Chapter 4: Guidelines for the Provision of Anaesthetic Services for Postoperative Care 2019
All patients who have undergone anaesthesia are at risk of postoperative complications including compromise to the airway, breathing and circulation. Therefore, management and transport of patients immediately after anaesthesia can potentially be hazardous. If adequate standards of care are not provided, it is quite likely serious complications can occur. When considering the provision of anaesthesia, the Royal College of Anaesthetists recommends that specific areas should be addressed to reduce these complications and harm, improve outcomes and promote patient wellbeing. These areas include appropriate staffing, equipment, services and facilities; training and education; research and quality improvement; financial management, and appropriate organisation and administration.
Ultimately, the goal of these guidelines is to ensure a comprehensive, high-quality service dedicated to the care and wellbeing of patients at all times and to the education and professional development of staff.
1. Staffing requirements
Emergence from anaesthesia is potentially hazardous, with patients requiring close observation until recovery is complete.3 The responsibility of anaesthetists for the care of their patients extends into the postoperative period until their discharge from recovery or handover of care to another clinician such as an intensivist. Appropriately staffed recovery facilities must be available during whatever hours of the day elective and emergency surgery is undertaken.3
On many occasions, patients will be handed over to the recovery practitioner with a laryngeal mask airway or other supraglottic airway device in place. The person taking over direct clinical care should be specifically trained in the management of these patients and in the safe removal of the airway device.5
If a patient is transferred to the post-anaesthesia care unit (PACU) with a tracheal tube in place, the anaesthetist remains responsible for the removal of the tube but may delegate its removal. Delegation should be to an appropriately trained member of the PACU staff who is prepared to accept this delegated responsibility.4
An anaesthetist should have overall responsibility for the transport of patients from theatre to the PACU.6
The patients’ anaesthetist should retain overall responsibility for the patient during the recovery period and should be readily available for consultation until the patient is able to maintain their own airway, has regained respiratory and cardiovascular stability and is able to communicate, unless this care has been handed over to another named anaesthetist
Until the patient is able to maintain their own airway, has regained respiratory and cardiovascular stability and is able to communicate, continuous individual observation and care of each patient should be performed on a one to one basis. All PACUs should be staffed to a level that allows this to be routine practice (this could be assessed using queuing theory or other models of staffing)9 and the recovery staff should not have any other duties during this time.6,10
A minimum of two members of staff should be present (of whom at least one should be a registered practitioner) when there is a patient in the PACU who does not fulfil the criteria for discharge to the ward. If this level of staffing cannot be assured, an anaesthetist should stay with the patient until satisfied that the patient fulfils discharge criteria.10
Adequate provision should be made for an anaesthetist led acute pain service.12
Adequate provision should be made for a member of the anaesthetic team to visit the following groups of patients within 24 hours following their operation:
- those graded as ‘American Society of Anesthesiologists (ASA) Physical Status 3, 4 or 5’
- those receiving epidural analgesia in a general ward
- those discharged from recovery with invasive monitoring in situ
- those for whom a request is made by other medical, nursing or other clinical colleagues
- those for whom there is any other appropriate need.
2. Equipment, services and facilities
All patients who have had an anaesthetic affecting central nervous system function and/or a loss of protective reflexes should remain where anesthetised until recovered or be transported safely (with care and monitoring as indicated below) to a specifically designated recovery location for post-anaesthesia recovery.6
The size, design and facilities of the PACU must meet the Department of Health guidelines.13
The bed spaces should allow unobstructed access for trolleys, x-ray equipment, resuscitation carts and clinical staff. The facility should be open plan, allowing each recovery bay to be observed but with the provision of curtains for patient privacy.10
Oxygen and suction should be present in every recovery bay and ideally delivered by pipeline.10
An emergency audible and visible call system should be in place, checked regularly to maintain functionality and understood by all staff.14
There must be a system for ordering, storage, recording and auditing of controlled drugs in all postoperative areas in which they are used, in accordance with statutory legislation.15
An individualised post-anaesthesia care plan should be implemented for each patient.16
Careful records including instructions, patient observations and drug administration should be maintained (increasingly in electronic form) and recovery staff should be able to interpret the information and initiate appropriate action where necessary.
Capnography has the potential to aid early detection of airway obstruction and should be available in recovery and used in high risk cases. If patients remain intubated or they have their airways maintained with a supraglottic or other similar airway device, continuous capnography should be used.5,10,18
A brief interruption of monitoring during transfer of the patient from theatre is only acceptable if the recovery area is immediately adjacent to the operating theatre. Otherwise monitoring should be continued during transfer to the same degree as any other intra or inter hospital transfer.17
Supplementary oxygen should be available for transport after general anaesthesia.5
Airway adjuncts should be available in the post-anaesthesia care unit to minimise the incidence of upper airway obstruction that may lead to post obstructive pulmonary oedema and severe hypoxaemia.5
Patient information should be continuously recorded and updated (in electronic or written format). Anaesthetic Information Management Systems, a specialised form of electronic health record, should be considered as electronic patient charts in the perioperative and recovery period as they provide a more accurate and complete reflection of the patient’s perioperative physiologic parameters.19
Protocols and equipment should be available for the postoperative management of various symptoms, signs and conditions deemed locally appropriate. Such examples include the management of postoperative nausea and vomiting, pain relief of patients with chronic pain,21 hypothermia, blood transfusion, fluid therapy, diabetes,22,23 acute coronary syndrome, the deteriorating and dying patient,24 delirium, respiratory diseases, hypotension, hypertension and vulnerable adults and children.
If a patient has known visual or hearing impairment or wears dentures, then their corrective lenses/hearing aid/dentures should be readily accessible and available postoperatively.25
3. Areas of special requirement
Recommendations for children’s services, including the postoperative phase of anaesthesia, are comprehensively described in chapter 10.
A designated separate recovery area for children and young people should be available in the paediatric anaesthesia location. This should have sufficient capacity for children to recover, be child friendly and staffed by suitably trained and qualified recovery practitioners to look after babies, children and young people.10
If this is not available, in the absence a dedicated PACU for children, a discrete segregated area in the general PACU should be available. The environment should be made as child friendly as possible.13
Children should never be left unattended in the recovery area.28
Departments should consider making comforters and favourite toys available for children upon emergence from anaesthesia, to reduce anxiety.29
Children have an increased incidence of postoperative delirium. Recovery staff should have an increased awareness and there should be local protocols for its management.29
Children with learning difficulties should ideally be recovered in an area with lower levels of noise and lighting and a familiar presence, such as their carer.29
The presence of learning disability practitioners in recovery when a patient with learning disability is being recovered should be considered.29
All staff working in paediatric recovery should be trained and competent in protocols, and familiar with the relevant procedures and personnel if there are safeguarding or child protection concerns that arise while the child is in theatre.30
There should be a minimum of one member of the recovery staff, or an anaesthetist, with advanced training in paediatric life support on duty and all members of recovery staff should have up-to-date paediatric competencies including resuscitation.10
Paediatric equipment to cover all ages should be available in recovery, including a full range of sizes of facemasks, breathing systems, airways, nasal prongs and tracheal tubes. Essential monitoring equipment includes a full range of paediatric non-invasive blood pressure cuffs and small pulse oximeter probes. Capnography should also be available.10
Parents and children should be appropriately educated and equipped with information to address common issues they may face postoperatively, in recovery and on discharge. This information should include leaflets for common procedures highlighting risks and these should be developed locally with support from area networks.31
Guidelines and commonly used algorithms for paediatric emergencies should be readily available and regularly rehearsed.10
Guidelines for fluid management specific to children, and equipment for accurate fluid delivery, should be available.32
Frail, older patients
Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures. There is an age related decline in physiological reserve and the elderly are at relatively higher risk of mortality and morbidity after both elective and emergency surgery. Therefore, specific provision should be made for the care of elderly patients in the postoperative period.2,35
Cross specialty teams, including surgeons, anaesthetists, geriatricians and allied health professionals should be initiated to provide quality postoperative care to frail older surgical patients.2
Guidelines should be developed for the prevention, recognition and management of common postoperative geriatric complications and/or syndromes, including delirium, falls, functional decline and pressure areas.
Provisions should be made for the assessment and management of pain in older people, and more specifically in those with dementia.37
Mechanisms for the early recognition of patients requiring specialist postoperative input from geriatrician led services and/or critical care should be developed. These should include patients at risk of or presenting with delirium, multiple medical complications, functional decline or complex discharge planning.
In the postoperative period, the safety of obese patients may be improved by supplemental oxygen, non-invasive ventilation (continuous positive airway pressure), monitoring of sedation, and ideally continuous pulse oximetry and the post-anaesthesia care unit should have the necessary equipment and staff to provide this.43
Patients with obstructive sleep apnoea have a higher incidence of postoperative complications including hypoxia, renal failure, unplanned intensive care unit (ICU) stay, and delayed discharge. Therefore, consideration should be given to monitoring such patients in an high dependency unit (HDU) environment postoperatively.44
Particular provision should be made for the care of obstetric patients. Specific recommendations are covered in chapter 9.
Critically ill patients
The care of critically ill and high risk patients may be influenced by perioperative medicine services, overnight intensive recovery or PACU. Therefore, postoperative critical care impacts on the provision of core anaesthetic services. The Faculty of Intensive Care Medicine and the Intensive Care Society have produced Guidelines for the planning and delivery of UK Intensive Care Services.45 Although critical care is largely outside the scope of GPAS, the following recommendations are highly relevant to immediate postoperative patient management.
When critically ill patients are held in the recovery area because of a lack of availability of appropriate facilities elsewhere, this should only occur if recovery staff are appropriately trained, and the recovery area is appropriately equipped to enable monitoring and treatment to the standard of a level 3 critical care unit. In some circumstances, such as a flu pandemic or a major incident involving mass casualties, this may not be possible due to a huge surge in demand, but this should be seen as exceptional rather than the accepted norm. Non-critical transfer to another hospital should be considered where necessary. It cannot be assumed that it is safe to use the recovery facility as an extension of critical care, and local policies and procedures should govern this issue.46
Excellent nursing care with prompt access to medical support will ensure that many key aspects of care are proactively managed to ensure good patient outcomes. Nurse-led, protocol driven care of frequently occurring problems for high risk surgical patients (such as pain, fluid imbalance, nutrition and mild cardiorespiratory compromise) can often be provided in a level 2 critical care unit or specifically developed post-anaesthetic care unit (PACU). This can provide some but not all the organ support treatments available in a level 3 critical care unit, e.g. invasive ventilation, low dose inotrope support.
Where the postoperative destination is a level 2 critical care unit, consideration should be given to initial care in a standard PACU until the patient has fully regained consciousness. This is of particular importance for critical care units that are not staffed with airway trained doctors.
All hospitals should have a clear policy describing the safe triage of surgical patients considered to need postoperative critical care, with guidance on which patients should be admitted immediately to critical care, and which can wait in a standard PACU for a short period while a critical care bed becomes available. Staff in critical care and PACUs should develop procedures to ensure safe and effective patient care during this transition. While the patient is located in the PACU, their care should be the primary responsibility of the staff and doctors working in that location.
Hospitals should have written policies on the management of patients whose surgery is sufficiently urgent that this proceeds when postoperative critical care is desirable but not available; this situation should be considered exceptional.
4. Training and education
Continued professional development and the training of other staff should be facilitated by activities such as the establishment of lead practitioners.
Members of clinical staff working within the recovery area should be certified to a standard equivalent to immediate life support providers, and training should be provided.
At all times, at least one advanced life support provider or an anaesthetist should be immediately available.
For children, a staff member with an advanced paediatric life support qualification or an anaesthetist with paediatric competencies should be immediately available.4
Core competencies should be updated according to local and national guidelines.
Wherever possible, training should be multidisciplinary.16
5. Organisation and administration
All institutions should have protocols and the necessary facilities for managing postoperative care and should review and update these regularly.16
Immediate postoperative management involves multidisciplinary care but overall responsibility is the named consultant anaesthetists.
There should be a named anaesthetist clinical lead (see glossary) for recovery.10
Standardisation of the handover process can improve patient care by ensuring information completeness, accuracy and efficiency (the use of checklists should be considered). Staff should comply with the local standardised handover processes.16
If responsibility for care is transferred from one anaesthetist to another, a ‘handover protocol’ should be followed, during which all relevant information about the patient’s history, medical condition, anaesthetic status, and plan should be communicated.6
Patients should be transferred to the ward accompanied by two members of staff, at least one of whom should be suitably trained to locally agreed standards. The anaesthetic record, recovery and prescription charts together with the postoperative plan, should accompany the patient and be clearly communicated to the receiving ward nurse.
Processes for the communication and implementation of patient safety alerts should be in place.
6. Financial considerations
Part of the methodology used in this chapter for developing recommendations is a consideration of the financial impact for each of the recommendations. However, very few of the literature sources from which these recommendations have been drawn have included financial analysis. Therefore, it is difficult to make many recommendations on the financial impact of these recommendations with the current available information.
The introduction of clinical pathways that encompass the entire perioperative period from the preoperative evaluation to the post discharge disposition should be considered, with the aim of reducing healthcare cost while improving outcomes.19
7. Research, audit and quality improvement
Regular revision at locally agreed timeframes and audit of standards of care, guidelines and protocols and critical incident reporting are essential in the ongoing development and improvement of post-anaesthetic patient care.10
Use of patient reported outcome measures (PROMs) to assess physiological and other recovery domains after surgery could be considered.49
Specific, measurable, attainable, relevant and time-bound (SMART) quality improvement initiatives and safety measures could be embraced in order improve safety and develop perioperative anaesthesia services.50
Nurturing a safety culture, learning from mistakes, preventing harm and working as part of a team are all part of the discipline of safety. To this end, shared learning and quality improvement that contribute towards improvements in safety, such as critical incident reporting with thematic analysis, and communication through morbidity and mortality meetings, could be undertaken.
Anaesthetists should participate in departmental audit throughout a full audit cycle. This participation should adhere to the standards and principles outlined in the College’s Compendium of audit recipes.50
Postoperative care audits and quality improvement projects from the College’s Compendium of audit recipes could be considered.50
8. Implementation support
The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, aims to provide support for departments of anaesthesia to implement the recommendations contained in the GPAS chapters. The scheme provides a set of standards, and asks departments of anaesthesia to benchmark themselves against these using a self-assessment form available on the RCoA website. Every standard in ACSA is based on recommendation(s) contained in GPAS. The ACSA standards are reviewed annually and republished approximately four months after GPAS review and republication to ensure that they reflect current GPAS recommendations. ACSA standards include links to the relevant GPAS recommendations so that departments can refer to them while working through their gap analyses.
Departments of anaesthesia can subscribe to the ACSA process on payment of an appropriate fee. Once subscribed, they are provided with a ‘College guide’ (a member of the RCoA working group that oversees the process), or an experienced reviewer to assist them with identifying actions required to meet the standards. Departments must demonstrate adherence to all ‘priority one’ standards listed in the standards document to receive accreditation from the RCoA. This is confirmed during a visit to the department by a group of four ACSA reviewers (two clinical reviewers, a lay reviewer and an administrator), who submit a report back to the ACSA committee.
The ACSA committee has committed to building a ‘good practice library’, which will be used to collect and share documentation such as policies and checklists, as well as case studies of how departments have overcome barriers to implementation of the standards, or have implemented the standards in innovative ways.
One of the outcomes of the ACSA process is to test the standards (and by doing so to test the GPAS recommendations) to ensure that they can be implemented by departments of anaesthesia and to consider any difficulties that may result from implementation. The ACSA committee has committed to measuring and reporting feedback of this type from departments engaging in the scheme back to the CDGs updating the guidance via the GPAS technical team.
9. Patient information
The written and verbal information given to patients before their admission to hospital should explain the purpose and nature of their recovery and the recovery department. You and your anaesthetic, published by the Royal College of Anaesthetists and the Association of Anaesthetists is an example of this.51 Further details on information to be given preoperatively can be found in the chapter 2.
Some patients, both adults and children, may need interpreters, parents or other members of their family to be with them. This need is best determined at preassessment, so that sensitivities can be taken into account in the operative process.52
Patient information regarding postoperative and post-discharge care, including contact details and protocols if complications arise, should be provided.
Areas for future development
There is a large gap in the evidence on the provision of service and most appropriate level of care after anaesthesia and surgery, particularly major surgery in the high risk patient. Further research is ideally needed to address this uncertainty, so all patients receive the most appropriate post-anaesthetic care available.
Clinical lead – SAS doctors undertaking lead roles should be autonomously practising doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. They should usually have experience in teaching and education relevant to the role, and they should participate in quality improvement and CPD activities. Individuals should be fully supported by their clinical director and be provided with adequate time and resources to allow them to effectively undertake the lead role.
Immediately available – unless otherwise defined, ‘immediately’ means within five minutes.
Post-anaesthesia care unit – may also be referred to as PACU, post-anaesthetic recovery unit, theatre recovery, recovery or recovery unit. It is an area, normally attached to theatres, designed to provide care for patients recovering from general anaesthesia, regional anaesthesia, or local anaesthesia.
Responsibility – refers to being accountable and ensuring completion of the specified action rather than physically completing the action yourself.
SMART objectives – SMART is an acronym, giving criteria to guide in the setting of objectives standing for specific, measurable, attainable, relevant and time-bound.
Sterile cockpit – distraction-free period during which only essential and urgent tasks are performed.