Perioperative Handovers in Low- and Middle-Income Countries

Marta Ines Berrio Valencia, MD, MSc

Perioperative HandoversPerioperative handovers involve knowing how to communicate in an efficient, organized, and coordinated manner. There are increasing publications about handovers in the literature, but most of them come from affluent nations. There is a lack of published information about perioperative handovers in low-income countries. The limited reporting on the topic in middle-income nations mainly deals with the intensive care unit (ICU) or the postanesthetic care unit environments. This situation could be caused by the lack of incentives for research in countries with fewer resources, but other potential explanations could apply to these nations.

Many anesthesia professionals do not receive education in handovers in medical and anesthesia curriculums; others do not use a standardized tool for a handover. In addition, recently, fewer human resources are located in the operating rooms because many anesthesia professionals have shifted their responsibilities to the needed support in the critical care units during the coronavirus pandemic. This has undoubtedly increased time constraints to develop standardized handovers and also has increased production pressure. The current organizational objectives might not be aligned with the importance of performing efficient handovers, which could result in no allocated professional time for education in proper patient handovers. On the other hand, proper training of professionals could reduce overall health care costs and increase production and satisfaction among patients and health care workers in the future. Another limitation in low- and middle-resources countries is the lack of integration of a handover into the electronic medical record (EMR). This integrated handover with the EMR could streamline the process of face-to-face communications such as the one presented by Mershon et al. in a recent APSF Newsletter.1

Recommendations for effective handovers suggest that the leader should check that all the relevant members are present and verify that the patient is hooked up to monitors and is stable before starting the handover.2,3 During the handover, one person should speak at a time in an organized and coordinated manner.4 The code status, the contingency plans with the use of “if-then” statements, the goals of treatment4 or an explicit indication of no anticipation of adverse contingencies,5 the action list with “who and when“ will perform the pending tasks, a shared mental model with the active participation of the receiving team, and verbal confirmation of accepting the patient are all key components to the handover process success. A more advanced process entails several structured processes, including continuous feedback, readback, closed-loop communication, and cross-monitoring.6,7 It means that handovers require ongoing education,8 considering the experiences and backgrounds of the stakeholders.

Despite the barriers, having efficient leaders in anesthesia could motivate colleagues to embrace the challenge, engage with stakeholders, and expose the danger of not performing handovers to the institution to get support. For example, an anesthesiology leader could design a universal information form that fits straightforward cases and tailors to a specific surgical population during a small-scale implementation. The next phase would be receiving feedback from all stakeholders as a multidisciplinary collaborative approach, promoting its use, and emphasizing the importance of the structure of handovers through different resources such as institutional emails and meetings to empower staff to work as a team. Finally, the appropriate evaluation of the process, compliance, and professional satisfaction would require organizational support.

In conclusion, improving perioperative handovers in low- and middle-income countries will be a long journey, but it is a must for better teamwork dynamics and patient safety. Thanks to the APSF for being a leader in education in handovers and paving the way for many anesthesia professionals.


Marta Ines Berrio Valencia, MD, MSc is an anesthesiologist at IPS Universitaria in Medellín, Antioquia, Colombia.

The author has no conflicts of interest.


  1. Mershon BH, Greilich PE. The MHC story: accelerating implementation of best practices through improved organizational macro-ergonomics updates from the Perioperative Multi-Center Handoff Collaborative (MHC). Accessed June 23, 2021.
  2. Methangkool E, Tollinche L, Sparling J, Agarwala AV. Communication: is there a standard handover technique to transfer patient care? Int Anesthesiol Clin. 2019;57:35–47.
  3. López-Parra M, Porcar-Andreu L, Arizu-Puigvert M, Pujol-Caballé G. Cohort study on the implementation of a surgical checklist from the operating room to the postanesthesia care unit. J Perianesth Nurs. 2020;35:155–159.
  4. 8 tips for high-quality hand-offs. Accessed June 23, 2021.
  5. Jorro-Barón F, Suarez-Anzorena I, Burgos-Pratx R, et al. Handoff improvement and adverse event reduction programme implementation in paediatric intensive care units in Argentina: a stepped-wedge trial. BMJ Qual Saf. 2021 Apr 23;bmjqs-2020-012370. doi: 10.1136/bmjqs-2020-012370. Online ahead of print.
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  7. Pocket Guide: TeamSTEPPS. Team strategies & tools to enhance performance and patient safety. Accessed June 23, 2021.
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