Table 2 outlines the SBAR elements of the intraoperative to PACU transition, highlighting OR events that have occurred. Being as specific as possible is critical. Informing the PACU nurse about the patient’s past medical history also may be vitally important.
TABLE 1
Elements of the
Preoperative to Intraoperative Hand-Off Communication
Situation
Name of patient and date of birth
Name of operative or invasive procedure to be performed including modifiers and site
Pertinent documents are present and consistent
Background
Elements of patient history pertinent to surgery
Medical clearance
Patient allergies and NPO status
Patient’s vital signs and pain level
Medication profile and medications taken today
Specific laboratory results
Code status of patient
Assessment
Patient’s current level of understanding of the surgery
Special patient needs or precautions
Pertinent aspects of the patient’s emotional and spiritual status
Pertinent cultural implications
Anesthesia requests
Recommendations
State whether the patient has been seen preoperatively by the surgeon and anesthesia care provider
Determine whether the patient is ready for surgery
Allow an opportunity for preoperative and intraoperative staff members to ask questions or voice concerns TABLE 2
Elements of the Intraoperative to
Postanesthesia Care Unit (PACU) Hand-Off Communication
Situation
Name of patient and date of birth
Name of operative or invasive procedure performed including modifiers and site
Background
Type of anesthesia administered and name of anesthesia care provider
Intraoperative medications administered including dose and time
IV fluids administered
Estimated blood loss
Pertinent information related to the surgical site such as dressings, tubes, drains, or packing
Any significant OR events
Assessment
Hemodynamic stability
Airway and oxygenation status
Thermal status (eg, presence of hypothermia or hyperthermia)
Urine output
Presence or absence of surgical complications
Level of pain
Method of pain management
Recommendations
Ensure that immediate postoperative orders have been completed
Discharge from the PACU when stable
Allow opportunity for intraoperative and
PACU staff members to ask questions or voice concerns