According to the Association of periOperative Registered Nurses (AORN), the goal of perioperative nursing practice is “to assist patients and their designated support person(s) with achieving a level of wellness equal to or greater than that which they had before their operative or other invasive procedures.”¹ At the core of the Perioperative Patient Focused Model is the patient surrounded by the four domains of “patient safety, physiological responses, behavioral responses of the patient and support person(s), and the health system in which the perioperative care is delivered.” ¹ Perioperative care is delivered by a nurse during the preoperative, intraoperative, and postoperative phases of the patient’s surgical experience in a variety of environments, including hospital surgical suites, outpatient centers, catheterization suites, endoscopy units, radiation departments, clinics, physician offices, and other sites. The model for competency for perioperative nurses is evidenced through perioperative assessment, diagnosis, outcome identification, planning, implementation, and evaluation. “Standards, knowledge, judgment, and skills based on scientific principles”¹ serve as the solid foundation for perioperative practice. The perioperative nurse, therefore, has the requisite skills and knowledge to use the nursing process to design, coordinate, and deliver care to patients to meet their specific needs when their protective reflexes or self-care abilities are potentially compromised because of an operative or invasive procedure.¹ The care of the surgical patient continues through the transportation to the PACU, where this care is transferred to the perianesthesia nurse.

Perianesthesia nursing

According to the American Society of PeriAnesthesia Nurses position statement on perianesthesia safety, characteristics of the culture of safety are identified by activities representing communication, advocacy, competency, efficiency, timeliness, and teamwork.² When a patient’s care is safely transferred to another provider, these six characteristics are also present. Appropriate communication requires “ensuring a complete and systematic approach to hand-off processes and transfer of care and developing and using effective listening skills.”² Advocacy mandates protecting the patient from injury and implementing best practices. This requires a complete understanding of the patient’s condition and status by actively participating in the hand-off process. Competency involves clinical judgment and critical thinking as the care of the surgical patient is transferred to the perianesthesia nurse postoperatively. Patient hand-offs must be timely so that efficiently of care is encouraged. Finally, teamwork is vital so that the promise of safety can be guaranteed to the recovering patient.

Evidence-Based Practice

A qualitative detailed observational study of 17 anesthesia providers and 15 nurses was conducted to determine how anesthesia providers hand over information to PACU nurses within a British health care system. The study also described the handover of professional responsibility for the patient. There were 45 handovers that were observed in an event-driven setting that is prone to distractions. The nurses and anesthesia providers had differing views as to the content and timing of the transfer of patient information. The actual transfer of responsibility depended on the patient’s condition and the professional relationship between the physician and nurse. The handover information included the patient’s intraoperative course and plans for management of the patient’s care. Conclusions noted that most handovers in the PACU are largely informal, often with professional and organizational tensions. The nurse usually determines when he or she will take the responsibility from the physician for the care of the recovering patient. Formal standardized handovers usually will work best when the informal elements (trust, balance of power) and cultural factors are identified.

Implications for practice

Although handovers from an anesthesia provider to a postanesthesia care nurse are often standardized and formal, the informal elements and cultural factors must not be overlooked. For example, a PACU nurse usually sets the boundaries of when the responsibility of the patient ’s care can actually be safely shifted from the physician to the nurse. If the nurse is unsure of the patient’s condition or believes that the anesthesia provider cannot safely leave the patient’s side, then the PACU nurse intervenes and freely voices these concerns.

Source: Smith AF, et al: Interpersonal handover and patient safety in anaesthesia: observational study of handovers in the recovery room, Br J Anaesth 101:332–337, 2008.

According to the American Society of PeriAnesthesia Nurses, the scope of perianesthesia nursing practice involves “age-specific assessment, diagnosis, intervention, and evaluation of individuals within the perianesthesia continuum. Those individuals have had or will have sedation/analgesia and/or anesthesia for surgical, diagnostic, or therapeutic procedures.” The practice “is systematic, integrative, and holistic and involves critical thinking, clinical decision making, and inquiry. The specialty of perianesthesia nursing encompasses the care of the patient and family/significant other along the perianesthesia continuum of care – Preanesthesia, Postanesthesia Phase I, Phase II, and Extended Care.”³

“Professional behaviors inherent in perianesthesia practice are the acquisition and application of a specialized body of knowledge and skills, accountability, and responsibility, communication, autonomy, and collaborative relationships with others.”³

The perianesthesia nurse has a responsibility to the patient to provide quality care and safety. The American Society of PeriAnesthesia Nurses (ASPAN) Perianesthesia Standards for Ethical Practice state that the perianesthesia nurse “communicates pertinent information as the patient progresses through the continuum of perianesthesia care.”³ The nurse also has the professional responsibility to collaborate “with appropriate healthcare providers as needed to ensure optimum care.” ³

According to the ASPAN Practice Recommendation 2, “components of initial, ongoing, and discharge assessment and management” provides recommendations for the different phases of perianesthesia patient care. For example, when the patient’s care is transferred from the perioperative nurse to the perianesthesia nurse in phase 1, the integration of the information about the patient should include ³:

• Relevant preoperative status

• Anesthesia or sedation technique and agents

• Length of time anesthesia or sedation was administered; time reversal agents given

• Pain and comfort management interventions and plan

• Medications administered

• Type of procedure

• Estimated fluid and blood loss and replacement

• Complications that occurred during anesthesia course; treatment initiated; response

• Emotional status on arrival to the operating or procedure room

The perioperative nurse or the anesthesia provider should remain in the PACU until the PACU nurse accepts the responsibility of the nursing care of the patient. Patient safety is compromised when a patient is transferred to the PACU and abandoned by the transporting surgical team members before the perianesthesia nurse is able to assume the responsibility for that patient’s care.

Communication between perioperative and perianesthesia nurses

Whether nurses describe their practices or roles as perioperative or perianesthesia, the basic foundation of nursing practice remains the same: high-quality care for the surgical patient. Therefore nurses who provide care during surgical procedures that involve sedation, analgesia, or anesthetics must work closely with nurses who provide care after the procedure to foster continuity, quality services, and desired patient outcomes.

Safe transportation of the surgical patient must be incorporated into the overall patient plan of care. The perioperative nurse must establish a safe environment for the transportation of the surgical patient with use of transportation safety devices, plans for special patient needs during transfer (e.g., oxygen needs), and active participation in the safe transportation of the patient. The patient’s individual needs are determined so that the patient can be transferred without injury and without alteration in the patient’s condition, such as changes in temperature, respirations, tissue perfusion, discomfort, or pain.

The transportation and transference of care of the surgical patient involves planning, collaboration, and communication between the perioperative and perianesthesia registered nurses. Communication between perioperative and perianesthesia nurses is essential for patient safety and appropriate and consistent nursing care. Both AORN and ASPAN have written recommendations on proper and accepted hand-off procedures.

AORN recommended practices for transfer of patient care information

AORN has published a recommended practice that specifically addresses the transfer of patient care information. This recommended practice provides guidance for perioperative nurses who are responsible for accurately transferring patient information to succeeding healthcare professionals, including perianesthesia nurses. AORN has also created a hand-off tool kit available to all AORN members that provides a companion resource to the recommended practices that are described as follows.¹

• Recommended practice I: “A transfer of patient information process should be developed, standardized, and based upon the best available and most current evidence.” ¹ Reliability and accuracy of information is improved when standardization is enforced to prevent communication breakdowns. Everyone on the multidisciplinary team (perioperative nurses, perianesthesia nurses, anesthesia providers, surgeons, and others) should be involved with creating a format and process upon which a standardized transfer policy can be created. Written and verbal formats are both included in a successful patient transfer. When nurses use both verbal (like face-to-face interaction) and a standardized written form, data loss is minimal.⁴ Actual transfers should be made in an environment that has minimal interruptions and extraneous sounds.

• Recommended practice II: “Patients, families, and significant others should have an active role in transfer of patient information processes whenever possible.” ¹ When families or support persons are kept informed about an impending patient transfer from surgery to PACU, anxiety is reduced and realistic expectations are promoted.

• Recommended practice V: “Policies and procedures for standardized transfer of patient information processes should be developed, reviewed periodically, readily available in the practice setting, and reflect the rules and recommendations from regulatory and accreditation bodies.” ¹ Policies and procedures guide practices within a health care facility, should emanate from evidence-based practices, and may often be used as the basis to validate competencies of practice.

• Recommended practice VI: “A quality management program should be implemented to evaluate and monitor the processes for the transfer of patient information. Components should include patient, process, and structural (e.g., format) outcome indicators. A fundamental precept of AORN is that it is the responsibility of professional perioperative registered nurses to provide safe, high-quality nursing care to patients undergoing operative and invasive procedures.” ¹ Quality review activities help to identify communication problems, practice issues, and practices that may need improvement. Evaluation efforts of transfer activities should be ongoing to ensure patient safety and compliance with evidence-based practices.

Hand-off communication

Patient hand-offs today are extremely variable and often lack purpose and structure.⁵ In the past, The Joint Commission’s National Patient Safety Goals included implementation of a standardized approach to hand-off communication. The 2011 National Patient Safety Goals note that communication errors can occur when patient care is transferred from one provider to another.⁶ A standardized approach to patient hand-off must include a reconciled list of medications and this communication must also be documented.⁶ Accurately communicating the patient’s reconciled list of medications to the next provider “reduces the risk of transition-related adverse drug events.”⁶ The interface between the preoperative nurse to the operating room (OR) nurse and the OR nurse to the PACU nurse are crucial to continuity of care and safety for the patient. Standardizing a process in which all information about patient care is communicated in a consistent manner assures that the information about the patient will be accurate and pertinent.

During a comprehensive literature search, approximately 400 articles were reviewed that identified seven primary functions for patient hand-offs. These include ⁷:

1. Information processing (transfer of patient data)

2. Highlighting deviations from stereotypical narratives (e.g., the patient is allergic to the preferred antibiotic that would be used to treat his or her condition)

3. Identification of erroneous assumptions and actions (e.g., a nurse questioning a surgeon or anesthesia provider about a specific patient order)

4. Accountability (e.g., transfer of responsibility and authority over the patient’s care)

5. Social interactions (in support of interdisciplinary team communication and actions)

6. Distributed cognition (promoting the ease of transfer of up-to-date information to all professionals involved in the patient’s care)

7. Cultural norms (negotiating and educating about hand-off procedures)

Hand-off information needs to be standardized and communicated in a logical and meaningful manner. Current literature notes that hand-off quality measures lack consensus regarding the primary purpose of the hand-off.⁷ Basic principles of hand-off practices include written and verbal communication along with the essentials of documentation.

Different standardized documentation formats have been developed that have gained popularity in the United States. These formats are easy to remember as the letters represent the name of the step within the process of handing off a patient from one provider to another. The goal of these standardized formats is to reduce communication breakdowns. Some of these formats include ¹:

• SBAR: situation, background, assessment, recommendation

• I PASS the BATON: introduction, patient, assessment, situation, safety concerns, (the) background, actions, timing, ownership

• SURPASS: surgical patient safety system

• SHARED: situation, history, assessment, request, evaluate, document

The SBAR is one of the most popular and accepted standardized documentation formats today. This format can be used for patient hand-offs during the perioperative experience as shown in Box 26-1.

BOX 26-1 Sample of SBAR Format Used for Perioperative Patient Transfers

Modified from Sandlin D: Improving patient safety by implementing a standardized and consistent approach to hand-off communication, J Perianesth Nurs 22:289–292, 2007.

Written and verbal communication

Researchers have documented that approximately 20% to 30% of the information relayed during a patient hand-off is not documented in the medical record.⁷ Written documentation provides a basis for verbal reports and is usually in the form of standardized operative or anesthesia records. AORN’s recommended practice for Documentation of Perioperative Nursing Care notes that the “patient’s record should reflect the perioperative patient’s plan of care, including assessment, diagnosis, outcome identification, planning, implementation, and evaluation.”¹ Documentation should include information about the patient’s status, assessment notes, plan of care, nursing interventions, and a continuous evaluation of nursing care and patient responses. The written patient operative record facilitates communication and provides continuity of care and also serves as a legal record of the care provided.

A verbal report is used for a snapshot or abbreviated synopsis of the patient status and care delivered. The perioperative nurse should give direct and concise information about the surgical patient in a consistent and organized manner. The perianesthesia nurse must listen to the report and ask questions when appropriate. Effective listening involves more effort than speaking, because concentration is vital for processing of this critical information. Feedback by the perianesthesia nurse is often needed for clarification so that information is not misinterpreted.

For an examination of the issues of communication and documentation between the perioperative nurse and the perianesthesia nurse, the basic questions of why, when, where, who, how, and what must be explored.

• Why? Verbal reports highlight written documentation on the patient record. A written report records the details of the patient care, whereas a verbal report is a quick description or overview used when the patient’s care is transferred to another nurse. This communication and documentation is vital so that continuity and safe patient care can be maintained.

• When? A formal written report begins with the admission of the patient for the surgical procedure and extends through discharge from the surgical arena. Written reports that document patient information before admission or after discharge may be added to the patient’s chart. A verbal report from the perioperative nurse to the perianesthesia nurse begins with the call to the PACU to announce the completion of the surgical procedure and the request to transfer the patient to the PACU. At this time, any special needs must be communicated (i.e., ventilator needed). The verbal report continues when the patient is actually admitted to the PACU.

• Where? Ideally the written patient record is kept with the patient during transfer from the operating room into the PACU. The verbal report is given when the patient’s care is transferred from the perioperative nurse to the perianesthesia nurse in the PACU. Sometimes with a recovering patient from the obstetric unit, the postanesthesia care can be delivered in an area outside the normal postanesthesia care unit. Wherever the postanesthesia care is given, the standards of care (including communication) are no different than those used for nonobstetric surgical patients.⁸

• Who? Written patient reports are completed by the perioperative nurse, anesthesia provider, and surgeon (or a designee). Usually the verbal report is given by the anesthesia provider and the perioperative registered nurse. In a few surgical environments, the perioperative nurse may phone the perianesthesia nurse to give a report while the anesthesia provider and an orderly (patient care assistant) transfer the patient to the PACU. Ideally the perioperative nurse and anesthesia provider should both accompany the patient to the PACU. Sometimes the surgeon or the surgical assistant may also participate in the patient transportation and verbal report.

• How? The written patient record is documented on a health care facility–approved standardized form. The verbal report is usually given in person from one professional to another, but verbal reports have also been given via telephone or computer, depending on the patient acuity and facility protocols.

• What? The reporting of specific and appropriate information about the patient’s surgical experience is critical. The perianesthesia nurse must receive the full details of the patient’s condition, interventions, and plan of care so that continuity and safety can be maintained.

Care of certain patients, such as the patient recovering from cesarean section, can pose unique challenges. Documentation and verbal reports should alert the perianesthesia nurse to watch for signs and symptoms of adverse anesthetic effects, pulmonary problems, hemorrhage, infection, and other specific potential complications.⁸ The care of a pregnant patient who is transferred from the operating room presents distinctive challenges because the status of the fetus must also be assessed, documented, and reported verbally.

Patient reporting when care is transferred from one provider to another should include but not be limited to: