CRNA S3 116 | PACU Handoff

A report from the Joint Commission reveals that 80% of serious medical errors are related to miscommunication during the transfer of care. There is a need to standardize a safe handoff process in the Post-Anesthesia Care Unit (PACU). This episode’s guest is helping our nursing tribe overcome this issue. Jenny Finnell sits down with Cathy Zuniga, the founder of PACU Nursing Minutes—your Perianesthesia nursing education resource! Cathy shares with us how she hopes to streamline the handoff process, providing us access to some of her tools and resources so we can implement them in our work and improve patient outcomes. Join this insightful conversation and get your hands on one of the most thorough PACU reports.


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PACU Anesthesia Handoff With Cathy Zuniga From PACU Nursing Minutes

In this episode, we have a cool topic, which is the PACU hand-off and all of the components that go into it. I want to welcome a special guest, Cathy Zuniga, welcome to the show.

Jenny, thank you for having me. It is a pleasure to be with you again.

Cathy found me through an email chain, but she runs a business called PACU Nursing Minutes. She is a passionate educator and mentor. She is here to inspire nurses to do this safe hand-off. I thought, “What better way than to talk about this here on the show since our readers are going to the school and are going to give plenty of PACU hand-offs?” Some of you may have a PACU background. She provides a wealth of information. Why don’t you go ahead and share a little bit about your background and PACU Nursing Minutes?

I founded PACU Nursing Minutes a few years ago. What I mainly do is help nurses prepare for the certification test for a post-anesthesia nurse or an ambulatory perianesthesia nurse for CAPA® and CPAN® certification. When I was practicing in the PACU, we would get patients out of the OR. We get the report. You are writing down the same information over and over again.

In the first PACU I worked in, we had a simple framed-out outline of what we wanted to have. I took that simple framework and added to it over the years after I left that hospital. I moved to a hospital that did more cardiothoracic procedures like TAVRs and things like that. I grew from that. When I started the business, I thought, “What could I do to help the next generation of nursing streamline their thinking so that they are not missing a thing when they get the report for that fresh patient?” Sometimes you have no time to prepare, they roll out of the OR, and they come into your bay. You don’t get to look at the EMR. You’ve got to be able to immediately start getting reports on that patient.

I made this at home. I would make copies of it at work and shove it in my work bag. Whenever I would get a fresh post-op, I would grab another sheet out of my bag. I made it double-sided so I could fit four patients all on one page, 2 on the front and 2 on the back. Sometimes I have a busy day and have 12 recoveries in my 12-hour shift. Sometimes it would be eight recoveries. You never knew how quickly they were going to recover. Sometimes you have two patients for the whole day. It depends on the situation if you are doing ICU holding.

This report sheet helps a new nurse and even an experienced PACU nurse not miss a thing. Some people might think it is a little overkill. I think it is right. I made it available for nurses on my website to download as a free PDF. They can take it and tailor it to their patient population. Maybe they work in a surgery center, and it is just ortho and they never see a neurotrauma patient. Maybe they work in a GI center. They don’t need all the details of it. Everyone is free to take it and tailor it.

I have been approached by one hospital that has had nothing, and they had some near misses. They want to roll out a safe hand-off process. They are going to go back and look at whether it has improved safety and prevented complications. That is how this safe hand-off download was born through PACU Nursing Minutes.

If you go to PACUNursingMinutes.com, there is the Safe Hand-Off download. Once you click on it, you will come to this page. I was tired of seeing nurses writing reports on paper towels. You know what I’m talking about because it happens everywhere. It is time to toss the paper towels and get standardized with a safe hand-off because 80% of serious medical errors are related to miscommunication in the transfer of care, and that comes from The Joint Commission. It is a national patient safety goal for improving communication between caregivers at hand-off.

If you were like me and you got tired of writing the same thing down, like the name, the surgeon, and the OR room, it helps you to quickly get the report and not be missing anything. It is a safety measure. There was a study done by Harvard. They looked over 5 years of 350,000 malpractice cases. Thirty percent of the claims were related to miscommunication. It costs about $1.7 billion in legal fees, and 32% of nursing cases involve one or more miscommunications.

Within the surgery, 26% had one or more communication errors. More than 1/4 of our surgeries have miscommunication at hand-off. That is huge. Forty-eight percent are happening in the ambulatory setting. The ambulatory setting is a fast-paced setting. We have a huge room for improvement in minimizing communication errors and improving our patient’s outcomes.

I have worked in large teaching hospitals and small community hospitals. Depending on where you are, there could be over 4,000 hand-offs a day going on in one institution. ASPAN recommends safe hand-off. They recommend using standardized tools. It is a practice recommendation for the perianesthesia association. For the ASA, it is a standard that all patients, upon arrival, are evaluated. A verbal report is provided to the PACU nurse who is going to be responsible for that patient. It needs to be provided by a member of the anesthesia team, not by the OR nurse or the circulator. It can’t be given.

In a new place I was working, I had one anesthesia provider say, “It is all in the EMR.” She walked away. I said, “No, you need to give me a verbal report.” We need to be able to ask questions. Those questions need to be answered to the nurse’s satisfaction for that to be a safe hand-off for that report. The Joint Commission recommends standardization tools either through forms, templates, checklists, protocols, or mnemonics to communicate and avoid only using electronic or paper format.

If people aren’t familiar with the Laidlaw versus Lions Gate, this was a sentinel event with a patient death. After this case, they said the judge declared the PACU as the most important room in the hospital because if certain things aren’t communicated, there is a risk for serious complications. It shouldn’t be taken lightly. It should be standardized and rolled out in a multidisciplinary process where all the teams are involved, the anesthesia teams, the nursing team, and the surgical team are involved. Everybody has their say in what they want to be communicated in that report.

The PACU is the most important room in the hospital because if certain things aren't communicated, there is a risk for serious complications. Click To Tweet

These are some other things from that Harvard miscommunication study, 23% of inadequate consent communication, 19% provider miscommunication, 13% of sympathetic response to patient complaints, 34% resulted in high severity injuries, and 14% resulted in deaths, wrong site surgery, medication errors, delay in care, and sentinel events. There is a lot of room for improvement in our practice. I have a video spreading awareness about this free download for Safe Hand-Off. You put your name and info here. You can get the download sent right to your inbox. These are all the references from which I referred.

This would be a great idea for your DNP project. For those of you reading, I would jot down this idea because this is an impactful area that we all need to be hyper-vigilant and aware of. Studying things like effective PACU hand-off would be a great thing to study and do your DNP project on. It would only help your institutions.

I believe you would get a lot of support from the hospitals where you are doing this Doctoral degree project because this is a big pain point and something they know is incredible as far as the impact it can make, whether that is good or bad. Thank you for sharing. That was great. What information should a PACU hand-off include? Let’s start from top to bottom.

Let’s go right to the report sheet because that is going to keep us focused. This is the download for the Safe Hand-Off Report. First is going to be the patient’s name, gender, allergies, code status, if there are any precautions that we need to be aware of, their age, and weight. That is standard demographic information. There is the name of the surgeon and the OR room because if you ever have to go back to the OR or you need to call back into that surgeon, you want to know what OR room you are going to be calling into.

It saves you time if you have complications and need to call back into the room to ask a question. There is what surgery they had room to list the surgery and order if you have your surgeon’s orders for phase 1 care and you have your anesthesia team’s orders for phase 1 care. The name of your anesthesiologist or your CRNA, their cell number, and the arrival time are important for billing, tracking, staffing, and regulatory because many PACUs charge per minute for phase 1 care. Some charge per five minutes, and some for fifteen. I have worked in a place where they charge every single minute for phase 1 care. Once we moved to phase 2 care, it was a different billing amount. They wanted it right down to the minute.

The PACU report saves you time if you have complications and you need to call back into the room to ask a question. Click To Tweet

You also do a time stamp on your EMR. What anesthesia? You can quickly circle if it was a GA, TIVA, or MAC. If they had a block where they did it, we could circle if it was an LMA or an ET tube. If they had OPA upon arrival, when you take it out, that has to be charted in the respiratory flow sheet on the EMR because that is when the airway is protected from being unprotected in case they aspirate, vomit, or something like that.

For those of you reading in case, you are like, “What is an OPA?” It is the Oral Pharyngeal Airway to clarify the readers.

Your LMA is your supraglottic airway and your ET tube. Your ASA score is your surgical risk score. The anesthesia team always comes out and says they are an ASA 2 or 3. It gives you an idea of their comorbidities, the risk factor, and if you have your orders. A lot of times, you will get a report from them, and they will say what they had used for induction. If it was 2 milligrams of Versed propofol, they got dosed with fentanyl. Later on, they start developing MH symptoms. If they had ketamine, that would be important to know. You are not going to go stir that patient up immediately.

Rocuronium, if they had that on board. What gas did they use? Placebo, ISO, or nitrous oxide, their PONV prophylaxis, Zofran, Reglan, and scopolamine patch. They are important to know because if they already had Zofran, Reglan, and a scop patch and they are still nauseated, you are not going to go back to your Zofran or Reglan. You are going to amend or do something different.

It helps you figure out if you have those problems in the PACU. If they got an antibiotic pre-op, that is important to know, especially if they had any implants. Multimodal analgesia, if they had gabapentin pre-op, Celebrex, Toradol, and Tylenol so you can know when you can give that second gram of Tylenol if they already have a gram. There are reversal agents, neo, glycopyrrolate, and sugammadex.

If they needed any hemodynamic support in the OR, that is important to know because it is going to tell me if they are going to be maybe a little bit more challenging and hemodynamically fragile. Maybe they have a poor EF already. They are septic on board of whatever. Maybe they had a gallbladder rupture. I had somebody with that post-COVID. I was like, “That is a gallbladder rupture.” They sat on it for so long before coming in.

CRNA 116 | PACU Handoff
PACU Handoff: It is important to know if a patient needs any hemodynamic support in the OR because it’s going to tell you if they’re going to be a little bit more challenging or a little bit more hemodynamically fragile.

All of these things can prepare you for hopefully a successful recovery with no complications. Another surgical thing is the incision dressing. Where is it? You could add LP sites here and Trocar sites. If they had local drains, how many drains? You can put your numbers 1, 2, 3, right and left. If they need to have a post-op chest X-ray or have their hardware imaged before they leave PACU, that is common with the total knees, hips, and shoulders.

This part I gather if I have time before a patient comes to me. When we have time, and we are not slammed, the OR calls and says, “We are closing. We will be out in 15 or 20 minutes.” I let my nurses know. As soon as I get that phone call from the OR room that they are closing and coming out, I assign the room, and I let my staff know. That gives them time for them to look up the past medical history, the past surgical history, and anything neuro, cardiac, and respiratory. All of these things are assessed pre-op. We always do a baseline skin assessment in pre-op. We can identify if there was skin breakdown in the OR.

We did what was their PONV risk score, and what was their STOP-Bang score. Are they positive for OSA? Do they have their home CPAP? In my OSA patient population, I will bring that. I will get their belongings. That is another standard thing we do once we know the patient’s coming. We get their belongings. We bring it to the bedside. If they have a CPAP, we set it up. We have the oxygen bleed in all ready to go. Once they wake up, we can put them on that and start reversing their atelectasis.

What is huge with COVID? Did they have a negative COVID? What are their recent coags and ACT for our patients who have had heparin interop? I’m an old-school nurse. I like to see my most recent labs. I have my room for H&H platelets, white count, electrolytes, and glucose. We always do glucose postop on most of our patients nowadays. It is an industry standard.

We notify the family once they come out of the OR and once they are leaving Phase 1 PACU and going to Phase 2. We always make sure we get our belongings. There is going to be a hand-off either to the Phase 2 RN. If you are the Phase 2 RN, you will be doing hand-off if they are going to go to inpatient, or you may be discharging them straight home. If they are going to go to the room as an inpatient, what room were they assigned? Is the room dirty? Do you have to wait? All of those things can be put down here.

If they have outpatient prescriptions, the nurses need to get them from the pharmacy before we discharge them home. The discharge time is when you finally wrap up your chart. That ends the billing cycle for these patients. There are interventions and vital signs. We need to do neuro checks more frequently. What is their pain management? This is where I keep track of my fentanyl and Dilaudid. I know I put it all in the EMR, but I also like to have it on a piece of paper so I know I gave that three minutes ago. I’m going to wait so I don’t give too much opioids and suppress their respiratory drive.

It is my way of having it as a quick reference, especially if I’m getting ready to go to lunch, take a break, or hand it off to a coworker. They should be logging into the EMR and looking at the last dosing. It is also here for a quick reference. This is also what you get from the anesthesia provider, your CRNAs, their eyes, and their nose. It is if they know how much LR they had, saline or blood, what their lines are if they are peripheral or an art line.

Some patients have central lines, but most of our patients have peripheral lines. There is their EBL, if they had an OG tube in, and if they had output from that. Their urine output, we are tracking that because we report anything under 30 an hour. Venous access and arterial access are important if you got multiple sheaths for your cardiothoracic patients or your IR patients. Also, hemostasis time for your arterial time and your venous time.

If you are doing a lot of sheets, I would even recommend having a different report sheet more focused because you could have four different sheets so that you don’t run into problems with that and making sure you are checking your neurovascular checks on those grind sites. This is for patient number two, and you can print it on both sides. You can do four patients on one. Make sure you shred this. This is Scott’s HIPAA information. It always has to be shredded properly. This is my PACU brain.

I would love to go over some of my thoughts as far as giving that PACU report. You mentioned quite a few of them, but I also want to highlight some things for those going into anesthesia school and getting ready to start clinical about what you will see in clinical. I will say this is in-depth. If you were to fully fill this out before you gave PACU report, this would be the most thorough PACU report of all time.

I want to hit on some of the big points here. Allergies are huge, especially allergies that are real allergies, not just pollen or seeing many random things. It is true drug allergies, especially drugs that you anticipate them needing to give. If they are allergic to Zofran, these are things that you want to make sure that you are making them well aware of.

One thing I would love to stress is when you are communicating, and this even goes for in the OR when you are talking to the surgeon, the best way to understand they truly have had effective communication is by making eye contact. If you want to drive a point home, have them repeat it. That is always key. If you think they heard you, make sure they have repeated what you said. At the end of my report, I always ask them, “Are you happy?” That is their last chance to have me do anything else for them.

If I have a patient who is maybe a little bit hemodynamically unstable because they have been requiring neo, you know the last time you gave neo, don’t lie about it. This is a tactic I have seen with CRNAs. I have seen them shoot some neo into the bag and bring them over. That is not an okay practice. I know you will see it done. I’m speaking from my own experience and things that I have seen in clinical that I’m like, “That doesn’t feel right.” If it doesn’t feel right, it is not right. Don’t do it.

If they are soft, you need to tweak your anesthetic and stay with the patient until they are stable. Hang out. In PACU, do your charting, circle back around, double-check on the nurse, and make sure they are okay because they can’t easily push neo. The only thing they can do is give fluids and wait for some orders. You have the ability to stabilize a patient quickly. Your job, as post-anesthesia, is to make sure they are stable for that hand-off.

This is also why it is important for you guys in the operating room to start this process early on. Some of your patients will require a neo drip throughout the case. You better start weaning that neo off early on. If they are not able to wean off, something is not right. You got to check your lab and assess your depth of anesthesia, how much narcotic is on board, and what their pain level is.

Maybe they are overly narcotized and don’t have a lot of pain that you overdid it. That means your anesthetic has to be lightened up as much as possible. We don’t typically do it in PACU a lot, but it can be done given an IM shot of ephedrine if they truly need a longer-lasting effect of some drug to get them through. There are sleepy, drowsy anesthetic aspects of recovery.

If BMI is over 50, I tend to point that out. I also like to point out whether they were difficult airways or masks. You mentioned things like what type of anesthetic I also like to let them know, “They were a difficult airway and mask.” If they were to lose that airway, and it was difficult for us to secure the airway or handbag them, they are equally going to struggle. I also had PACU nurses want to rip that oral airway out as soon as possible because they wanted to leave the bedside. When they have an oral airway, they cannot leave the bedside. They are 101 at that point because it is considered an airway.

The problem is, would you rather rip an airway out and have to manually hold someone’s jaw open because now they are obstructing constantly and desatting, or would you rather leave it and let them wake up a little bit? When I anticipate these potential problems, I make sure I let them know, “They are difficult airways. They obstructed that oral airway. You should stay in until I take it out.”

Ideally, you want to try to take it out before you even go over to PACU, especially in a surgery center. You mentioned the quick turnover, “How do 45% of these issues occur in surgery centers?” That is one of the main reasons why I could not do a surgery center. The efficiency over safety to me was a huge deal. You were giving PACU report. You see them wheel your next patient back. You are like, “No, I haven’t even had time to say hi to my next patient.” You are taking them back to the OR. I would run into the hallway and try to do an airway assessment before they rolled into the room. It was not my cup of tea. There were some times you had to hang out and make sure your patient was stable.

Cathy did mention they could look it up in their medical records. However, I don’t go through a thorough medical history, but I do make sure I highlight the big things. What is their most recent EF? Do they have stents in their heart? What is their most recent EKG? Is it abnormal? Do they normally have a lot of PVCs? Are they occasionally slipping into bigeminy? It’s those things that you were like, “Is this new?” Make sure you are giving them a big picture overview that they are severe COPD, and they require a liter of oxygen at baseline, or they have OSA or CPAP. Their machine should be with their belongings.

For labs, it is the same thing. I don’t go through every single lab, but I will hit the ones I know are abnormal or ones that I know they should be keeping an eye on, like the glucose we checked inter-operatively or what it was in pre-op. They know that if it drops by 100 points, that is a big deal because maybe they were diabetic and still took some of their meds. That is why I checked intraoperatively. Maybe you gave them some potassium. That can affect your insulin. Maybe some of the things maybe you gave a bunch of blood products. That raises your potassium, and it can affect your insulin or your glucose.

All of these dynamic shifts back in the OR have implications when it comes to the labs. Let them know what the most recent crit was or the EBL and estimate where their hematocrit may be based on their EBL. If they are on a heparin drip, the most recent ACT, especially post-EP lab or cath lab where you are giving heparin, you want to make sure that when the last protamine was given and what their final ACT was. All are important things. This is one of these questions I used to get that I’m like, “I do see what is going on over the drapes,” but sometimes there are so many little tiny holes and incisions that I don’t always count. Are there 2 or 1 drains? I don’t know. I know there are drains. I don’t know how many.

Sometimes I don’t always pay as close attention as I should to the drains. These are things you can easily pick up the patient’s gown and look at. I have them ask me whether the surgeon uses local. Sometimes I’m not necessarily always staring over the drape every single second while they are closing. I didn’t see whether they used local, and they didn’t tell me if they used local. I don’t know if they use local.

These are things that you can ask even the OR nurse prior to leaving the bedside because they tend to have a better handle on that because they are the ones drawing up the local for the surgical team. Typically, a resident or a surgical resident of some kind comes with you to the bedside and gives those detailed reports on post-op imaging labs and things of that nature. Anesthesia orders are one thing, but for surgical orders, you wouldn’t know what they wanted for the patient unless you communicated that with the surgeon prior to ending the case.

My report is not complete until I have my anesthesia orders and my surgical orders for that phase 1 care. When you circle around on that end, and you are like, “Do you have any more questions?” I always make sure that I see the orders in and they are there for me to release them. If I don’t see them and I can’t release them, they are not there. I can’t give any care until I see them release them because I can’t get any meds activated on their MAR if they are not released.

CRNA 116 | PACU Handoff
PACU Handoff: Always make sure that you see the orders in and that they’re there for you to release them.

As soon as you are calling your anesthesia team or anesthesiologist to say, “We need post-op orders,” ninety percent of the time, they are good, but even the surgical team sometimes delays drugs on that. You have to have the OR nurse call the team. If it is anesthesia, that is your responsibility to make sure the orders get there. If it is the surgical team, you need to let the OR nurse know, or if you see the surgeon or the resident, let them know.

I don’t typically mention things like propofol or the type of gas I have given unless they ask. Propofol is standard. I will mention if we don’t give it because maybe they have an allergy of some kind or maybe their EF was low so we use others instead. I will mention things like that. I always tell them because it can make them groggy. Sometimes people lose days of their life because of Versed. You never know how sensitive someone is. They don’t even remember they even came. They will be like, “Did I have surgery?” They will ask you that question, and you are like, “Yes.”

It can send some people for a loop. For other people, it is like nothing happened. I tend to let them know when the last dose of Versed is or if I had to give it even an emergence because maybe I anticipated more of a wild emergence. It is the same thing with precedex. If I gave precedex towards the end, I would always let the hand-off nurse know that. The last dose of fentanyl is Dilaudid, morphine, and any opioids.

Ketamine can come with a lot of side effects, such as hallucinations. Versed can usually help with that. Ketamine is important because it is a great drug. It helps not decrease that respiratory drive. It takes away the pain. The patient starts saying they see ants on the wall or they are itching their skin until it bleeds. There could be something going on. They would be like, “What going on?” The ketamine would be the explanation there.

Succs is great with the MH to be triggered for that. Succs tends to be given to you guys, not airway emergencies but difficult airways or risk of aspiration. It also alerts the PACU nurse to say, “Was there a problem? Why did they get succs? Was there a risk of aspiration? Is it something I need to be aware of?” As PACU nurse, they could vomit on me. Is it an MH thing? Is there an airway issue that I need to know about? It is great that you would pass on something like succs. Also, Toradol and Tylenol.

It is also one of the number one causes of myalgia afterward. Their muscle aches. If they wake up and they are like, “I ache everywhere,” it could be from the succs.

There are some contradictory studies out there where a little bit of a priming dose of roc can combat that myalgia. I have heard that it can and doesn’t. In clinical, I haven’t since I don’t take care of them in the full-blown recovery. I haven’t seen a significant difference. I also haven’t had too many patients complain about the myalgia. It will be the younger, more muscular people who complain if it were to happen.

If you use a priming dose of roc, which is five milligrams before you give succs, you won’t get the fasciculations when those succs kick in. It supposedly decreases the risk of muscle fatigue afterward. Gabapentin and Celebrex are the same thing for post-op sleepiness which can play into that picture. There is Toradol tunnel for post-op medication. That is one of those drugs to be cognizant of in patients who are at high risk for bleeding or severe asthmatics. They need to know when they can give medications that also have these drugs in it, NSAIDs, and things like Tylenol.

I usually let them know I reverse them. One thing that I want to put about reverse is you can have four twitches and have 70% blockade. In most healthy people, 70% blockade of your muscle receptors is not going to cause any issues, which is incredible. In patients who are a little more compromised, who have some respiratory issues, or an elderly, it can cause a significant issue where they might be desatting and have to take deep breaths. It could be because of the residual paralytic that was not adequately reversed.

These are things that be cognizant of you guys as you’re practicing anesthesia. Don’t ever be afraid to give a little bit of reversal. I have had people say, “We don’t want to give it if you don’t have to. There are side effects.” If you match your neostigmine with Robinul, especially if you are giving one and one, it is enough if it has been four hours since you last gave it. If you give a little bit, it will cover anything that’s left over because you could still have some residual. I’m not somebody who holds back from giving it.

Neostigmine takes longer to take effect. Sugammadex is the quicker reversal. In your practice, I haven’t seen the need to give additional reversal after sugammadex. Have you needed to do that after that?

Yes, I have, but it usually happens quickly that you usually handle it back in the operating room, which is neostigmine. The problem with neostigmine is if you only have one twitch when you give it, and you give the full dose where there is always the maximum dose you can ever give, you could cause more weakness. That is why it is not the best drug, but it is what we have. It can cause a mix where you almost get a reversed blockade, but patients can be weak. Not only is it slow to kick in, but it can wear off. Technically if they had that full blockade when it was given, they become weak again. I don’t think it is common, but I’m sure it can happen.

Sugammadex, on the other hand, is quick. It is quick to fully reverse the rocuronium type of paralytic, which is the majority of what we use. It is not as effective in rocuronium. Rocuronium is the main drug that it reverses. With that being said, if they have no twitches, you have to go to that max dose of sugammadex to truly reverse it. It can be a big dose, milligram-wise.

I haven’t seen people need it in PACU again. In the OR, I have seen it only once. That was for a procedure in which the surgeon needed them to have zero out of zero twitches up until they were done. When they were done, it was like undoing the robot, which is done. I was like, “I don’t have time to have the roc wear off at all where that occurred.” This is good to let them know if they have a history of it. If they don’t, you still give them Zofran.

For me, Phenergan has always been the best rescue drug. Prevention is always key. Once you get active nausea, Zofran doesn’t do a whole lot. Phenergan always does, but I usually give a small dose because otherwise, it will knock you back out in combination, especially with drugs like Versed, fentanyl, and things like that. Scopolamine is a great drug. You should let patients know that they can leave it on for three days and not touch their eyes after they have it on their hands because it can dilate their pupils and give them blurry vision.

For the elderly with scopolamine, if they have any emergence of delirium, we take it off in the PACU because it can worsen the emergence of delirium with the scop patch. I didn’t talk about TXA there, but I got TXA next to the antibiotic. We usually give another dose of TXA after our total joints in the PACU before they go home.

You want to let them know when the last time they got their antibiotic or if they are due for the next dose of antibiotics. It is the same thing with the TXA when you last gave it. All surgeons are different on TXA. Most of them give it prior to incision and with closure and pass that on to the recovery room nurse. Input and output are always huge. You have to let them know. I don’t usually give normal saline. I don’t know who would give normal saline, but I’m sure there’s a use for it. I, 99% of the time, always use LR because too much normal saline can cause hypermetabolic acidosis.

After giving blood, you want to give normal saline because there are not many electrolytes that can interact with the blood, like calcium. I did an open heart for several years. We always used LR with blood. We never had any issues. It was standard. We still didn’t use saline. They were like, “That is like garbage. Don’t give it.”

It was uncommon, but there were some times when they would switch over from LR. I have it there as a placeholder. Usually, they come out with a full bag of LR or at least another 500 in there to know how many liters they had. If there is a renal failure patient, you will do saline instead of LR for them. It is very uncommon to see saline in the surgical population.

Renal failure is a population where we always use oral saline, but it is a 500 bag. We would be careful not to even give the whole thing. Those can be challenging cases because they come in dry. They had dialysis and their blood pressure. They don’t tolerate it. They are usually under MACs. Renal failure patients are a lot trickier and harder to manage, especially post-operatively. They have to schedule dialysis and things of that nature.

Those are all things that you would do in pre-op to plan for this type of case. Not just do they get blood, but what types of blood products, how much, and when, and any labs that correlate with the last ABG after they got the last unit of blood. Maybe you did a tag. The results of the last tag will be important lines, peripheral IVs, A-Lines, and other central lines if they have sheaths.

When they have sheaths coming from the EP lab and things of that nature, these are things that the OR nurse or the fellow tends to report on, but it is also your responsibility to make sure that the nurse is aware of that. Those are something they have to manage and keep a close eye on because there is a risk of bleeding. They can’t sit up. They have to lay flat for a certain period of time.

Make sure those things are all communicated, even though there should be someone else to help you do those types of hand-offs. At the end of the day, you have to do everything. You have to make sure everything has been addressed. You can’t say, “That is not my thing.” Most of the time, you are supported in that realm, but you get familiar with the hand-off because you will listen to it many times when they are going over the venous access. If something gets dropped or the ball gets dropped and it doesn’t happen, you can jump in and help the PACU nurse with that part of the report.

At one of the hospitals I worked at, when we would get the patients from the cath lab, they had a yellow report sheet. It wasn’t white. It was yellow so that it stood out. It would have the right groin, left groin, arterial-venous, the size of the sheath, the pulled time, the closure device, the hemostasis time, the ACT, and the last protamine dose. It had all of those things to make sure that you knew when how much drugs they had, the reversals for the protamine, and how they closed if it was a StartClose, a PerClose, or a manual pressure.

Those are things that always trick me. I’m like, “I don’t remember what closure device it was.”

If it is a manual pressure, it is a six-hour bedrest. If it is an arterial closure device, it is 2 to 3 hours, depending on the product. If it is a venous closure device, it is 1 to 2 hours, depending on the product. Don’t hold me. You need to know what your hospital’s using and your doc’s order for those times. Once it opens up, you are back to manual pressure. You are back to the six-hour bedrest, and you are holding pressure.

CRNA 116 | PACU Handoff
PACU Handoff: You need to know what your hospital is using and what your doctor’s order for those times.

Maybe they need another dose of protamine. You need to let the anesthesia and the team know or the cardiac provider surgeon. I have seen horrible pseudoaneurysms arterial occlusive bleeding. It can be bad. I worked in IR for years. We were good in IR, but once they left us, you didn’t know the knowledge level. Sometimes it can be a capillary bed bleed where it is superficial. It is not like the femoral artery. It could be the femoral artery, and you can have a retroperitoneal bleed from that if it is not addressed quickly.

There are hemostatic dressings like D-stat or some of the ones that are out on the market. If you get a bleeder, I like to keep those in the PACU, especially for that patient population that is coming from the cath lab. Sometimes, there are superficial capillary beds. I have even seen one hospital do local lido with epi injections around it to manage that superficial bleeding. It depends on what your facility does and what the protocol is for managing those bleeds if they re-bleed.

When they have to hold manual pressure, patients do not like it because it hurts. Make sure that you address it quickly, whether they need more protamine. Before we ever leave the cath lab, usually, it needs more protamine of some kind. If we are questioning it all, we give a little bit more and dry them up a little bit.

The other big thing is making sure the patient is aware after the anesthetic to be still, which can be hard when they are a little bit delirious and disoriented. They want to sit up. They want to move around and turn on their side. Try to reorient them as quickly as possible so they know the hold to still, not from the lights.

I’m a little Nurse Ratchet on that. I’m like, “No coughing, no laughing, no sneezing, no crossing your legs, and no wiggles.” I want to know when their last void was. Were they straight-cathed? The biggest thing for the nurses is if they have a full bladder. I have had a guy six foot with four sheaths that were pulled. I’m trying to keep him in stasis. He is trying to climb out of bed because he’s got to go pee. Make sure they get straight cath at the end of the case so that we don’t have to deal with that.

When I worked in IR, and we would have our strokes, we do arterial TPA to get the clots out like the MCA, those embolic strokes. We used a bunch of heparin to prevent clots from forming on all those sheaths or catheters. We would give a bunch of protamine at the end, and we would also straight cath them to make sure that we emptied the bladder so people weren’t trying to get up from bed.

As an anesthesia provider, you can play a role in this because you can be like, “I have to give them a liter of fluid. They are going to have to pee.” Sometimes those cases go for so long that even if you don’t give them a lot of fluid per hour, you end up giving them a lot of fluid overall because it is a long case. Those are good cases for straight cath. They wake up combative because they are in pain. A full bladder causes pain. You will see that a lot with elderly men, where they wake up combative and agitated. It is because they have to pee.

It can add to the emergence of delirium for postoperative urinary retention. Once that bladder gets large, the detrusor muscle and the bladder get overstretched. They can’t pee. They can’t recoil it. You have to straight cath them because of that retention. We have seen some big retainers. I don’t hesitate. I’m like, “Hold them down. We are cathing them.”

Let’s wrap this up with what are some common mistakes that nurses should avoid during PACU hand-off.

The biggest thing is don’t interrupt. Let everyone have their chance. To backpedal it, you need to have a system and a process in place. The first mistake is if there is no process in place. Get the surgical team, the anesthesia team, and the nursing team together and say, “This is what we are going to agree upon for the report.” Roll it out and trial it.

One of the hospitals ended up laminating the report process because everybody was getting frustrated with interruptions because you would have a nurse say, “What about this?” He would be like, “If you give me a moment, I will tell you all that.” They laminated it and put it above the bed. It was quiet, and no interruptions. That also means everybody is coming to help to get them settled.

The anesthesia provider and the PACU nurse are face-to-face, and the anesthesia provider says, “Are you ready for the report?” They say, “Yes.” Sometimes the PACU nurse wants to get them on the monitor, which is fair, and get those baseline vitals. Getting them connected, getting their oxygen on, and getting your baseline vitals. Once you got your EMR opened up, you can say, “We are ready for the report.” Let your anesthesia provider give you the report. Wait for them to finish, and they say, “Do you have any questions?”

That is when the PACU nurse can start asking questions. They can say, “Are you satisfied?” The PACU nurse can say, “Yes.” A nurse usually jumps in during that process once the anesthesia provider is completed. They will do the local and the dressing. I recommend that the PACU nurse looks at and assesses the dressing with the OR nurse while the anesthesiologist or the CRNA is still there, making sure we don’t have any bleeding, the dressing didn’t get pulled off on the transfer, or the drain didn’t get dislodged or any of those things. It could all be addressed right then and there. The OR nurse gives their report. The PACU nurse should be able to safely accept that report.

The OR nurse gives their report and then the PACU nurse should be able to safely accept that report. Click To Tweet

I also jump and put them on the monitor. Help with it. Don’t stand there and watch them struggle with that. Some PACU will have more than one nurse who comes over and tucks in a patient. They usually have extra hands. Not all places do. Sometimes it is one PACU nurse trying to talk to the patient. Help them to put them on the monitors. Get them on the EKG. Put the pulse ox in. You will need those vitals for your hand-off anyways for your own charting. Helping speed that process along helps.

We typically drop them off and get them hooked on the monitors. We make sure the O2s are okay and they are comfortable with warm blankets. Take care of the patient first. Always the patient first and the hand-off. I usually always say, “Are you ready for a report?” They want to pull open their medical record and make sure that everything is squared away.

If the patient is combative and having pain, you address that right then and there. You don’t start giving reports while the patient’s screaming and agony or rolling over the bed, ripping out their IVs. You always address the patient first. That is a great point to point out to communication. Luckily, I don’t think I have ever had many issues with that. Not usually from the PACU nurse. It is usually the resident that interrupts.

I feel like anesthesia usually gets to go first. I don’t care if the resident wants to go first, but I look at that resident and say, “Go ahead.” They are waiting. Usually, they are quick. They have to get back to the room to finish up the post-operative note. I say, “Yes, go ahead,” and the resident talks. Sometimes depending on the OR nurse, it is the same thing. I say, “Yes, go ahead.”

Anesthesia should always be the last one to leave the bedside. I know that might not feel good to you because you have the stuff to get back in the room and do, but you want to make sure that you are the last set of eyes that is on that patient. That way, you can circle back around and address any pain needs before you leave. You may have to still get orders settled. You have extra Dilaudid.

I always ask before I leave, “Are you good? Do you want any additional pain medication? Are you happy with the way they look?” You can give that extra pain medicine and help them out. Sometimes I will give 25 MICs up high or 25 MICs down low. We will have the IV dripping in. They know they have a little bit of pain medication in the line.

All of my PACU situations have been in nine teaching hospitals. I don’t have the med students or residents there when I was in a teaching hospital. Our surgeons will come out, go right over and start dictating while the report is happening with the PACU nurse and the anesthesia provider. Once they are done dictating, they will come over, check the dressing, and ask if we have any questions. If they have high blood pressure or it is maybe a neuro patient, specific things, I will ask them, “What are your parameters for certain things?”

They always give you a chance to ask a question before they start their next case. If the multilevel spinal fusions, they will want to look at that dressing one more time before they go back in and start the next case to make sure that there is no hematoma forming or anything like that. It does depend on where you work. In community hospitals, they are always right there dictating, and they got eyes on their patient while they are looking up. They are making sure that the patient’s breathing. They are checking their vitals because they got to put it in on their dictation note or post-surgical note.

For those of you reading, if you are taking a patient other than PACU and you are taking them to the ICU for hand-off, make sure you are always packing a travel kit. You want an extra airway, a blade, some propofol, and emergency drugs. You always want to make sure you are traveling with that in mind. That is one thing that if you get familiar with and comfortable traveling in the PACU and it is right down the hall, but now you have to haul a patient to the ICU, sometimes it is hard to get into that habit of taking those transport drugs.

Think about it when you are back in the ICU and you are transporting a patient. You always have emergency drugs and supplies. The same thing applies to anesthesia. We will wrap this up by being patient with the process. This can be overwhelming at first. You can feel like you are feeling through it. Never hesitate to ask the PACU nurse if you left anything out. They will tell you, and they understand.

There have also been times, not as many, that I do it, but I will give a drug right before I leave the OR, but my chart will already be closed. I will think I will chart it in PACU, but I forget. That does happen. They are like, “You said you gave this much but only as much as charted.” I’m like, “Thank you.” I will have to do it after the fact.

There are times when I forget to document I have already removed the oral airway because maybe they had it in and either impacted you or on the way over, I take it out, or right before I leave the room when they see it is still in on their documentation. Try to be thorough with your charting. The PACU nurses get to know you, and they can give you some forgiveness. It is key to try to be as thorough as you can to make sure you are tightening up your chart, making sure all your drugs are charted that you gave, and trying to do that prior to even leaving the operating room.

Try to do that as you are wrapping up the case, which can be hard if it is a rapid turnover case, but do the best you can, be open in your communication, and be patient with yourself as far as getting into a groove. Cathy, thank you very much. You were awesome and shared wonderful insight. How can our readers connect with you?

Thanks, Jenny, for having me. It was a pleasure. You brought in so much insight too. It is great to bring the two sides together. Thanks for the opportunity. It is going to be valuable for your CRNA students, new PACU nurses, and even experienced PACU nurses looking to streamline that safe hand-off communication. If people want to utilize this tool, they can go to PACUNursingMinutes.com. Halfway down the page is the free hand-off, and click on that. It will bring you to the page. Plug in your name and your email, and it will go right to your inbox.

It might be a little overkill, but I don’t think you can ever be too overkill when it comes to after-surgery because there is no simple surgery. There is no free lunch. Thanks again for the opportunity to share it with your teams. I look forward to seeing how people implement it. Hopefully, somebody will use it for their DNP project.

I hope our readers are taking notes on that. Thank you so very much. This was wonderful. We will have you on the show again.

You are welcome, Jenny. Thank you.

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