Recovery room / PACU safety protocol

KEIT DAY HOSPITAL

Official Manual of Clinical, Care and Organizational Protocols

Document Code	KEIT-SOP-17	Version	2.0
Revision	02	Status	Official
Issue Date	28/03/2026	Next Review	28/03/2027
Prepared by	Medical Directorate / Quality	Approved by
Signature and Date		Distribution	Controlled - Internal Use

Purpose of the document. To officially define the scope, responsibilities, operating procedure, KEIT standards, records and protocol review criteria.

1. Document Control Information

Application	All clinical, nursing, technical and organizational personnel involved in the described process.
Archiving	KEIT internal document management system and controlled copy in the relevant areas.
Review	At least annually or earlier in the event of regulatory, organizational or technological updates

2. Scope of Application

Applicable to all patients transferred to the recovery room/PACU following general anesthesia or sedation. .

3. Responsibilities

Anesthesiologist: definition of transfer criteria, clinical supervision and discharge from the PACU.
Recovery nurse: continuous monitoring, pain and PONV management, and prompt reporting of abnormalities.

4. Operating Procedure

Receive the patient through a structured handoff from the operating room.
Monitor vital signs, level of consciousness, pain, nausea, bleeding, urine output when indicated and overall comfort.
Apply the PACU discharge score or criteria defined by the internal protocol.
Promptly manage hypoxia, hypotension, agitation, pain, PONV or bleeding.
Transfer the patient to the ward only after the safety criteria have been met and complete information has been communicated to the receiving team.

5. KEIT Operational Standards

The recovery room is a mandatory and structured stage before transfer to the ward for patients undergoing general anesthesia.
Immediate postoperative monitoring is an integral part of the KEIT safety pathway.

6. Records and Documentation

PACU monitoring chart.
Transfer handoff documentation.
PACU discharge score.

7. Review and Updates

Periodic review of immediate postoperative outcomes and PACU length of stay.

Implementation Note
This document is an internal operational draft. Before final adoption, review by the Medical Directorate, Clinical Directorate, Legal Advisor and the relevant department managers is recommended.

8. Related Attachments and Forms

Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol.
Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.