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Transition From the Operating Room to the PACU
Definitions
Perioperative Nursing
Perianesthesia Nursing
Communication Between Perioperative and Perianesthesia Nurses
AORN Recommended Practices for Transfer of Patient Care Information
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Transition From the Operating Room to the PACU
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Kay A. Ball, BSN, MSA, PhD, RN, CNOR, FAAN
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 or perianesthesia 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 one area to another within the surgical department, especially from the operating room (OR) to the postanesthesia care unit (PACU).
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 (or Handover) Transfer of accurate information about a patient’s care (including current condition, treatment, and recent or anticipated changes) so 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 may requires anesthesia, sedation, or local anesthesia during the perianesthesia continuum: before (preanesthesia) and after (postanesthesia Phase I, postanesthesia Phase II, extended care).
Perioperative Care Includes care of a patient before (preoperative), during (intraoperative), and after (postoperative) surgery or intervention.
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 (may be electronic).
According to an Association of periOperative Registered Nurses (AORN) position statement, the goal of perioperative nursing practice is “to assist patients to achieve a level of wellness equal to or improved from the preoperative level, and to support the patients’ family members and significant others during the perioperative period.”1 At the core of the Perioperative Patient Focused Model is the patient surrounded by the four domains of “patient safety, physiologic responses, behavioral responses of the patient and support person(s), and the health system in which the perioperative care is delivered.”2 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, interventional radiology 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. Knowledge, judgment, critical thinking, competency, and skills based on scientific principles and guidelines 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.2 This care requires the communication of pertinent and accurate patient information by the perioperative nurse and anesthesia provider during handoffs when the patient is transported to the PACU and the care is transferred to the perianesthesia nurse in the PACU.
According to the American Society of PeriAnesthesia Nurses (ASPAN) position statement on perianesthesia safety, characteristics of the culture of safety are identified by activities representing communication, advocacy, competency, efficiency, timeliness, and teamwork.3 These characteristics are also described in ASPAN’s Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, Standard II: Principles of Safe Perianesthesia Practice.4 When a patient’s care is safely transferred to another provider, these six characteristics should be present. Appropriate communication requires “ensuring a complete and systematic approach to handoff processes and transfer of care and developing and using effective listening skills.”3 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 handoff process. Competency involves clinical judgment and critical thinking as the care of the surgical patient is postoperatively transferred to the perianesthesia nurse. Patient handoffs must be timely so efficiency of care is encouraged. Finally, teamwork is vital so the promise of safety can be guaranteed to the recovering patient.
According to ASPAN, 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.”4 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.”4
The perianesthesia nurse has a responsibility to the patient to provide quality care and safety. The ASPAN Perianesthesia Standards for Ethical Practice state that the perianesthesia nurse “communicates pertinent information as the patient progresses through the continuum of perianesthesia care.”4 The nurse also has the professional responsibility to collaborate “with appropriate healthcare providers as needed to ensure optimum care.”4
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, such as changes in temperature, respirations, tissue perfusion, discomfort, or pain, so the patient can be transferred without injury and without alteration in the patient’s condition.
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. AORN, ASPAN, the American Society of Anesthesiologists (ASA), and the American Association of Nurse Anesthetists (AANA) all have written recommendations and guidelines on proper and accepted handoff procedures.
According to the ASPAN Practice Recommendation 6, Safe Transfer of Care: Handoff and Transportation, the perianesthesia nurse is one of the providers “responsible for the safe transition of care of patients between care providers.”4 The Joint Commission notes that 80% of serious medical errors involve miscommunication between health care professionals when the care of patients is transferred or handed off.4 The process of transferring the responsibility of patient care between professionals involves communicating to the receiving provider that an impending transfer will occur, giving a complete report at the time of transfer, and allowing the receiver to ask questions about the patient being received.4
The handoff should have a structured standardized and predictable process to reduce the rate of errors, decrease the omission of critical information, and increase the effectiveness of the handoff process.4 When the patient is transported to the PACU, a report is communicated during the handoff process that should include but not be limited to the following4:
• Name and age of patient
• Pertinent patient history including allergies, precautions, surgeries, hospitalizations, medical history, and physical limitations
• Name of surgeon and procedure performed
• Type and tolerance of anesthesia/sedation
• Pertinent information regarding unusual events during the procedure
• Estimated blood loss and fluid replacement (amount and type of intravenous [IV] fluids infused)
• Clinical history and assessment (e.g., level of consciousness, vital signs, dressings, drainage tubes, medications, pain management, test results, sensory device use [glasses, hearing aids], social support [family, significant others], and postoperative orders)
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. The PACU nurse should have time to ask questions about the patient’s status before the transporting professionals leave the PACU area.2,4
Safely transferring a patient who has been given an opioid in surgery should be timed to avoid the peak effect of the opioid administered. Communication about all anesthesia or sedative/narcotic agents and medications must be comprehensive and individualized so the perianesthesia nurse can be alert to possible side effects, untoward complications, or patient tolerance issues.
AORN has published a guideline entitled “Guideline for transfer of patient care information”2 that specifically addresses the safe practices for transfer of patient care information. This guideline provides direction for perioperative nurses responsible for accurately transferring patient information to succeeding health care professionals including perianesthesia nurses. AORN has also created a handoff toolkit that provides a companion resource to the guidelines available at www.aorn.org/toolkits/patienthandoff. The following recommendations are found in this guideline2:
• Recommendation I: “A transfer of patient information process should be developed, standardized, and based upon the best available and most current evidence.”2 Reliability and accuracy of information are 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 (such as face-to-face interaction) and a standardized written form, data loss is minimal.5 Actual transfers should be made in an environment that has minimal interruptions and extraneous sounds. Interruptions can lead to providers failing to convey valuable information or forgetting to include specific information.
• Recommendation II: “Patients, families, and significant others should have an active role in transfer of patient information processes whenever possible.”2 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.
• Recommendation III: “Personnel should receive education, training, and competency validation on effective communication skills and processes for the transfer of patient information.”2 Because communication problems are often the cause of sentinel events, effective communication techniques and skills are mandatory.
• Recommendation 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.”2 A standardized documentation tool promotes timely and accurate patient information and continuity of care. Nurses at one facility reported that using a brightly colored standardized reporting form improved compliance with using the form to complement the verbal report during patient handovers.5
