Identification, Checking and Transfer of Patients to the Operating Theatre - Standard Operating Procedure

Publication: 26/04/2018  --
Last review: 01/01/1900  
Next review: 26/04/2021  
Standard Operating Procedure
CURRENT 
ID: 5508 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Identification, Checking and Transfer of Patients to the Operating Theatre

1. Background

This policy exists to ensure that there is a robust system in place that facilitates the identification of the correct patient for theatre which provides a comprehensive handover to ensure continuity of care and patient safety in the transfer from the pre-operative ward, through the intra-operative phase and return to the post-operative ward.

This policy should be invoked for every patient who is transferred to the operating theatre department.

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2. From the Ward/Admissions Units to Theatre pre wait area

  1. The decision is made by the theatre team for a patient to be brought to theatre.

  2. At team brief, clarification from the Surgeon/Anaesthetist is sought regarding the correct wards which all of the patients are on.

  3. When the team are ready to request a patient to be transferred to theatre, a phone call is made to the ward to inform the ward staff that a porter is going to be requested to collect the patient. If the patient is not ready on the ward for any reason, this must be communicated to the theatre staff at this time and reasons documented on TMS.

  4. Using the information on the theatre list a booking request will be entered on to the CARPS system. To ensure the correct patient is requested staff will:
    • enter the patients’ full name
    • date of birth
    • NHS number
    • Ward patient to be transferred from
    • Theatre patient to be transferred to

      Staff must enter the time the patient is sent for on TMS.

  5. The information on CARPS will be displayed on the porters hand held device when they collect the patient from the relevant ward.

  6. The porter will arrive on the relevant ward and will locate the nurse in charge of the patient.

  7. If a theatre practitioner goes to collect and escort a patient to theatre then they must take a theatre collection slip (appendix 1) with them to use to check the correct details of the patient. The collection slip must have the following information recorded on it:
    • patients’ full name
    • date of birth
    • NHS number
    • Ward patient to be transferred from
    • Theatre patient to be transferred to

  8. The nurse in charge of the patient will then show the porter (and theatre practitioner) to the patient’s bedside.

  9. The patient will be correctly identified by checking the information on the porters’ handheld device or theatre collection slip with both of the patient’s ID wristbands information:-
    • patients’ full name
    • date of birth
    • NHS number
    • Theatre patient to be transferred to

  10. The Nurse responsible for the patient will:
    • Check the patient understands the nature of the operation
    • Check that site of operation is marked and the consent form is signed
    • Check that any property going to theatre with the patient is identified and recorded in the Operating Theatres Record of Care (page 2) and that provision is made for safe keeping in property envelopes or bags e.g. inhalers, hearing aids.
    • Ensure the correct notes matching the details on the patients ID wristbands accompany the patient.
    • Ensure the patients’ prescription/infusion charts accompany the patient to theatre

    The ward nurse should also document if there are any care issues which need to be handed over to any member of the theatre team.

  11. The ward nurse must then check and sign the pre-operative checklist in the Operating Theatres Record of Care indicating the correct patient has been identified and the correct documentation is present.

  12. If there is a discrepancy in any of the above checks it must be reported to the member of staff in charge of the relevant theatre before leaving the ward and documented accordingly.

  13. Prior to leaving the ward and for the patient’s safety the bed should be at its correct level for the individual in line with Moving and Handling requirements and have all the relevant attachments, e.g. Pillows, cot sides attached and in position, drip stands etc.

  14. Patients who are willing and able to walk to the Anaesthetic Room may do so. They must be appropriately dressed e.g. dressing gown and slippers to ensure privacy and dignity is maintained. Trolley / bed should be organised for the patient and taken to theatre by the appropriate staff.

  15. The patient should then be safely transferred to the pre-wait area or relevant anaesthetic room and be accompanied by a trained practitioner from the ward. (Unless a theatre practitioner is escorting the patient)

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3. In reception/ pre-wait area (This step may be missed if the patient is transferred straight to the theatre)

  1. The Practitioner in Charge of the individual theatre (or Deputy) is responsible for initiating patient collection from the reception/pre-wait area.

  2. The trained practitioner designated to collect the patient from reception/pre-wait area should be given the collection slip and on entering the reception area/pre-wait area, should request the correct patient by stating to the reception/pre-wait area staff the:
    • Patient’s name
    • Date of Birth
    • NHS number
    • Theatre number

  3. The designated theatre practitioner will:
    • Check both of the patient’s ID wristbands and the documentation with the patient against the collection slip.
    • Any property with the patient should be identified and recorded on the checklist within the Operating Theatres Record of Care and provision made for safe keeping in property envelopes or bags e.g. inhalers, hearing aids, dentures
    • Receive any information that needs to be handed over from the ward to theatre from the reception staff
  4. Please Note: The Safer Surgical Checklist, Sign In must not be completed in the pre wait area. This must take place in the anaesthetic room/theatre with the Anaesthetist and Anaesthetic Practitioner.

  5. If there is a discrepancy in any of the above checks it must be conveyed to the member of staff in charge of the relevant theatre before leaving reception.

  6. The patient is transferred according to the appropriate patient moving and handling procedure to the anaesthetic room/theatre.

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4. Transfer to the anaesthetic room (where applicable)

  1. If a trolley is used for transfer then cot sides must be securely in position.

  2. There MUST be sufficient members of staff available to safely transfer the patient to the anaesthetic room on the trolley.

  3. Oxygen tubing, facemask and drip stand must be available and in working order.

  4. Patients who are willing and able to walk to the Anaesthetic Room may do so. They must be appropriately dressed e.g. dressing gown and slippers to ensure privacy and dignity is maintained. Trolley / bed should be organised for the patient and taken to theatre by the appropriate staff.

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5. In the Anaesthetic Room (or in theatre when there is no anaesthetic room)

  1. The patient should be introduced to the receiving practitioner and Anaesthetist in the anaesthetic room.

  2. Prior to the start of anaesthesia being given, the Safer Surgical Checklist, Sign In procedure must be completed by the Anaesthetist with the Anaesthetic Practitioner together.
    IMPORTANT:
    When confirming the patient’s identification, the following sources must be checked:
    • confirm with patient verbally by asking the patient to state their full name and date of birth (where patients are not able to confirm their ID, then the wristband must be checked with the patients notes and consent form)
    • check information on both ID wristbands (all patients transferring to theatre must have 2 ID wristbands)
    • check information contained in the patient’s notes
    • check printed operating list

  3. If either of the patient identification wristbands is removed at any time they should be replaced immediately by the person who removed it.

  4. The patient should not be left unattended in the theatre department anywhere at any time.

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6. In the Operating Theatre

  1. Once the patient is positioned safely on the operating table and before being draped ready for surgery the Safer Surgical Checklist, Time Out must be completed by the entire team.

  2. If either of the patient’s identification wristbands is removed at anytime this should be replaced immediately by the person who removed it.

  3. At the end of the procedure the Safer Surgery Checklist, Sign Out is completed and all post-operative instructions/patient pathway changes are recorded in the Operating Theatres Record of Care to hand over to the recovery staff.

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7. In PACU

  1. On arrival to PACU the patient should be checked by the PACU/escort practitioner to ensure the wrist band is in place.

  2. The patient should be handed over to the PACU staff by the anaesthetist and scrub practitioner.

    The anaesthetist /theatre practitioner will provide the following information:-
    • Patient’s name
    • The procedure carried out
    • The type of anaesthesia given
    • The duration of anaesthetic
    • Any local infiltration to the wound
    • Patient prescription documentation
    • Anaesthetic sheet giving details of drugs given during the perioperative period
    • Records of IV therapy given and what is currently in progress
    • IV therapy prescription for follow on fluid replacement
    • All IV lines have been flushed
    • Any allergies noted
    • Relevant medical history/problems
    • Any communication difficulties
    • Any other information which is specific to the patient.
    • Type of wound closure and any drains present
    • Presence of stoma
    • Presence of urinary catheter
    • Presence of any implant requiring specific care (e.g. breast)
    • Dressings
    • Property
    • Skin assessment from theatre (if applicable)

    N.B. for Local Anaesthetic patients in the Operating Theatre all the information will be given to the Day Surgery Unit, ward nurse.

  3. Prior to the patient returning to the ward the patient must meet the PACU discharge criteria.

  4. During transfer back to the post-operative ward, the patient should be accompanied by a registered or trained member of staff and, if required, a porter.

  5. Oxygen and suction equipment and drip stand (if relevant) must be available for the transfer journey.

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8. PACU to Ward transfer

A registered or trained member of the Ward or PACU team will transfer the patient to the ward and hand over to the receiving care team the:

  • Patient’s name
  • The procedure carried out
  • The type of anaesthesia given
  • The duration of anaesthetic
  • Any local infiltration to the wound
  • Patient prescription documentation
  • Pain relief given in PACU
  • Anaesthetic sheet giving details of drugs given during the perioperative period
  • Records of IV therapy given and what is currently in progress
  • IV therapy prescription for follow on fluid replacement
  • All IV lines have been flushed
  • Any allergies noted
  • Relevant medical history/problems
  • Any communication difficulties
  • Any other information which is specific to the patient.
  • Type of wound closure and any drains present
  • Presence of stoma
  • Presence of urinary catheter
  • Presence of any implant requiring specific care (e.g. breast)
  • Dressings
  • Property
  • Any other nursing specific info e.g. pressure area care

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Appendix 1

Provenance

Record: 5508
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Registered Nurses Working in Critical Care
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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