Immediate Post-anaesthesia recovery 2013 supplement - aagbi

UK National Core Competencies for Post-anaesthesia Care 2013Immediate Post-anaesthesia Recovery 2013 supplement

CONTENTSGlossary of terms 3Introduction 5Competency 1 Communication 7Competency 2 Professional development 9Competency 3 Clinical leadership 10Competency 4 Clinical governance 11Competency 5 Assessment and management of the airway 13Competency 6 Assessment and management of breathing 16Competency 7 Assessment and management of the circulation 17Competency 8 Assessment of level of consciousness 18Competency 9 Monitoring during recovery 19Competency 10 Intravenous access and fluid balance 21Competency 11 Applied knowledge of pharmacology in peri-operative care 22Competency 12 Management of postoperative pain, nausea and vomiting 24Competency 13 Recovery emergencies 26Competency 14 Post surgical care 29Appendix 1 312

GLOSSARY OF TERMSAAGBIAIMSAVPUBARNABVMCODPCPAPCPDDVTECGGCSHDUHPCICULMAMHNCEPODNESNIBPNMCNPSAODPPACUAssociation of Anaesthetists of Great Britain and IrelandAnaesthetic Incident Monitoring StudyAlert, Verbal, Pain Unresponsive scoring system for conscious levelBritish Anaesthetic and Recovery Nurses AssociationBag, valve, mask ventilationCollege of Operating Department PractitionersContinuous positive airway pressureContinuing professional developmentDeep vein thrombosisElectrocardiogramGlasgow Coma ScaleHigh dependency unitHealth Professionals CouncilIntensive care unitLaryngeal mask airwayMalignant hyperpyrexiaNational Confidential Enquiry into Patient Outcome and DeathNHS Education ScotlandNon-invasive blood pressureNursing and Midwifery CouncilNational Patient Safety AgencyOperating department practitionerPost-anaesthesia care unit3

PCApCO2PDPPONVPPEQISRAERCNRCSSaO2SPSPETTPatient controlled analgesiaPartial pressure of carbon dioxidePersonal development planPostoperative nausea and vomitingPersonal protective equipmentNHS Quality Improvement ScotlandRing/Adair/Elwyn endotracheal tubesRoyal College of NursingRoyal College of SurgeonsOxygen saturationScottish Patient Safety ProgrammeTracheal tube4

INTRODUCTIONThe provision of safe care during recovery from anaesthesia and surgery relies heavily on investment in the education and training of post-anaesthesia careunit (PACU) staff. Maintenance of standards requires continual update such as resuscitation skills, application of new techniques and advances in painmanagement. PACU staff are specialists and often play a key role in the education of others, including other theatre staff, ward-based nurses, midwives andtrainee doctors. All PACU staff should receive training, tailored to meet the needs of the individual and the local service but meet the national standardsdefined in this document.The concept of recovery rooms was first discussed and documented in the late 19 th century as anaesthesia was evolving. The importance of specialistnursing care for postoperative patients was recognised [1]. A study during the 1940s in the United States recommended the continuing development of therecovery room as being an essential part of the post-anaesthesia care pathway. This study highlighted, amongst other factors, airway obstruction as a keyfactor contributing to potentially preventable postoperative deaths [2].Dramatic advances in anaesthesia and surgery over the last 150 years have contributed significantly to the fall in morbidity and mortality. Nonetheless deathsstill occur during the recovery phase of postoperative care. The National Confidential Enquiry into Peri-operative Outcome and Death (NCEPOD) addressedthis issue in its 2001 report Changing the way we operate [3] and stated “Immediately after surgery all patients not returning to a special care area (e.g. ICU orHDU) need to be nursed by those trained and practised in the postoperative recovery area. If there are separate arrangements for staffing the operatingtheatre out of hours, these must include the provision of specialised recovery staff.”A review of recovery room critical incidents was published by the Anaesthetic Incident Monitoring Study in 2002 [4] that detailed the proportion and type ofincidents encountered in recovery rooms in Australia and the United States and called for ongoing education and quality assurance programmes to bedeveloped to reduce these events.A report released by NHS Quality Improvement Scotland (2003) demonstrated that not all staff who recover patients postoperatively are fully trained to therequired standard and that much of the recovery training was on an ad hoc and informal basis raising particular concerns in remote locations such asremotely located operating theatres and the radiology departments [5].Basic training for PACU starts with achievement of entry-level competence during nursing or operating department practitioner (ODP) training programmes oflearning. This individual requires supervision and mentoring until he/she has acquired the competencies to care safely and successfully for a patient in thePACU. Thereafter they are expected to maintain, develop and enhance their practice through practical experience, further learning and continuingprofessional development. They will be expected to populate and maintain a lifelong portfolio of experience during their training and working life. Registeredpractitioners with current experience of working in the PACU are able to have prior qualifications and experience recognised.The competencies required by PACU staff are both professional and clinical. The professional components are:• Communication• Professional development• Clinical leadership• Clinical governance5

The clinical components are:• Assessment and management of the airway• Assessment and management of breathing• Assessment and management of the circulation• Assessment of consciousness• Monitoring during the immediate postoperative phase• Intravenous access and fluid balance• Applied knowledge of pharmacology in peri-operative care• Management of postoperative pain,• Management of postoperative nausea and vomiting (PONV)• Management of surgical and anaesthetic emergenciesIn specialised areas of surgery, such as paediatrics and obstetrics, additional specific competencies are required.This document uses work previously published by Quality Assuring Continuing Professional Development and by NHS Education Scotland. The threerelevant documents are A Route to Enhanced Competence in Perioperative Practice for Operating Department Practitioners and Nurses. (NHSEducation for Scotland. A Route to Enhanced Competence in Perioperative Practice for Operating Department Practitioners and Nurses. Edinburgh:NES, 2002.)Core Competencies for Anaesthetic Assistants 2011 http://www.nes.scot.nhs.uk/media/4239/anaesthetic_core_competencies_2011.pdf andPortfolio of Core Competencies for Anaesthetic Assistants 2012 http://www.nes.scot.nhs.uk/media/1410332/nesd0050_smaad_portfolio_2012.pdfThis document has been modified following consultation with other stakeholders across Great Britain and Ireland (see appendix 1). All standards andrecommendations described in this document should be applied to all recovery areas where anaesthesia is administered including obstetric, cardiology,radiology, dental and mental health units as well as community hospitals.References1. Radford M. Recovery nursing services: An evolution. British Journal of Perioperative Nursing 2003; 13:155-8,160-1.2. Hatfield A, Tronson M. The Complete Recovery Room Book, 4 th edition. New York: Oxford University Press, 2009.3. NCEPOD. Changing the Way we Operate. www.ncepod.org.uk/pdf/2001/01full.pdf (accessed 18/10/12).4. Kluger MT, Bullock MFM. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002;57: 1060-66.5. Healthcare Improvement Scotland. National Overview September 2005, Anaesthesia – Care Before, During and After Anaesthesia.http://www.healthcareimprovementscotland.org/idoc.ashx?docid=b19010c9-13fc-4f4a-be49-916919990246&version=-1 (accessed 18/10/12).6. Association of Great Britain and Ireland. Immediate Post-anaesthesia Recovery 2013. Anaesthesia 2013; 68: 288-97.6

COMPETENCY 1: COMMUNICATIONCompetency 1 Knowledge and skills Suggested indicators1.1 Apply effective communication skills inorder to promote clinically effective patientcare.Understands and applies principles of goodcommunication with patients, carers andperi-operative team members.Assess, plan, implement and evaluateindividualised care using a recognised nursingframework in collaboration with all members ofthe multidisciplinary team.1.2 Establish and maintain effective,professional relationships with patients, carersand staff in all disciplines.Provides accurate, concise and relevant verbaland written information related to peri-operativepatient care.Alerts appropriate members of themultidisciplinary team to changes in patientʼscondition.Acquires knowledge of Guidelines for recordsand record keeping (Nursing and MidwiferyCouncil (NMC), 2004) and Standards ofconduct, performance and ethics (HealthProfessionals Council (HPC), 2003).Demonstrates use of information technologyincluding computers and data managementskills.Uses appropriate listening and respondingskills to develop relationships with patients,carers and staff.Interpret an anaesthetic chart that includespre-operative assessment and intraoperativeobservations of vital signs and documentationof fluids and drugs administered.Communicate changes in patientʼsobservations appropriately.Treat patients in a non-judgmental manner,maintaining their dignity at all times.Demonstrate concern and respect for patientsand carers.7

Articulates role within peri-operativeteam Demonstrates knowledge ofteamwork strategies related to the perioperativeenvironment.Use effective communication strategies withpatients, anaesthetists and surgeons.1.3 Apply the principles of good communicationto promote trust and confidence.Educates and informs patients and carersattending the PACU.Complies with local and national policies andprotocols regarding record keeping.Keeps accurate and comprehensive records.Recognise patientʼs feelings of vulnerability.Provide reassurance, comfort and appropriatephysical and psychological support.Maintain patient records completely andaccurately.1.4 Admission of patient to PACU. Understands admission protocol for PACU.Describes preparation of PACU for receiving apatient into the unit.Identifies patients not suitable for admission toPACU.Safely admit patient to PACU includingmandatory documentation.Start discharge planning of patient toappropriate area.1.5 Discharge of patient from PACU. Understands discharge criteria for the unit.Explains significance of each criterion forpatients well being.Understands the process for discharge fromPACU to trained staff accepting the patient intotheir care.Identify patient fit for discharge and meetingagreed discharge criteria.Ensure completion of relevant documentation.Handover care to appropriately trained staffmaintaining patient dignity including fulldocumentation of the process.8

COMPETENCY 2: PROFESSIONAL DEVELOPMENTCompetency 2 Knowledge and skills Suggested indicators2.1 Demonstrate personal continuingprofessional development (CPD) in recoveryskills.2.2 Contribute to the continuing professionaldevelopment needs of the multidisciplinaryteam.2.3 Contribute and promote an environmentthat encourages CPD.Keeps a professional portfolio of learning andexperience gained.Recognises own limitations, identifiesprofessional development needs and developsa personal development plan (PDP).Uses appropriate resources and reflectivepractice to enhance knowledge and skills.Demonstrates personal accountability forensuring own clinical competence.Contributes to peri-operative teachingprogrammes by promoting clinically effectivepractice.Supports and assesses learners.Offers clinical supervision to others asappropriate.Participates in performance appraisalprogrammes.Develops and delivers teaching appropriate tothe PACU environment.Demonstrates ability to develop and accesslearning resources.Maintain a personal portfolio.Undertake appraisal and document evidence ofachievements.9

COMPETENCY 3: CLINICAL LEADERSHIPCompetency 3 Knowledge and skills Suggested indicators3.1 Demonstrate leadership skills in order toenhance patient care.3.2 Support and promote clinical effectivenessby developing an evidence-based approach topostoperative care.Develops autonomy in own role within therecovery room.Makes effective clinical decisions and managesresources.Shows evidence of research awareness.Adapts clinical practice in light of currentresearch.Motivates and supports others in developingevidence-based practice.10

COMPETENCY 4: CLINICAL GOVERNANCECompetency 4 Knowledge and skills Suggested indicators4.1 Identify and manage risks andhazards.4.2 Understand how to recognise acritical incident or near miss and followlocal and national reportingmechanisms.4.3 Participate and contribute to aquality assurance strategy.Understands the principles, issuesand factors relating to riskmanagement.Uses knowledge appropriately toeliminate or reduce these risks.Understands critical incidents, theirdefinition, actions required including aworked example.Aware of local and national criticalincident reporting policies.Uses knowledge of national and localmeasures of quality assurance todevelop and participate in highquality peer review audit.Apply manual handling techniques appropriately using availableaids. Attend regular updates.Demonstrate safe management of clinical waste, sharps, drugsand chemicals.Use personal protective equipment (PPE) and be aware ofinfection control principles.Comply with national and local guidance on single-use items andmedical device decontamination.Report and feedback on critical incidents.Complete local critical incident forms satisfactorily.Critical incidents that may occur include:Acute or sub-acute airway obstructionCardiopulmonary arrestNeed for cardiovascular support (inotropes, vasoconstrictors,anti-arrhythmics)Inadequate reversal of neuromuscular blocking drugsNeed for urgent review of patient by anaesthetist.Need for ventilatory support (CPAP, tracheal intubation,lung ventilation)Severe pain that is difficult to control Unduly prolonged stayin PACU (>2 h) Significant hypothermia (

4.4 Demonstrate and promote thedelivery of recovery care within aprofessional, ethical and legalframework.4.5 Demonstrate personal andprofessional accountability in relationto the role of recovery of thepostoperative patient.Discusses and applies the principlesof ethical, legal and professionalissues affecting patient care,ensuring appropriate documentationthat follows national and localdirectives. Understands theimportance of confidentiality.Applies the principles ofaccountability to the care of thepatient following surgery. Practiseswithin the limitations of personalscope of practice and, whereappropriate seeks guidance andsupport from colleagues whenexposed to new or unfamiliarprocedures or situations.Awareness of concept of:informed consent in adults and childrenlegal issues relating to patients with learning disabilities or mentalhealth difficultiespatient groups including Jehovahʼs Witnesses and advance patientdirectives.Adhere to the NMC and HPC codes of conduct.http://www.aagbi.org/sites/default/files/Jehovah%27s%20Witnesses_0.pdfTake on appropriate responsibility.Show recognition of own limitations with reflection onperformance.12

COMPETENCY 5: ASSESSMENT AND MANAGEMENT OF THE AIRWAYCompetency 5 Knowledge and skills Suggested indicators5.1 Apply knowledge of the anatomy andphysiology of the upper airwaytomanagement of the airway in the PACU.5.2 Can maintain an airway during emergencefrom anaesthesia.Understands those aspects of the anatomy ofthe upper airway which are relevant to airwaymanagement including physiological changesto the airway postoperatively as aconsequence of anaesthesia and surgery.Can recognise signs of upper airwayobstruction or compromised airway using theʻlook, listen and feelʼ approach.Can perform simple manoeuvres to establisha clear airway:effective head tilt chin liftjaw-thrustoropharyngeal suctioninsertion of an appropriate oropharyngealor nasopharyngeal airway.Describe the anatomy and physiology of theupper airway.Discuss the physiological changes caused byanaesthesia and surgery.Discuss oxygen requirements in the immediatepostoperative period.Describe signs of partial and complete airwayobstruction.Demonstrate manoeuvres to clear the airwayon a patient or manikin as described inimmediate life support (ILS) coursecurriculum.5.2a Assist in maintaining an airway duringbag and mask ventilation.Can hold a face mask in position, ensuring agas-tight seal, or perform manual intermittentpositive pressure ventilation (IPPV).Can identify suitable breathing systems.Can describe features of self-inflating bag anddemonstrate its use.Demonstrate ability to perform either role intwo-person bag and mask ventilation asdescribed in the immediate life support (ILS)course curriculum.Demonstrate bag-valve-mask (BVM)technique for ventilatory support using anAmbu self- inflating bag or similar.Explain need of proficiency in this skill in thetheatre suite, PACU and during intra-hospitalpatient transfer.13

5.3 Understands features of oxygen deliveryequipment.Demonstrates familiarity with and use offace masks: (types, design features, includingfixed and variable performance designs).nasal cannulaenebulisersbreathing circuits including T-piecespiped gases and oxygen flowmetersoxygen cylinders.Choose an oxygen delivery system appropriatefor a particular patient.Explain rationale behind choice.5.4 Can set up and assist the anaesthetist withemergency intubation of the trachea.Sets up intubation equipment tray / trolley. Ableto test the equipment.Can select appropriate tracheal tube (TT).Positions the patient appropriately and assiststhe anaesthetist with routine intubation of thetrachea.Assist in elective intubation of patient ormanikin.Calculate TT size (diameters and lengths)using standard formulae.Explain morbidity associated with use ofincorrect tube size.5.5 Ability to select appropriate airwayequipment for use in an emergency.Demonstrates detailed knowledge ofemergency airway equipment, including salientfeatures of each and their use.Demonstrates detailed knowledge of laryngealmask airway (LMA), TT and other methods ofsecuring the airway.Describe indications for use of straight andcurved bladed laryngoscopes, specialisedlaryngoscopes, forceps, bougies andintroducers.Describe indications for the use ofLMAintubating LMATT (including double lumen, RAE andmicrolaryngeal tubes)cricothyroidotomy and tracheostomy.14

5.6 Demonstrate ability to place a LMAin an adult patient.5.7 Awareness of risks and complications ofremoving an airway.Ability to assess when it is safe to do so.5.8 Ability to prepare and check appropriatesuction equipment.Demonstrates LMA placement in an adultpatient equating to ILS course standard. (PACUstaff need to be proficient in using an LMA in anemergency).Objectively assesses patientʼs neuromuscularfunction.Prepares and positions patient for removal ofairway devices.Appropriate airway management followingremoval.Demonstrates knowledge of types of suctioncatheters and their appropriate use.Site an LMA in a manikin.Demonstrate appropriate management forremoval of airway devices.Describe the range of suction equipmentavailable. Demonstrate the assembly and useof appropriate equipment.5.9 Ability to prepare and check appropriateairway equipment.Demonstrates knowledge of oxygenadministration devices and masks.Describe the range of airway equipmentavailable. Demonstrate the assembly andcorrect use of appropriate devices.15

COMPETENCY 6: ASSESSMENT AND MANAGEMENT OF BREATHINGCompetency 6 Knowledge and skills Suggested indicators6.1 Can apply knowledge of the anatomy andphysiology of the respiratory system toassessing the adequacy of breathing inpatients in the PACU.6.2 Can apply knowledge of effects ofpharmacology of anaesthetic agents and ofsurgery upon the respiratory system.Understands those aspects of the anatomy andphysiology of the respiratory system incontrolling breathing.Understands effects of anaesthesia andsurgery on respiration.Understands the effects of anaesthesia andsurgery on respiratory function.6.3 Can assess respiration. Describes postoperative patterns of respiration.Describe the signs of obstructed breathing.Can describe, identify and use equipment usedfor assessing the respiratory system.Describe the anatomy and physiology of therespiratory system.Discuss the physiological changes caused byanaesthesia and surgery and the changes inoxygen requirements in the immediatepostoperative period.Describe the signs and symptoms ofinadequate reversal of neuromuscular blockadeand central respiratory depression. Seecompetency 11.Describe the mechanism of inspiration andexpiration and factors controlling respiration.Assess the airway, chest movement,respiratory rate, rhythm and colour.Accurately measure respiratory rate.Can identify use of accessory muscles andpresence of tracheal tug.Demonstrate safe use of pulse oximeters andstethoscopes.6.4 Can identify patients with pre-existingrespiratory disease.Recognises patients with pre-existingrespiratory disease and the effects of surgeryand anaesthesia.Identify and demonstrate appropriatemanagement of patients with respiratoryinsufficiency.6.5 Can identify patients at risk of postoperativehypoxia and manage appropriately.Can identify signs and symptoms of hypoxia,respiratory depression and impendingrespiratory failure.Understands the use of appropriate monitoringequipment.Describe hypoxia and cyanosis. UsesUse pulse oximetry and capnographyappropriately.16

COMPETENCY 9: MONITORING DURING RECOVERYCompetency 9 Knowledge and skills Suggested indicators9.1 Can undertake full patient assessment onadmission to the PACU and in the immediatepostoperative period.9.2 Demonstrate knowledge of monitoringequipment used in PACU including normalparameters and need for interventions whenoutside these parameters.9.2a Can establish routine monitoring.Understands physiological consequences ofsurgery and anaesthesia.Able to use and identify abnormalities using:Pulse oximeters including indications forarterial blood gas sampling.Capnographs including significance ofend-tidal CO2 values.Invasive arterial pressure lines includingrecognition and management of hyperandhypotension.ECG including basic interpretation of rate,rhythm and ischaemia. Understandsindications for performing a 12 lead EGC.Temperature probes and warmingdevices.Recognises signs and symptoms ofadequate neuromuscular function.Urine output as an indicator of renalfunction.Able to assess wound drainage andsurgical procedure.Demonstrate ability to assess airway,breathing, circulation, conscious level, drugtherapy, dressings, drains and fluid balance.Set up routine monitoring of SpO2, NIBP,ECG and temperature.Demonstrate ability to establishcapnography measurement, use nervestimulator and urimeter appropriately.Perform 12-lead ECG and documentaccurately.Measure temperature using appropriateequipment and take appropriate action tomaintain normothermia.Use a urimeter.Record wound drainage accurately. Changedrain bottles. Troubleshoot and managewound drainage systems.19

9.3 Perform charting of physiological data anddescribes patientʼs clinical status appropriatelyto the anaesthetist and other staff members.Understand the significance of trends.9.4 Uses available near-patient testing as amonitoring tool.Can measure haemoglobin (Hb) and bloodglucose concentrations and describe risksassociated with abnormal values.9.5 Can assist during establishment of centralvenous and invasive arterial pressuremonitoring.9.6 Able to record and interpret data frominvasive central venous and arterial monitors,identifying values outside normal parameters.Can set up a pressure transducer and takeblood samples from central venous and arteriallines.Able to chart monitor values using standardsymbols.Recognises adverse trends which indicate risk.Identifies common artefacts.Describes patientʼs clinical status to theanaesthetist. Able to alert staff to adversemonitoring trends pre-empting development oflife-threatening emergencies.Able to use near-patient testing for Hb andblood glucose and describe risks associatedwith abnormal values.Shows knowledge of normal parameters andactions to be taken when values are abnormal.Understands relevance in paediatric patients.Can calibrate near-patient testing machines(using manufacturersʼ guidelines).Able to prepare the necessary equipment.Assists in positioning and supporting thepatient, skin preparation and helping to preventaccidental movement during the procedure.Shows knowledge of complications and riskfactors.Able to recognise complications and actappropriately.Understands indications for invasivemonitoring.Able to set up, attach and calibratepressure transducers and maintainpatency of lines. Able to take bloodsamples from these lines.Accurately monitor and record physiologicalparameters.Describe the appropriate course of action forabnormal trends and adverse events.Able to use Situation, Background,Assessment, Recommendation (SBAR)methodology to communicate with appropriateprofessional colleagues.Attain certification of competency for all nearpatienttesting equipment in use.Describe the process and discuss the principlerisks.Monitor and record physiological dataaccurately.Describe appropriate course of actionfor adverse readings or abnormaltrends.20

COMPETENCY 10: INTRAVENOUS ACCESS AND FLUID BALANCECompetency 10 Knowledge and skills Suggested indicators10.1. Can set up intravenous infusion equipment. Able to set up intravenous infusions, includingfluid-warming devices, pressure bags,volumetric infusers and volumetric pumps.Undertake training on equipment usedlocally.10.2 Understand basic principles and participatesin postoperative fluid management.10.3 Knowledge of equipment associated withtransfusion of blood and blood products.10.4 Understands the principles involved in safeadministration of crystalloids, colloids, blood andblood products.Understands postoperative fluid maintenanceDemonstrates ability to accurately record fluidbalance including fluid intake and losses.Understands use of equipment foradministration and warming of blood andblood products.Understands clinical aspects of blood and bloodproducts administration including safety checksand documentation.Able to recognise and manage an adversereaction to transfusions.Accurately monitor and record fluid balance.Recommend appropriate measures in theevent of adverse readings and trends.Ensure acquisition of current Better BloodTransfusion competency.Familiar with indications for transfusion ofCrystalloidsColloidsconcentrated red cellsplateletsfreshfrozenplasmacryoprecipitae salvaged red cells.See competency 7.3.10.5 Knowledge of safe placement and use ofnasogastric tubes.Aware of local protocols regarding safeadministration of blood products.Understands the rationale of use of salvagedblood and the workings of cell-savers.Understands the indications for the use ofnasogastric tubes and checks for accurateplacement.http://www.aagbi.org/sites/default/files/red_cell_08.pdfhttp://www.aagbi.org/sites/default/files/cell%20_salvage_2009_amended.pdfDemonstrates appropriate management ofnasogastric tubes and confirmation ofaccurate placement.21

COMPETENCY 11: APPLIED KNOWLEDGE OF PHARMACOLOGY IN PERIOPERATIVE CARECompetency 11 Knowledge and skills Suggested indicators11.1 Can calculate appropriate doses andconcentrations in clinical use.11.2 Understands the clinical indications,location, preparation, and labelling of drugsrelevant to the PACU.Able to calculate doses and concentrations inclinical use (as per local policy).Prepares drugs for administration duringemergencies.Familiar with safe practice and local policies.Aware of clinical indications, complications,side effects and clinical preparation offollowing drugs as well as their labelling andstorage location within the PACU includinglocal Standard Operating Procedures forControlled Drugs:antacidsinotropespressor agentsvasodilatorsantiarrhythmics anticoagulantsbronchodilatorssteroidsantibioticsantiemeticsintravenous induction agentsanticholinergicssedatives and their antagonistsnon-steroidal analgesicsopioids and their antagonistssuxamethoniumnon-depolarising neuromuscularblocking agents and reversal agentsrespiratory stimulantslocal anaesthetic agentsAttain local course certification.Describe local intravenous drug administrationpolicies.22

11.3 Can set up patient-controlled analgesia(PCA) equipment and other infusion devices.11.4 Can set up equipment to deliver nebuliseddrugs.Understands the principles of PCA includingknowledge of PCA pumps and safety features.Demonstrates knowledge of opioidpharmacology.Understands local protocols, standardoperating procedures and monitoring.Understands the principles of epiduraladministration of local anaesthetics andopioids.Demonstrates knowledge of pharmacology oflocal anaesthetics and opioids (seecompetency 11.2).Demonstrates knowledge of pumps used forcontinuous epidural analgesia infusions in linewith local protocols and monitoring.Understands the principles of nebulised drugadministration.Demonstrates knowledge of pharmacology ofnebulised drugs.Understands local protocols and monitoring ofpatients on nebulised drugs.Set up a PCA pump according to localprotocols.Monitor patient appropriately.Attain certificate of competency in use of locallyprovided PCA pumps.Set up an epidural infusion according to localprotocols.Monitor patients appropriately.Attain certification of competency in use ofepidural pumps in local use.Set up a nebuliser to deliver drugs.23

COMPETENCY 12: MANAGEMENT OF POSTOPERATIVE PAIN, NAUSEA AND VOMITINGCompetency 12 Knowledge and skills Suggested indicators12.1 Assess and manage postoperative pain. Can describe pain pathways includingphysiology of pain transmission.Use pain scoring tool and knowledge of painphysiology to select appropriate techniques forpain management.12.2 Can match prescribed analgesia topatientʼs pain score.Understands how the following analgesictechniques can modify transmission of painsensation:opioidsparacetamolnonsteroidal analgesicslocal anaesthetics.Select and deliver appropriate prescription toachieve adequate analgesia before dischargefrom the PACU.12.3 Management of side effects of analgesics. Understands side effects and complications ofthe following analgesic techniques:opioidsparacetamolnonsteroidal analgesicslocal anaesthetics.Recognise side effects and complicationsassociated with administration of analgesics.Act promptly and appropriately to minimisemorbidity.Administer naloxone according to localprotocols.Explain dermatome chart and the significanceof levels of neuraxial block.Explain local protocols for management of localanaesthetic toxicity (see competency 13.9).24

12.4 Can manage patients with centralneuraxial and peripheral nerve block.Understands indications, side effects,complications and rationale for:spinal anaesthesiaepidural analgesiaregional nerve blockade.Is aware of specialist nursing care needed forpatients in these groups.Explain structure and function of the spinalcolumn.Explain signs and symptoms of:dural puncture headachehigh spinal blockmigration of epidural catheter.Measure sensory and motor blockade andrecord extent of block using a dermatome chart.Administers epidural top-ups in accordancewith local protocols.12.5 Can assess PONV. Demonstrates knowledge of the physiology andpathophysiology of PONV Including knowledgeof risk factors.Assess and manage PONV using localprotocols and multi-modal therapy.25

COMPETENCY 13: RECOVERY EMERGENCIESCompetency 13 Knowledge and skills Suggested indicators13.1 Knows how to contactanaesthetic, surgical and otherappropriate staff for assistance.Is aware of the importance of callingfor urgent help when needed.Well versed with localcommunication protocols forcontacting appropriate clinicians.Explain mechanisms in place to contact appropriate members of staff forassistance.13.2 Can perform ILS. Demonstrates knowledge of ILS.Understands local protocols foraccess and use of defibrillatorsand support.Attain current certification of attendance of locally approved ILS course –Ref: ILS Resuscitation Council (UK).13.3 Recognises significantcardiac dysrhythmias.13.4 Understands principles ofmanaging the shocked patient.13.4a Recognises andunderstands principles ofmanaging anaphylaxis.Understands the aetiology,relevance, and management ofsignificant cardiac dysrhythmias.Understands types and grades ofshock, their significance, andprinciples of management.Demonstrate knowledge ofanaphylactic shock managementguidelines published by theAAGBI.http://www.aagbi.org/sites/default/files/anaphylaxis_2009_0.pdfhttp://www.aagbi.org/sites/default/files/ana_web_laminate_final.pdf26

13.5 Recognises pathophysiologyof malignant hyperthermia (MH)including management of patientwith proven MH susceptibility.13.6 Recognises andunderstands principles ofmanaging suxamethoniumapnoea.13.7 Can implement localprotocol for management ofsudden life-threateninghaemorrhage.13.8 Can describe detailedmanagement of patient with latexallergy.Demonstrate knowledge of MHmanagement guidelines publishedby the AAGBI.Can prepare dantrolene in anemergency situation.Understands causes ofsuxamethonium apnoea, itssignificance and principles ofmanagement.Understands local protocol formanagement of sudden lifethreateninghaemorrhage includinguse of rapid infusors / warmerswhere available.Understands pathophysiology andclinical management of latex allergyincluding use of local protocols.http://www.aagbi.org/sites/default/files/MH%20guideline%20for%20web%20v2.pdfhttp://www.aagbi.org/sites/default/files/MH%20task%20allocations%20for%20web.pdfhttp://www.aagbi.org/sites/default/files/MH%20recommended%20contents%20for%20web.pdfParticipate in local simulation using date-expired dantrolene.Set up pressure infusors for rapid infusion of fluids.Explain major blood transfusion protocols.Explain rationale and use of tourniquets and pressure dressings to reduceblood loss.Identify latex allergy patient and explain risk factors.Source and prepare equipment and environment safe for use in patientswith latex allergy.13.9 Can describe detailedmanagement of patient with localanaesthetic toxicity.Demonstrates knowledge ofsevere local anaesthetic toxicitymanagement published by theAAGBI.Be aware of location of Intralipid.http://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdfhttp://www.aagbi.org/sites/default/files/la_toxicity_notes_2010_0.pdf 27

13.10 Short term management ofa patient requiring unexpectedventilation in the PACU.13.11 Understand appropriatespecialty specific complications,side effects and principles ofmanagement.Understands the indications forshort-term postoperativeventilation.Demonstrates knowledge of localprotocols including documentationand relevant nursing interventionsin these patients.Fat embolismPulmonary embolismAmniotic fluid embolismGlycine inducedhyponatraemiaOrthopaedic cementUnstable cervical spine.Prepare a recovery bay, ventilator and essential equipment forpostoperative ventilation.Describe local protocols for the care of a ventilated patient in the PACU.Seek appropriate support from other clinical staff as appropriate.Explain local protocols for these complications.28

COMPETENCY 14: POST SURGICAL CARECompetency 14 Knowledge and skills Suggested indicators14.1 Thromboembolicprophylaxis.14.2 Management ofnormothermia.14.3 Management of thediabetic patient.Demonstrate knowledge of riskfactors and current localprophylaxis regimens andunderstand clinical reasons forvariance.Understands importance ofnormothermia and indications forintra-operative hypothermia andpostoperative management.Understands importance ofnormoglycaemia and use ofinsulin infusion pumps. Able todetermine blood glucose levelsusing near-testing equipment.Adherence to current thromboembolic prophylaxis regimens.Use of available equipment to promote normothermia and hypothermiawhere clinically appropriate.Maintenance of normoglycaemia in diabetic patients with appropriateintervention of clinicians to maintain normoglycaemia. Institute therapy tomaintain normoglycaemia in diabetic patients using appropriate, protocols,equipment and clinical guidance.14.4 Surgical site inspection. Ability to assess the operative siteincluding dressings forcomplications.Communicate effectively between theatre teams and PACU staff withregard to surgical site and dressing complications. Establish parametersfor surgical interventions.14.5 Orthopaedic and otherstabilising casts.Recognises poor circulationsecondary to oedema or failingcirculation.Explain clinical signs and symptoms of complications associated with theuse of plasters, casts and splints.14.6 Circulatory observations. Observes peripheral circulation andpulses.Explain use of ultrasound Doppler and appropriate charting todemonstrate adequate peripheral circulation and demonstrate anunderstanding of the limitations of Doppler assessment.29

14.7 Urinary catheters andbladder irrigation systems.Accurately documents urinaryoutput and demonstrateunderstanding of bladder irrigationsystems with knowledge ofincluding issues associated withpoor output.14.8 Wound drainage. Accurately records wound drainageand understands the principles ofreinfusion systems.Demonstrates understanding ofindividual patient parameters wheresurgical intervention may beappropriate.Accurately document urine output.Use bladder irrigation systems and indicate clearly need for surgicalintervention.Explain factors requiring intervention while monitoring wound drains.14.9 Specialist dressings. Demonstrate knowledge ofsurgical specific dressings.14.10 Surgery specific care. Demonstrate knowledge ofsurgical specific care requiredby individual patient.30

APPENDIX 1Stakeholder groups consulted were:Association for Perioperative PracticeBritish Anaesthetic and Recovery Nurses AssociationCollege of Operating Department PractitionersRoyal College of NursingRoyal College of Surgeons31

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