General Hospital
1. Why this policy exists
The transition from the operating table to the PACU is one of the highest-risk moments in the perioperative journey. The patient arrives physiologically vulnerable — still recovering from anaesthesia, with open surgical wounds, altered thermoregulation, and unpredictable pain responses. A single failure in this handover — incomplete information, delayed monitoring, absent equipment — can turn a successful surgery into a preventable harm event.
This policy defines how OT and PACU collaborate as one safe system, not two separate departments. It establishes the structured verbal and written handover, the minimum monitoring requirements in PACU, the discharge criteria that protect patients from being moved too soon, and the escalation pathways when things deteriorate.
The goal: every patient who leaves OT arrives in PACU with a nurse who knows exactly what happened — and what to watch for.
2. Purpose
- Define the structured OT-to-PACU patient handover using SBAR or equivalent tool.
- Establish minimum monitoring standards and nurse-to-patient ratios in PACU.
- Specify evidence-based discharge criteria (Aldrete / Modified Aldrete / PADS score).
- Clarify roles and responsibilities of OT team, anaesthetist, and PACU nurse at each transition point.
- Establish escalation and re-admission pathways for patients who deteriorate post-transfer.
- Ensure continuity of documentation from anaesthetic record through to PACU discharge note.
3. Scope
- All patients transferred from any OT suite to PACU / recovery room.
- All anaesthetists, OT nurses, surgical technologists, and PACU nurses involved in the perioperative pathway.
- Day-surgery patients using a modified discharge pathway (PADS score).
- Paediatric patients (see Section 8.8 for age-specific modifications).
- Patients transferred directly to ICU/HDU bypassing standard PACU (documented exception pathway).
4. Guiding Principles
"The handover is not a report — it is a transfer of responsibility."
The anaesthetist remains responsible for the patient until the PACU nurse verbally acknowledges the handover and monitoring is confirmed running.
"Discharge criteria protect — not delay."
Aldrete scoring is a safety gate, not a bureaucratic hurdle. No patient leaves PACU without meeting criteria or documented physician override with rationale.
"One nurse — one patient — in the critical recovery window."
Minimum staffing ratios are non-negotiable during the first 30 minutes post-arrival.
"Escalate early — never manage alone."
PACU nurses have explicit authority to call the anaesthetist or activate the emergency response at any point without seeking supervisor approval first.
5. Definitions
| Term | Definition (Practical) |
|---|---|
| PACU | Post-Anaesthesia Care Unit — the recovery area where patients are monitored immediately after surgery until they meet criteria for safe transfer. |
| Aldrete Score | A standardized 10-point scoring system (activity, respiration, circulation, consciousness, O₂ saturation) used to determine PACU discharge readiness. Score ≥9 required for transfer. |
| SBAR Handover | Situation–Background–Assessment–Recommendation: the structured communication framework used for OT-to-PACU handover. |
| PADS Score | Post-Anaesthetic Discharge Scoring System — used for day-surgery patients to assess readiness for home discharge. |
| Phase I Recovery | Immediate post-anaesthesia recovery (PACU) — intensive monitoring until patient is haemodynamically stable and airway is protected. |
| Phase II Recovery | Extended recovery — patient is awake and stable, progressing toward ward or home discharge. |
6. Policy Statement
Every patient transferred from OT to PACU must receive:
- A structured verbal SBAR handover from the anaesthetist to the receiving PACU nurse before the anaesthetist leaves the bedside.
- Continuous monitoring initiated within 2 minutes of PACU arrival (SpO₂, ECG, NIBP, RR, temperature).
- A completed anaesthetic/intra-operative record transferred with the patient (paper or electronic).
- Pain assessment using the institution's validated scale within 5 minutes of arrival.
- Discharge from PACU only when Aldrete score ≥9 (or Modified Aldrete ≥9) and documented anaesthetist approval.
- No transfer to ward/ICU until receiving unit confirms readiness and accepting nurse is present.
7. Detailed Procedures (SEC 8.1–8.9)
7.1 OT-to-PACU Transfer: Pre-departure Checklist
Before the patient leaves the OT suite, the anaesthetist and circulating nurse must confirm:
| Item | Responsible | Documented |
|---|---|---|
| Airway patent and protected (or airway device in situ if applicable) | Anaesthetist | ✓ Anaesthetic record |
| Haemodynamic stability confirmed (BP, HR within acceptable range) | Anaesthetist | ✓ Anaesthetic record |
| IV access patent and secured | OT Nurse / Anaesthetist | ✓ Transfer note |
| All surgical wounds covered / drains labelled and secured | Scrub / Circulating Nurse | ✓ OT record |
| Patient identity band confirmed on patient | Circulating Nurse | ✓ IPSG checklist |
| Oxygen supply confirmed for transport (portable O₂ if required) | Anaesthetist | ✓ Transfer note |
| Intra-operative medications documented (include any allergies/reactions) | Anaesthetist | ✓ Anaesthetic record |
| PACU notified and bed / nurse confirmed ready | Circulating Nurse | ✓ Communication log |
7.2 Structured SBAR Handover at PACU Bedside
The anaesthetist delivers a verbal handover to the receiving PACU nurse using the SBAR framework. The PACU nurse must be present and attentive — no monitoring tasks during handover reception.
S — Situation
Patient name, MRN, age, procedure performed, surgeon, type of anaesthesia used, time of extubation / LMA removal.
B — Background
Relevant PMH, allergies, pre-op medications, baseline vitals, ASA classification, any known difficult airway.
A — Assessment
Intra-op events (blood loss, fluid balance, temperature, pain level, complications), current vitals, IV access, drains, wounds, last analgesic given.
R — Recommendation
Anticipated concerns, specific monitoring requirements, analgesic plan, anti-emetic orders, when to call anaesthetist, expected PACU duration.
⚠ Non-negotiable rule: The anaesthetist may not leave PACU until the receiving nurse verbally confirms they have received and understood the handover.
7.3 Monitoring Standards in PACU — Phase I Recovery
Mandatory Continuous Monitoring
- SpO₂ — pulse oximetry (continuous)
- ECG / Heart rate (continuous)
- Non-invasive blood pressure (NIBP) — every 5 min for first 30 min, then every 15 min
- Respiratory rate (continuous or every 5 minutes)
- Temperature (on arrival; repeat if hypothermic)
- Level of consciousness / sedation score (RASS or equivalent) — every 15 minutes
- Pain score — on arrival, then every 15 minutes and PRN
- Nausea/vomiting assessment — every 15 minutes
Additional Monitoring (when applicable)
- Invasive arterial pressure (if arterial line in situ)
- Central venous pressure (if CVP line in situ)
- Urine output (catheterised patients — hourly)
- Drain output — label, measure, document every 30 minutes
- Blood glucose (diabetic patients — on arrival, 1 hour)
- End-tidal CO₂ if intubated / LMA in situ
Staffing Ratio (non-negotiable):
- • Phase I (first 30 min): 1 nurse : 1 patient minimum
- • Phase I (30 min–Aldrete ≥9): 1 nurse : 2 patients maximum
- • Paediatric / high-risk: 1 nurse : 1 patient throughout Phase I
- • Never leave a Phase I patient unattended, even briefly
7.4 Pain & PONV Management in PACU
Pain Management Protocol
- Use validated pain scale (NRS 0-10 / FLACC for paediatrics / CPOT for intubated)
- NRS ≤3: reassess in 15 minutes, non-opioid analgesia PRN
- NRS 4–6: titrated IV opioid per standing order + non-opioid; reassess in 15 min
- NRS ≥7: immediate anaesthetist notification; do not manage alone
- Document every analgesic dose: drug, dose, route, time, score before/after
- Respiratory rate and SpO₂ monitored continuously when opioids administered
PONV Management Protocol
- Apfel score ≥2: prophylactic anti-emetic per anaesthetic plan
- PONV on arrival: ondansetron 4mg IV (or per prescription) unless contraindicated
- Refractory PONV: call anaesthetist for second-line agent
- Maintain lateral position for any patient with active nausea/impaired airway
- Ensure suction immediately accessible at every PACU bay
7.5 Aldrete Discharge Scoring System
Discharge from Phase I PACU requires Aldrete score ≥9 (or Modified Aldrete ≥9). Score must be documented in the PACU record.
| Parameter | Score 2 | Score 1 | Score 0 |
|---|---|---|---|
| Activity | Moves all 4 limbs voluntarily | Moves 2 limbs | Unable to move |
| Respiration | Breathes deeply; coughs freely | Dyspneic / shallow | Apneic |
| Circulation | BP ±20% of pre-op | BP ±20–49% of pre-op | BP ±50% of pre-op |
| Consciousness | Fully awake | Arousable on calling | Not responding |
| O₂ Saturation | SpO₂ >92% on room air | Needs O₂ to maintain ≥90% | SpO₂ <90% with O₂ |
| Minimum score for Phase I discharge: ≥9/10 — Anaesthetist must approve transfer | |||
Exceptions to Aldrete ≥9 requirement:
- • Direct OT-to-ICU transfer: Aldrete scoring not required if ICU receiving and accepting (document in record)
- • Physician override: anaesthetist documents clinical reason for transfer with score <9 and accepting ward notified
- • Both exception types require explicit written documentation and senior physician signature
7.6 PACU-to-Ward / Day Surgery Discharge (Phase II)
Ward Transfer Criteria (inpatients)
- Aldrete score ≥9 sustained for 30 minutes
- Pain score ≤3 on NRS or patient-acceptable level
- No active nausea/vomiting
- Haemodynamically stable (no new interventions needed)
- Temperature ≥36.0°C or active warming en route
- Receiving ward nurse confirms bed and readiness
- Written PACU discharge note completed and signed
Day Surgery / Home Discharge (PADS Score ≥9)
- PADS score ≥9 (vital signs, ambulation, nausea, pain, surgical bleeding)
- Patient able to drink fluids and tolerate oral intake (where applicable)
- Responsible adult escort confirmed and present
- Verbal and written post-op instructions given in patient's language
- Emergency contact number provided
- Follow-up appointment confirmed
- Anaesthetist / surgeon approves — documented
7.7 Escalation Pathways: When the Patient Deteriorates in PACU
Immediate (within 1 minute) — call the anaesthetist:
- • SpO₂ <90% despite O₂ supplementation
- • Respiratory rate <8 or >30 / minute
- • Systolic BP <80 mmHg or >180 mmHg (unresponsive to initial measures)
- • HR <40 or >140 bpm
- • New loss of consciousness or seizure
- • Active haemorrhage (wound or drain)
- • Suspected malignant hyperthermia (fever + rigidity + tachycardia)
Urgent (within 5 minutes) — notify anaesthetist:
- • Pain NRS ≥7 unresponsive to initial analgesia
- • Refractory PONV (≥3 episodes despite treatment)
- • Temperature <35.5°C or >38.5°C
- • Urine output <0.5 mL/kg/hr for 1 hour (catheterised patient)
- • Patient agitation / delirium / unexpected prolonged sedation
Activate Emergency Response (Code Blue / Rapid Response):
- • Cardiac arrest or pulseless rhythm
- • Complete airway obstruction unresponsive to manoeuvres
- • If anaesthetist unreachable within 2 minutes during life-threatening emergency
7.8 Special Populations
8.8.1 Paediatric Patients
- Parent / guardian present in PACU as soon as patient is awake and stable (facility permitting)
- Use FLACC or FACES pain scale (age-appropriate)
- Strict weight-based dosing for all analgesics and anti-emetics
- Temperature management — paediatric warming devices available
- 1:1 nursing ratio until Aldrete / modified discharge criteria met
8.8.2 Elderly / Frail Patients
- Delirium risk assessment — CAM-ICU or equivalent on arrival
- Reduced opioid dosing with enhanced monitoring
- Fall risk — side rails up, call bell within reach at all times
- Pressure injury prevention — reposition every 30 minutes if immobile
8.8.3 Patients with Difficult Airway
- Difficult airway alert must be visibly communicated to PACU team at handover
- Difficult airway trolley available at bedside throughout Phase I
- Anaesthetist remains on site (or immediately available) until extubation stability confirmed
- "Difficult Airway" wristband applied and documented in discharge summary
8.8.4 Direct OT-to-ICU Bypass
- Pre-planned ICU transfer: documented in pre-op plan, ICU bed confirmed before surgery
- Unplanned ICU transfer: anaesthetist documents clinical reason, ICU consultant notified, bed confirmed
- Full intra-operative documentation transferred with patient
- ICU nurse receives the same SBAR handover as PACU protocol
7.9 Documentation Requirements
- PACU Arrival Note: time of arrival, Aldrete score on arrival, vital signs, pain score, level of consciousness, IV access, wounds/drains status.
- Ongoing Flow Sheet: vital signs (per frequency protocol), pain scores, analgesics/anti-emetics given (dose, route, time), interventions.
- Aldrete Scoring Record: documented at arrival, every 30 minutes, and at discharge.
- PACU Discharge Note: final Aldrete score, time of discharge, receiving unit, accepting nurse name, patient condition on transfer, outstanding medications.
- Incident Documentation: any escalation event, adverse reaction, or unplanned intervention must be documented in the incident reporting system within 24 hours.
8. KPI Dashboard & Audit
8.1 Compliance Audits (monthly)
- 8.1.1 % of handovers with completed SBAR documentation.
- 8.1.2 % of PACU arrivals with monitoring initiated within 2 minutes.
- 8.1.3 % of PACU discharges with documented Aldrete ≥9.
- 8.1.4 Aldrete exception rate (transfers with score <9) — must be reviewed by OTMC if >2%.
8.2 KPI Targets
| KPI | Target | Alert Level | Review |
|---|---|---|---|
| SBAR handover completion rate | ≥98% | <95% | Monthly OTMC |
| Monitoring within 2 min of arrival | 100% | <98% | Monthly OTMC |
| Aldrete ≥9 at PACU discharge | ≥97% | <93% | Monthly OTMC |
| PONV incidence in PACU | ≤15% | >25% | Quarterly |
| Unplanned re-admission to PACU within 24h | ≤0.5% | >1% | Monthly OTMC |
9. Noncompliance Management
9.1 Critical noncompliance includes:
- Patient transferred from OT to PACU without a verbal SBAR handover
- Monitoring not established within 5 minutes of PACU arrival
- Patient discharged from PACU with Aldrete score <9 without documented physician override
- PACU nurse leaving a Phase I patient unattended
- Failure to escalate a deteriorating patient within required timeframes
9.2 Consequences:
Critical noncompliance is treated as a patient safety event. It requires: immediate incident report, root-cause analysis within 72 hours, and OTMC review at next meeting. Repeat noncompliance triggers formal HR process.
10. References & Evidence Base
- Joint Commission International (JCI) — IPSG.1, ACC.3, COP.2, ASC.7 Standards
- World Health Organization (WHO) — Safe Surgery Saves Lives; Surgical Safety Checklist
- American Society of Anesthesiologists (ASA) — Standards for Post-Anesthesia Care (2019)
- American Society of PeriAnesthesia Nurses (ASPAN) — Standards of Perianesthesia Nursing Practice (2021-2022)
- Aldrete JA. (1995). The post-anesthesia recovery score revisited. Journal of Clinical Anesthesia, 7(1), 89–91.
- Marshall SI, Chung F. (1999). Discharge criteria and complications after ambulatory surgery. Anesthesia & Analgesia, 88(3), 508–517. (PADS Score)
- ISBAR Communication Framework — Australian Commission on Safety and Quality in Health Care
- NHS England — National Safety Standards for Invasive Procedures (NatSSIPs) 2015
Appendix: PACU Monitoring & Discharge Record
Form: PACU-MON-001 (Reference — attach to patient record)
Patient Name
MRN
Date / Time of Arrival
Procedure
Anaesthetist
PACU Nurse
| Time | SpO₂% | HR | BP | RR | Temp | Pain (NRS) | Aldrete | Notes |
|---|---|---|---|---|---|---|---|---|
| Arrival | ||||||||
| +15 min | ||||||||
| +30 min | ||||||||
| +45 min | ||||||||
| +60 min | ||||||||
| Discharge |
Discharge Aldrete Score / Criteria Met
Time of Discharge from PACU
Receiving Unit / Nurse
Anaesthetist Signature & Time