2025 FY Safety in HR/PACU (Licensed-Ambulatory

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2025 Ambulatory

Safety in HR/PACU

01

Communication

Bad communication ends a lot of good things. Good communication ends a lot of bad things.

Describe effective communication between the OR circulator and the HR/PACU nurse

03

Describe effective communication between anesthesia provider and the HR/PACU nurse

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Utilize the Face-to-Face hand-off tool

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OBJECTIVES

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• Make patients feel valued. When we give another person our undivided attention, it shows we value the person.

• Help patients feel in control. Good communication can help people see they still have a voice concerning their own lives.

• Help patients feel at ease. Patients commonly feel anxious about their health and what their future holds. This can cause the patient to come across as rude or aggressive. Having good communication with health care workers can reduce their anxiety and build their confidence.

Effective communication can:

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Communication errors are the most common cause of medical errors and are essentially preventable

• patient safety

• quality of care

• patient outcomes

• patient satisfaction

• staff satisfaction

Poor communication can have a negative effect on:

Establish rapport with the patient and their family

Show respect

Be responsive to the issues they raise

Allow them to voice their concerns

• Introduce yourself

• Maintain eye contact - it shows you care

• Actively listen - affirm the speaker

• Watch your body guestures

• Show empathy & be friendly

• Answer their questions

• Allow them to voice their concerns

• Be responsive to the issues they raise

Communicate with your patient

This may not be the exact tool at your entity.

Utilizing your Face-to-Face handofftool for HR/PACU helps to ensure accurate communication.

Communicate with your colleagues

• Surgery on consent matches orders
• No abbreviations in consent
• Signed by patient and surgeon
• Date within the 60 day window

Consent is checked for:

Check Consent

#2

Check Armband

Armband check should be done with patient by anesthesia and bedside RN before giving handoff.

Patient, Bedside RN, and Anesthesia

#1

• Check armband for correct patient (with patient and anesthesia)
• Check consent for correct procedure, signed by both patient and MD, dated, and timed.
• H&P has been updated
• Site is marked (if applicable)
• Orders are completed
• Antibiotics handed off
• Checklist signed
• Chart verified

Handoff from Preop to OR

• Connect oxygen saturation monitor first to see how sats and HR is doing.
• Place BP cuff on and hit start on the monitor
• Connect EKG leads

Connect to monitor & obtain a set of VS

Connect to monitor

#2

Correct patient

Armband check should be done when patient rolls into your slot.

Check armband

#1

• Check armband for correct patient
• Connect to monitor and get a full set of VS with temperature before receiving handoff from anesthesia
• Surgeon gives report first if present
• Circulator performs handoff
• Anesthesia should give handoff last to ensure patient is stable before leaving bedside
• Checklist signed

Handoff from OR to PACU

02

Quality and Safety

“Carefulness costs you nothing. Carelessness may cost you your patient's life.”

Identify safetey measures in HR/PACU

02

Describe quality metrics for prevention of HACs (hospital aquired conditions)

01

Objectives

• Yellow non-skid socks in place
• Yellow armband
• Sign on door if in private room
• Education to patient and family if at bedside (and documented in EPIC)
• Belongings in reach
• Assist to the bathroom
• Bed in locked position and siderails up

ALL surgical patients are considered "high risk" for falls once they receive:

• Pre-op sedation
• Epidural, spinal, or peripheral nerve blocks
• General anesthesia
• Moderate sedation

ALL surgical patients are considered "high risk" for falls once they receive sedation!

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FALL Prevention:

Documentation of skin and wound status should occur:

• On admission - document all wounds, incision, & skin breakdown
• Check under dressings and document what you assess
• Assess bony prominences
• Take picture of all pressure injuries and upload into patient chart
• Veritas all pressure injuries found
• If patient in HR/PACU greater than 2 hours, ensure patient is turned every 2 hours while waiting to go to surgery or waiting on inpatient room
• Place sacral Mepilex dressing on EVERY patient in HR
• Use heel mepilex on high risk patients and keep heels floated while in HR/PACU

Assess Skin for Pressure Injury on Admission to HR and Admission to PACU

Pressure Injury Prevention

Ensure proper placement - do not place too high!

Mepilex sacral dressing on every patient unless provider specifically asks for one NOT to be placed

Pressure Injury Prevention:

• Use BADGE BUDDIES or K-CARDS (see next slide)
• Involve patient or guardian
• All parties involved should participate in the time out (RN, Anesthesia Attending, and Anesthesia Resident)
• Verify information
• Identify patient (name, DOB, and MRN)
• Ask patient to state their planned procedure and document in their own words
• SITE MARKING BY ANESTHESIA VERIFIED
• Confirm patient info given
• Confirm procedure

We MUST perform an Anesthesia Time Out for ALL invasive procedures such as anesthesia blocks

Time Out for Blocks:

Do not proceed below RED line until all checks above red line are met

Badge Buddy

K-Card

Documentation of Time Out can be found under the "Sedation" tab

Time Out for Blocks

• Confirm that surgical site is marked

• Confirm surgical site marking matches consent for procedure and the patient H&P

• Confirm the correct laterality was marked (may need to confirm with radiologic studies)

• Confirm that surgical site was marked by the provider who will be performing the procedure

Site marking must be completed by a provider who will be present in procedure

Surgical Site Marking:

03

Phases of Care

Perioperative nursing is the nursing care given before, during, and after surgery.

Identify the difference between phases of care in HR/PACU

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Objective

Focus on providing ongoing care for patients who are awaiting transition to an inpatient unit or who require extended observation post-op

PHASE III

Transition from a totally anesthetized state to one requiring less acute intervention

PHASE I

Phase III

Phase I

Focus on preparing the patient for self-care, care by family members, or others outside of the medical center.

PHASE II

Pre-operative patient preparation

PREOP

Phase II

Preop

Four Phases of Care:

Pre

PREOP

• Introduce yourself to the patient
• Identify patient by checking ID band with patient and chart
• Verify ID band and medical record match
• Verify surgery or procedure
• Verify NPO status
• Verify last dose of meds and update med list
• Identify allergies and update chart
• Identify when last voided
• Verify responsible adult who will be taking patient home
• Complete a thorough head to toe assessment

Preop Checklist Items:

Patient must have orders, a valid signed consent, and a full, updated H&P prior to transferring to OR

• Consent is good for 60 days

• Orders are good for 30 days

• H&P is good for 30 days - must be updated no more than 24 hours prior to procedure

Chart Review

• Preop meds
• Labs
• Type & Screen
• Foley catheter
• ERAS orders
• Beta Blockade
• Antibiotics

• IV solution
• Pregnancy testing
• SCDs or Heparin
• Pre-procedure site scrub
• Hair clipping protocol

Orders Review

Preop Checks:

Obtain a clean catch urine specimen - test takes 3 minutes to complete. Enter results into the computer and document results on preop checklist (care partners may perform test & enter results innto eStar afer completion of POCT training)

MUST HAVE AN ORDER FOR THE TEST!

Perform on female patients who have a uterus and who are:

• Post-menarche and pre-menopausal
• Between 12 and 50 years of age except for those who are menopausal
• menopause is defined by having not menstruated for 1 year
• Not otherwise know to be pregnant
• Have not undergone surgical sterilization (tubal ligation)
• Do not refuse pregnancy testing

Pregnancy Testing

Check for antibiotic orders:

• Prophylatic antibiotics are to be administerd within 30-60 minutes of surgical incision time.

• Most antibiotics are sent to the OR for intraoperative administration - place on IV pole with fluids - Do NOT activate or spike

• Some antibiotics are given in HR - always check your orders to see comments and/or administration directions.

***LOOK AT YOUR ORDERS CAREFULLY TO SEE IF IT IS TO BE HANDED OFF OR GIVEN IN PREOP***

Antibiotic Prophylaxis

Propranolol Timolol Nadolol

Non-selective Beta-Blockers

Carvedilol Labetalol

Alpha/Beta-Blockers

Report to the anesthesia provider if the patient has NOT taken their beta blocker prior to their procedure

When reviewing home meds:

Document in the "Home Medication" section

Inpatients - review MAR report for last doses of meds

Verify medication, date, & time of last dose with patient

Metoprolol Nebivolol Atenolol Bisoprolol

BETA BLOCKADE

Selective Beta-Blockers

Be sure to use vacuum attachment to prevent loose clippings from remaining on bed linens.

Hair removal should be completed before patient arrival in the OR.

• When prepping for cardiac procedures, remember to clean and clip from chin to toes. Pay close attention to the groin areas because when hey harvest grafts from the legs, this is a possible source of infection. All pubic hair (males or females) must be removed to decrease the chance of a surgical site infection

• In cases where the surgeon will perform a "mini thoracotomy" such as a mitral valve and tricuspid valve replacement or in an ASD repair, hair in the axilla region must be completely removed.

Site Prep- Hair Clipping

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2% CHG Cloth Skin Prep Instructions:

• Use first cloth to prepare the skin area indicated for a moist or dry site, making certain to keep the second cloth where it will not be contaminated. Use second cloth to prepare larger areas.

• Dry surgical sites (such as abdomen or arm): use one cloth to cleanse each 161 cm2 area (approx. 5X5 inches) of skin to be prepared. Vigorously scrub skin back and forth for 3 minutes, completely wetting treatment area, then discard. Allow area to dry for one(1) minute. Do not rinse.

• Moist surgical sites (such as inguinal fold): use one cloth to cleanse each 65 cm area (2X5 inches) of skin to be prepared. Vigorously scrub skin back and forth for 3 minutes completely wetting treatment area, then discard. Allow to air dry for one(1) minute. Do not rinse.

Site Prep - Site Scrub

PHASE I

Patients who have not had general anesthesia or deep sedation may bypass Phase I at the disceretion of Anesthesia

GOAL: regain physiological hemostasisCRITERIA: patients enter Phase I upon arrival to PACU after receiving general anesthesia or deep sedation VITAL SIGNS: documented at least every 15 minutesPHASE I PROGRESSION CRITERIA: Modified Aldrete Score (8-10 or baseline) RASS score (0 to -1) CAM-ICU score (negative) Vital Signs (preop baseline or better) Pain/Nausea levels (controlled) Surgical Site (stable with no signs of bleeding)

LENGTH OF TIME DOES NOT DETERMINE PROGRESSION

Phase I

II

PHASE II

Discharge Criteria:

Document VS, pain & nausea upon progression and every 30 minutes until discharge unless more frequent assessment is indicated. Complete physical re-assessment, I&Os at time of progression and a minimum of every 4 hours until discharge. Document teaching, activity/ambulation, advancing PO intake, and voiding. Document mode of transportation and responsible adult present to take over care of the patient upon discharge. RESPONSIBLE ADULT MUST BE OVER 18 YEARS & PRESENT TO ASSUME CARE AND DRIVE HOME

Phase II

• Stable VS - at baseline or better
• Pain & N/V controlled
• Stable dressing/incision site
• Tolerating PO intake
• Able to void without difficulty as ordered
• Return to baseline level of mobility
• Received all post-op teaching/discharge instructions & prescriptions

SHOULD BE GIVEN TO PATIENT & RESPONSIBLE ADULT

• Information about expected behavior following sedation
• Limitations of activities/precautions
• Instructions for eating
• Warning signs of complications
• Special instructions in case of emergency
• Specific procedure-related discharge instructions

• A 24-hour telephone contact number for post procedure concerns
• Information about resuming pateint's home medications

Discharge Instructions:

04

Enhanced Recovery After Surgery (ERAS)

It's when we start working together that the real healing takes place. ~David Hume

Understand all the components in Enhanced RecoveryAfter Surgery (ERAS)

01

Objective

Goal is to provide a full surgical pathway that focuses on minimizing complications, avoiding opioids, early ambulation, eating sooner, and tracking data and outcomes.

Enhanced Recovery After Surgery (ERAS)

Post-op

Intra-op

Pre-op

Audits

Review LOS, complications, readmissions

Audit Compliance

Early, routine mobilization

Early removal of catheters

Early oral nutrition

Short incisions, NO drains

No nasogastric tubes

Structured PONV prophylaxis

Non-opiate PO, GABA/NSAID/APAP

Avoid Na+/IVF overload (no NS)

Warm air body heating

Avoid IV opioids (consider lido/ket)

Short-acting anesthetic agents

Epidural/regional anesthesia

No/minimal sedating premeds

CHO/Fluid loading up to 2 hours preop

Preadmission Counseling

No BowelPreparation

ERAS Components

Patients are given education and tools to help them avoid nicotine prior to surgery

Nicotine

Patients will have an extensive workup with VPEC or HiRiSE to ensure all pre-existing health issues are addressed

VPEC or HiRiSE

Patients are started on protein and carbohydrate loaded drinks to consume pre-op to promote healing and to keep glucose constant during OR

Diet

Patients are seen in clinic and given a booklet with education and specific instructions of pre-requisites before surgery

Clinic Education

Pre-Surgery & Pre-op

Look for the blue banner indicating an ERAS patient

• Release the pre-op orders for ERAS patients - may have orders for a nerve block or epidrual with Acute Pain Service (APS) or have medications sucah as Acetaminophen or Gabapentin ordered
• Ask Compliance questions - important to answer accurately in order to track their adherance to protocols

ERAS in Pre-op

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The ERAS Assessment is at the top of the Pre-op Navigator as a stand-alone navigator topic. It is will only appear for Enhanced Recovery After Surgery (ERAS) patients. It appears with a red header to call out its importance.

ERAS in Pre-op

As a reminder to staff, a Pre-op Verification will also appear for nursing to complete the ERAS assessment on identified ERAS patients.

ERAS in Pre-op

May not be all of these - service line specific

Multi-modal Pain Regimen:

Goals:

• Optomize Patient Comfort - multi-modal pain regimen that avoids opioids as a routine method of pain control (used sparingly). When used, focuses on PO opioids (rather than IV) for longer duration of action with less stimulation of muscle receptors

• Fastest Functional Recover - encourage drinking, eating, mobilizing, and sleeping

• Fewest Side Effects - prophylaxis for PONV with routine use of TIVA and antiemetics pre-op and intra-op

ERAS in PACU

• Regional anesthesia (nerve blocks) if not done prior to surgery

• Acetaminophen

• Gabapentin

• Ketorolac or NSAIDS (for some protocols)

• Muscle relaxants (for some protocols)

• Lidocaine infusion (for some protocols)

• Ketamine infusion (for some protocols)

• Epidural (for some protocols)

POD-0=OOB to chair & walking in room; POD-1=walking with assistance at least 4 times/day

Patient receives clear liquids as early as possible and advance as tolerated (per orders)

VTE Prophylaxis

Minimize foley duration

Protocol specific

Pneumonia avoidance - IS, Cough, Oral care, HOB raised

Minimize IVF adnd saline lock IV when patient tolerating oral intake

Determined by population and as directed by surgery order set

Early Ambulation

I-COUGH

Fluid management

Dietary Management

ERAS in PACU

The ERAS Assessment in the PACU Navigator is a stand-alone topic. It will only appear for Enhanced Recovery After Surgery (ERAS) patients and will have a red header to call out its importance.

ERAS in PACU

• Perioperative Services Policy - Phases of Care Progression and Discharge from the PACU

• Perioperative Services SOP - Patient Identification - Adult

• Anesthesia SOP: Anesthesia Team Time-Out Process for Regional Blocks

• Perioperative Services SOP: Required Preoperative Documentation

References: