We found that having a checklist in the operating room improves the quality of intraoperative change of shift handoff for scrubs and circulating, although the increasing quality of handoff process was only significant for scrubs. Also, the presence of a checklist in the operating room significantly reduces the omission percentage of information in the shift report during surgery in both circulations and scrubs compared to before the intervention.
After performing the intervention and introducing the contents of checklist and the items to be transferred during the shift delivery at the time of surgery, an increase in handoff duration was seen in both B and C groups (with and without checklists) with the improvement of data transfer status.. The difference between this increases of time in the checklist group before the intervention was 35.3 seconds among scrubs and 17.3 seconds among circulations. Researchers in similar studies have reported different perceptions of increasing or decreasing handoff duration after intervention and introduction of a checklist.[2, 23–25] For example, in the study of Salzwedel et al., the increase in handoff time, which was less than 1 minute in their study, was considered to be short-lived, and this slight increase in time was compared to the improvement in the status of information transfer as well as quality of positive patient care.[2] In contrast, in the study of Catchpole et al., a decrease was observed in the handoff duration by intervening and introducing a checklist, citing the structuring of handoff and defining responsibilities.[24]
Increasing handoff duration in this study may not be economically viable at first glance; however, this slight increase over time can be ignored because of the positive aspects of using a checklist to reduce the amount of omitted information that improves the quality of handoff process and ultimately increases the quality of patient care.
The quality of handoff process in this study was evaluated in two aspects: environment (noise and interruptions created) and behavior (organization, communication skills, clinical judgment and professionalism). According to the results of the environmental aspect, no change in the improvement of situation was observed after the intervention. In other similar studies, for example, in the Lo study concerning the handoff delivery of medical attending, or in the study of Joy investigating the patient handoff between cardiac surgery department and ICU, improvement in the environment and interruptions during the handoff after the application of the checklist have been reported.[26, 27]
However, the operating room environment is full of sound generating sources (sound of electrical equipment, air conditioning system, moving devices and tools, etc.).[28, 29] these sounds can have many adverse effects on the correct transmission of information. On the other hand, the circulating and scrub roles during surgery are such that multiple interruptions during handoff are inevitable. Therefore, in this study, after the intervention, we did not observe any significant change in the environment of handoff process. However, behavioral intervention in the two areas of handoff organization and communication skills showed better results, which was made possible due to the existence of a checklist. In other words, the existence of a checklist enabled the surgical team to resume the process of transferring information from the part that had been stopped despite numerous interruptions. On the other hand, the checklist improves communication skills by approaching the deliverer and recipient to each other. This occurred during the handoff, and eventually reduced the lost information of handoff reports despite lack of change in the scope of environment after the intervention.
Our findings support the study hypothesis that we can increase the quality of handoff content during surgery by introducing a relatively structured and regular method.
Hanley cites three potential reasons for handoff errors: interruptions during hand-off, lack of standard format, and unreliability of the sender and receiver of the information to be transmitted.[30] In this study, by performing the intervention despite the inability to control interruptions during handoff via introducing the standard format and teaching the information to be transferred during shift delivery, we observed a reduction in information omission percentage as well as improved quality of handoff content in both circular and scrub roles.
The use of a standard model for handoff in similar studies has also improved the information transfer. In the study of Ding et al., the patient handoff between neurological intensive care unit to neurological department after the intervention showed a reduction in handoff errors from 18.8–5.7%.[31]
In the study of Craig et al., the percentage information omission was reduced from 36.8% before the intervention to 15.7% after it through introducing the standard format for handoff among cardiology and ICU staff (28). In Mitchelle's study on the same statistical population, the amount of information lost after the intervention was reduced from 26 to 18% (29). In the Negpal’s study, the amount of information lost after using the standard checklist was reduced from 9 to 3.[3]
Participants' satisfaction is another important element in evaluating the success of an intervention. In the present study, handoff satisfaction increased from 67.5–85.5% using the checklist, which was consistent with previous studies that have successfully implemented a standard handoff process. In the study of Petrovic et al., the satisfaction of recovery nurses with handoff increased from 73.8–92% after using the checklist for patient transfer.[22] In a study by Johnson et al., nurses' satisfaction with patient's handoff after the introduction of checklist increased from a total score of 21.7 to 24.[32] In the study of Kazemi et al., which was conducted with the aim of evaluating the effect of delivery of nurses' shifts in the patient's bedside with patient's participation, total satisfaction score increased from 81.6 to 93.[33]
Limitations
One of the limitations of our study was the evaluation of shift-change handoff during surgery with the presence of a researcher in the operating room, which could cause Hawthorne effect and influence the results. However, this effect was limited because the assessor did not communicate with the surgical team during handoff. Also, the assessor was present in both periods before and after the intervention. On the other hand, the researcher was not a member of the operating room staff and had no control over them. Nevertheless, the presence of an assessor was necessary to evaluate the handoff in the operating room, unless a camera was used in subsequent studies to assess handoff to reduce the effect. Another limitation was the COVID-19 pandemic during the study, which could affect the research process and was beyond the researcher's control, although this effect was the same in both B and C groups.