3.3 Patient Transfer, Report, and Post-op Assessment

The postoperative phase begins the moment the surgical dressing is applied. The immediate priorities shift to the safe transfer of the patient from the operating room bed to the transport stretcher, delivering a comprehensive hand-off report to the Post-Anesthesia Care Unit (PACU) nurse, and conducting an initial assessment of the surgical site. The CSFA plays a crucial collaborative role during this transition.

Safe Patient Transfer

Transferring an anesthetized or emerging patient is a high-risk activity that requires coordinated teamwork. The patient lacks muscle control and cannot protect their airway or limbs, making them vulnerable to musculoskeletal injury, shear forces, and accidental extubation. Furthermore, sudden shifts in position can trigger orthostatic hypotension (a rapid drop in blood pressure) due to the vasodilatory effects of anesthetic agents. This is particularly common when returning a patient from the lithotomy or prone position to a supine position on the stretcher.

Transfer Protocols

• Personnel: A minimum of four staff members is required to safely transfer an adult patient.
• Role Allocation: The anesthesia provider stands at the head of the bed, coordinating the team. One staff member stands at the feet, while the remaining two stand on either side of the patient (one on the OR table side and one on the stretcher side) to slide the patient.
• Anesthesia Control: The anesthesia provider is in command of the move, ensuring the airway (endotracheal tube or LMA) remains secure. The move must only occur on the anesthesia provider's count.
• Securing Lines and Drains: Before any movement, the CSFA and circulator must verify that all Foley catheters, IV lines, arterial lines, and surgical drains are untangled, have sufficient slack, and will not be snagged or pulled during the transfer. Drains should be temporarily clamped or kept below the level of the patient to prevent backflow of fluid.
• Use of Transfer Devices: To minimize shear stress on the patient's skin and protect the staff's backs, friction-reducing transfer devices such as roller boards, slider sheets, or hover mats should always be utilized.
• Positioning: The patient is typically transferred in a supine position. Once on the stretcher, side rails must be immediately raised and locked. If the patient is at risk of aspiration, they may be placed in the lateral recovery position, provided the surgical site allows it. Stretcher brakes must be locked during the entire transfer process.

The Hand-Off Report to PACU

Clear, accurate communication during the transition of care is essential for patient safety. The hand-off report provides the PACU nursing staff with the necessary context to manage the patient's recovery effectively.

Many institutions utilize the SBAR communication framework to ensure all critical information is conveyed systematically:

• S - Situation: Patient name, age, the specific surgical procedure performed, and the primary surgeon.
• B - Background: Pertinent patient medical history, comorbidities (such as diabetes, hypertension, or sleep apnea), allergies, and baseline preoperative status.
• A - Assessment: Intraoperative course, including the type of anesthesia used, estimated blood loss (EBL), total fluid and blood products administered, urine output, and any intraoperative complications or unexpected findings.
• R - Recommendation: Postoperative orders, pain management plan (e.g., regional blocks or PCA), specific instructions regarding the surgical site (e.g., "keep leg elevated", "ice pack to wound"), and parameters for notifying the surgeon.

The CSFA can assist the circulating nurse by confirming the accuracy of the surgical details, the exact type and location of all drains, and any specific wound closure techniques utilized. The hand-off is not complete until the PACU nurse verbally acknowledges receipt of the report and accepts custody of the patient.

Initial Postoperative Assessment

Before the patient leaves the OR, and again immediately upon arrival in the PACU, an initial assessment of the surgical site and the patient's overall status is conducted.

Wound and Dressing Evaluation

• Hemorrhage: The dressing must be inspected for immediate breakthrough bleeding. A small amount of serosanguinous spotting may be expected, but active pooling or rapid saturation indicates a potential hemorrhage requiring immediate intervention.
• Dressing Integrity: Ensure the dressing is secure and firmly adhered to the skin, especially if it is a pressure dressing. Loose edges can compromise the sterile barrier. Do not remove or alter the surgical dressing within the first 24 to 48 hours post-op unless specifically ordered by the surgeon, as it protects the fresh incision.
• Drain Function: Verify that all active drains (JP, Hemovac) are compressed and holding negative pressure. Ensure there are no kinks in the tubing and that the collection reservoir is positioned below the level of the wound to facilitate gravity drainage.

Systemic Assessment

While the anesthesia provider and PACU nurse focus on hemodynamic stability (vital signs, airway patency, oxygen saturation), the CSFA should remain observant. Any signs of expanding hematoma in the neck (which can compromise the airway), sudden limb ischemia (loss of pulse distal to a vascular repair), or severe unremitting pain should be immediately brought to the attention of the attending surgeon and anesthesia team. The CSFA should also watch for post-anesthesia shivering, which can increase oxygen consumption by up to 400% and is treated with warming blankets or medications like Meperidine.