.
One resident participant discussed the issue of patient privacy. Specifically, concern was expressed over the security of the on-linedocument, and the potential for an unauthorized user to gain accessto the hand-off spreadsheet.
Theme 4
Although participants more often identified drawbacks of theelectronic-based hand-off system, some benefits of the system alsoemerged. The electronic hand-off document was more legible than theprinted document. Eighteen (86%) participants experienced legibilityissues at least once with the paper-based hand-off. Sometimes thiswas due to poor handwriting or smudges from repeated erasing andrewriting. For example, one resident stated, “Probably 30% to 40% ofthe time I can’t read someone’s handwriting, or maybe I can’t tell ifthey meant to erase that or meant to keep it kind of thing, so you haveto interpret it.”
Another benefit of the electronic spreadsheet was its relativecompleteness compared to the printed document. Participantsnoted that the expanding free text fields of the electronic spreadsheetallowed them to produce a more detailed clinical picture of thepatient, providing the oncoming obstetric anesthesia team with “amore complete understanding.” With the paper-based hand-off,participants were limited by the physical size of the printed box foreach patient.
The electronic spreadsheet could be accessed on multiplecomputers at once, which allowed all members of the oncoming teamto view the hand-off summary. In addition, the spreadsheet couldbe projected onto a wall during face-to-face team hand-offs. As onefellow noted, “you get both the verbal and the visual confirmation ofwhat’s going on.” A major limitation of the paper hand-off templatewas that it was a single printed document.
Theme 5
In discussing the shortcomings and benefits of the electronicbasedhand-off system, participants suggested several improvements.The most popular suggestion was auto-population of fields in thespreadsheet with patient information from the electronic medicalrecord (EMR). Participants felt that entering information into thespreadsheet from the EMR was “tedious” and “time-consuming.”
Furthermore, auto-population was suggested as a means of optimizingpatient safety by avoiding errors in written communication.
Another suggestion for improvement addressed the lackof portability of the electronic-based hand-off system. Severalparticipants stated that having access to the electronic spreadsheet ona tablet computer or smartphone would make it easier to update orreference when the service gets busy. Most participants (95%) saidthey would carry the electronic hand-off on a tablet computer orsmartphone if it was available.
Many participants stated that if the shortcomings of theelectronic-based hand-off system were corrected, they would preferit to the paper-based system. However, given the current paper-basedand electronic options, 66% percent of those interviewed preferredthe paper hand-off template to the electronic one.


This study begins to delineate some of the potentially importantcharacteristics of an optimal obstetric anesthesia patient hand-off. Agood hand-off contains a patient’s pertinent medical and obstetricalhistory, includes pertinent laboratory values, and places emphasis onpatient data that affects anesthetic management. It is also complete,accurate and contains no extraneous information. Despite havinga structured hand-off system, all study participants felt that somecritical information was left out of the verbal hand-off and that handoffsoften contained irrelevant information. These issues could beimproved through training in effective hand-offs [16,17].
In addition to formal training in patient hand-offs, use of anelectronic hand-off tool may improve hand-off quality and enhancepatient care [18]. Prior to implementation, our study suggests thatconsideration should be given to synchronization with the EMRto eliminate tasks such as typing in demographic informationor laboratory values. Electronic hand-off templates must alsoconsider how patient data is presented so that it can be viewed andinterpreted with ease. Additionally, the use of electronic devicessuch as tablets would increase their portability. Also, ensuring thatnetwork connectivity is maintained would minimize interruptionsin access. Finally, security features should be implemented withcare to maximize data safety while minimizing deleterious effects onworkflow. Such improvements in our electronic hand-off system mayhave allowed our institution to reap potential gains in efficiency, aswell as the improvement in legibility and completeness described byour participants.
Our study conclusions have several limitations. All of theparticipants worked at a single institution. At our institution, theobstetric anesthesia service follows all patients admitted to thelabor and delivery unit, consequently, all patients on the unit arehanded off. Anesthesia providers at other institutions may havedifferent expectations for patient hand-offs. For example, at someinstitutions, the obstetric anesthesia service does not hand off allpatients and sometimes hand-offs are shared with the obstetricservice [9]. Furthermore, this study was not designed to test orcompare the effectiveness of information transferred during patienthand-offs using the two hand-off templates; however, other studieshave demonstrated that an electronic hand-off template can increasethe completeness of patient information transferred during handoffs[19]. Another limitation is that this study was not designed tocapture safety information, such as near-misses or patient harms thatresulted as a consequence of poor-quality hand-offs. A recent study evaluating rates of medical errors after implementation of a residenthand-off bundle found that use of standardized communication andhandoff training, the use of a verbal mnemonic, and a new teamhandoff structure decreased the rate of medical errors from 33.8 per100 admissions to 18.3 per 100 admissions. In that study, a subgrouputilized an electronic hand-off tool linked to the EHR in additionto the hand-off bundle. Compared to the group that used a paperhand-off document, the group using the electronic hand-off toolhad fewer omissions of key handoff elements [20]. The effect of ourhand-off intervention on patient safety in the labor and delivery wardremains to be explored. Finally, we did not measure user satisfactionin our study; however, more users preferred the paper hand-off toolcompared with the electronic hand-off tool. This is incongruent withother studies that have demonstrated increased user satisfaction afterimplementation of a computerized hand-off tool [5,18]. Unlike ourstudy, in which the electronic hand-off tool was not integrated withthe hospital EMR, the studies which found increased user satisfactionwith the electronic tool had a tool that was integrated with thehospital EHR.
We hope that this preliminary study will inform future attemptsto standardize patient hand-offs as well as aid in the developmentof electronic hand-off systems for use in obstetric anesthesia care.Ultimately, understanding and improving how care is transferred inthe obstetric anesthesia setting may have profound implications forthe majority of women in this country.

Author Disclosure Statement

Funding for this study was provided by: Robert Wood JohnsonFoundation, Grant 69779. Robert Wood Johnson Foundation, Route1 and College Road East, P.O. Box 2316, Princeton, NJ 08543-2316,Phone: 1-877-843-7953. The Robert Wood Johnson Foundationhad no role in study design, data collection or analysis, writing ofthe report, or in the decision to submit the study for publication.The content is solely the responsibility of the authors and does notnecessarily represent the official views of the Robert Wood JohnsonFoundation. The authors have no other competing financial interests.


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