This measure is calculated based on data extracted from the electronic medical record combined with administrative data sources such as professional fee and discharge diagnoses data. This measure is explicitly not based on provider self-attestation.
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.
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.
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/
Anesthesia provider in the room providing care at Anesthesia End
Method for determining Responsible Provider:
Postop Location MPOG Concept IDs |
Handoff MPOG Concept IDs |
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50066 |
Phase I Recovery Room In Date/Time |
50623 |
Compliance- PACU/ICU Handoff of care performed, report given. |
50067 |
Phase I Recovery Room Out Date/Time |
|
|
50068 |
Phase II Recovery Room In Date/Time |
|
|
50069 |
Phase II Recovery Room Out Date/Time |
|
|
50070 |
Phase III Recovery Room In Date/Time |
|
|
50071 |
Phase III Recovery Room Out Date/Time |
|
|
50008 |
AACD Patient Out of Room Date/Time |
|
|
50010 |
AACD Recovery Room In Date/Time |
|
|
50706 |
Categorized Note – Postoperative Recovery |
|
|
50734 |
Emergence – Patient Recovery Location |
|
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
Not applicable