The Structure and Process of PACU Handoff – How to Implement a Multidisciplinary PACU Handoff Checklist

Dr. Christopher Potestio

Letter to the Editor:

To the Editor:

We would like to thank Tan and colleagues for their response to our study, “Improving Post Anesthesia Care Unit (PACU) Handoff by Implementing a Succinct Checklist.”1,2 They address many of the important challenges in standardization of healthcare processes and we are happy to continue the discussion. This topic is of growing concern among anesthesia providers as evidenced by several studies published in the past year that have examined the benefit of a standardized handoff.3,4 Tan and colleagues bring up two important topics that we would like to emphasize in this letter: the structure and process of PACU handoff.

At their institution, Tan and colleagues found that: "following a rigid checklist may elicit resistance among more experienced clinicians because it interferes with the ‘flow’ of their practiced, yet not necessarily complete, handoff reports." A less-structured handoff/checklist may appeal to experienced clinicians; however, at Medstar Georgetown University Hospital (MGUH), the majority of PACU handoffs are completed by trainees (residents and student nurse anesthetists). Patient handoff is a clinical skill that we expect all of our trainees to master. Reinforcing this structured format of PACU handoff establishes a culture of patient safety that will continue as our trainees graduate into practice. Our experienced clinicians may adopt a similar handoff structure described by Tan and colleagues with a verbal "story" preceding a "Read and Verify" review of the checklist, although a structured reading of the checklist is encouraged. Even the most experienced clinicians are at times distracted or leave out important information.

We agree with another point emphasized by Tan and colleagues—it is not sufficient to address the content of PACU handoffs, we must also address the process. We are now engaged in a PACU handoff initiative that includes our surgical colleagues. This multidisciplinary PACU handoff will bring all parties to the (bedside) table to ensure complete, efficient handoff of care in the PACU. Our multidisciplinary handoff allows for a structured handoff, starting with "Patient Admission and Assessment," where each of the three handoff teams engages in specific activities to ensure a quick, efficient admission to the PACU. This first step addresses patient safety and stability prior to focusing on face-to-face handoff.

We are encouraged that Tan and colleagues include a surgical handoff on their checklist and we wonder whether it is included in a structured handoff effort or whether the two handoffs exist independently. At MGUH, one of the keys to success in an organized multidisciplinary handoff effort is the support we have received from PACU nursing as well as both anesthesia and general surgery departments. The appointment of "local champions" has been cited as an important ingredient to success in previous successful checklist endeavors.5 We feel that strong support, from both the resident leaders and department faculty, has been integral in our overall success.

We would like to thank Tan and colleagues for providing their thoughtful feedback. We welcome continued discussion as we improve the exchange of information during the crucial moments of PACU handoff.

Dr. Christopher Potestio CA-2 resident Department of Anesthesiology Medstar Georgetown University Hospital Washington, DC


References

  1. Tan J, Bhavsar S, Hagan K, Lasala J. An alternative succinct checklist offered for PACU handoff communication. APSF Newsletter 2015; 30(2):37–38.
  2. Potestio C, Mottla J, Kelley E, DeGroot K. Improving post anesthesia care unit (PACU) handoff by implementing a succinct checklist. APSF Newsletter 2015;30:13–15.
  3. Weinger MB, Slagle JM, Kuntz AH, Schildcrout JS, Banerjee A, Mercaldo ND, Bills JL, Wallston KA, Speroff T, Patterson ES, France DJ. A multimodal intervention improves post-anesthesia care unit handovers. Anesthesia and Analgesia 2015;121:957–971.
  4. Caruso TJ, Marquez JL, Wu DS, Shaffer JA, Balise RR, Groom M, Leong K, Mariano K, Honkanen A, Sharek PJ. Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration. Joint Commission Journal on Quality and Patient Safety 2015;41:35–42.
  5. Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. Effective surgical safety checklist implementation. Journal of the American College of Surgeons 2011;212:873–879.