The Post Anesthesia Care Policy And Procedure Manual is part of MCN Healthcare’s ellucid® Policy Library. MCN Healthcare is the health care industry’s leading provider of TJC (formerly JCAHO) accreditation tools and CMS accreditation help, consisting of policy and procedure templates, forms, competencies and other compliance tools. MCN’s policy and procedure manuals are used in more than 25,000 healthcare organizations throughout the world to help with compliance, accreditation, and health care quality improvement.

All customizable policies, procedures, forms and compliance tools are provided as templates in Microsoft Word format. MCN’s policy and procedure library consists of 87 policy and procedure manuals and more than 18,000 compliance tools. This is the most comprehensive collection of customizable policy templates, policies, procedures, forms, competencies, job descriptions, and performance evaluations available anywhere—all kept up to date with the latest standards from CMS, Joint Commission, FDA, HIPAA, OSHA, ACHC, AAAHC, USP, and utilizing standards of practice from ANA, AORN, ENA, and more.

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SECTION I - ENVIRONMENT OF CARE

Environment of Care

PACU Safety

Guidelines to Prevent Common Equipment Hazards in the PACU

Hazardous Materials and Waste - Training

How to Read MSDS

Compressed Gas and Oxygen Use

Monthly Radiation Exposure Monitoring (Dosimeter)

Fire Safety

Use of Electrical Equipment in Oxygen Enriched Environment

Electrical Equipment Safety in the PACU

Maintenance and Repair of Patient Care Equipment

Use of Clinical Alarms on Medical Equipment

Infusion Pumps - Equipment Inspection, Care and Maintenance

Patient-Ventilator Maintenance/Monitoring - Recommended Parameter

SECTION II - EMERGENCY MANAGEMENT

HICS Responsibilities Job Action Sheet - Surgical Services Nurse Manager

SECTION III - HUMAN RESOURCES

Management of Personnel

Staff Qualifications and Competency

Evaluation of Staff Competency

New Employee Orientation

PACU RN Orientation

PACU Orientation Checklist

Staff Education and Training

Education Profiles

BCLS/ACLS Resuscitation Certification

Student Role/Preceptorships in the PACU

Position Description/Performance Evaluation - PACU Head Nurse

Performance Evaluation - Population-Specific/Age-Related Competency - PACU Head Nurse

Annual Competency Clinical Skills Assessment - PACU Head Nurse

Position Description/Performance Evaluation - PACU Registered Nurse

Performance Evaluation - Population-Specific/Age-Related Competency - PACU Registered Nurse

Annual Competency Clinical Skills Assessment - PACU Registered Nurse

Annual Competency - 2008 Joint Commission National Patient Safety Goals

Restraint Application/Removal Competency Checklist - Acute Medical Surgical Setting

SECTION IV - INFECTION PREVENTION AND CONTROL

Attire in the PACU

Attire in the Operating Room

Hand Hygiene - CDC Guidelines

Standard Precautions

Transmission-Based Precautions (Isolation Precautions)

Asepsis

Infection Control in the PACU

Event-Related Shelf Life - Sterile Storage

Management of Patients with Methicillin Resistant Staphylococcus Aureus (MRSA)

Care of Immunosuppressed Patients

Visitors in the PACU

Management of Accidental Blood or Body Fluid Exposure/Contamination

Disposal of Sharps

Sharps Injury Protection Plan

Sharps Injury Log Form

Definition of Biohazardous Waste

Handling of Biohazardous Waste

Cleaning of Ultrasonic Nebulizer

Cleaning and Maintenance of Stretchers

SECTION V - INFORMATION MANAGEMENT

Confidentiality of Information - General Issues

Legibility of Medical Record Documentation

Unacceptable Abbreviation and Symbol List

Acceptable Abbreviations List

SECTION VI - LEADERSHIP

Scope of Service

PACU Nursing Philosophy and Goals

Scope of Responsibility - Chairpersons of Surgical and Anesthesia Services Committees

Medical/Nursing Administration of the PACU

Staffing Patterns

Staff Scheduling

On-Call Staffing

Sentinel Event

Resolution of Potential Conflict with Staff Member’s Cultural/Ethical/Religious Belief System

Responsibility and Accountability to the Medical Staff and Administration

Research

Committee Representation by the PACU/Operating Room Staff

SECTION VII - MEDICATION MANAGEMENT

Medication Reconciliation/Verification

Medication Reconciliation/Verification Form

High Alert Medication Management

Decreasing Medication Errors

Independent Double Check Before the Administration of Heparin

Concentrated Electrolyte Solutions and Other Drug Concentrations

Automated Dispensing Machines - Policies and Procedures

Automated Dispensing Machines - Access to

Automated Dispensing Machines - Stock Medication

Automated Dispensing Machines - Inspection and Inventory

Automated Dispensing Machines - Malfunctions/Downtime

Automatic Dispensing Machines - Controlled Substances

Controlled Drug Management on Patient Care Units

Disposal of Controlled Substance Patches

PACU Narcotics

Controlled Drug Sheet

Emergency Crash Carts

Emergency Crash Cart Security and Accountability

Sample Crash Cart and Defibrillator Checklist Signature Form

Emergency Medications

Emergency Medications List

Prescribing/Ordering - General Practices

Verbal and Written Orders - General

Medication Ordered STAT and at Specified Time Intervals

Standing Orders

Titrating Medications

Range Orders for Medications

Telephone, Verbal and Written Orders for Medication

Pediatric Dosing - General Guidelines

Pediatric Dosing Guidelines for Emergency Medications

Pharmacist Order Verification

Automated Dispensing Machines - Pharmacist Order Verification and Drug Distribution

Automated Dispensing Machines - Emergency/STAT Medication Orders

Medication Administration

Automated Dispensing Machines - Removing Medications

Programmable Pumps for the Administration of Continuous IV Heparin

Pain - Patient Controlled Analgesia (PCA)

Use of Multiple Dose Vials (MDVs)

Medication and Solution Administration - Invasive Procedures

Safe Medication Practices

Monitoring Effects of Medications on Patients

Adverse Drug Reaction Reporting Form (Internal)

Potential Adverse Drug Reaction Form

Medication Errors

Medication Inadvertent Incident Report

Medication Inadvertent Incident Report Form

Medication Error Analysis Tool

Performance Improvement Analysis - Medication Inadvertent Incident Form

SECTION VIII - PROVISION OF CARE, TREATMENT AND SERVICES

Admission and Assessment

Patient Assessment and Reassessment

Use of PACU Scoring Guidelines

Pain Assessment, Reassessment and Management

Pain Assessment in Children

Assessment Pain Scale

Pain Scale Examples

Behavioral-Physiological Pain Scale for Nonverbal and Preverbal Patients

Care of the Latex Sensitive Patient

Latex Allergy Assessment Form

Latex and Non-Latex Alternatives

Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation

Documentation in the PACU

Post Anesthesia Care Unit Record Form

Pre and Post Anesthesia Evaluation Policy

Pre and Post Anesthesia Evaluation Form

Care, Treatment and Services

Patient Identification for Clinical Care and Treatment

Hand-Off Communication

Routine Patient Care in the PACU

Critical Tests and Critical Results and Values Reporting

Invasive Procedure Site Identification

Invasive/Surgical Procedure Verification/Time Out Checklist

Criteria for Notifying Anesthetist

Planning and Implementation of the Plan of Care

Postoperative Care Plan

Evaluation of Nursing Interventions

Perioperative Nursing Care Plan

Interdisciplinary Collaboration

Post Anesthesia Orders Form

Physician Visits

Arterial Line Pressure Monitoring

Blood/Blood Components - Transfusion

Blood/Blood Components - Transfusion Reactions

Capnography

Code Blue in the PACU

Emergency Equipment in the PACU

Defibrillation

Doppler Ultrasound

Endotracheal Suctioning in Mechanically-Ventilated Adults and Children Using Artificial Airways

Endotracheal Suctioning - Blind

Endotracheal Tube Care

Extubation of Post Anesthesia Patients

Hypothermia

Initiation of Ventilator Care

Management of Patient with Malignant Hyperthermia (MH)

Malignant Hyperthermia (MH) Cart

Nursing Management of Patients with Casts

Oral and Nasal Pharyngeal Airway Insertion

Oral/Nasal Suctioning

Oxygen Administration per Nasal Cannula

Oxygen Administration per Simple Mask

Patients with Sleep Apnea

Post Anesthesia Care of the Geriatric Patient

Post Anesthesia Care of the GI Lab Patient

Post Anesthesia Care of Joint Arthroplasty Patients

Post Anesthesia Care of Patients Post Cesarean Section

Post Anesthesia Care of the Patient with Spinal Anesthesia

Post Anesthesia Care of the Pediatric Patient

Prevention of Tubing/Catheter Misconnections

Restraint Use for the Management of Nonviolent, Non-Self Destructive Behavior (Non-Behavioral Health Purposes)

24-Hour Restraint Record Form

Sedation

Sedation Monitoring Form

Techniques for Elevating Blood Pressure

Standard of Care - PACU Services - Discharge Appropriateness

Standard of Care - PACU Services - Management of Spinal Anesthesia Recovery

Standard of Care - PACU Services - Postoperative Pain Management

Jail Custody Patients

Patient and Family Education

Education of Patient and Family

Sample Patient Educational Materials

Discharge Instructions

Outpatient Post-Op Instructions and Physician’s Orders

Outpatient Post-Op Instructions and Physician’s Orders - D&C

Outpatient Post-Op Instructions and Physician’s Orders - Breast Surgery

Outpatient Post-Op Instructions and Physician’s Orders - Cataract

Outpatient Post-Op Instructions and Physician’s Orders - Laparoscopy - GYN

Outpatient Post-Op Instructions and Physician’s Orders - Hernia

Outpatient Post-Op Instructions and Physician’s Orders - Orthopedic Procedure

Outpatient Post-Op Instructions and Physician’s Orders - Tonsillectomy

Outpatient Post-Op Instructions and Physician’s Orders - Post Transfusion

Outpatient Post-Op Instructions and Physician’s Orders - GI Patients

Patient Discharge/Transfer

Discharge from PACU

Transfer of the Surgical Patient to the Special Care Unit

Direct Admit of Postoperative Patient to the Special Care Unit

Patient Transfer from PACU to the Patient Care Unit

Transfer Report to the Patient Care Unit for Patients from PACU

Discharge from Pain Management Program

SECTION IX - PERFORMANCE IMPROVEMENT

Performance Improvement Plan

Post Anesthesia Care Unit PI Monitoring and Evaluation Plan

Post Anesthesia Care Unit PI Trending Sheet

Post Anesthesia Care Unit PI Outcome Evaluation

Post Anesthesia Care Unit PI Volume Measures/Statistics

Standard of Care - Admission

Standard of Care - Blood and Fluid Precautions

Standard of Care - Care of the Patient

Standard of Care - Maintenance of Fluid/Electrolyte Balance

Standard of Care - Management of Pain

Standard of Care - Discharge from PACU

Performance Measure Summary Form

Performance Improvement Quarterly Report Form

Incident Reporting in the PACU

Performance Improvement Indications and Notification Form - Surgery - Anesthesia - PACU

Incident Reporting Staff Questionnaire Form

SECTION X - RECORD OF CARE, TREATMENT AND SERVICES

Documentation of Operative and Other High-Risk Procedures

Maintenance of Logbook for PACU

SECTION XI - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

Patient Rights and Responsibilities

Informed Consent

Authorization for and Consent to Surgery or Special Diagnostic or Therapeutic Procedures

Blood/Blood Component - Informed Consent

Blood/Blood Component Transfusion Consent Form

Recordings, Films or Other Images of Patients

Authorization and Consent Form - Recordings, Films or Other Images, and Publication

Refusal of Blood/Blood Component Transfusion

Refusal to Permit Blood/Blood Component Transfusion Form

Do Not Resuscitate (DNR)

Advance Directives

Pain Management Policy Statement

Patient Rights and Responsibilities for Pain Management

SECTION XII - WAIVED TESTING

Waived Testing