Developing a standardized safety handover system for post-anesthesia patients in gastrointestinal surgery: Construction and validation

Abstract

BACKGROUND

The anesthesia recovery period after gastrointestinal surgery is a critical stage with a high risk of hypothermia, agitation, infusion failure, and other adverse events. Delayed or incomplete transfer of key information during handover may result in missed risks, inappropriate management, and compromised patient safety. Current handover practices vary widely and lack standardized, quantifiable indicators tailored to gastrointestinal surgery. This study was conducted to address these gaps by developing and validating a structured safety handover management system. The hypothesis was that a standardized indicator-based system would improve handover quality and reduce postoperative adverse events.

AIM

To construct and validate a safety handover indicator system for patients undergoing gastrointestinal surgery in the anesthesia recovery period.

METHODS

This observational study included 500 patients recovering from gastrointestinal surgery at a tertiary hospital from June 2024 to June 2025. A preliminary handover indicator system was developed through literature review, semi-structured interviews, and Delphi consultation. Indicator weights were determined using the analytic hierarchy process. The system was applied to 250 patients and compared with 250 patients receiving conventional handover. Outcomes included handover time, omission rate, complication incidence, adverse events, and staff satisfaction. Statistical analysis used χ² and t-tests.

RESULTS

Expert engagement in both Delphi rounds was 100%, with authority coefficients of 0.87 and 0.89, respectively. Kendall's harmony coefficient increased from 0.216 to 0.331 (both P < 0.01). The final system comprised three first-level, 12 second-level, and 38 third-level indicators. Compared with the control group, the experimental group showed longer handover time but markedly lower omission rate. Rates of hypothermia, agitation, and infusion failure were significantly reduced (all P < 0.05), and staff satisfaction scores were higher across all dimensions (P < 0.001).

CONCLUSION

The validated safety handover system standardizes postoperative transfer in gastrointestinal surgery, reduces errors and adverse events, and enhances patient safety and workflow efficiency, supporting its suitability for clinical implementation.

Key Words: Gastrointestinal surgery; Anesthesia recovery period; Safety handover; Indicator system; Nursing safety

Core Tip: This study developed a structured safety handover system for patients undergoing gastrointestinal surgery using literature review, Delphi consultation, and the analytic hierarchy process. The final system included three first-level, 12 second-level, and 38 third-level indicators. In clinical application, the experimental group showed longer handover time, reduced information omission, lower rates of hypothermia, agitation, and infusion failure, and higher staff satisfaction (all P < 0.05). These findings demonstrate the effectiveness of the system in improving handover quality and patient safety.

INTRODUCTION

Patients undergoing gastrointestinal surgery often require multiple tubes, including gastric tubes, abdominal drains, and central venous catheters. They also face several challenges, such as pain, nausea and vomiting, fluid management needs, and temperature instability. Gastrointestinal surgery is among the most common procedures in general surgery, and these patients frequently have complex physiology and multiple comorbidities. Metabolic disturbances, electrolyte imbalance, poor nutritional status, and perioperative cardiopulmonary fluctuations all increase the difficulty of anesthetic recovery and postoperative monitoring. Omissions during handover - such as special intraoperative events, blood loss, antibiotic duration, or specific medical orders - can delay decision-making, lead to inappropriate management, and result in serious complications that compromise patient safety[1,2].

The postoperative anesthesia recovery period is a critical transition between the operating room and the ward. During this phase, respiratory and circulatory functions have not fully stabilized, and the capacity for physiological self-regulation remains limited. This creates a vulnerable window marked by rapid physiological fluctuations and a high incidence of complications[3,4]. Given the complexity of gastrointestinal surgery - often involving prolonged operative times, substantial fluid shifts, and multiple drainage tubes - the recovery period carries a particularly high risk, making accurate handover essential for early detection of complications. Inadequate safety handover can lead to misjudgment of patient conditions, hindering the delivery of timely and effective treatment and nursing care[5,6].

Existing international guidelines and standards largely provide overarching principles but lack refined, quantifiable, and operable management indicators tailored to specific specialties, clinical scenarios, and patient populations[7,8]. Most available tools do not offer detailed or structured criteria for postoperative handover in gastrointestinal surgery, nor do they incorporate weighting, risk prioritization, or measurable evaluation components. This emphasizes the urgent need to develop a specialty-specific, scenario-based, and standardized safety handover system for patients in the anesthesia recovery period after gastrointestinal surgery.

To address this gap, this study aimed to establish a scientifically rigorous safety handover management indicator system specifically for patients undergoing gastrointestinal surgery during postoperative anesthesia recovery. Using literature review, semi-structured interviews, and Delphi expert consultation, a multi-dimensional indicator framework was developed and refined. The analytic hierarchy process was applied to determine indicator weights, enabling quantification and prioritization of key items. The resulting system was then validated in clinical practice through a controlled study, which demonstrated improved information completeness, fewer postoperative complications, and higher staff satisfaction. This dual approach - system construction combined with empirical verification - represents the primary innovation of this study and provides a foundation for promoting standardized handover practices in clinical settings.

MATERIALS AND METHODS

Study subjects

After receiving approval from the Ethics Committee of the hospital, 500 patients who underwent gastrointestinal surgery at the Affiliated Hospital of Nantong University between June 2024 and June 2025 were enrolled. Of these, 250 patients who received the traditional handover method from June 2024 to December 2024 were assigned to the control group, and 250 patients who received handover based on the new indicator system developed in this study from January 2025 to June 2025 were assigned to the experimental group. The inclusion criteria were as follows: Patients aged 18 years or older, those undergoing elective or urgent open or laparoscopic gastrointestinal surgery, those classified as American Society of Anesthesiologists physical status I-III, and those admitted to the post-anesthesia care unit (PACU) for postoperative recovery. The exclusion criteria were as follows: Emergency surgery, death during the operation, or direct transfer to the intensive care unit without recovery in the PACU, and incomplete clinical data.

This study employed a time-series grouping method, assigning patients from June 2024 to December 2024 to the control group and those from January 2025 to June 2025 to the experimental group, without random allocation. The primary rationale was that the newly established handover system required unified implementation within a defined period, as simultaneous use of different handover protocols could disrupt workflow and compromise safety. To minimize bias associated with non-random grouping, the study applied strict inclusion criteria and conducted statistical comparisons of baseline characteristics between the two groups. No significant differences were found (P > 0.05), indicating good comparability.

Study methods

Traditional handover method: The traditional handover process followed routine clinical practice and consisted of the following steps: (1) Operating room nurses and anesthesiologists jointly transferred the patient to the PACU, connected the electrocardiographic monitor and oxygen delivery device, and ensured that vital signs were stable; (2) The anesthesiologist, serving as the primary handover provider, delivered a free-narrative oral handover. The main content included basic patient information, anesthesia method, current vital signs, key intraoperative events, level of consciousness, respiratory status, tube conditions, and medication status. Operating room nurses supplemented additional information, such as the submission of surgical specimens, intraoperative counts, and skin integrity. The receiving nurse documented key points and asked clarifying questions when necessary; (3) Operating room nurses completed a general, non-specialized operating room patient handover record form, which primarily consisted of checkboxes and a few open fields (e.g., vital signs were recorded as stable or unstable; tube condition was assessed as normal or abnormal); (4) The handover was deemed complete once the anesthesiologist and operating room nurses confirmed that all essential information had been communicated, the receiving nurse had no further questions, and the paper handover form had been fully completed. Both parties then signed the form to confirm the handover; and (5) The operating room team departed, and the PACU staff assumed full responsibility for patient monitoring, recovery, and treatment.

Construction of the safety handover management indicator system: The construction of the safety handover management indicator system proceeded through the following steps: (1) A research team of 10 medical staff members was formed, including the directors of gastrointestinal surgery, anesthesiology, and the nursing department; the head nurses of the PACU and the gastrointestinal surgery ward; senior operating room nurses; and postgraduate students. The team carried out a literature review, development of interview outlines and expert consultation questionnaires, expert selection, organization of consultations, data collection and analysis, system construction, and implementation of the empirical plan; (2) A preliminary draft of the indicator framework was developed through systematic searches of PubMed, Web of Science, the China National Knowledge Infrastructure, and Wanfang, combined with Joint Commission International standards, International Patient Safety Goals, and existing hospital systems; (3) Semi-structured interviews were conducted with 30 medical staff involved in the handover process to obtain detailed insight into current handover practices, existing problems, and improvement needs. Based on the interview findings, a preliminary indicator framework was established, comprising three first-level, 13 second-level, and 42 third-level indicators; (4) Twenty experts from tertiary grade A hospitals in the province were selected, covering gastrointestinal surgery, anesthesia and resuscitation, and nursing management. Two rounds of expert consultation were conducted using the Delphi method. The inclusion criteria for experts were associate senior professional title or above, bachelor’s degree or above, more than 10 years of work experience, and voluntary participation; (5) The Likert five-point scoring method was used during consultation to rate the importance of each indicator. Open-ended questions were included to gather revision suggestions. Indicators were screened and adjusted according to opinion concentration (mean importance score and full-score rate), coordination degree [coefficient of variation and Kendall’s harmony coefficient (Kendall’s W)], and expert authority coefficient. Indicators with a mean importance score < 3.5 or coefficient of variation > 0.25 were removed; (6) After two rounds of consultation, the final indicator system was formed, consisting of three first-level, 12 second-level, and 38 third-level indicators; (7) A hierarchical structure model was built based on the confirmed indicator system. Experts performed pairwise comparisons of indicators at the same level to generate a judgment matrix and determine indicator weights. Yaahp 10.3 software was used to calculate weights and conduct a consistency test, with a consistency ratio < 0.1 indicating acceptable consistency; and (8) Safety handovers were implemented using the safety handover checklist for gastrointestinal surgery patients during the postoperative anesthesia recovery period, constructed in this study. The checklist included all third-level indicators, and both parties participating in the handover were required to review each item sequentially and sign for confirmation. Tables 1 and 2 present the indicators and corresponding weights of the safety handover management system.

Table 1 Level 1 and level 2 indicators and weights of the safety handover management system.

Primary indicator and weight	Secondary indicator and weight	Composite weight
A1: Pre-handover preparation (0.3512)	B1: Completeness of patient information preparation (0.4015)	0.1411
	B2: Preparation of drugs/supplies/equipment (0.3287)	0.1155
	B3: Environment and personnel readiness (0.2698)	0.0948
A2: Handover process execution (0.4635)	B4: Accurate patient identification (0.2150)	0.0997
	B5: Completeness of intra-operative status transfer (0.1832)	0.0849
	B6: Handover of vital signs and level of consciousness (0.1714)	0.0794
	B7: Tubing check and secure fixation (0.1555)	0.0721
	B8: Fluid balance and medication summary (0.1349)	0.0625
	B9: Skin integrity and belongings transfer (0.0751)	0.0348
	B10: Special issues and key medical orders (0.0649)	0.0301
A3: Post-handover verification (0.1853)	B11: Information recheck and clarification of doubts (0.6328)	0.1172
	B12: Mutual signature and documentation (0.3672)	0.0681

Table 2 Importance scores and weights for selected level 3 indicators.

Level 2 indicator	Level 3 indicator	Importance score (mean ± SD)	Weight
B4: Accurate patient identification	Use at least two methods to verify identity (name, hospital ID)	4.95 ± 0.22	0.402
	Check wristband information	4.85 ± 0.37	0.318
	Verify operative site and procedure	4.75 ± 0.44	0.280
B7: Tubing check and secure fixation	Name, insertion depth, and fixation of each tube (drains, NG, CVC, etc.)	4.90 ± 0.31	0.256
	Confirm drain patency and characteristics/volume of drainage	4.95 ± 0.22	0.294
	IV access patent; insertion site without leakage or swelling	4.80 ± 0.41	0.235
	Oxygen catheter/mask patent and properly secured	4.60 ± 0.50	0.215
B11: Information recheck and clarification of doubts	Receiving nurse repeats key data (blood loss, special drugs, allergies)	4.75 ± 0.44	0.421
	Handover staff confirm or correct the repeated information	4.70 ± 0.47	0.342
	Both parties immediately clarify any discrepancies and reach agreement	4.85 ± 0.37	0.237

IV: Intravenous; CVC: Central venous catheter; NG: Nasogastric; SD: Standard deviation.

Evaluation indicators

Baseline data: Baseline data for the two groups were recorded, including sex, age, surgical type, American Society of Anesthesiologists classification, and operation duration. These variables were compared to determine whether differences existed between the groups.

Results of expert consultation: A descriptive analysis was performed for basic expert information, the expert positive coefficient, and the expert authority coefficient for both rounds of consultation. The degree of coordination among expert opinions was also analyzed.

Handover quality: Differences between the two groups were compared in terms of handover time and the handover information omission rate, defined as the proportion of checklist items not addressed during handover.

Patient outcome indicators: The incidence of outcomes during the anesthesia recovery period was compared between the two groups. Complications included hypothermia (temperature < 36 °C), agitation (Riker Sedation-Agitation Scale score ≥ 5), and nausea and vomiting. Adverse events included unplanned extubation, falls, and medication errors.

Healthcare staff satisfaction: A self-developed satisfaction questionnaire (Cronbach’s α = 0.892) was used for assessment. The questionnaire evaluated clarity of process, completeness of information, work efficiency, and safety. Each dimension was scored out of 100, and the total score was calculated as the average of all dimension scores.

Statistical analysis

Data analysis was conducted using SPSS 26.0. Categorical data, expressed as n (%), were analyzed using the χ² test. Continuous data, expressed as mean ± SD, were tested for normality using the Shapiro-Wilk test, and intergroup comparisons were performed using the independent samples t-test. A P-value < 0.05 was considered statistically significant.

RESULTS

Comparison of baseline data

No significant differences were found in sex, age, type of operation, American Society of Anesthesiologists grade, or operation duration between the two groups (P > 0.05; Table 3).

Table 3 Baseline data comparison between the two patient groups, n (%).

Group	n	Sex		Age (years)	Surgery time (minutes)	ASA			Types of surgery
		Male	Female			II	Ⅲ	IV	Open-abdominal surgery	Laparoscopic
Experimental	250	142 (56.80)	108 (43.20)	58.76 ± 8.23	182.54 ± 35.63	48 (19.20)	152 (60.80)	50 (20.00)	95 (38.00)	155 (62.00)
Control	250	139 (55.60)	111 (44.40)	57.95 ± 9.14	178.96 ± 35.26	52 (20.80)	146 (58.40)	52 (20.80)	88 (35.20)	(64.80)
χ2/t	-	0.073		1.091	1.239	0.218			0.456
P value	-	0.787		0.276	0.216	0.897			0.500

ASA: American Society of Anesthesiologists.

Results of expert consultation

Both rounds of consultation achieved an effective recovery rate of 100%, with an expert positive coefficient of 100%. The expert authority coefficient was 0.87 in the first round and 0.89 in the second round. Kendall’s W was 0.216 (χ² = 135.24, P < 0.001) in the first round and 0.331 (χ² = 207.51, P < 0.001) in the second round. Figure 1 and Table 4 present basic expert information and consultation results, respectively.

Figure 1 Basic information of the consultation experts. A: Distribution of professional titles; B: Educational background distribution; C: Educational background distribution; D: Distribution of years of work experience. Dr.: Doctor of medicine; MM: Master of medicine; MBBS: Bachelor of medicine, bachelor of surgery; PUCA: Post anesthesia care unit.

Table 4 Expert consultation results.

Round	Questionnaires distributed	Valid responses	Valid response rate	Expert authority coefficient	Kendall’s W	χ2 value	P value
1	20	20	100	0.87	0.216	135.24	< 0.001
2	20	20	100	0.89	0.331	207.51	< 0.001

Comparison of handover quality indicators

Compared with the control group, the experimental group showed a longer handover time and a lower information omission rate, with statistically significant differences (P < 0.05; Table 5).

Table 5 Comparison of handover quality indicators between the two patient groups.

Group	n	Handover time (minutes)	Information omission rate (%)
Experimental	250	9.86 ± 1.83	3.28 ± 1.57
Control	250	8.52 ± 2.15	15.86 ± 4.34
t-value	-	8.624	45.217
P value	-	< 0.001	< 0.001

Comparison of the incidence of complications and adverse events during the anesthesia recovery period

The incidence rates of hypothermia, agitation, and infusion failure in the experimental group were lower than those in the control group, with statistically significant differences (P < 0.05; Table 6).

Table 6 Comparison of complication and adverse event incidence during the anesthesia recovery period, n (%).

Group	n	Hypothermia	Agitation	Nausea/vomiting	Respiratory depression	Unplanned extubation	Infusion failure	Pressure ulcer
Experimental	250	35 (14.00)	28 (11.20)	33 (13.20)	5 (2.00)	0 (0.00)	4 (1.60)	1 (0.40)
Control	250	68 (27.20)	55 (22.00)	42 (16.80)	8 (3.20)	2 (0.80)	15 (6.00)	3 (1.20)
χ2 value	-	15.789	11.429	1.563	0.714	2.008	7.143	1.026
P value	-	< 0.001	0.001	0.211	0.398	0.156	0.008	0.311

Comparison of healthcare staff satisfaction with handover

Scores for process clarity, information completeness, work efficiency perception, overall sense of safety, and total handover satisfaction in the experimental group were all higher than those in the control group, with statistically significant differences (P < 0.05; Table 7).

Table 7 Comparison of handover satisfaction among medical staff in the two groups.

Group	n	Process clarity	Information completeness	Work efficiency	Overall security	Total score
Experimental	30	90.22 ± 5.35	93.66 ± 4.14	85.45 ± 6.83	92.51 ± 5.02	90.43 ± 4.56
Control	30	76.43 ± 8.26	72.81 ± 9.58	70.69 ± 10.14	75.27 ± 8.75	73.88 ± 7.64
t-value	-	7.892	11.234	6.543	9.876	10.123
P value	-	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001

DISCUSSION

In recent years, with the widespread adoption of enhanced recovery after surgery principles and rapid advances in minimally invasive technology, perioperative management in gastrointestinal surgery has become increasingly refined, placing higher demands on medical quality and patient safety[9,10]. During the postoperative anesthesia recovery period, patients are transferred from anesthesiologists and operating room nurses to nurses in the PACU. The long information transmission chain, multiple handover links, and complex content make this phase a high-risk management node for medical errors and adverse events[11,12]. Evidence indicates that up to 70% of serious medical adverse events are associated with communication failures, with information omission, misunderstanding, or delay during handover identified as major contributing factors[13,14]. For these reasons, and considering the specialized characteristics of gastrointestinal surgery and the practical needs of handover during postoperative anesthesia recovery, the construction of a scientific and operable safety handover management indicator system - together with verification of its application effect - holds significant theoretical and practical value.

This study followed rigorous scientific procedures and successfully established a safety handover management indicator system for patients undergoing gastrointestinal surgery during the postoperative anesthesia recovery period using the Delphi method. The system consists of three first-level, 12 second-level, and 38 third-level indicators. Weights were assigned through the analytic hierarchy process, providing an effective management tool to enhance safety during postoperative anesthesia recovery. Extensive literature review and in-depth qualitative interviews ensured comprehensive indicator sources and strong clinical applicability, covering the modern three-dimensional quality management framework of structure, process, and outcome[15,16]. The application of the Delphi expert consultation method was central to system development. The 20 participating experts came from several relevant fields and demonstrated high authority (expert authority coefficient > 0.8) and strong representativeness. The effective recovery rate of 100% across both rounds of consultation reflected high expert engagement. Kendall’s W in the first round was relatively low (0.216), a common finding during early consultation among senior experts, indicating variation in opinion. After revision and feedback, Kendall’s W increased markedly to 0.331 in the second round (P < 0.05), demonstrating stronger consistency and good coordination. The final indicator system, therefore, achieved a high degree of expert consensus and robust content validity. The analytic hierarchy process transformed subjective expert judgments into objective weight assignments, allowing the system to reflect indicator importance while clearly differentiating priorities. For example, the indicator related to handover process execution had the highest weight (0.4635), emphasizing its central role in safe handover practice. In addition, the system includes three key components - pre-handover preparation, handover process execution, and post-handover confirmation - reflecting a full-process management approach consistent with International Patient Safety Goals[17] and Joint Commission International standards.

The study findings showed that the average handover time in the experimental group was slightly longer than in the control group (P < 0.05). Although this may appear to indicate reduced efficiency, the additional duration (approximately 1.3 minutes) was mainly allocated to item-by-item verification and confirmation using the standardized checklist. This approach eliminated skipped items and selective handover driven by the pursuit of speed, and the direct result was a substantial reduction in the information omission rate - from 15.8% in the control group to 3.2% in the experimental group (P < 0.05). This outcome aligns with the findings of Jacobsen et al[18], which showed that a small increase in time investment produces marked improvement in information completeness and prevents the additional time required for repeated communication and clarification later in the process. Considered from a whole-process perspective, this approach enhances both safety and efficiency.

Regarding patient outcomes, the incidence rates of hypothermia, agitation, and infusion failure in the experimental group were significantly lower than those in the control group (P < 0.05). This improvement reflects the refinement and application of relevant items in the indicator system, such as body temperature monitoring and heat preservation measures, pain assessment and sedation scoring, and tube handover and fixation checks. The standardized handover process allowed medical staff to identify risks in advance and implement preventive measures, thereby reducing the occurrence of complications and adverse events. This result aligns with the findings of Kaltoft et al[19], which reported that structured handover tools can significantly improve safety during the postoperative recovery period.

In addition, the study found that handover satisfaction among medical staff in the experimental group was significantly higher than that in the control group across all evaluated dimensions (P < 0.05). This indicates that the standardized handover system not only improves work efficiency but also enhances the sense of safety and job satisfaction among medical staff. Several factors may explain this finding. First, the structured process reduces uncertainty and randomness during handover, lowering anxiety that arises from information omission or misunderstanding[20-22]. Second, the two-way verification mechanism strengthens team collaboration and communication, increasing professional engagement and work identity[23-25]. Third, clear division of responsibilities and explicit documentation requirements provide legal protection and reduce the risk of medical disputes[26-28]. Improvement in satisfaction contributes to the development of a positive safety culture, thereby supporting progress toward patient safety goals.

However, this study was conducted at a single center with a relatively limited sample size and research scope. Long-term effect tracking of the indicators was not performed, which introduces certain limitations. Future studies should include multicenter, large-sample randomized controlled trials and establish long-term follow-up mechanisms to more comprehensively verify the effectiveness and reliability of the indicator system.

CONCLUSION

In conclusion, the safety handover management system for patients undergoing gastrointestinal surgery during the postoperative anesthesia recovery period developed in this study is scientific, systematic, and reliable. It standardizes the handover process, reduces handover errors and adverse events, and improves both safety assurance and work efficiency. This system is therefore suitable for wider clinical adoption.