Original Research

Quality of handover in the post-anaesthetic care unit at a quaternary children’s hospital in Cape Town, South Africa: A clinical audit

John M. Breedt, Anisa Z. Bhettay, Johan van der Walt, Sarisha Govender

Received: 08 Dec. 2025; Accepted: 14 May 2026; Published: 14 July 2026

Copyright: © 2026. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Postoperative handover involves multidisciplinary collaboration among anaesthesia providers, surgeons and nurses, and the absence of standardised protocols can lead to communication errors that compromise patient safety. The Red Cross War Memorial Children’s Hospital (RCWMCH) lacks a standardised protocol for handover between anaesthesia providers and recovery nurses in the post-anaesthetic care unit (PACU), underscoring the need to evaluate current practices.

Aim: To evaluate the quality of postoperative handover between anaesthetists and recovery nurses in the PACU using a standardised checklist.

Setting: The PACU of the RCWMCH, a quaternary academic children’s hospital in Cape Town, South Africa.

Methods: This was a cross-sectional observational study conducted in the PACU at the RCWMCH. A Paediatric Anaesthesia Handover Checklist was used to evaluate current handover practices. The checklist consisted of 26 mandatory items requiring verbal handover. Based on each item handed over, a score was calculated out of 26, and this was expressed as a percentage.

Results: Fifty-five handovers were observed, involving 20 anaesthetists. The average duration of handover was 54.23 s. Handovers were frequently incomplete, with scores ranging from 0 out of 26 to 17 out of 26 (65.38%), and an average score of 5.54 out of 26 (21.31%). The most commonly handed-over item was intraoperative analgesia 42 out of 55 (76.36%). Despite routine administration, use of sedative premedication was reported in only 26 out of 55 (47.27%) of cases.

Conclusion: The quality of handover in the PACU at the RCWMCH was low. Critical patient safety information was frequently omitted, highlighting the need for intervention. The use of checklists may improve the quality of communication and prevent potential adverse events.

Contribution: This audit demonstrates significant gaps in paediatric PACU handover in a resource-limited setting and supports the introduction of a structured handover checklist as a low-cost intervention to improve communication and patient safety.

Keywords: paediatric anaesthesia; post anaesthesia care unit; postoperative complications; handover checklist; interdisciplinary communication; patient safety.

Introduction

The early postoperative period is defined as the time from discontinuation of anaesthesia until the return of protective airway reflexes and motor function.¹ During this crucial period, it is essential to identify and address anaesthesia- and surgery-related complications, which are typically managed in the post-anaesthetic care unit (PACU).² These complications may result from comorbidities, sequelae from the surgery or anaesthetic or inadequate transfer of patient information.^3,4,5

Patient handovers require collaboration among anaesthetic providers, surgeons, scrub nurses and PACU staff. Their interdisciplinary nature increases the risk of communication errors because of varying experience levels, perspectives and priorities. A structured handover is crucial for ensuring the receiving team is well-informed about the patient’s medical history, clinical progression, treatment plan and ongoing care, thereby promoting continuity and patient safety.⁶ Communication breakdowns are a major cause of anaesthesia-related sentinel events, leading to significant morbidity and mortality.⁷

Observational studies on postoperative patient handovers in the PACU among adults have found them to be frequently incomplete and unstructured.^8,9 While data on paediatric patients are limited, two studies similarly highlight a lack of standardisation and completeness in the transfer of care.^10,11

The Red Cross War Memorial Children’s Hospital (RCWMCH), a quaternary academic children’s hospital, performs approximately 10 000 anaesthetics annually. Currently, there is no standardised protocol for handover between anaesthetists and recovery nurses in the PACU. This prompted the need to evaluate current practices.

Research methods and design

The study was conducted from 02 October 2023 to 13 November 2023.

This was a cross-sectional, descriptive, observational study. The primary outcome was to evaluate the current handover practice in the PACU between anaesthetists and recovery room nursing staff at the RCWMCH using a standardised checklist. All patients admitted to the PACU were eligible for inclusion in this study. Patients who were held in the PACU briefly en route to the intensive care unit (ICU), and those who had procedures undertaken in the ICU were excluded. The Paediatric Anaesthesia Handover Checklist (PAHC) was created using the Post-Anaesthesia Team Handover trial checklist and previous paediatric handover study checklists as guides.^11,12 The investigators identified 26 items that were essential for handover to nursing staff in the PACU. These items were categorised into introductory, preoperative, intraoperative and postoperative information. The PAHC was reviewed by three specialist anaesthetists, including a paediatric anaesthetist, to establish validity. Handovers were observed and data collected by two investigators. Each handover was scored out of 26 according to the items on the PAHC verbalised during the transfer of information, and the result expressed as a percentage. Key definitions were provided to avoid confusion and ambiguity. Box 1 depicts the PAHC.

This study was primarily descriptive; therefore, only limited statistical analyses were performed. Convenience sampling was used during data collection, with a minimum of 50 handovers required to improve the generalisability of the results.

Anaesthetists were de-identified and assigned numerical codes to determine the total number observed. Their level of experience was categorised using standardised definitions. If multiple handovers occurred simultaneously, only one was included. The investigators were not involved in the handover process or clinical care of the patient. The observer maintained a discreet presence, positioned close enough to both witness the handover and clearly hear the exchange. To minimise the Hawthorne effect, staff were unaware of being observed. This effect occurs when behaviour is altered because of awareness of observation, often leading to temporary improvements in performance. After completion of each handover, the anaesthetic chart was reviewed to determine whether important information was omitted. Following data collection for every 10 patients, a comprehensive evaluation was conducted jointly by two investigators to identify omissions that may have resulted in life-threatening events. This may have necessitated protocol review for ethical reasons.

Ethical considerations

Ethical clearance to conduct this study was obtained from University of Cape Town Faculty of Health Sciences Human Research Ethics Committee (No. HREC 453/2023). Institutional and explicit consent was obtained from key stakeholders.

Results

Data were collected from 55 handovers performed by 20 anaesthetists. Figure 1 illustrates their experience levels. Most handovers occurred between junior anaesthetic consultants and PACU staff, while the least involved junior trainees.

FIGURE 1: Distribution of handovers according to level of experience.

A ‘hands-off’ handover, defined as initiating the process only after essential tasks (e.g. applying monitors), was followed in 47 out of 55 (85.5%) cases. The average handover duration was 54.23 s. Additional questions were asked in 13 out of 55 (23.6%) cases, with medication being the most common inquiry. Interruptions occurred in 9 out of 55 (16.3%) handovers, totalling 12 occurrences – 4 because of oxygen desaturation requiring the anaesthetist’s attention and two as a result of suspected emergence delirium. There were eight patients for whom a formal handover did not take place.

Introduction rates were low: 4 out of 55 (7.2%) anaesthetists and two out of 55 (3.6%) PACU and scrub nurses introduced themselves, with PACU staff requesting an anaesthetist’s name in one instance.

Patient identifiers were inconsistently reported – name in 13 out of 55 (23.6%), age in 17 out of 55 (30.9%), and weight in 8 out of 55 (14.5%). The presence or absence of allergies was not mentioned for any patients, and relevant medical history was communicated in 24 out of 55 (43.6%) cases.

Table 1 presents the reporting rates for procedural details from the PAHC checklist. The procedure performed was the most frequently communicated item (> 50% of cases), whereas vascular access, airway difficulties, and fluid management were seldom reported. For medications (Table 2), analgesic agents were commonly handed over, while use of neuromuscular blocking agents and their pharmacological reversal were the least reported items.

Postoperative concerns were flagged for 22 patients out of 55 (40%) patients, and further instructions were given for 14 patients out of 55 (25.5%) patients. One patient was taken to the PACU with a nasopharyngeal airway in situ, with no further instructions provided. The caregiver’s location was found in only two out of 55 (3.6%). Some items (e.g. allergies, antibiotics, developmental delays) were not relevant for all patients, yet the investigators emphasised the importance of reporting salient negatives to ensure clarity and mitigate assumptions.

Figure 2 depicts the PAHC score distribution. Most handovers scored between 0 and 5 out of 26, with a maximum score of 17 out of 26 (65.4%) and an average of 5.54 out of 26 (21.3%). The data were right-skewed, with a median score of 5 and an interquartile range of 3–8.

FIGURE 2: Histogram representing the distribution of the paediatric anaesthesia handover checklist score.

Discussion

This study demonstrates that postoperative handovers at RCWMCH are often incomplete, unstructured and lack critical information. This is congruent with findings from similar studies globally.^10,11 Most handovers were undertaken by senior anaesthetic staff, consistent with the consultant-led service provided at the RCWMCH. While experienced providers may deliver concise handovers, their routine involvement can lead to assumptions about what information has been communicated, potentially omitting key details.¹³

Patient safety should be the priority during handovers, with information transfer initiated only after monitors are applied and critical tasks completed. Non-essential conversation should be avoided, similar to the ‘sterile cockpit’ rule in aviation, where the crew focuses solely on essential tasks during critical flight stages.¹³ Most anaesthetists in our study adhered to this principle.

The average duration of the observed handovers was less than a minute. It varied depending on several factors such as the number of interruptions, patient stability, environmental distractions and the need for intervention. Nagpal et al.¹⁴ found that using a standardised checklist reduced handover time, while Salzwedel et al. showed no change and van der Walt et al. showed an increased duration post-checklist implementation.^15,16 A structured checklist may lengthen handovers, but can improve communication and patient safety by ensuring a more thorough exchange of information.

The World Health Organization Surgical Safety Checklist promotes team introductions to improve communication and cohesion, but these were rarely observed during handovers at the RCWMCH. While regular interactions between staff may explain this, the frequent rotation of trainees and nurses renders introductions essential. Clarifying roles and promoting a flattened hierarchy enhances communication and empowers the receiving team to voice concerns.^17,18

Key patient details – name, age (years), and weight – were consistently documented but rarely communicated during handovers, despite being essential for patient safety.⁹ Verifying the patient’s name prevents misidentification errors, while weight is crucial in paediatric anaesthesia for selecting equipment and dosing medications. In emergencies, quick access to this information can significantly improve response times and prevent delays in care.⁹

Perioperative respiratory adverse events are prevalent in the paediatric population, often because of conditions such as upper respiratory tract infections and asthma, which heighten airway sensitivity and may increase the risk of bronchospasm, laryngospasm, and atelectasis, potentially resulting in hypoxia. In our study, oxygen desaturation was observed during four handovers. The South African Paediatric Surgical Outcomes Study reported an incidence of severe anaesthetic-related critical incidents in 15.9% of cases, with respiratory events being the most common at 8.5%.¹⁹ In contrast, the large multicentre ‘Incidence of severe critical events in paediatric anaesthesia’ study conducted across 261 hospitals in Europe reported an overall incidence of severe perioperative events of 5.2%, with respiratory events accounting for 3.1% – substantially lower than the rates seen in our middle-income setting.²⁰ In addition, the Fourth National Audit Project of the Royal College of Anaesthetists highlighted that 38 out of 184 reported major airway complications resulted in death, underscoring the severity of such events.²¹ Jaulin et al.¹² demonstrated that communicating airway difficulties significantly reduces hypoxic events in adults, underlining the importance of such disclosure – especially in vulnerable paediatric patients.

These findings emphasise the critical need for structured handovers that thoroughly communicate medical histories and comorbidities. Such detailed communication enables recovery nurses to anticipate and prepare for potential complications, thereby enhancing patient safety.⁹

Multiple factors impair handover quality, including time constraints, multitasking, environmental distractions and a lack of structure.^6,13 Piekarski et al.¹¹ found that some items, like resolved intraoperative issues (e.g. difficult intravenous access or airway management), may be omitted because of their perceived irrelevance. Additional barriers include distractions from non-participating staff, prioritisation of documentation and the need for anaesthetists to manage immediate postoperative complications such as emergence delirium, hypoxia and pain.

While documentation supports continuity of care, it should not replace a structured verbal handover. Electronic health records (EHRs), increasingly used in high-income countries (HICs), can streamline postoperative handovers by displaying key patient data and providing real-time updates.²² Sun Yao-Kuang et al. demonstrated that an electronic handover system structured with a checklist improved communication, reduced handover duration and enhanced perceived information completeness. The high cost of EHRs presents a barrier in low- and middle-income countries.

As a practical interim solution, the use of visual prompts and targeted staff training – for both giving and receiving handovers – can help to standardise the process and improve information transfer without significant financial investment.

Medication handover focused primarily on scheduled agents such as opioids and sedatives. The sedative effects of midazolam, used routinely at the RCWMCH as a premedication, may extend into the postoperative period, especially when procedures are of short duration. It can also be associated with paradoxical agitation and restlessness, underscoring the importance of preparing the recovery staff for these potential complications.²³

Handovers should conclude with an explicit expression of concerns and relevant discharge instructions, including the caregiver’s location. This is particularly important in children with developmental delay or behavioural concerns. However, such details were often omitted.

An ideal handover is timely, structured and concise, avoiding information overload while ensuring critical points are covered. A systematic review identified key practices for safe handovers: preparation of the environment, completing urgent tasks before handover, applying the sterile cockpit rule, minimising interruptions and including all relevant staff.¹³

Communication should be structured, with one speaker at a time, guided by a checklist and supported by documentation when needed.

Conclusion

The quality of PACU handovers at RCWMCH requires improvement as a critical patient safety priority. Introducing a structured checklist may enhance communication and help to prevent adverse events.^24,25

Clear role definitions and integration of key patient information into EHRs have been shown to improve handover quality and patient outcomes. Leveraging EHRs presents a promising strategy to address current gaps and strengthen handover practices.

Limitations

This study has several limitations. Firstly, the observational nature of data collection may have introduced the Hawthorne effect, despite efforts to minimise it. Convenience sampling was used, which may limit the generalisability of findings to other institutions. Secondly, patient outcomes related to handover quality were not directly assessed, leaving an open question about the clinical impact of incomplete handovers. Retention of information by receiving staff was not assessed.

Future directions

Future research should focus on post-intervention analysis following the implementation of a structured handover checklist, such as PAHC, to assess its effectiveness in improving handover completeness and communication. Studies evaluating the impact of handover quality on postoperative patient outcomes, such as complication rates and length of stay, would provide further insight into the clinical relevance of structured handovers. Furthermore, qualitative research involving PACU nurses and anaesthetists could help identify barriers to effective handovers and inform targeted training initiatives.

Acknowledgements

The research presented in this article formed part of John M. Breedt’s postgraduate studies and was originally conducted as part of their master’s thesis titled ‘Quality of handover in the Post-Anaesthetic Care Unit at a quaternary children’s hospital in Cape Town, South Africa: A clinical audit’, submitted to the Faculty of Health Sciences, University of Cape Town in 2025, under the supervision of Anisa Z. Bhettay, Sarisha Govender and Johan van der Walt. The thesis was submitted in partial fulfilment of the requirements for the MMed degree. Portions of the thesis have been revised, updated and adapted for publication as a journal article. The thesis is currently unpublished and not publicly available.

This article is based on research originally presented as a poster at the South African Society of Anaestesiologists conference in Cape Town, held at the Cape Town International Convention Centre, from 17 to 21 September 2025. The content has since been expanded and revised for journal publication. This republication is done with permission from the conference organisers.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

CRediT authorship contribution

John M. Breedt: Conceptualisation, Data curation, Investigation, Methodology, Writing – original draft, Writing – review & editing. Anisa Z. Bhettay: Conceptualisation, Data curation, Investigation, Methodology, Project administration, Supervision, Writing – review & editing. Johan van der Walt: Conceptualisation, Methodology, Writing – review & editing. Sarisha Govender: Methodology, Project administration, Validation. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication and take responsibility for the integrity of its findings.

Funding information

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References

Appendix 1

Data collection instrument

Admission to post-anaesthesia care unit

Person handing over:

• Junior registrar (1st rotation)
• Post-1st rotation
• Senior registrar (2nd rotation)
• Consultant < 5 years’ experience
• Consultant > 5 years’ experience

PAHC checklist

Start time of handover:

‘Hands off’ handover? □ YES □ NO

Questions asked by receiving team: □ YES □ NO

If questions were asked, how many? ____

Interruptions during handover: □ YES □ NO

If YES, number of interruptions: ____

End time of handover:

Duration of handover: ____: ____

Post-handover period

Postoperative nausea and/or vomiting: □ YES □ NO

Excessive pain (NIPS, R-FLACC or VAS > 3): □ YES □ NO

Call to theatre team for additional information: □ YES □ NO

Call to theatre for assistance: □ YES □ NO

Definitions

1. ‘Hands off’ handover refers to a handover situation where no non-essential tasks are being performed while the handover is taking place.

2. Developmental delay: significant lag or delay in a child’s physical, cognitive, emotional or social development compared to typical developmental milestones.

3. Anaesthetic technique: General anaesthetic versus regional anaesthesia and sedation.

4. Anaesthetic complications: This would be any adverse event that occurs because of drug administration or anaesthetic management.

5. Perioperative complications: This includes haemorrhage, hypo- or hypertension, inadvertent nerve injury or organ perforation, pneumothorax, bronchospasm, laryngospasm and equipment malfunction.

6. Airway device used: Endotracheal tube, supraglottic airway or facemask.

7. Difficulty with airway management: more than one attempt at securing an airway.

8. Anticipatory guidance: A proactive approach involving anticipating potential problems before they arise and addressing them promptly.