Appendix D. Site Visit Comparison Process (continued)

Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers

D3. Post-Operative Steps

Process Step / Facility FeatureAcademic Hospital, Off-Site ASCCommunity Hospital, Co-Located ASCFree-Standing ASCPediatric Hospital, Off-Site ASC
Placed on stretcher and transported to PACUSurgical assistant, nurse and anesthesiologist take patient to PACU.OR nurse call to check that PACU has room, otherwise wait in OR. Surgical assistant, nurse and anesthesiologist take patient to PACU.Anesthesiologist and nurse take to PACU. Anesthesiologist is at head and nurse is at foot. Call out "OR 2 to PACU".Circulating nurse take to PACU.
PACU facility9 bays separated by curtains. 3 reclining chairs for local anesthesia patients. PACU could technically hold 12 patients but not typical, 9 patients more usual.Recovery has curtained bays. There are 22 beds in phase 1, have to meet phase 1 criteria to then downgrade to phase 2, 30 minutes in phase2. Each bay has a bed with table at the foot. Sanitizer at every table. This is where the Purell and chart reside. There are also isolation rooms, but there are not many. In PACU nurses are gloved, not gowned. Also some patients stay for longer and if so then they get a blanket and a whole bed.  Outpatient is considered anything under 23 hours so some "outpatients" get room requests. These are observation patients.  
Patient to nurse ratio in PACU 2 patients to1 nurse, critical care is 1 to 1.Pediatric is 1 to 1, still asleep is 1 to 1, breathing problems is 1 to 1, and awake is 2 patients to 1 nurse. 
When needed: isolation ability and processNo isolation.Isolation room: designated cart for isolation, everyone with gown, mask, splash guard, disposable pulse ox. Used for MRSA, VRE, CDIF. Nurse never comes out into the rest of the room. Someone else will get meds. Cart stays outside the room so they only need one cart. It is stocked, just need someone to pass to the nurse. Sink is in room, gloves are outside. Pressure in room is set up for TB (negative pressure) if necessary. When transporting, clean rails of bed with Clorox wipes, then drape the entire patient with clean (not sterile) white sheet. Chart is wrapped in chucks (?) at end of bed. Private elevators. Try to discharge straight from the isolation room. Call Environmental Services to clean the isolation room. Tech will do own quick clean first. TB is closed for an hour before anyone goes in to clean. If you have several of these cases through the day, it tends to put the OR on hold.  
Blood pressure cuff: retained or attached in PACU?Attach blood pressure cuff in PACU.Blood pressure cuff is disposable and follows the patient.Retain blood pressure cuff, follows patient. These are cleaned between patients and not disposable. All patients get cuffs except localized.Not disposable. Full clean of blood pressure cuffs would be ideal between patients but not really possible. The reality is that cuffs are only wiped down between patients. Internal assessments show though that no difference in SSI between wiping cuffs off between patients or full cleaning, so not a concern.
Monitors attachedConnect patient to monitors.Connect patient to monitors.Connect patient to monitors.Connect patient to monitors.
Vitals collected: temperature, blood pressure, pulse (done several times to establish recovery progress)Vital signs every 15 minutes until discharge.  Looking for low oxygen, blood pressure, heart rate, temperature.Vitals, wakefulness, respiratory, oxygen. Temperature is a big concern because patient getting too cold can be a big risk.Hook up to monitor and pulse-ox, check blood pressure, oxygen, pulse, temperature. Monitoring breathing. Some people come out awake, or awake and talking, or out cold. Two sets of vitals taken that look good (maybe 3), indicates when phase one is finished.Yes.
CPAP machine used when needed Bariatric patients will need a CPAP machine to help breathing. At this ASC patients bring them from home. They hand it over to the ASC in Pre-op, where it is checked for functioning and the patient gets it back in PACU. Studies show that they do better with their own CPAP than another machine.  
Glucose checkedCheck blood sugar. Yes.Yes. If levels low, do sugar in IV.
Anesthesiologist gives report to PACU about patient and procedureYes.Anesthesiologist gives report to recovery room nurse. Circulating nurse also gives report which may have more details than anesthesiologist, but anesthesiologist debrief is usually more related to surgical issues.Anesthesiologist gives report on how procedure went.Yes.
Surgical site dressings checked for bleeding and bruisingCheck to see if the bandage shows signs of bleeding. If bleeding, call surgeon but do not take off dressings because the surgeon will redress the wound.Check dressing every half hour. If incision was large will check more often. Check for oozing and bleeding. PACU won't have a dressing changed unless the dressing is wet or bleeding. If change is necessary, apply gentle pressure and call Surgical Physician Assistant. Surgical PAs change dressings. Non-sterile gloves to take off old dressing, sterile gloves to put new dressing on. If it doesn't stop, maybe add suture.Check the site for color and bleeding and that dressing is clean and dry, no bleed through. Redress or reinforce based on surgeon's recommendation if problem.Depending on surgery will look at site. If sealed with Collodion then will look. If procedure was on urethra, will wait 45 minutes to maintain pressure on wound. Looking for bleeding and bruising, if surgeon available ask to look, if not, add pressure with gauze to stop bleeding and if bleed through add more and not remove original dressing. Bruising not visible at first. The main thing to get families to look for is hematomas, not just bruising.
What if complications are found?If bleeding not stopping will call anesthesia, they will then give instructions on what to do. If really nothing to do then call 911, stabilize patient before sending. Maybe once or twice a week send patient to ER.A common complication is colonoscopy perforation. Risk for perforation is .1%. Frequent because there are many colonoscopies since it only takes a good surgeon 15 minutes and it does not require a sterile room, only a clean room, and only uses one scope not lots of tools. Once perforated take directly to ER then are out in the hospital a couple of days, but most do not develop infections. Other complications can be if develop breathing problems and can't remove from ventilator or if extensive bleeding.  
Medicated for pain or nausea, if needed Medicate for nausea or pain.  
Hydration checked and water offered (no food) Monitor hydration through IV. Try not to give food in phase 1 except for medication. Water offered once awake.
Patient transitioned from Phase 1 to Phase 2 recovery When pain is below 5, hydration is ok, and nausea good, will transfer to phase 2. In phase 2 there are 3-4 patients per nurse.If they're thirsty, this can be an indicator of time to transfer to phase 2.Transferred to phase 2 when awake and drinking.
IV removedPACU tech takes out IV.Yes.Yes.IV removed in phase 2.
Bathroom trip offered Offer bathroom.  
Patient changes back into street clothes (sometimes after post-op instructions given)Tech helps them get dressed and bring upstairs since the facility is downstairs.Tech or family member will help them get dressed (after post-op instructions).Get dressed.Yes.
Patient transitioned to upright position in chair or wheelchair Patient put in recliner.Patient put in arm chair or wheel chair. 
Family allowed back into PACU?Rare for family to come back to PACU. If patient is younger or older, then will get family member to assist. Not considered sterile area so not restricted.Will bring in family to PACU early on only with special needs cases.Can bring anyone they want over 18 into PACU, but only one person. If they have a cough, then tell them to not come. Do not want small kids in PACU.Parents can go into PACU. Not let someone go back if visibly sick.
Wound care instructions and post-op instructions reiterated (given before in pre-op too)Give them wound care instructions as reminder to pre-op instructions.Call family back to PACU and go over discharge. Generic pre-printed instructions from ASC but also have physician specific pre-printed orders. Go over orders with them. Teach them how to empty/drain catheters etc. Teach them to give injections. Many patients come out with clear or gauze dressings. Told that they should not ever be saturated. Told if it is saturated, apply pressure, and add gauze. If bleeding doesn't stop with in 5 minutes, call doctor.Reiterate post-op care instructions given before in pre-op. Family cosigns post-op instructions, they get original. Some have special instructions based on physician and procedure. Some only have general instructions. Will instruct on drains if necessary. Discuss medications.Tell parents to not let children touch surgical site and dressings. Tell parent to keep kid's hands clean. If it is itchy, parents to put on gauze and ice pack. Provide both verbal and written instructions. If site had Chlorhexidine on it, told not to wash off because effective for 24 hours. If the wound is closed with Collodion then be careful not to remove. Do not wash for three days, then remove outer bandage wash with hydro peroxide and to only pat dry. Hard with urological procedure on baby, often get diarrhea in diaper, call urologist and maybe get permission to wash, but no sitting water.
Vitals checked once more before patient is then dischargedSurgeon checks on patient before discharge and will have written instructions about what to do before discharge but the final decision comes from anesthesia.Nurse checks vitals and re-assess. When nurse is certain that patient is okay, they ask if patient feels okay to go home.  
Transported out of ASCWheeled only if needed, walk otherwise.Sometimes leave in wheel chair, sometimes they want to walk and wait for car to come around.Yes.Yes.
PACU prepped for next patientYes.Yes.Yes.Yes.
How often are PACU bay curtains cleaned?Once a year curtains are cleaned. Once or twice a year the curtains are cleaned. 
How are monitors cleaned between patients? Wipe down cables and pulse-ox with alcohol swab. There are disposable pulse-ox, but they are not preferred. They are primarily used for pediatrics.Clean the pulse ox with wipes.Wipes.
Post-op call from ASC performedCall the next day to check in and ask how was your stay, do you understand instructions, do you know how to get a hold of surgeon?PACU nurses call every patient next day and ask about any problems or unexpected things. Check that they understand discharge instructions.Post-op phone call is done the next day. Brief call—how are you doing, pain, nausea, bleeding, happy with care, what to do for pain, trouble shooting as necessary. Tell them to check in with doctor.Next day post-op nurse does follow up call to see what the surgical site look like, if the child is vomiting, etc and answer questions. Many parents have a lot because parent get nervous so not remember all of their questions and will remember more by the time of the call.
Patient has post-op visit with doctor Have follow-up with surgeon to check adherence to instructions. A lot of the time people will actually not remove dressings when instructed to and the dressings will get wet and will macerate skin and allow bacteria into the wound.The surgeon will find out about any infections on post-op visit. Patient always calls surgeon back.  Surgeon sees patient a week later. 

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Page last reviewed April 2013
Internet Citation: Appendix D. Site Visit Comparison Process (continued): Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/stpra/stpraapd3.html