NHS Grampian's Foresterhill and Woodend sites contain large multi-specialty hospitals caring for half a million people, spread across the North East of Scotland.

The main suite Post-Anaesthetic Care Unit (PACU) at Aberdeen Royal Infirmary operates a 17 bedded unit divided across two rooms, 24/7 with 15 inputting theatres. The PACU at Woodend Hospital serves the elective orthopaedic theatres for NHS Grampian.

The standards of care within the units are modelled upon National Guidelines from the Royal College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI).

It was noted in the audit team's units that the anaesthetic handover was variable in terms of quality and content. Many handovers occur between anaesthetic and PACU teams on a daily basis. Without a consistent approach, there is the potential to compromise patient safety through the loss of critical information.

Approval was sought to carry out our audit from the theatre management and the consultant anaesthetic audit lead.

The standard by which we measured our performance was based upon standards proposed by the RCoA, covering the following aspects linked to the Situation Background Assessment Recommendation (SBAR) communication framework:

100% of handovers should include the following information:

Situation

• • Patient's name, procedure performed and designated theatre.

• • Allergies the patient may have.

Background

• • Relevant past medical history.

Assessment

• • Type of anaesthetic performed and how the airway was managed.

Recommendation

• • Relevant hospital documentation should be completed at the time of handover, including drug, fluid and analgesia prescription charts.

• • A plan detailing specific postoperative care and whether invasive monitoring was to remain.

The audit team performed a literature search to provide evidence to support the audit. Our search included national guidelines and peer-reviewed national and international articles – see references [Anwari, Reference Anwari2002; The Association of Anaesthetists of Great Britain and Ireland, 2010; The Association of Anaesthetists of Great Britain and Ireland, 2002; Chadwick and Norman, Reference Chadwick and Norman2012; Christie, Reference Christie2009; Crum Gregory, Reference Crum Gregory2006; Horn et al, Reference Horn, Bell and Moss2004; Manser and Foster, Reference Manser and Foster2011; Odom-Forren, Reference Odom-Forren2007; Royal College of Anaesthetists, 2009; Smith et al, Reference Smith, Pope, Goodwin and Mort2008; Sandlin, Reference Sandlin2007; Sullivan, Reference Sullivan2007].

The audit team held a weeklong brainstorming exercise asking recovery practitioners to write down what information they needed from a handover.

For the audit, prospective data were collected by utilisation of a questionnaire completed by the patient's recovery practitioner.

Patients who were admitted to the PACUs following general, spinal or epidural anaesthesia were included in the study. Groups excluded were patients having local anaesthetic or sedation only and those admitted for chest X-ray after central line insertion.

The study was carried out over 1 week in June 2012. In total, we received 192 completed audit questionnaires.

The data demonstrated that there were issues highlighted in each of the sections of the SBAR, summarised as follows:

Handover commencement

• • There was confusion over the responsibility for airway control during the handover process. Ideally an additional recovery practitioner should take airway control, to allow complete attention to be devoted to handover, and allow the primary practitioner to make an initial patient assessment.

• • Insufficient time was allocated to the reception of the patient into PACU prior to the commencement of handover. The consequence of this is that handover parties are engaged in other tasks (e.g. attaching monitoring) while handover is being given.

• • Not all parties were ready to receive handover. The consequence of this is a reduced focus of attention for the handover.

Situation

• • Generally full patient details were provided.

• • The handover of allergy information varied.

Background

• • Varying amounts of past medical history was handed over.

Assessment

• • Generally a full explanation of anaesthetic technique was provided.

Recommendation

• • The documentation and handover of airway management information (e.g. difficult airway, intubation grade) varied.

• • Contact and follow-up details were not always provided. The ability to contact the responsible anaesthetist in an emergency is critical as well as having an alternate contact.

After analysing the results, the audit team have discovered that there are issues relating to the content and consistency of anaesthetic handover, which need to be addressed. They would like to develop a proforma to aid the delivery of handover in a consistent fashion and promote the use of the SBAR communication tool within the whole perioperative environment.

A Plan, Do, Study Act (PDSA) model for improvement could be used to aid implementation, followed by re-audit.