Transition from the operating room to the PACU

Published on 20/03/2015 by admin

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26 Transition from the operating room to the PACU

Kay Ball, BSN, MSA, PhD, RN, CNOR, FAAN

Definitions

Documentation of Handoff:  Includes information about the patient’s status, assessment notes, plan of care, nursing interventions, and a continuous evaluation of nursing care and patient responses.

Patient Handoff:  Transfer of information about the patient so that the next health care provider can take responsibility for the patient’s safety and care while ensuring that continuity of care is preserved.

Perianesthesia Care:  Includes care of a patient undergoing a surgical procedure, intervention, or treatment that requires anesthesia or sedation during the perianesthesia continuum: before (preanesthesia), after (postanesthesia phase 1, postanesthesia phase 2, extended care).

Perioperative Care:  Includes care of a patient before (preoperative), during (intraoperative), and after (postoperative) surgery.

Verbal Report:  Used for a “snapshot” or abbreviated synopsis of the patient status and care delivered.

Written Report:  Provides a basis for verbal reports and is usually in the form of standardized operative or anesthesia records.

The practice of nursing is directed toward the assessment, planning, implementation, and evaluation of the patient’s care through a continuum of patient care services. Often the nurse is involved with the patient’s transition from one level of care to another as the patient is transferred from one specialty area to another or from one unit to another. This transition of care is common in the surgical environment as perioperative nurses transfer care from the preoperative holding area to the intraoperative surgical suite, and perioperative nurses and anesthesia providers transfer the patient’s care to a perianesthesia nurse at the completion of an operative procedure or treatment. Clear communication among these professionals is critical and directly affects the patient’s postoperative response and outcome.

Modern care of the surgical patient is complex because advanced technology, minimally invasive techniques, new anesthetic agents, and increased patient comorbidities challenge perioperative nurses to communicate a comprehensive report when shifting the patient’s care to the perianesthesia nurse. This chapter describes the importance of communication and what should be communicated when a patient is transitioned from the operating room to the postanesthesia care unit (PACU).

Perioperative nursing

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 include3:

• 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 III: “Personnel should receive education, training, and competency validation on effective communication skills and processes for the transfer of patient information.” 1 Because communication problems are often the cause of sentinel events, effective communication techniques and skills are mandatory.

• Recommended practice IV: “The perioperative registered nurse should document the process for the transfer of patient information using a standardized documentation format, and the document should be recorded and retained in a manner consistent with the health care organization’s policies and procedures.” 1 A standardized documentation tool promotes timely and accurate patient information and continuity of care.

• 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:

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