As symbolized by the seal of the American Society of Anesthesiologists (ASA), the practice of anesthesia is a profession based on vigilance. Attention to detail and continuous situational awareness are essential to anticipate and avoid preventable complications. Similar to other professions requiring constant vigilance, it is generally accepted that periodic relief of anesthesia providers is necessary to promote patient safety. Extrapolating from data in their landmark 1978 study regarding preventable mishaps in the practice of anesthesia, Cooper et al. found that the provision of periodic breaks to anesthesia personnel during long procedures had a favorable effect on preventing critical incidents by allowing their (earlier) detection by the relieving anesthetist. This finding has not been universal, as some evidence shows that continuity of care throughout the course of an anesthetic case decreases the risk of perioperative morbidity and mortality. Though examples have been observed of critical incidents attributed to, or perpetuated by, the exchange of personnel, most of these can be avoided by a detailed and inclusive personnel exchange protocol. This chapter presents a stepwise approach to organizing essential data during personnel exchanges to enhance patient care focusing on three critical categories: patient factors, surgical procedure factors, and key elements of the anesthetic plan.

Effective July 1, 2004, all Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-accredited surgical facilities became required to adopt the Universal Protocol to Prevent Wrong Site, Wrong Procedure, and Wrong Person Surgery. This “time-out” protocol provides a point of embarkation in the initiation of sign-out protocol between anesthesia providers. Confirming demographic information including age, gender, race, and name establishes the context in which all further information can be understood. Included in the introduction is mention of any medical allergies unique to the patient. Furthermore, it is essential that the replacing anesthetist be versed in what surgical procedure is being performed and its indications in order to anticipate anesthetic needs.

Anesthetic technique is dictated not only by surgical requirements but also largely by co-morbid conditions. Consequently, the next logical piece of information to cover deals with the patient’s relevant past medical history. The relieving anesthetist should assume care of the patient only after acquiring a thorough grasp of his or her medical problems, concentrating
on cardiovascular, pulmonary, renal, and neurologic status. Attention should be paid to objective measures of physiologic organ system function such as pertinent laboratory values, radiologic studies, and baseline vital signs. Anticipating and avoiding preventable morbidity hinges on planning around pitfalls inherent to the patient’s physiologic state. Knowledge of these co-morbidities helps explain the medications that the patient chronically takes that may compliment or complicate anesthetic management. Discovering that a patient is inadequately treated for a certain medical condition may help to modulate the anesthetic plan and thereby avoid morbidity.

The logic of the anesthetic plan should be apparent after establishing what is being done, to whom it is being done, and what special challenges are presented by the patient. To ensure that critical information is not overlooked, it is useful to conduct the discussion of anesthetic technique in chronological order. Beginning with induction, it is essential that the replacing anesthetist have a thorough understanding of what technique was used. Critical items to note include the mode (e.g., mask induction, intravenous induction, or rapid sequence induction) and the medications used.