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26: Transition from the Operating Room to the PACU
The transfer of care is common in the surgical environment as the patient moves from one area to another, such as from the operating room to the postoperative care unit. Perioperative and perianesthesia nurses are involved with this transfer of care, so clear communication among these professionals is critical as it directly affects the patient’s postoperative response and outcome. Due to complex procedures, minimally invasive techniques, patient comorbidities, and a variety of anesthetic agents, proper communication is imperative to report a comprehensive summary of the patient’s status along with vital information that can impact the patient during the recovery process. When standardized written or electronic and verbal formats are used, continuity of patient care and attention to the details of the surgical event and the patient’s responses to the interventions are vital to ensure a smooth transition of care. The perianesthesia nurse must be attentive and responsive in asking questions when more information is needed or there is confusion about the patient’s condition. The importance of an inclusive and standardized handoff procedure is a critical part of communication within nursing that should never be overlooked.
handoff process; hand-over process; perianesthesia nurse; perioperative nurse; standardized process; checklist; verbal and written documentation
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 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 Hand-over) Transfer of accurate information about a patient’s care (including current condition, treatment, and recent or anticipated changes) 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 may require anesthesia, sedation, or local anesthesia during the perianesthesia continuum: before (preanesthesia) and after (postanesthesia phase 1, postanesthesia phase 2, 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, physiological responses, behavioral responses, 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. 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 postanesthesia care unit.
A culture of safety should always form the foundation of patient care and should remain an essential health care priority. According to the Principles of Safe Perianesthesia Practice authored by the American Society of PeriAnesthesia Nurses (ASPAN), core values of a culture of safety are identified by “active leadership, psychological safety, accountability, teamwork and communication, negotiation and conflict management, transparency, reliability, improvement and measurement, and continuous learning.”3
When a patient’s care is safely transferred to another provider, these nine safety core values should be present. “Active leadership” promotes supportive efforts by leaders for enhanced nursing performance in an environment where staff can freely express any concerns, especially during handoff procedures. “Psychological safety” allows for staff members’ concerns to be accepted in a respectful manner. For example, a nurse should be able to offer suggestions to enhance a tool to document handoff communication without fearing consequences. “Accountability” reflects that staff members are accountable for their practices in a just culture that treats them fairly, even in adverse situations. The perianesthesia nurse is responsible for the safe transition of patient care among providers. “Teamwork and communication” foster structured communication and time management along with active evaluation and interdisciplinary risk management when needed. Standardized communication tools and verbalization enhance the process of patient care transfers so that vital information is not overlooked. “Negotiation and conflict management” focuses on collaborative methods to decipher conflicts and propose solutions so that quality patient care is augmented during handoff practices. “Transparency” identifies patient safety problems as learning prospects to help determine needed improvements in handoff procedures. “Reliability” promotes consistent and trustworthy outcomes during patient transfer of care while enhancing strengths and controlling weaknesses. “Improvement and measurement” pursue the implementation of best practices and continual improvement activities for patient handoff and transportation. “Continuous learning” promotes positive and ongoing education along with practice improvements when structured training has been provided regarding handoff principles. All of these safety core values can be found within successful and effective handoff practices.
The perianesthesia nurse has a responsibility to the patient to provide quality care and safety. The ASPAN Perianesthesia Principles for Ethical Practice state that the perianesthesia nurse “communicates pertinent information during handoff/handover as the patient transitions through the continuum of perianesthesia care.”3 The nurse also has the professional responsibility to collaborate “with the healthcare team as needed to ensure optimal care.”3
Whether nurses describe their practices or roles as perioperative or perianesthesia, the foundation of nursing practice remains the same: safe and 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 transfer 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. Proper patient handoffs have a profound effect on positive patient outcomes and safety.
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.”3 The Joint Commission estimates that “80% of serious medical errors involve miscommunication” between health care professionals when the care of patient is transferred to another provider.4 The process of handing off 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 process that is standardized and predictable to reduce the rate of errors, decrease the omission of critical information, eliminate redundancy and misunderstanding, enhance the addition of pertinent details, decrease patient length of stays, minimize costs related to communication errors, and increase the effectiveness of the handoff process.3 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 following:3
- • 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
- • Clinical history and assessment3 (e.g., level of consciousness, vital signs, dressings, drainage tubes, medications, IV fluids, 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.3
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 agents, sedatives, or opioid 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 Team Communication” in the Guidelines for Perioperative Practice that specifically addresses the safe practices for transfer of patient care information.5 These guidelines can be used when attempting to standardize patient transfer practices. Proper communication and documentation must be explored so that appropriate handoff practices are accepted and enforced. A transfer of patient information process should be developed, standardized, and based upon the best available and most current evidence. This guideline provides direction for perioperative nurses who are responsible for accurately transferring patient information to succeeding health care professionals, including perianesthesia nurses. The following recommendations are found in this guideline:5
- 2.1 “Establish and implement a standardized hand-over process for the transfer of patient information between individuals and teams.”5 There is not a current standardized process used today in all health care facilities. Each facility must develop their own standardized procedures to meet the needs of their patients and perioperative and perianesthesia teams. Reliability and accuracy of information is improved when standardization is enforced to prevent communication breakdowns. The most common causes of sentinel events in surgery are communication failure and incomplete or missing patient information that could compromise patient safety.4 By standardizing a hand-over process, optimal communication is fostered that leads to patient safety and efficiency.
- 2.2 “Establish an interdisciplinary team at the facility level to develop a standardized hand-over process.”5 Everyone on the multidisciplinary team (perioperative nurses, perianesthesia nurses, patient care unit nurses, anesthesia providers, surgeons, allied health care providers, support personnel, others) should be involved with creating a format and process upon which a standardized transfer policy can be created. Hand-over communication is a complex process that may occur between the operating room personnel and the PACU nurse, between the perioperative personnel and a patient care unit nurse, etc. A hand-over process should be created that fits the context in which the process takes place.5
- 2.3 The hand-over process should include a number of requirements.5 Team members should be assigned roles and responsibilities during the hand-over process to decrease ambiguity and confusion. Specific patient populations (age groups) and level of acuities (comorbidities, complexity of surgery, symptom severity) need to be considered and individualized in the hand-over process. The receiving team member needs to be notified when the patient is to be transferred. Any special equipment needs must be communicated so that availability can be ensured when the patient arrives. Hand-over communication should be limited to patient-specific information while allowing only one person to speak at a time.
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. A poor-quality hand-over process can lead to adverse patient safety events.5
- 2.4 “Use the read-back method when communicating patient information to other team members.”5 An informal study was conducted by Boyd et al., noting that read-back improves information transfer as compared to verbal acknowledgment without read-back or no verbal response at all.6
- 2.5 “Use standardized hand-over tools, checklists, or protocol.”5 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 should be minimal. A standardized documentation tool promotes timely and accurate patient information and continuity of care. Using a standardized tool, such as a checklist, improves the efficacy and quality of a hand-over of patient care while decreasing the chance of misinformation or forgotten information. By using a standardized tool, all required information is communicated, thus leading to patient safety and increased team satisfaction.5,7 Evidence-based tools, such as SBAR (situation, background, assessment, recommendation), can provide improvement in communication accuracy while maintaining focus on the patient during the transfer of care.
- 2.6 “Include all phases and locations of patient care in a standardized hand-over process design.”5 The transfer of pertinent patient information is mandatory in the perioperative environment. Incomplete transfer of information can have devastating effects on the patient’s care and outcome. The transfer of information begins when the physician’s office staff communicate with the surgery scheduling personnel during the preoperative phase. The hand-over process from the preoperative phase continues to the intraoperative phase when the patient leaves the holding area for the surgical suite. When surgery is complete, the postoperative phase begins as the patient is transferred to the recovery area, PACU, or directly to the intensive care unit.
Patients, families, and significant others should play an active role in the transfer of patient information processes when possible, such as in preoperative settings. Details of patient information may be revealed that could be critical to the outcome of the procedure which may be inadvertently overlooked by the patient, but provided by a family member. When families or support persons are kept informed about the patient’s plan of surgery, progress in surgery, and an impending patient transfer from surgery to PACU, anxiety is reduced and realistic expectations are promoted.
Education, training, and competency validation are vital to effective communication skills and processes during the hand-over of patient information. Because communication problems are often the cause of sentinel events, effective communication techniques and skills are mandatory.8 The AORN “Guideline for Team Communication” states that “initial and ongoing education and competency verification activities related to team communication and a patient safety culture”5 must be provided. Even though the health care organization is responsible for initial and ongoing education along with competency verification, the individual nurse is responsible for maintaining ongoing competency.5 Competency verification confirms that personnel understand the elements and processes of team communication and patient safety. The frequency of competency verification also must be determined. Patient safety and high-quality hand-overs should become a cultural priority in all perioperative environments.9
Participation in active training should include simulation scenarios to improve communication skills and teamwork for hand-overs. Also, video recordings and observational situations are effective, but not as powerful as active simulations for learning.5 Different hand-over tools should be evaluated considering the team’s preferences and ease of use.
Policies and procedures for standardized transfer of patient information processes should be created and then reviewed periodically, according to the health care facility’s requirements. The policy should be readily available in the practice setting for quick reference and should reflect the rules and recommendations from different regulatory and accreditation bodies. 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, especially in a court of law.
The AORN “Guideline for Team Communication” notes, “The health care organization’s quality management program should evaluate and monitor team communication and the culture of safety.”5 A quality management program should be implemented to evaluate and monitor the process for the transfer of patient information including both verbal and written communication. Components should include patient, process, and structural (e.g., format) outcome indicators. A fundamental precept of AORN is that the nurse has the professional responsibility to provide safe, high-quality nursing care including effective communication during the transfer of care process, which should be monitored regularly.
Quality review activities help to identify communication problems, process issues, and practices that may need improvement. Plans for corrective actions can then be formulated. Evaluation efforts of transfer activities should be ongoing to ensure patient safety and compliance with evidence-based practices. For consistency and high reliability, an organization must commit to regularly monitoring quality initiatives for sustained improvement. A patient safety culture along with comprehensive team communication must become top priorities within perioperative environments.
Patient handoffs today are extremely variable and sometimes lack purpose and structure. The Joint Commission’s National Patient Safety Goals over the years have included implementation of a standardized approach to enhance patient safety and handoff communication. The 2020 National Patient Safety Goals note that facilities need to improve staff communication, improve the safety of using medications, and prevent mistakes in surgery.9 A standardized approach to patient care and handoff must include the action to “record and pass along correct information about a patient’s medicines.”9 Accurately communicating the patient’s reconciled list of medications to the next provider increases safety and can reduce the risk of adverse drug events. The interface communication between the preoperative nurse and the perioperative nurse and between the perioperative nurse and the perianesthesia nurse is 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. The use of a checklist during handoff can increase the thoroughness of the verbal report while making sure all information is transferred accurately7 (see Evidence-Based Practice Box).
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