Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized.
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
Anesthesia start to Anesthesia End
A transfer of care protocol or handoff tool/checklist that includes the key handoff elements is 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: Postoperative destination is determined using the MPOG Postoperative Destination phenotype. Cases 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:
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.
MPOG sites interested in auditing the transfer of care process can utilize the PACU Handoff Form available through the MQUARK application. More information regarding the MQUARK audit application is available on the MPOG website: https://mpog.org/apps/
Not applicable
Anesthesia provider in the room providing care at Anesthesia End
Method for determining Responsible Provider:
Date Reviewed | Reviewer | Institution | Summary | QC Vote |
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NA |
NA |
NA |
NA |
NA |
Date | Criteria | Revision |
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None |