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).
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:
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.
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:
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.
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.
“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
e. John Hopkins Medical