Percentage of cases with documentation of transfer of care handoff in PACU.

Lack of communication or miscommunication between anesthesia providers and perioperative nurses can lead to patient harm.^1,2 The Anesthesia Patient Safety Foundation identified ‘Patient-related communication issues, handoffs, and transitions of care’ as one of the top twelve Perioperative Safety Priorities for the specialty in 2018.⁵ The Joint Commission cited communication error as the number one cause of all anesthesia related sentinel events reported between 2004-2015.  Because anesthesia providers routinely transfer patients from the operating room (OR) to the PACU, they are responsible for communicating important information regarding the patient’s history, intraoperative course, and plans for pain management during the recovery period. Literature suggests that the handover process is more effective in relaying this important information when supported by the use of a standardized checklist. ^3-4

PACU Start to 15 minutes after Anesthesia End.

All patients requiring anesthesia care and directly transferred from the anesthetizing location to PACU.

• ASA 5 & 6 including Organ Procurement (CPT: 01990)
• Patients not transferred directly to the PACU (determined by Postoperative Destination value codes: 0, 2, 3)
• Procedures:
  • Burn debridement/grafting for 9% TBSA (CPT: 01953)
  • Daily Hospital Management of Epidural (CPT: 01996)
  • Diagnostic arteriography/venography (CPT: 01916)
  • Labor Epidurals (determined by Obstetric Anesthesia Type) including Obstetric non-operative procedures (CPT: 01958).
  • Open Cardiac procedures (determined by Procedure Type: Cardiac value code: 1)
  • Unlisted Anesthesia Procedures (CPT: 01999)

Documentation of postoperative transfer of care in the electronic anesthesia record including the key handoff elements used.

The percentage of handoffs will be calculated as number of handoffs documented as “yes” in the electronic anesthesia record where the denominator equals the number of direct transfer to PACU events.

Note: Patients identified as transferred to ICU, another postoperative destination (floor, MRI, CT), or as an intraoperative mortality will be excluded from the measure. All other cases will be assumed to be transferred to PACU and therefore included.  

The key handoff elements that must be included in the transfer of care protocol or checklist include:

1. Identification of patient
2. Identification of responsible practitioner (PACU nurse or advanced practitioner)
3. Discussion of pertinent medical history
4. Discussion of surgical/procedure course (procedure, reason for surgery, procedure performed)
5. Intraoperative anesthetic management and issue/concerns
6. Expectations/Plans for the early post-procedure period
7. Opportunity for questions and acknowledgement of understanding of report form the receiving PACU team

Identification of patient- In the instance the identity of the patient is unable to be confirmed, identification provided by the clinical faculty would suffice toward meeting performance of the measure.

*This measure will include valid MPOG cases defined by the Is Valid Case phenotype.

Not applicable

Provider(s) signed in at Anesthesia End.

1. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401-407.
2. Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesthesia and analgesia. 2012;115(1):102-115.
3. Weinger MB, Slagle JM, Kuntz AH, et al. A Multimodal Intervention Improves Postanesthesia Care Unit Handovers. Anesthesia and analgesia. 2015;121(4):957-971.
4. Petrovic MA, Martinez EA, Aboumatar H. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Jt Comm J Qual Patient Saf. 2012;38(3):135-142.
5. Lane-Fall M. APSF highlights 12 perioperative patient safety priorities. APSF Newsletter. 2018; 33(2):33-68.