What is post operative care?
At the end of a surgical procedure, there are a number of tasks to be performed by the surgical team in post operative care, such as:
- Wound dressing
- Specimen handling
- Operating room cleaning
The tasks discussed in this blogpost not run the gamut of what may need to be done and only a selection of commonly performed tasks are discussed. These are:
- finalizing the procedure;
- handling the specimen;
- administrative tasks;
- transfer of the patient and preparation of the operating room for the next procedure.
It is important that these tasks be performed systemically with clear delineation of responsibility to ensure that they are performed appropriately and timeously after the procedure in the operating room.
Link to Academy course 'Postoperative Phase'
Wound care is a topic with too much breadth and depth to be covered by this post. A few basic principles pertaining to wound dressing in the operating room will be discussed and only common considerations will briefly be touched upon. Wounds should be covered or dressed as soon as possible following their closure. The main objective of wound dressing is to prevent surgical site infection. Factors contributing to an increased risk of surgical site infection are, amongst others: a dirty wound surface; incorrect application and handling of dressing materials; early removal of sterile drapes and door movements.
When there are multiple wounds present, it is important to dress them in a sequence that does not jeopardize sterility. Faced with a clean wound and a stoma for example, it is not appropriate to dress the stoma before the clean wound. Doing so could potentially contaminate gloves, gauze swabs and other wound dressing implements putting the clean wound at risk of the same. Working from wounds that are clean to those that are dirty is the correct sequence. The application of dressing to a surgical wound may be performed by any member of the surgical team wearing clean gloves. The circulating nurse, for example, can perform this task while the scrub nurse disposes of instruments. Care should be taken to ensure the wound surface is clean and free of debris before applying the dressing. When applying the dressing it is important that the bottom of the dressing not be touched in order to maintain sterility. It is advised to remove the sterile drapes only after the wound has been dressed. The side of the drape that was in contact with the patient can easily contaminate the wound. Movement of the drapes can also cause dust particles to be blown into the wound contaminating it. Take care to remove the sterile drapes with caution in order to prevent injury to the skin. Before the wound closure, the opening of the operating room door should be limited to only what is essential. The rate of surgical site infection increases with an increase in the number of door movements during a procedure.
In the absence of clinical signs of infection, it is recommended that a dressing should not be removed unless it is loose or stained. How often or for how long, a surgical wound needs to be dressed, is determined by local protocol. There are many options with regard to types of wound dressing but there is no evidence to suggest that use of a particular wound dressing to cover a closed surgical wound has any effect on the rate of surgical site infection.
Blistering may occur if dressings are applied under tension or over a joint where the movements cause friction between skin and dressing. The most commonly used dressings are low-adherent island dressings. These are dressings have an absorbent layer in the middle surrounded by an adhesive. These adhesives have been known to cause allergic reactions and care should be taken to enquire about and document these preoperatively.
Finalizing the procedure
Specimen Handling - Principles
During the course of a surgical procedure specimens may be collected from the patient. Tissue specimens, for example, are typically collected in aid of confirming the presence of malignancy or to confirm complete surgical excision of a tumor. Blood and other body fluid specimens may also be collected during a surgical procedure. The indications can range from excluding infection to intraoperative monitoring of physiological parameters such as coagulation. A variety of investigations can be conducted by the pathology laboratory on tissue and fluid specimens collected from a patient. The results of these investigations are used to make decisions that have extremely serious consequences for the patient and their care. It is imperative that specimens be handled appropriately at every point in the chain of custody between the operating room and the pathology laboratory. In handling specimens, members of the surgical team must have absolute clarity about the collection, labeling, preservation and transportation procedures. Failure to do so can have dire consequences for the patient resulting in legal ramifications for the individual carers or the institution. At all points in the chain of custody, precautions should be in place to protect the specimen handler from transmissible infection.
Different pathology investigations are used to analyse specimens. Having an understanding of these investigations aids in ensuring appropriate collection and preservation of the specimen in the operating room. A specimen can undergo a number of investigations such as: histological, cytological, clinical chemical, haematological or microbiological.
Histology is the microscopic examination of organs or tissue specimens removed during a surgical procedure. Apart from identifying the disease process at a cellular level, it also defines the relation between the diseased tissue and surrounding tissue and structures. This is information determines the classification and treatment of cancers.
Cytology is also a microscopic examination of cells. Specimens for cytological examination are often aspirate or fluid. Unlike histology, cytology provides information about the sampled cells only and not the surrounding tissue as well. Cytology may therefore be used to confirm the presence of cancer but does not define its extent.
Clinical Chemistry Investigations
Clinical chemistry analyses blood and body fluid specimens. Clinical chemistry measure constituents of these fluids such as: proteins, enzymes, nutrients, waste products, metabolites and hormones.
Hematological investigations are used to analyse both the cellular and plasma components of blood. A full blood count (FBC) measures the concentration of red blood cells, white blood cells and platelets as well as hemoglobin levels. These cell counts can be used to diagnose conditions such as: anemia, infectious and inflammatory conditions as well thrombocytopenia. Coagulation studies measure the level and function of clotting factors in the plasma. Hemoglobin levels, platelet count as well as clotting studies may significantly impact intraoperative decision making. In the context of a bleeding patient, abnormalities in the results of these investigations may warrant that the patient receive a blood transfusion.
Should transfusion of blood products be required, cross-match testing is required to determine, among others, blood type compatibility between the donor and recipient.
Arterial Blood Gas Test Investigations
This test uses arterial blood (usually sampled from the radial artery) to measure levels of oxygen and carbon dioxide as well make determinations about the patient's acid-base balance. These parameters are important measures of the patient's physiological status undergoing a surgical procedure and is used often to guide decisions related to anesthetic care.
Microbiology Tests Investigations
Microbiology tests are used to detect the presence of pathogenic microorganisms in a collected specimen. These specimens can be tissue or fluid aspirates. In addition to providing information about the presence and extent of an infection, microbiology tests also determine to which antibiotic a particular microorganism is sensitive.
Specimen Collection and Preservation
There are a number of different containers in which specimens can be collected and preserved for transfer to the pathology laboratory. Whether collected dry or preserved in a medium, specimen containers should of appropriate size and type and where required, sterile. The health care facility is required to provide containers and lids that appropriately sized to prevent contamination of the specimen. Safety is paramount and containers should also protect all who handle them from transmission of infection and contamination by preservation media such as formaldehyde. Radioactive specimens should be placed in appropriately shielded containers. Some commonly used collection and preservation methods are discussed below.
Dry collection Specimen Collection and Preservation
Specimen are either collected dry, or in a specific fluid, also known as medium.
An advantage to dry collecting a specimen is that it remains in its original state, without discolorations. Cytological specimens are often collected dry, and sent to a cytological laboratory. There are a few conditions that must be met for dry collection to be used, including:
- Transporting the specimen to the laboratory as soon as possible in order to optimize the yield of cultures and the interpretation of results. Bacteriological specimens should ideally be sent to the microbiology laboratory within one or two hours of collection.
- For a variety of specimens, if a delay is unavoidable, the specimen may require refrigeration. This does not apply for the following specimens: blood, cerebrospinal fluid, joint fluid, and cultures for Neisseria gonorrhoeae.
Frozen section Specimen Collection and Preservation
When immediate analysis of a tissue specimen is needed during a procedure, for example to determine oncological clearance, specimens are collected dry and transported to the laboratory to undergo a frozen section procedure. This entails quickly freezing the specimen then slicing and staining it. The specimen is then examined microscopically. The result frozen section is communicated from the pathologist to the surgeon intraoperatively. This is usually done telephonically with the circulating nurse relaying information between the two previously mentioned parties. Given the serious consequences of miscommunication, the circulatig nurse coordinates a verbal confirmation loop between the pathologist and surgeon. This involves having to say the result out loud and receiving a repeat-back of the result from both, confirming the result.
Formaldehyde Specimen Collection and Preservation
Formalin, a solution of 37% formaldehyde gas in water, is commonly used for preservation. This toxic solution is known as a fixative and it preserves tissue by: killing microorganisms, stopping enzymatic processes, and preventing decay. Fixation with formalin preserves the tissue collected for a long period of time. A disadvantage of fixation is that the specimen turns evenly gray, causing loss of macroscopic color differences. Formalin fixed specimens are not suitable for frozen section.
Formaldehyde has carcinogenic properties and caution should be taken whenever working with it. Contact must be kept to a minimum and the decantation of formaldehyde, or opening of containers with formaldehyde, is best be carried out in a fume cupboard with a ventilation that removes the noxious substances that are released.
Normal Saline Specimen Collection and Preservation
Specimens may also be preserved in normal saline. This solution does not directly prevent cellular decay but does have the advantage of being isotonic and does not therefore, cause lysis or swelling of cells.
Culture Swab Specimen Collection and Preservation
Bacteriological specimens collected with a cotton swab and packaged airtight in a ready-to-use test tube which contains a medium that ensures the survival of microorganisms without overgrowth. This collection method is used during procedures where there is a need to identify pathogenic microorganisms.
Collections of Fluids or Blood Specimen Collection and Preservation
Blood specimens can be collected in variety of tubes. Which tube to use is determined by the required investigation. Hemtological investigations are typically conducted on uncoagulated blood and therefore a tube containing EDTA (an anticoagulant) is used. Blood collected for clinical chemistry on the other hand requires that plasma be separated from the blood cells and its collection tube contains a gel that produces this effect.
Arterial blood for blood gas analysis should be collected in a special vacuum syringe and be transported to the laboratory immediately. This is important in order to prevent the mixing of blood with other gases such as oxygen which may affect the results of the analysis."
Handling the specimen
Specimen Handling - Practicalities
Specimen information should be discussed prior to the procedure to ensure there is clarity about what needs to be collected, how it should be prepared or preserved and what specific information needs to be communicated to the pathologist. This avoids errors such as incorrectly collecting a dry specimen in a fluid medium. Having specimen information to hand also aids smooth communication with the laboratory.
Typically the scrub nurse is the member of the surgical team who takes the lead in guiding the process of specimen handling. Labeling is a critical step in this process. The specifics may vary between centers but the method(s) chosen should fulfill the criteria of correct identification of specimen, using accurate and consistent information on labels and forms, or in a digital record. The labels and forms should include: date and time; personal data; nature of the specimen as well as its site of collection; the medium used for collection and the requesting surgeon.
Most rely on a courier system and/or pneumatic tube transport system to transport specimens from the operating room to the pathology labarotory. Wherever possible the transport of the specimen should be done by hand. Although this may introduce an element of delay, it mitigates against issues such as leakage and specimen misplacement.
Specimen handling very much relies upon the timeous relaying of accurate information as well as appropriate and timeous transit of the specimen through the chain of custody. This process will vary from hospital to hospital. A practical example is outlined below:
- The surgeon hands the specimen to the scrub nurse and verbally communicates the specimen's nature and what information should be added to the label.
- The scrub nurse hands the specimen over to the circulating nurse and verbally repeats the information received from the surgeon.
- The circulating nurse labels the container with the information obtained from the surgeon and scrub nurse. Again verbal confirmation is sought.
- The circulating nurse then performs preparation/preservation according to local protocol.
- At the end of the procedure the circulating nurse confirms which specimens have been obtained.
Specimen Rejection Criteria
Given the potential for serious adverse outcomes, pathology laboratories have strict guidance regarding rejecting specimens which have not been correctly handled. Errors that may occur during the during specimen handling are: incorrectly labeled containers; empty containers; an unidentified tissue site; the loss of a container during transport or the spilling, leakage or breakage during transport.
After the procedure, and before the patient leaves the operating room, a surgical checklist must be performed. This checklist is the third in a series of checklists that have to be performed perioperatively. A 'sign in' is performed before the induction of anaesthesia, a 'time out' is performed before the skin incision, and a 'sign out' is performed afterwards. It is important that all members of the surgical team are present during these 'stop-moments'. According to the World Health Organization, the following items must be included in this 'sign out' checklist:
- The name of the procedure performed
- Confirmation hat instruments, sponge and needle counts are correct
- How the specimens were labelled
- Whether there were any equipment problems that need to be addressed
- Surgeon, anaesthetist and scrub nurse review the key concerns for postoperative disposition of the patient
A digital or written operative report communicates perioperative patient information to other departments. It should be completed in full before the patient leaves the operating room. It is usually completed by the circulating nurse and the surgeon. The circulating nurse adds the operating time and the names of the entire surgical team as well as information from the 'sign out' checklist. The following information is added by the surgeon: preoperative diagnosis; the surgery performed; the findings during the procedure; complications; specimens collected and postoperative diagnosis.
What other information is documented is guided by local protocol. It include: the electrosurgical unit type and settings; operative positioning; drugs administered as well any additional actions taken.
Taking care of the administration
While the scrub nursed disposes of the instruments and the circulating nurse processes the specimens and clears the operating room, the anesthesia team deal with managing the patient's emergence from anesthesia. A member of the scrub team should be positioned by the patient's side during emergence. Uncontrolled movements during emergence place the patient at significant risk of falling.
If the patient is conscious, the team helps to transfer them to a hospital bed or trolley. In certain situations, the anesthetic team may elect to transfer before they have emerged from anesthesia. If the surgical table itself is a movable trolley, moving the patient from trolley to a hospital bed may be done in the recovery room. To avoid injuries to the surgical team, use of a transfer roller board is recommended. A HoverMatt may be used for the transfer of obese patients. This is an inflatable mattress onto which the obese patient is placed at the beginning of the procedure. It is not inflated at this point. At the end of the procedure, it is inflated and with an amount air supporting the patient it is easier to transfer them.
In certain circumstances has regained consciousness to the point that they are able to assist with the transfer. There is no situation in which it is appropriate for a patient who has received an anesthetic to transfer themselves without supervision and assistance.
Recovery Room Patient Transfer
After a surgical procedure, the patient is transferred to the recovery room for post-operative care. The patient's vital signs are monitored and anesthetic as well surgical complications watched out for. Post-operative issues such as pain and nausea/vomiting are managed. An element of disorientation is not uncommon and recovery staff should be on hand to reassure the patient as the anesthetic's effects wear off and they regain full consciousness. Patients in whom there is the expectation that no specialized postoperative nursing care will be required are managed in the recovery room and then transferred to the general ward when they meet discharge criteria. These criteria are determined by local protocol.
Post Anesthesia Care Unit (PACU) Patient Transfer
When it is clear that a patient's postoperative condition cannot be managed in the general ward, they are transferred from the operating room to the Post Anesthesia Care Unit (PACU). Here intensive monitoring equipment and specifically trained staff are used to provide more involved postoperative care. Ventilation may be provided, for example. PACU is typically part of the operating room complex and is run by staff from the anesthesiology department.
In some instances admission to the PACU is planned ahead. Patients in whom additional or intensive postoperative monitoring and care is anticipated, are candidates for admission. Patients undergoing major surgery and those with significant comorbidities are examples of candidates for PACU elective admission. The surgeon should discuss these patients with the PACU anesthetist timeously to allow for appropriate preparation. Emergency PACU admissions can be directly from the operating room or from the recovery room. Bed capacity is sometimes issue and it may be that need that patient's requiring PACU admission are instead admitted to the Intensive Care Unit (ICU). Local protocol guides these decisions."
Transfer to Recovery Room or PACU Patient Transfer
The transfer personnel should remove their gowns, masks and gloves before leaving the operating room. As described earlier, the transport takes place either on a trolley or on a bed, depending on the local protcol or specific surgical procedure performed. It is very important that at least three personnel are involved. An anesthesiologist or anesthesia nurse is positioned at the head in order to closelt monitor the patient while pushing the trolley. The scrub nurse or another surgical team member is positioned at the foot end and steers the trolley. 1 or 2 personnel guide the trolley from the side to prevent the patient from falling. This is very important because the patient is often still a bit restless and disoriented after following emergence from anesthesia. During the transfer the side rails of the trolley should be kept up.
Transfer of the patient
Upon arrival in the recovery room or PACU, a transfer of information takes place. Written communication alone is not sufficient to ensure patient safety when handing over responsibility passes for care. It is highly recommended that verbal communcation be used along with a postoperative checklist. The purpose of these checklists is to provide up-to-date, essential, and specific information about the patient. Information on the checklist is confirmed and where neccessary clarified verbally. The handover should allow for time to ask and respond to questions.
There will be interhospital differences in how and by whom patient handover should be conducted. Fairly commonly the anesthetist relays pertinent information regarding the anesthetic while the scrub nurse relays operative information. An example of a framework used for patient handover is the Situation, Background, Assessment and Recommendations (SBAR) system. The individual elements of this framework will briefly be discussed.
Situation Patient Handover
The name of the patient, and the date of birth should be clearly documented and noted. The procedure performed, including site and modifiers, if present, are also documented and noted.
Background Patient Handover
The following background information about the procedure is discussed:
- The type of anesthesic administered as well as the names of the anesthesia care provider(s) are noted. All medications administered intraoperatively are noted along with their dose and time of administration.
- Fluid balance whereby the type and volume of intravenous fluids administered are discussed, as well as the estimated urine output, blood loss and other fluid losses if applicable.
- Information related to the surgical site such as drains, tubes, dressings or packing.
- Any significant perioperative "operating room events "
Assessment Patient Handover
The following assessments are discussed:
- Airway and oxygenation status
- Hemodynamic stability
- Urine output
- Thermal status
- Presence or absence of surgical complications
- Level of pain
- Method of pain management
Recommendations Patient Handover
Furthermore, a number of recommendations for the post-operative provider to follow are made. With respect to postoperative care plan the following should be stated explicitly: what is required; how urgently, and what actions need to be taken when and by whom. For example post femoral popliteal bypass, the postoperative care plan should communicate that the leg should be checked at a set interval and the vascular surgeon contacted if pulses are absent or diminished.
Operating Room Cleaning
Disposal of instruments and environmental cleaning are important processes that when executed appropriately contribute to preventing contamination of: the surgical site; operating room personnel and equipment.
For a detailed description on how instruments are handled and delivered for to the course: "Cleaning, Disinfection & Sterilization of Instruments".
In most hospitals, the sterilization department is housed within the same building as the operating room.
After the patient has left the operating room the scrub nurse places the instrument sterilization cases in wire steel baskets. This is to prevent damage to the instruments during transport. The baskets are then placed in mobile container carts. These carts can be closed and locked with doors. The carts have a fixed place within the operating room complex, also known as a decontamination room. Instruments, other contaminated materials and trash are stored and transported from here.
Zoning Environmental Cleaning - Principles
Environmental cleaning, including the removal of trash or laundry should not be performed until the patient has left the operating room. Contaminated instruments should not be transferred through zones designated as a "clean zone". For a more detailed explanation of the different zones within an operating room complex refer to the course: 'Operating Room Design and Layout'. It is therefore to sensible to have the container cart placed near the operating room. The cart can be closed and transported to the decontamination room for the sterilization department staff to collect. When transport of instruments across a clean zone cannot be avoided, it is mandatory that they be covered with a clean surgical drape. An ideal zoning set up is to have a service corridor located next to the operating room complex, which can be accessed by sterilization department staff. After use instruments can then be placed directly into a hatch after which this is located between the operating room and this service corridor. The sterilization department staff can then take the instruments directly out of the hatch.
Biocontainer Environmental Cleaning - Principles
Blood and other potentially infectious materials or tissue should be discarded in a container that prevents leakage. The container must be labeled or color coded with a biohazard symbol. Suction containers with body fluids or blood are discarded in this container as well.
Garbage Bags Environmental Cleaning - Principles
Trash is either brought directly to the decontamination room, or transported via a hatch to the service corridor, where the support staff collect it. The kind of transport used depends on the layout of the operating room complex.
Sharps Disposal Container Environmental Cleaning - Principles
Care should be taken to distinguish between the nature of materials being disposed. For example, sharp disposables should not be disposed in a garbage bag. Doing so places the support staff at risk of injury or infection. Needles and scalpels disposed of in a specifically designed sharps disposal container. These are available in a variety of types and sizes. When full these sharps disposal containers should be disposed of appropriately.
Glass disposal container Environmental Cleaning - Principles
Medication is often packaged in glass bottles. These should be disposed of in a glass disposal container located inside the decontamination room.
Laundry Environmental Cleaning - Principles
Laundry bags are usually located in the corridor and are emptied by the support staff.
Cleaning between Procedures Environmental Cleaning - Practicalities
When the room is empty, equipment and furniture should be cleaned properly with an approved hospital disinfectant. Where available the cleaning staff are responsible for cleaning the operating room (OR). In other instances, the cleaning maybe needs to be performed by the scrub nurse and/or circulating nurse or the surgeon. The disinfectants used for this cleaning should contain antimicrobial pesticides. Cleaning between procedures should include cleaning of the anesthesia cart and equipment; the anesthesia machine; intravenous fluid stands; monitors; the surgical table and its attachments; transfer devices and overhead lights. The floor should be cleaned thoroughly.
Cleaning at the end of the operative schedule Environmental Cleaning - Practicalities
At the end of the operative schedule, the rooms should be cleaned by specifically trained personnel. The following areas should be cleaned:
- Fixed and ceiling mounted equipment
- Surgical lights
- All furniture and equipment
- Ventilation faceplates
- Horizontal surfaces
- Handles of cabinets
- Kick buckets
- Scrub sinks
Preparation of the operating room for the next procedure
Closing the Operating Room
At the end of the day the electrosurgical unit is unplugged, and the wall suction unit disconnected. The surgical table which runs on a rechargeable internal battery mains power plugged into the mains outlet to charge overnight.
The circulation cart and the anesthesia cart should be restocked with depleted disposables and medications, to ensure there is enough stock for the next day or next operative schedule. The lights are turned off.
In emergency operating rooms different rules often apply, given the constant requirement for readiness. Local protocol should be followed by operating room staff.