Post-Op Carers Checklist

Post op carers form part of the anaesthesia care team.12 The team consists of the anaesthetist who performed the anaesthetic, the anaesthetic assistant (ODP) and the recovery room nurses or other appropriately trained persons working in the recovery area. The anaesthetist can delegate the immediate care of a patient to an appropriately trained individual3 in one or other of these specially designated and equipped areas of the hospital.

Postoperative wards may be a High dependency unit (HDU), an intensive care units (ITU) or Post anaesthesia care units (PACU or Recovery). The destination of postoperative patients depends on their requirements for physiological support (e.g. lung ventilation or continual requirement for drugs to support the heart, preoperative physical status, extremes of age).

The most common destination for patients following surgery is the Recovery ward or Post anaesthesia care unit (PACU), whatever the type of anaesthetic (e.g. general or epidural). The AAGBI publishes a set of standards to be met by areas designated as Recovery facilities.4 Other organisations in different countries do the same.5

After surgery the anaesthetist and their assistant usually transfer of the patient from the operating theatre to the recovery ward. The anaesthetist formally hands over the patient to the recovery ward nurse with a brief report of the surgical procedure, anaesthetic used including narcotics used, relevant medical history and specific instructions for the patient’s management.

All patients are cared for on a one to one basis until they can maintain their own airways, they have a stable cardiovascular system and are able to communicate. Removal of an endotracheal tube is the responsibility of the anaesthetist and should not be delegated. There should be a means of issuing an emergency call for immediate assistance from other members of staff and the anaesthetist.

All members of the recovery team are required to be trained to nationally agreed standards.6, 7

The same standards of equipment and training are required irrespective of the location of the recovery area – x-ray, dental clinic, main theatres, psychiatric units or community hospital.

Clinical observation should be supplemented by a minimum of pulse oximetry and non-invasive blood pressure monitoring. An ECG, nerve stimulator, thermometer and capnograph (for measuring exhaled carbon dioxide) should be immediately available.

All drugs, equipment, fluids and algorithms required for resuscitation and management of anaesthetic and surgical complications should be immediately available.8

Trained personnel in recovery areas are expected to have core competencies and be able to deal with any one of the known complications that may occur in recovery wards.9 The primary objectives of clinical management in recovery wards are:

Holding the jaw to maintain a clear passage of air to and from the lungs, clearing secretions (suctioning) and ensuring adequate oxygenation with or without oxygen supplements.

All staff should be competent in all aspects of basic life support. In addition, at least one member of staff should be a certified ALS (Advanced Life Support) provider and in units receiving children the appropriate paediatric equivalent. Each recovery area must have appropriate resuscitation facilities including an electrical defibrillator.

References

Discharge from the recovery room

All hospitals and clinics must have appropriate criteria that patients must conform to before they can be released from the recovery area to a general ward where there is normally a reduced staff-to-patient ratio.

The following criteria for discharging a patient from recovery wards, published by the AAGBI, are similar to standards set by other professional bodies in other countries. In the UK these criteria must be fulfilled prior to discharge from PACU:

  • The patient is fully conscious without excessive stimulation, able to maintain a clear airway and exhibits protective airway reflexes.
  • Respiration and oxygenation are satisfactory.
  • The cardiovascular system is stable with no unexplained cardiac irregularity or persistent bleeding. The specific values of pulse and blood pressure should approximate to normal pre-operative values or be at an acceptable level commensurate with the planned postoperative care. Peripheral perfusion should be adequate.
  • Pain and emesis should be controlled and suitable analgesic and anti-emetic regimens prescribed.
  • Temperature should be within acceptable limits. Patients should not be returned to the ward if significant hypothermia is present.
  • Oxygen and intravenous therapy, if appropriate, should be prescribed.

Staffing levels and the law

Staffing levels in PACU areas require that two trained staff should be present during phase 1 of any patient’s recovery from anaesthesia. Phase 1 implies a patient is dependant on others to maintain an adequate airway. In California safe staffing levels are not contentious as law set them in 2004.1 At least 13 other States have introduced legislation that would mandate nurse staff to patient ratios.2 Assembly Bill 394 3 directs the California Department of Health Services (DHS) to establish “minimum, specific, and numerical licensed nurse-to-patient ratios by license nurse classification and by hospital unit” for inpatient units in acute care hospitals. Similar initiatives are underway in the UK.4

Where staffing levels fall short of this standard, even temporarily, and the shortage of staff has resulted in harm to the patient, supervisory staff and hospital administrators have been found negligent. In Laidlaw v. Lions Gate Hospital5 a supervisor had allowed a nurse to have a coffee break during which three patients arrived in PACU. Laidlaw, who had had an uneventful cholecystectomy, suffered brain damage from unobserved hypoxia. The Canadian court found the hospital and the supervisor to have been negligent. The absent nurse would have been found equally liable had she been cited.

In Krujelis v. Esdale 6 hypoxic brain damage also occurred in a ten-year-old boy who had a hypoxia induced cardiac arrest. Three of 5 assigned nurses were taking a coffee break during the incident. He died after a 4-year coma.

In a New York case, Horton v. Niagara Falls Memorial Medical Centre 7 the patient was found outside a window on a balcony. The family were requested to send a member to look after the patient to prevent this happening again. It took the family 15 minutes to arrive by which time the patient had again exited the window and fallen, sustaining severe injuries. The hospital was found liable for failing to move the patient to a secure room, restraining the patient or deploying a member to observe the patient during that 15-minute period.

References

Handing over to ward staff

Provided the discharge criteria have been met then the patient may be discharged to the ward, accompanied by a trained member of staff. Details of the procedure undertaken, the anaesthetic record and the postoperative instructions from the surgeon and the anaesthetist should accompany the transfer. A formal verbal handover is required. This should include details of patient controlled analgesia (PCA), intravenous infusions and syringe driver settings.

Information for patients and relatives should be made available prior to surgery. Many hospitals make these pamphlets available but in their absence most professional organisation can provide this information.

Sample information sources and documentation:

Royal College of Anaesthetists UK
http://www.rcoa.ac.uk/patients-and-relatives
http://www.rcoa.ac.uk/patientinfo

c. Relatives and friends. Anaesthesia explained at http://www.aagbi.org/sites/default/files/Anaesthesia%20explained.pdf accessed 4 August 14.

“This booklet is designed to be read in clinics, wards, waiting rooms and surgeries. It explains what anaesthesia is and how important it is to provide information and choice for patients. It was written by a partnership of patient representatives, patients and anaesthetists, and is one of a series that includes information about anaesthesia in specific situations. You can find more information about having an anaesthetic on the inside front cover of this booklet.”

d. University Hospital Southampton discharge advice
http://www.uhs.nhs.uk/Media/Controlleddocuments/Patientinformation/Childhealth/Epidural-discharge-service—patient-information.pdf

e. John Hopkins Medical
http://www.hopkinsmedicine.org/healthlibrary/conditions/surgical_care/types_of_anesthesia_and_your_anesthesiologist_85,P01391/