SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA EVALUATION OF POST ANAESTHESIA CARE AFTER GENERAL ANAESTHESIA AT EASTERN REGIONAL HOSPITAL BY LINDA SARFOA KISSI (10934814) GHS-ERC 030/01/23 THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MSc IN PUBLIC HEALTH MONITORING AND EVALUATION Degree APRIL, 2023 University of Ghana http://ugspace.ug.edu.gh DECLARATION I declare that this dissertation is a result of my own work done under the supervision of Dr. Paulina Tindana. Acknowledgement has been made to the work of others duly. I also declare that this work has not been accepted for the award of another degree nor being submitted for the award of any other degree. 03/05/2023 ……………………………… …………………… Linda Sarfoa Kissi Date (10934814) 03/05/ 2023 …………………… Dr. Paulina Tindana Date (Supervisor) University of Ghana http://ugspace.ug.edu.gh ii DEDICATION This study is dedicated to my dear husband Dr. Kwaku Owusu and my lovely children Nana Akua Korkor Owusu, Stephanie Owusu, and Yasmine Adobea Owusu for their love, patience, and encouragement through this study period. University of Ghana http://ugspace.ug.edu.gh iii TABLE OF CONTENTS DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii TABLE OF CONTENTS ............................................................................................................... iii LIST OF TABLES ....................................................................................................................... viii LIST OF FIGURES ....................................................................................................................... ix ABBREVIATION........................................................................................................................... x OPERATIONAL DEFINITION OF TERMS ............................................................................... xi ABSTRACT .................................................................................................................................. xii CHAPTER ONE ........................................................................................................................... 1 INTRODUCTION......................................................................................................................... 1 1.1 Background to the Study ....................................................................................................... 1 1.2 Statement of the Problem ...................................................................................................... 4 1.3 Research Questions ............................................................................................................... 6 1.4 General Objective ................................................................................................................. 7 1.5 Specific Objectives ............................................................................................................... 7 1.6 Justification ........................................................................................................................... 7 1.7 Outline of Thesis ................................................................................................................... 8 CHAPTER TWO ............................................................................................................................ 9 LITERATURE REVIEW ............................................................................................................... 9 2.0 Introduction ............................................................................................................................... 9 2.1 The Concept of Post Anaesthesia Care ................................................................................. 9 University of Ghana http://ugspace.ug.edu.gh iv 2.2 The Concept of General Elective Surgery .......................................................................... 12 2.3 Post Anaesthesia Care after General Elective Surgery ....................................................... 16 2.4 Standards for Post Anaesthesia Care after General Elective Surgery................................. 19 2.4.1 Adherence to PACU Protocols .................................................................................... 21 2.4.2 Factors Facilitating or Impeding the use of Protocols. ................................................ 22 2.5 Post Anaesthesia Care Monitoring and Evaluation ............................................................ 25 2.6 Conceptual Framework ....................................................................................................... 32 2.7 Summary of Literature Review ........................................................................................... 34 CHAPTER THREE .................................................................................................................... 37 METHODS .................................................................................................................................. 37 3.0 Introduction ............................................................................................................................. 37 3.1 Research Design.................................................................................................................. 37 3.2 Research Setting.................................................................................................................. 38 3.3 Study Population ................................................................................................................. 39 3.3.1 Inclusion Criteria ......................................................................................................... 39 3.3.2 Exclusion Criteria ........................................................................................................ 39 3.4 Description of Study Variables ........................................................................................... 40 3.4.1 Dependent variables ..................................................................................................... 40 3.4.2 Independent variable .................................................................................................... 41 3.5 Indicators for process evaluation of post-operative anaesthesia care. ................................ 42 3.5.1 Logical Framework ...................................................................................................... 44 3.6 Sampling Technique and Sample Size ................................................................................ 47 University of Ghana http://ugspace.ug.edu.gh v 3.7 Method of Data Collection .................................................................................................. 48 3.8 Quality Control Assurance............................................................................................... 50 3.9 Data Analysis ...................................................................................................................... 50 3.10 Ethical Considerations ..................................................................................................... 51 3.10.1 Ethical Approval and Permissions ................................................................................. 51 3.10.2 Consent Process ......................................................................................................... 51 3.10.3 Potential risks ............................................................................................................. 52 3.10.4 Benefits of the study .................................................................................................. 52 3.10.5 Cost of participation ................................................................................................... 52 3.10.6 Source of funding ....................................................................................................... 52 3.10.7 Compensation ............................................................................................................ 53 3.10.8 Privacy and confidentiality ........................................................................................ 53 3.10.9 Data security and storage ........................................................................................... 53 3.10.10 Voluntary consent and withdrawal .......................................................................... 53 3.10.11 Conflict of interest ................................................................................................... 53 CHAPTER FOUR ......................................................................................................................... 54 RESULTS ..................................................................................................................................... 54 4.0 Introduction ......................................................................................................................... 54 4.1 Socio Demographic Characteristics of Respondents .......................................................... 54 4.2. Assess the measures in place to ensure client safety during post anaesthesia care. .......... 57 4.2.1 Health Facility Inventory ................................................................................................. 57 4.2.2 Surgical Procedures Patients underwent .......................................................................... 60 University of Ghana http://ugspace.ug.edu.gh vi 4.3.1 Post-Anesthesia Care Protocols and Standards: .......................................................... 62 4.3.2 Referral to Standards.................................................................................................... 63 4.3.3 Motivation for following standards ............................................................................. 63 4.3.4 Discharge assessment................................................................................................... 64 4.4 Factors That Hinder Operationalization of Post Operative Care of Clients After General Elective Surgery ........................................................................................................................ 65 4.4.1 Lack of Standardization ............................................................................................... 65 4.4.2 Resistance to change .................................................................................................... 65 4.4.3 Patient Factors .............................................................................................................. 66 CHAPTER FIVE .......................................................................................................................... 68 DISCUSSION ............................................................................................................................... 68 5.0 Introduction ......................................................................................................................... 68 5.1 Measures in place to ensure client safety during post anaesthesia care. ............................. 68 5.2 Adherence to the use of the protocol in post anaesthesia care of clients after general elective surgery…………………………………………………………………………………………69 5.3 Factors that hinder operationalization of post operative care of clients after general elective surgery…………………………………………………………………………………………71 CHAPTER SIX ............................................................................................................................. 73 CONCLUSION AND RECOMMENDATIONS ......................................................................... 73 6.0 Introduction ......................................................................................................................... 73 6.1 Conclusion .......................................................................................................................... 73 6.2 Recommendations ............................................................................................................... 76 6.2.1 Eastern Regional Hospital............................................................................................ 76 University of Ghana http://ugspace.ug.edu.gh vii 6.2.2 Ministry of Health (MOH) ........................................................................................... 77 6.2.3 Future research ............................................................................................................. 78 REFERENCES ............................................................................................................................. 80 APPENDIX A ............................................................................................................................... 85 HEALTH FACILITY INVENTORY QUESTIONNAIRE .......................................................... 85 APPENDIX B ............................................................................................................................... 90 PATIENT QUESTIONNAIRE ..................................................................................................... 90 APPENDIX C ............................................................................................................................... 93 INTERVIEW GUIDE ................................................................................................................... 93 APPENDIX D ............................................................................................................................... 98 INFORMATION SHEET ............................................................................................................. 98 APPENDIX E ............................................................................................................................. 102 CONSENT FORM FOR PATIENTS ......................................................................................... 102 APPENDIX F.............................................................................................................................. 103 CONSENT FORM FOR ANAESTHETISTS AND PACU NURSES....................................... 103 APPENDIX G ............................................................................................................................. 104 ETHICAL APPROVAL ............................................................................................................. 104 APPENDIX H ............................................................................................................................. 105 APPROVAL LETTER FROM EASTERN REGIONAL HOSPITAL ...................................... 105 University of Ghana http://ugspace.ug.edu.gh viii LIST OF TABLES Table 3.1: Dependent variables of the study…………………………………………………….. 33 Table 3.2: Independent variables of the study………………………………………….……….. 34 Table 3.3: Indicators for process evaluation of post-operative anaesthesia care…………………35 Table 4.1: Socio-Demographic Characteristics of The Respondents............................................50 Table 4.2: The socio-demographic characteristics of the respondents (Anaesthetists and PACU nurses)............................................................................................................................................54 Table 4.3: Status of PACU………………………………………………………………………47 Table 4.4: Availability of Equipment’s at the PACU ……………………………………………48 Table 4.5: Availability of Drugs at the PACU…………………………………………..……….49 Table 4.6: Respondents transport to PACU..................................................................................52 Table 4.7: Parameters of patients………………………………………………………………..53 University of Ghana http://ugspace.ug.edu.gh ix LIST OF FIGURES Figure 2.1: Eastern Regional hospital Anaesthesia protocol sheet ............................................... 31 Figure 2.2: Conceptual Framework on PACU .............................................................................. 33 Figure 3.1: Map of New Juaben South Municipal ........................................................................ 38 Figure 5.1 : Logic Model……………………………………………………………….………..39 Figure 4. 1: Surgical Procedures patients underwent....................................................................52 University of Ghana http://ugspace.ug.edu.gh file:///D:/INVENTORS/LIBRARY/anaesthesia%20research/%23%20IN%20USE%20ALL%20PROJECTS%20SCHOOL%20LIST/UG%20LEGON%20KSI%20n%20Accra/%23%202022/1%20Sarfowaa/1%20final%20in%20use/FROM%20SUPER/after%20edit.docx%23_Toc116725000 x ABBREVIATION AANA AMERICAN ASSOCIATION OF NURSE ANAESTHESIOLOGY CPSP CHRONIC POSTSURGICAL PAIN CRO CLIENTS-REPORTED OUTCOME GES GENERAL ELECTIVE SURGERY PACU POSTANAESTHESIA CARE UNIT PADS POST ANAESTHETIC DISCHARGE SCORING SYSTEM PAC POST ANAESTHESIA CARE University of Ghana http://ugspace.ug.edu.gh xi OPERATIONAL DEFINITION OF TERMS Anaesthetist: A person who is trained to provides anaesthesia care Client: An adult who have undergone elective general surgery and is currently on recovery University of Ghana http://ugspace.ug.edu.gh xii ABSTRACT Background: Good management of post-operative anaesthesia care has resulted in greater client care and surgeon satisfaction. The concept of “continuity of care”, that is, preanaesthesia evaluation, the performance of anaesthesia and post-operative care by the same anaesthetist are difficult to practice in many health facilities. Moreover, there are no established protocols for post- operative anaesthesia care. The main objective of the study was to evaluate post anaesthesia care after general elective surgery at the Eastern Regional Hospital in Ghana. Methods: A mixed-method research design was employed to evaluate post anaesthesia care after general elective surgery at the Eastern Regional Hospital. The study population was made up of patients who have undergone general elective surgery, anaesthetists and post anaesthesia care unit (PACU) nurses of the Eastern Regional Hospital, Koforidua. Secondary data from patients’ anaesthesia protocol and PACU observational chart to evaluate post anaesthesia care of clients after general elective surgery. Convenience sampling technique was used to select 94 patients’ anaesthesia protocol and PACU observation chart and 12 anaesthetists and PACU nurses were selected for in-depth interviews. Purposive sampling was used to select the anaesthetists and PACU nurses for the in-depth interviews. In addition, health facility inventory questionnaire was used to collect data on equipment’s and drugs used at Eastern Regional Hospital, Koforidua. Quantitative data gathered were entered into the STATA version 16 software for analysis. The qualitative data were transcribed verbatim after data collection and thematic content analysis was conducted manually. This allowed the researcher to explore emerging issues deeper in subsequent interviews. Results: The study found that PACU lacked essential equipment such as ECG, capnograph, bispectral index and narcotrend monitors. All patients were received and cared for postoperatively University of Ghana http://ugspace.ug.edu.gh xiii at PACU and transported with an anesthesia team member, with 67% continuously evaluated during transport. The importance of discharge assessment was emphasized in the study, with participants sharing experiences and highlighting the importance of patient communication in assessing pain accurately. Some participants admitted to not being aware of post-anesthesia care standards, indicating a need for better adherence to guidelines. Conclusion: Some healthcare workers at the hospital are not aware of post-anesthesia care standards, indicating a need for better adherence to protocols. In addition, it is recommended that the Eastern Regional Hospital address the issue of the lack of functional post-anaesthetic machines in the PACU. Finally, at the PACU, vitals such as oxygen saturation, pulse rate, blood pressure, temperature, and level of consciousness, pain was not always continuously monitored for all patients. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background to the Study Post anaesthesia care refers to the period from the completion of anesthesia and procedure until the client is discharged from the hospital. In other words, it is the management of a client after anaesthesia and surgery. This includes care given during the immediate postoperative period, both in the theater and post anaesthesia care unit (PACU) as well as days following the procedure (Perry, Potter & Ostendorf, 2014). The purpose of post anaesthesia care is to prevent complications such as infection, promote healing of the surgical incision, and to return the client to a state of health, and decreasing length of hospitalization, and thus prevent nosocomial infection. The primary causes of early complications and death after major procedure are acute pulmonary, cardiovascular, and fluid derangements. Post anaesthesia recovery starts immediately after the surgery and anaesthesia. When recovering from anaesthesia in the post anaesthesia care unit (PACU), the clients commonly progress along a continuum from dependence to independence. The client becomes vulnerable during this process, and therefore will be in need of support. Dahlberg (2018) has suggested that there are three phases of recovery. Phase one of recovery starts when the client leaves the operation room. During this period, the client is monitored in the PACU until fully awake from anaesthesia and motor functions as well as protective reflexes are regained. Numeric systems are often used for assessing the client’s recovery from anaesthesia. During the second phase of recovery, the client is still cared for but not monitored as closely as in the first phase. During this phase, post anaesthetic discharge scoring system (PADS) is widely used to assess client’s recovery. This includes: activity level, vital indicators, pain, surgical bleeding, nausea and vomiting. The third phase starts when the client University of Ghana http://ugspace.ug.edu.gh 2 is discharged from the unit after usual function is gained. At this stage, self-care is a central part of recovery. The client is expected to manage his/her recovery by himself/herself or trusted relative. Recovery can last within the range of few days to several months (Ahlsson, 2008). Hence, it can be a time-consuming process to the extent that the client may be surprised at how much his/her physical and psychological status has been affected after the surgery (Parihar, 2008). During postoperative recovery, clients may experience several different surgical and anaesthesia-related symptoms such as nausea, vomiting, drowsiness, dizziness, fatigue, sore throat, back pain, headache, coldness/shivering, urinary retention, postoperative cognitive dysfunction and postoperative pain (Parihar, 2008). In the process of providing post anaesthesia care (PAC), there is the need for anaesthetists to receive the right preoperative and intraoperative information on clients. Loss of information can occur during the phases of care (Holly-May, 2015). This can lead to an increase in sentinel events, medication errors and poor client outcomes (Effken, Carley, & Gephart, 2011). King, Battle & Baker (2013) estimates that 80% of medical errors are due to communication failure during the handoff process. For this reason, teamwork is required to ensure that clients receive the right quality of PAC (Hyder, Bohman, Kor & Montori, 2016). Client satisfaction is widely used as an indicator to monitor the quality of PAC. It enables the evaluation of clients’ PAC experience which is based on their own perceptions, values and interactions with the healthcare environment. It can therefore provide unique feedback which can improve the quality of PAC (AANA, 2019). Clients-reported outcome (CRO) is an assessment performed by themselves regarding their functional status and wellbeing. It measures healthcare in general or can be associated with specific University of Ghana http://ugspace.ug.edu.gh 3 conditions. It is a suitable way of collecting data about clients when they are not under observation. This is because clients are their own expert on data about their health status, symptoms and response to healthcare. A valid and reliable data collection instrument is of great importance in improving the quality of PAC. The PACU plays a crucial role in ensuring the safety of patients by serving as a specialized observation area aimed at reducing the risk of adverse events following surgery and anesthesia procedures. Patients with pre-existing medical conditions may experience worsened health outcomes after exposure to surgical interventions and anesthesia, necessitating medical and nursing interventions to restore them to their pre-procedure state. Research has indicated that approximately 20% of all admissions to the PACU require some form of anesthesia intervention (Seglenieks & Painter, 2014). A systematic and well defined post anaesthesia care helps anaesthetists and recovery ward nurses to administer directed postoperative care and avoids delays in recognition of post anaesthesia/surgical complications (Ateleanu & Laurent, 2013). The early recognition of deterioration and the starting of therapy in PACU can prevent post general anaesthesia complications or reduce their severity. This can only be achieved if an effective post anaesthesia care system is in place at PACU. Studies have shown that delay in recognizing and errors in initiating management for clients at PACU compromise client safety and may increase staff frustration due to inefficiency (Braaf & Manias, 2011). Inadequate post anaesthesia care is attributed to high incidence of acute changes and deteriorating condition experienced by patients in most hospitals in Ghana (Awube et al., 2018). Most complications that occur at PACU during post anaesthesia care of clients can be prevented if proper monitoring system and PACU protocols are adhered to. (Andersen et al., 2016). Several authors University of Ghana http://ugspace.ug.edu.gh 4 have documented the factors that impedes on protocol use in Ghana. These include leadership perceptions of protocols (Nkrumah & Abekah-Nkrumah, 2019), lack of clear goals and strategies for their use (Grol et al., 2013), communication barriers (Nkrumah & Abekah-Nkrumah, 2019), ownership type of health facilities (public or private) (Amissah et al., 2018), centralization of decision-making (Grol et al., 2013), financial constraints (Amissah et al., 2018), workload and staff shortages (Nkrumah & Abekah-Nkrumah, 2019), low motivation and incentives (Amissah et al., 2018), resistance to change (Grol et al., 2013), lack of evidence or relevance of protocols (Grol et al., 2013), and patient preferences and expectations (Grol et al., 2013). These factors affect how protocols are perceived, developed, disseminated, implemented, and evaluated in the healthcare system. They also influence the willingness and ability of health workers to adhere to and promote protocols in their practice, and the responsiveness of patients to protocol recommendations. There are documented evidence pointing to the fact that post anaesthesia care practices varies from hospital to hospital in both advanced and developing countries of which Ghana is no exception (Schittek et al., 2020). Also, there are reports of numerous challenges with post anaesthesia care of clients at PACU that is more profound in developing countries (Adjei et al., 2018). However, there are limited studies that have evaluated post anaesthesia care especially in Ghana. It is against this context that this study seeks to evaluate post anaesthesia care after general elective surgery at New Juaben Municipality. Findings will be used to implement measures, policies and programs that will enhance post anaesthesia care. 1.2 Statement of the Problem The concept of “continuity of care”, that is, pre anaesthesia evaluation, the performance of anaesthesia and post-operative care by the same anaesthetist are difficult to practice in many health facilities. Moreover, the practice of post-operative visits by anaesthetists is not universally University of Ghana http://ugspace.ug.edu.gh 5 followed and there are no established protocols for post-operative anaesthesia care. Adequate post- operative anaesthesia care results in greater client care and surgeon satisfaction (Schittek et al., 2020). On the other hand, inadequate post operative care of clients after general surgery can lead to undesirable post operative complications such as obstructive sleep apnoea, cardiac arrest, laryngospasm and aspiration (Cook, 2017). In addition, inadequate management of post-operative complications can result in chronic post-surgical pain and fatal outcomes which can lead to high morbidity and mortality rate (Rodríguez-Betancourt et al. 2014). Across the world, studies have estimated that 10-30% of clients develop post anaesthesia complications after surgery (Cook, 2017). Post anaesthesia complications can be attributed to patient, surgical and anaesthesia factors (Agbamu & Menkiti, 2017). Also, complications during post anaesthesia care of clients are associated with inadequate knowledge of staff, poor pain assessment, lapses in post anaesthesia care and fear of analgesic-related complications (Anjani, 2017). In Ghana, a number of studies have been conducted in the field of pre-anaesthesia and intra-anaesthesia care. Unfortunately, studies within the context of post anaesthesia care are scanty. A recent study was conducted by Asams, Varaei & Jalalinia (2020) to investigate nurses’ knowledge and attitude toward postoperative pain management in Ghana. While the finding provided useful information, it was only restricted to postoperative pain and perception of nurses. It did not evaluate post anaesthesia care after general elective surgery. It did not identify the measures that are put in place to ensure client safety during post anaesthesia care and it did not provide clients’ evaluation of post anaesthesia care. At the Eastern regional hospital in Ghana, postoperatively, clients are nursed at the post anaesthesia care unit (PACU) or recovery ward till full recovery from anaesthesia before transfer to the surgical ward or intensive care unit for further management. Some of the clients develop post -operative complications like obstructive sleep apnoea, cardiac arrest and aspiration University of Ghana http://ugspace.ug.edu.gh 6 after general anaesthesia while being nursed at PACU which may lead to death if not properly managed. Evidence from studies have demonstrated that the performance of adequate post - anaesthesia care may improve patient satisfaction and physician recognition (Fink et al., 2016). To improve perioperative quality control, studies have suggested the implementation of an interdisciplinary post-anaesthesia care (Cook, 2017). Currently, it is unknown how client safety is ensured during post anaesthesia care. No data is available on the standard protocol used or valued by anaesthetists in post anaesthesia care of clients after general elective surgery at Eastern regional hospital. More so, no previous study has evaluated the practice of post anaesthesia care and factors that influence adequate post anaesthesia care of clients after general elective surgery at Eastern regional hospital. This study therefore aims to evaluate post anaesthesia care after general elective surgery at Eastern Regional Hospital to determine how client safety is ensured during post anaesthesia care, adherence to the use of standard protocol in post anaesthesia care and also to identify factors that hinder operationalization of post operative care of clients after general elective surgery. 1.3 Research Questions 1. What measures are put in place to ensure client safety during post anaesthesia care? 2. Do health professionals adhere to the use of the protocol in post anaesthesia care of clients after general elective surgery? 3. What factors hinder operationalization of post operative care of clients after general elective surgery? University of Ghana http://ugspace.ug.edu.gh 7 1.4 General Objective The main objective of the study is to evaluate post anaesthesia care after general elective surgery at the Eastern Regional Hospital in Ghana. 1.5 Specific Objectives The following are the specific objectives: 1. To assess the measures in place to ensure client safety during post anaesthesia care. 2. To assess adherence to the use of the protocol in post anaesthesia care of clients after general elective surgery 3. To determine factors that hinder operationalization of post operative care of clients after general elective surgery 1.6 Justification There was the need to conduct this study for several reasons. First, by exploring the measures put in place to ensure client safety during post-anaesthesia care, the study seeks to understand the extent of the safeguards and protocols in place. This is particularly important given the vulnerability of patients during the post-anaesthesia period. In the second place, the study aims to uncover the barriers and challenges in providing effective post-operative care by identifying the factors that hinder operationalization of post-operative care of clients after general elective surgery, This will provide insights for improving the systems and practices in place to optimize patient outcomes. In the third place, it will inform anaesthetists about the best practices in PAC. University of Ghana http://ugspace.ug.edu.gh 8 Finally, it will serve as a source of literature for future case studies, baseline studies and academic discussion. 1.7 Outline of Thesis This thesis is structured into six (6) main chapters. This first chapter has described background information on the research topic, the problem statement, research questions and research objectives as well as the justification for the study. The next chapter, Chapter two will present a review of relevant literature on the topic from a global, regional and national perspective. Chapter three will describe the study design, study area, population and data collection methods and ethical consideration. Chapter four will report on the key results of the research. Chapter five will discuss the results of the study in relation to existing literature. The final chapter, Chapter six will present a summary of the study, the main conclusions of the study and key recommendations to inform policy, practice and research. University of Ghana http://ugspace.ug.edu.gh 9 CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter reviewed relevant literature on the concept of post anaesthesia care, the concept of general elective surgery, post anaesthesia care after general elective surgery, post anaesthesia care monitoring and evaluation and conceptual framework. 2.1 The Concept of Post Anaesthesia Care Post anaesthesia care refers to the period from the completion of anaesthesia and procedure until the client is discharged from the hospital. In other words, it is the management of a client after anaesthesia and surgery. This includes care given during the immediate postoperative period, both in the theater and PACU, as well as days following the procedure (Perry, Potter & Ostendorf, 2014). McQuoid-Mason (2016) pointed out that post anaesthesia care includes the time when the client is in theatre, in the recovery room, in an intensive care unit, in a surgical ward, and may even continue after the client has been discharged from hospital. It is associated with restoration of normal physiological functions, healing of tissues from the surgical trauma and a gradual return of physical strength (Saad, 2010). The level of post anaesthesia care required will depend on the client’s preoperative condition and the nature and consequences of the procedure. The purpose of post anaesthesia care is to prevent complications such as infection, promote healing of the surgical incision, and to return the client to a state of health, and decreasing length of hospitalization, and thus prevent nosocomial infection. The primary causes of early complications and death after major procedure are acute pulmonary, cardiovascular, and fluid derangements. Good post anaesthesia care ensures a smooth and quick recovery from procedure. Therefore, efforts should be made towards achieving its purpose by focusing on each individual’s University of Ghana http://ugspace.ug.edu.gh 10 circumstances with attention to the particular needs of every client. Standardization of care can be implemented, but should be utilized with a degree of flexibility to allow the individualization of post anaesthesia care. The immediate postoperative period covers the first 24 hours after procedure and entails the time in which the client remains in the PACU. This period is associated with physiological changes that are basically unconsciousness in clients, requiring continuous observation and specific care (Serra et al. 2015). The primary urgent issues that require attention are managing pain, protecting the airway, monitoring mental status, and facilitating wound healing. Additionally, it is crucial to prevent urinary retention, deep venous thrombosis (DVT), constipation, and blood pressure fluctuations. In the case of diabetic patients, close monitoring of blood glucose levels through fingerstick testing every 1 to 4 hours is necessary until they are awake and eating, as better glycemic control leads to improved outcomes. Depending on the type of procedure, there are many potential complications that can arise. For instance, many procedures put clients at risk of infection, bleeding at the theater, and blood clots caused by inactivity. Prolonged inactivity can also cause loss of some muscle strength, cardiovascular complications, and respiratory complications. Recovery after procedure includes gaining control of physical, psychological, social, and habitual functions. Postoperative recovery starts immediately after the surgery and anaesthesia. When recovering from anaesthesia, the clients commonly progress along a continuum from dependence to independence. The client is at risk and vulnerable during this process, and therefore will be in need of support. This requires constant awareness and assessment that can only be achieved with effective communication between the anaesthesia provider and the PACU nurses (Manser et al., 2013). It also requires systematic and documented care and highly qualified PACU health University of Ghana http://ugspace.ug.edu.gh 11 personnel. It also includes the assistance of physiotherapists, dieticians, pharmacists, and microbiologists. This assistance will ensure the safety of clients. Dahlberg (2018) indicated that there are three phases of recovery. He indicated that phase one of recovery starts when the client leaves the theater. During this period, the client is monitored in the PACU until fully awake from anaesthesia and motor functions as well as protective reflexes are regained. Numeric systems are often used for assessing the client’s recovery from anaesthesia. During the second phase of recovery, the client is still cared for but not monitored as closely as in the first phase. During this phase, post anaesthetic discharge scoring system (PADS) is widely used to assess client’s recovery. This includes: activity level, vital indicators, pain and surgical bleeding nausea and vomiting. The third phase starts when the client is discharged from the unit after usual function is gained. At this stage, self-care is a central part of recovery. The client is supposed to manage his/her recovery by himself/herself or trusted relative (Serra et al. 2015). Saad (2010) also indicated that most clients in their first few hours of recovery from the anaesthesia, gradually regain their respiratory, cardiovascular and neurological functions, and establishes homeostasis. Within a period of 1-3 days, recovery of the gastrointestinal tract and mobilization occur after uncomplicated surgery. Within a period of 1-6 weeks, healing of tissues and return of full physical strength continue after discharge from hospital. While most complications from procedure occur in the early postoperative phase, they can still occur after discharge from the hospital. There is therefore the need to stakeholder in postoperative to support the client whilst at home and to manage late adverse complications. Nursing Care Systematization (NCS) is a methodology of nursing care that is often considered a best practice. The NCS helps to identify health and illness situations and prescribe specific actions for promoting, preventing, recovering, and rehabilitating client health. However, due to the high University of Ghana http://ugspace.ug.edu.gh 12 turnover of clients in the PACU, the NCS may not always be fully utilized. It is important to prioritize reviewing nursing care in the immediate postoperative period and focus on detecting, preventing, and treating any complications that may arise. The hospitalization period in the PACU is critical for preventing potential complications, which is why the use of NCS in the immediate postoperative period is highly relevant for facilitating dynamic, organized, and systematic care provided by PACU nurses (Serra et al. 2015). Handoff, which is the transfer of information from one healthcare provider to another, plays a crucial role in ensuring client safety in post anaesthesia care. It enables health personnel to gain a wider knowledge of client management priorities, thus promoting better client outcomes. In an ideal scenario, the postoperative handover between anesthetists and PACU nurses facilitates the exchange of critical client information, creates a platform for mutual information sharing, and ensures efficient transfer of client care and responsibilities while adhering to organizational safety standards (Rose & Newman, 2016). In the PACU, anesthetists generally exercise responsibility for cardiopulmonary function. The client can be discharged from the recovery room when pulmonary, cardiovascular, and neurologic functions have returned to baseline. Clients who require continuing circulatory or ventilatory support, or who have other conditions that require frequent monitoring, are referred to an intensive care unit (ICU). Monitoring equipment are available to enable early detection of cardiorespiratory derangements. 2.2 The Concept of General Elective Surgery Elective surgery is a procedure that a surgeon considers necessary but that can be delayed by at least 24 hours (BHI, 2013). It includes hip replacements, cataract extraction and ligament, refractive surgery, gynecological surgery, ACL reconstruction, Anaphylactic shock, Bariatric University of Ghana http://ugspace.ug.edu.gh 13 surgery, tubal ligation, vasectomy, hysterectomy, exploratory or diagnostic surgery, cardiovascular surgery, nonemergency, musculoskeletal system surgery, donation of a kidney by a living donor, and ACL reconstruction. It includes all optional procedures performed for non- medical reasons. For instance, cosmetic procedures, such as a rhytidectomy, abdominoplasty, breast implants, liposuction, breast reduction, and rhinoplasty. Cosmetic procedures, may not be medically indicated, but they may benefit the client in terms of raising self-esteem. A procedure, such as cataract surgery improve functional quality of life. Some procedures are necessary to clients’ health and well-being. This includes procedures like hernia surgery, angioplasty, kidney stones surgery, hip replacements, and breast cancer surgery (Rusciano, 2020). Unlike emergency surgery that requires immediate attention, elective procedures can be scheduled at the convenience of both the client and surgeon. The National Center for Health Statistics of the U.S. Centers for Disease Control and Prevention (CDC) reported that in 2005, over 44 million elective procedures were carried out in the United States, with heart disease and Cesarean section being the most common types. In certain instances, insurance providers may necessitate a second opinion before granting payment for elective procedures. The process allows clients to collaborate with the health team, giving them ample time to conduct the necessary clinical assessments before scheduling the procedure on an appropriate date and time. The postponement of the intended intervention can heighten the psychological and emotional effects experienced by the client following admission for the procedure (Kajja & Sibinga, 2014). In less developed nations, delays in performing procedures are predominantly caused by inadequacies in the essential components of the healthcare system, such as insufficient University of Ghana http://ugspace.ug.edu.gh 14 infrastructure like hospital beds, operating theaters, diagnostic equipment, and intensive care units. Furthermore, a shortage of dedicated, highly trained, and motivated healthcare professionals contributes to the delay. The inconsistent supply of vital resources such as surgical supplies and medication also hinders the timely execution of elective surgical procedures. Depending on the severity of the condition, a postponed procedure may result in increased morbidity and mortality for the client and may also incur high hospital costs due to extended hospital stays (Kajja & Sibinga, 2014). The optimal process for a surgical journey commences with a referral of the client to a surgical clinic. A preoperative assessment is carried out to aid the surgical team in organizing the procedure. The preoperative evaluation typically involves a comprehensive medical history, physical examination, and laboratory tests. Specific preoperative measures may vary depending on the nature of the procedure. In cases where general anesthesia is required, the client may be instructed to adhere to dietary restrictions prior to the procedure, as per Queensland Health guidelines (2017). A major benefit of general elective surgery is the days or weeks clients could use to improve their health before their procedure. The procedure can be a physically demanding experience, and thus the best time for clients to improve their overall health is prior to procedure. Health improvements before procedure include: avoiding smoking, losing weight, eating healthier foods, and exercising more. Increased smoking and having diabetes can prevent healing and can result in wound complications after procedure. Reducing these risk factors offers clients the best chance of a successful procedure (Rusciano, 2020). The procedure required an entire team effort. Once a client is scheduled for procedure, an entire team of doctors and health care professionals are expected to be in constant contact with each other University of Ghana http://ugspace.ug.edu.gh 15 to coordinate care and deliver the best outcomes. The team must include surgeon, anesthetist, nurses, laboratory technicians, and operating room staff. The teams may also include a pathologist, radiologist, and nutritionist. The goal is to give the client the best possible healthcare outcome (Rusciano, 2020). General elective surgeries is typically performed by a surgeon at the theater. The type of procedure will mandate the qualifications and background of the surgeon who performs it. For instance, the removal of a mole is performed by a dermatologist, while gastric bypass procedure is performed by a bariatric surgeon. Autologous donation is required in most cases before commencement of procedure. The recovery time and postoperative care after a procedure may vary depending on the nature of the procedure performed. Prior to returning home after surgery, patients are provided with comprehensive written instructions for post-anaesthesia care, which are fully explained to them by the responsible surgical staff. The risks associated with a procedure are dependent on the specific type of procedure performed. In general, most surgeries carry the risk of complications such as bleeding, infection, and circulatory problems, such as shock or thrombosis. Additionally, there may be risks associated with the anaesthesia used during the procedure. The ultimate outcomes of a procedure are contingent on the type of procedure performed. The healthcare team will discuss the optimal results for the procedure with the patient before the procedure takes place. In some instances, the results of a surgery may be temporary, while in other cases, they may be lifelong. For example, a facelift may necessitate a subsequent procedure as the patient ages, whereas a tubal ligation will produce permanent results. University of Ghana http://ugspace.ug.edu.gh 16 The treatment alternatives available for a given procedure will depend on the purpose of the procedure. For example, other methods of birth control may be an alternative to any procedure used for sterilization. In some cases, there may be no alternative treatments available other than foregoing the procedure and living with the medical consequences. As part of the informed consent process, the surgeon should review all possible treatment options before scheduling the procedure (ACS, 2008). 2.3 Post Anaesthesia Care after General Elective Surgery The post anaesthesia period provides a transition from the procedure period to assess and manage the clients towards optimal recovery. Timely identification and management of complications immediately after procedure may be life-saving. The probability that a specific complication will emanate for a given client hinges on the preoperative medical assessment, nature of the procedure, anesthetic techniques adopted, client’s comorbidities, and optimization (ASA, 2013). It is fundamental practice for clients who receive anaesthesia to be monitored in a PACU, prior to discharge from the hospital. The exception to this practice is clients in critical condition, who may bypass the PACU and be recovered directly in an intensive care unit (ICU). A surgeon is responsible for the discharge of the client from the PACU. The PACU must be a uniquely staffed and equipped area for client safety. In most PACUs, medical oversight of clients is the responsibility of the anaesthetists and PACU nurses (AANA, 2019). When a client is taken to the PACU, it is necessary for an anesthesia care team member who has knowledge about the client's health history, physiologic condition, diagnostic tests performed, and procedures carried out to accompany them. The client's condition should be continuously monitored and treated during transportation. Prior to transportation, the anesthesia professional University of Ghana http://ugspace.ug.edu.gh 17 and procedure team evaluate the client's response to anesthesia and procedure-related factors so that complete perioperative information can be conveyed to the receiving team. The circulating nurse or appropriate staff member contacts the PACU, nursing unit, or ICU to confirm their readiness to accept the client. Before transportation, the need for client oxygenation, monitoring, ventilation, medication, and additional equipment is taken into account. Furthermore, preparation for client care during transportation and on arrival at the PACU is considered. When the client arrives, they must be reassessed, and the accompanying anesthetist must report to the PACU nurse in charge. These guidelines were stated by the American Society of Anesthesiologists (2013). Continuous assessment of the client's condition through appropriate methods is required in the PACU. This assessment includes monitoring the client's blood pressure, heart rate/rhythm, airway patency, oxygen saturation and circulation, ventilatory rate/character, temperature, level of pain, and level of consciousness and/or sedation, which should be documented. In the initial phase of recovery, a quantitative method for assessing oxygenation, such as pulse, should be used. After the initial client assessment, a handoff is conducted to transfer professional responsibility, critical and essential client information, and accountability from the theater team to the PACU team. Both healthcare providers should be actively engaged in the communication during the handoff, which should take place in an interruption-free environment with an open communication platform, including the opportunity to ask and answer questions. A standardized handoff checklist focuses on the vital points to be addressed for a complete handoff and aims to decrease the duration of the verbal report. The elements of the handoff include Client, Procedure, Health History, Anaesthesia Medication, and PACU. The Client section contains information about the client's name, age, gender/identified gender, level of consciousness/orientation, weight (for pediatric clients), vital signs and assessment University of Ghana http://ugspace.ug.edu.gh 18 findings, allergies/reactions, airway status, procedures performed, relevant client medical and surgical/procedural history, physical limitations, and intraoperative course (including unanticipated intraoperative events) and considerations for management of similar issues in the PACU/ICU. The Procedure section includes information about the client's positioning (if other than supine), vascular access/lines/catheters, type and difficulty of airway management, crystalloid colloid/blood products, status of dressings and surgical/procedural site, fluids/losses (including drainage tubes), urine output, and estimated blood loss. The Health History section contains information such as preoperative vital signs, preoperative cognitive function, pertinent health and medication history, physical status score, and extremity restrictions and preoperative level of activity. The Anaesthesia and Medications section includes information about the type of anesthesia delivered, vital signs and monitoring trends (CV, respiratory, neuromuscular function), airway management concerns, relevant lab values, current medications/administration/dose/timing, client-specific procedure and hemodynamic considerations, antiemetics, time of last and next dose of antibiotic, analgesia management plan, other intraoperative medications (steroids, antibiotics, antihypertensives, etc.), and regional anesthetic (for postoperative pain). The PACU section includes information such as medications due during PACU, pain and comfort management plan, and PACU orders. The post-anesthesia period is divided into three levels of care: Phase I, Phase II, and Phase III. Each phase of recovery may occur in one PACU or in multiple locations. During Phase I care, the focus is on the client's recovery from anesthesia and the return to baseline vital signs. The procedure, client comorbidities, anesthesia care, and the client's physical status are taken into consideration to recognize and manage any complications. Hemodynamic and respiratory changes are managed, and the effects of the procedure and the necessary analgesia and antiemetics are University of Ghana http://ugspace.ug.edu.gh 19 provided. The priorities of this phase include maintaining a stable airway with adequate ventilation and oxygenation, managing analgesia and PONV, discontinuing or adapting IV (enhanced recovery protocol), oral intake, and hemodynamic stability. Possible complications include airway compromise, cardiovascular depression, pain, side effects, nausea, vomiting, delirium, and procedure-specific considerations. Prevention of complications includes encouraging early mobilization, such as active daily exercise, deep breathing and coughing, muscular strengthening, joint range of motion, and walking with aids Once phase one conditions are met, a client is transitioned to Phase II care. In Phase II care the goal is to prepare the client to be transferred home or to an extended care facility. The frequency of assessing vital signs is often facility-specific. It begins on arrival and ends at discharge. During this phase the client is able to take nutrition, ambulate, and receive education and instructions necessary for self-management of care at home. The priorities of this phase include mobility, oral intake, adequate analgesia, education for discharge, and prescriptions. Possible complications include pain, nausea, and vomiting (Kellner et al. 2018). The condition for discharge from this phase includes adequate pain relief and comfort; hemodynamic stability; nausea addressed; takes fluids; ambulates; understands discharge instructions, medications and management of any issues; and safe transportation from the facility (AANA, 2019). Phase III, otherwise known as extended care. This phase is for clients who have met criteria to leave Phase I, but are not able to go to another location. For instance, in a situation where there are no available inpatient beds. These clients are assessed and treated as inpatient (AANA, 2019). 2.4 Standards for Post Anaesthesia Care after General Elective Surgery The standards for post-anaesthesia care ensure proper management of patients after surgery or anaesthesia, with the aim of improving their outcomes. These guidelines are individualized to meet University of Ghana http://ugspace.ug.edu.gh 20 each patient's specific needs. The American Society of Anaesthesiologists (ASA) has established five standards for post-anaesthesia care. The first standard requires that all patients who receive general, regional, or monitored anaesthesia care must receive appropriate post-anaesthesia management. A Post Anaesthesia Care Unit (PACU) or equivalent area must be available to receive patients after anaesthesia care. Patients should only be discharged from the PACU upon the specific order of their anesthesiologist. The medical aspects of care in the PACU should follow approved policies and procedures, and the PACU's design, equipment, and staffing should meet accrediting and licensing requirements. The second standard mandates that a member of the anaesthesia care team accompany a patient during transport to the PACU and continually evaluate and treat them according to their condition. The third standard requires that upon arrival in the PACU, the patient should be re-evaluated and their condition verbally reported to the responsible PACU nurse. The patient's status upon arrival in the PACU should be documented, and relevant information about their preoperative condition and surgical/anaesthetic course transmitted to the PACU nurse. The fourth standard specifies that the patient's condition should be continually evaluated in the PACU with monitoring appropriate to their medical condition. Particular attention should be given to monitoring oxygenation, ventilation, circulation, level of consciousness, and temperature. The use of a quantitative method for assessing oxygenation, such as pulse oximetry, is encouraged in the initial phase of recovery from all anesthetics except those used for obstetrical patients in labor and vaginal delivery. An accurate written report of the PACU period should be maintained, and an anesthesiologist should be responsible for general medical supervision and coordination of patient care in the PACU. University of Ghana http://ugspace.ug.edu.gh 21 The fifth standard states that a physician is responsible for discharging the patient from the PACU. The discharge criteria should be approved by the Department of Anesthesiology and the medical staff, and the patient's destination after discharge (hospital room, Intensive Care Unit, short stay unit, or home) may affect these criteria. If the physician responsible for discharge is absent, the PACU nurse should determine that the patient meets the discharge criteria and note the name of the physician accepting responsibility for discharge on the record. 2.4.1 Adherence to PACU Protocols Adherence to post-anaesthetic care unit (PACU) protocols is essential for ensuring the safety and quality of care of patients recovering from anaesthesia and surgery. PACU protocols are designed to provide guidance on the staffing, monitoring, handover, discharge and documentation of patients in the PACU, as well as the management of common postoperative complications such as nausea, vomiting, pain, bleeding and hypothermia. PACU protocols should be based on current best evidence and regularly updated by medical staff (Introduction to the post-anaesthetic care unit, 2013). According to the Royal College of Anaesthetists (2018), the PACU denotes any clinical area where patients recover from anaesthesia, including those referred to as ‘recovery’ or ‘the recovery room’ in many UK hospitals. The PACU is a high-risk area for life-threatening airway complications, as highlighted by several national audits and reports. Therefore, patients require a high standard of observation until recovery is complete. The RCoA and the Association of Anaesthetists recommend that PACU staffing and monitoring standards should be maintained in any area where anaesthesia is administered, such as labour wards, cardiology and radiology suites, dental, psychiatric and community hospitals. According to a review by Simpson and Moonesinghe (2013), PACU protocols are essential for improving the outcomes of high-risk surgical patients, who are more prone to develop life- University of Ghana http://ugspace.ug.edu.gh 22 threatening emergencies in the immediate postoperative period. The authors recommend that PACU protocols should be based on evidence-based practices and tailored to the local context and needs. They also suggest that PACU protocols should be audited and evaluated regularly to ensure their effectiveness and compliance. However, there is limited evidence on the implementation and adherence of PACU protocols in low- and middle-income countries (LMICs) such as Ghana. A study by Boney et al. (2014) found that PACU staffing and monitoring provision in Ghana was inadequate and inconsistent with international standards. The authors reported that PACU nurses were often untrained, overworked, and lacked essential equipment and supplies. They also noted that PACU monitoring was often limited to pulse oximetry and blood pressure, and that ECG, capnography, nerve stimulator, and glucometer were rarely available or used. Another study by Agyei-Baffour et al. (2019) examined the factors influencing the adherence to PACU protocols in Ghana. The authors used a mixed-methods approach to survey 120 PACU nurses and conduct 12 focus group discussions. They found that the adherence to PACU protocols was influenced by individual, organizational, and contextual factors. Some of the individual factors included knowledge, attitude, motivation, and experience of PACU nurses. Some of the organizational factors included leadership, supervision, feedback, teamwork, communication, and availability of resources. Some of the contextual factors included patient characteristics, workload, culture, and policy. 2.4.2 Factors Facilitating or Impeding the use of Protocols. Protocols are defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances" (Field & Lohr, 1990, p. 38). Protocols can help improve the quality, efficiency and consistency of healthcare services, as well as reduce variations and errors in practice (Grol et al., 2013). However, the implementation University of Ghana http://ugspace.ug.edu.gh 23 and adherence of protocols are influenced by various factors at the individual, organizational and system levels. In this section, we will review some of the factors that have been identified in the literature as facilitators or barriers of protocol use in Ghana, a lower middle-income country in West Africa. Ghana has adopted a primary health care (PHC) approach to deliver essential community-based health services through the Community-based Health Planning and Services (CHPS) initiative. The CHPS initiative aims to improve access, equity and quality of healthcare by involving communities in planning, delivery and monitoring of health services (Awoonor-Williams et al., 2004). Protocols are an integral part of the PHC system, as they provide guidance and standards for community health officers (CHOs) who are the frontline providers of clinical care, preventive and promotive services at the community level. However, the use of protocols by CHOs and other health workers in Ghana is not optimal, and several factors have been reported to affect their implementation and adherence. Some of the factors that facilitate protocol use in Ghana include leadership commitment and support, training and education, availability and accessibility of protocols, feedback and supervision, and community participation. Leadership commitment and support are crucial for creating a conducive environment and culture for protocol use, as well as providing adequate resources and incentives for health workers (Nkrumah & Abekah-Nkrumah, 2019). Training and education can enhance the knowledge, skills and attitudes of health workers towards protocol use, as well as increase their confidence and competence in applying them in practice (Amissah et al., 2018). Availability and accessibility of protocols refer to the extent to which protocols are present, visible and easy to use by health workers in their workplaces (Grol et al., 2013). Feedback and supervision can help monitor and evaluate the performance of health workers in relation to protocol use, as well as provide constructive criticism and reinforcement for University of Ghana http://ugspace.ug.edu.gh 24 improvement (Nkrumah & Abekah-Nkrumah, 2019). Community participation can foster trust, collaboration and accountability between health workers and community members, as well as increase the demand and acceptability of protocol-based services (Awoonor-Williams et al., 2004). Some of the factors that impede protocol use in Ghana include leadership conceptualization of protocol use, lack of goals and activities for protocol use, communication challenges, ownership type of health facilities, degree of centralization of decision making, financial constraints, workload and staff shortages, lack of motivation and incentives, resistance to change, lack of evidence and relevance of protocols, and patient preferences and expectations. Leadership conceptualization of protocol use refers to how leaders perceive and define protocol use in relation to their roles and responsibilities, as well as their level of involvement and support for protocol implementation (Nkrumah & Abekah-Nkrumah, 2019). Lack of goals and activities for protocol use means that there are no clear objectives, plans or strategies for promoting protocol use among health workers or evaluating its outcomes (Grol et al., 2013). Communication challenges refer to the difficulties or barriers in exchanging information or opinions about protocol use among health workers or between health workers and other stakeholders (Nkrumah & Abekah-Nkrumah, 2019). Ownership type of health facilities refers to whether the facilities are public or private, which may affect their governance structure, resource allocation, accountability mechanisms and autonomy in decision making (Amissah et al., 2018). Degree of centralization of decision making refers to how much authority or discretion health workers have in applying protocols in their practice, which may vary depending on their level or position in the health system hierarchy (Grol et al., 2013). Financial constraints refer to the lack or insufficiency of funds or resources to support protocol development, dissemination or implementation (Amissah et al., 2018). Workload and staff shortages refer to the high demand for healthcare services that University of Ghana http://ugspace.ug.edu.gh 25 exceeds the capacity or availability of health workers or facilities (Nkrumah & Abekah-Nkrumah, 2019). Lack of motivation and incentives refer to the low morale or satisfaction of health workers due to poor working conditions, low remuneration or recognition for their work (Amissah et al., 2018). Resistance to change refers to the reluctance or opposition of health workers to adopt new or revised protocols due to habit, tradition or fear of losing autonomy or authority (Grol et al., 2013). Lack of evidence and relevance of protocols refer to the perception or reality that protocols are not based on sound scientific research or local context, and therefore do not reflect the best or most appropriate practice for the patients or the setting (Grol et al., 2013). Patient preferences and expectations refer to the influence of patients' values, beliefs, attitudes or demands on the decisions and actions of health workers regarding protocol use, which may sometimes conflict with the recommendations or guidelines of protocols (Grol et al., 2013). 2.5 Post Anaesthesia Care Monitoring and Evaluation In the delivery of post anaesthesia care, the anaesthetist provides medical services before and after the client is transported to the PACU. Before the post-operative period, an essential part of the anesthesiologist’s work is to perform an initial evaluation. This is performed to assess risk and develop a post anaesthesia plan. By assessing risk, it uncovers hidden conditions that could cause complications during post anaesthesia care. Elements of the initial evaluation include: reviewing the client's medical history, pre anaesthesia data, intra anaesthesia data, and procedure data. Monitoring is the process of observing and checking progress and quality of post anaesthesia over a period of time. Post anaesthetic monitoring is a vital requirement for client evaluation and the recognition of risks in post-operative clients (Ahmed et al. 2013). It includes clinical observation and measurement of applicable and relevant variables. These variables are recoded by automated computerized methods. In principle, post anaesthesia monitoring provides information and University of Ghana http://ugspace.ug.edu.gh 26 feedback on the body’s response to therapeutic interventions or changing clinical conditions. It is very important for ensuring the safety of the recovery process. It leads to the prevention of possible complications. These allows adjustment of management to achieve the best possible healthcare outcomes (ANZCA, 2017). Monitoring is done by hearing, feeling, seeing, perceiving, asking, and by recording and analyzing data. All of this form one big picture to evaluate a client. Before monitoring is performed, the clients should be made as comfortable as possible. Minimizing the risk of complications is crucial for a client who has undergone surgery. Knowledge and understanding of the main areas of risk and local policies can help in reducing the likelihood of potential complications. Monitoring of the client's vital signs, such as pulse, respiratory rate, systolic blood pressure, temperature, and level of consciousness is essential. Other aspects of monitoring may involve evaluating the client's pain levels, capillary refill time, percentage of oxygen being administered, oxygen saturation, central venous pressure, infusion rates, and hourly urine output, as outlined in Ahmed et al. (2013). The National Early Warning Score (NEWS) has been developed in some practices as a standardized method for monitoring and tracking acutely and critically ill patients. It consists of six physiological parameters, namely pulse rate, respiratory rate, oxygen saturation, systolic blood pressure, and level of consciousness. Additionally, a weighting score of two is assigned if the patient is receiving supplemental oxygen through a mask or nasal cannulas. When utilizing NEWS to monitor postoperative patients, it is crucial to observe for signs of shock, sepsis, hemorrhage, and the effects of anesthesia and analgesia. Patients who are receiving intravenous opiates are at risk of having their vital signs and consciousness levels compromised if the infusion rate is too high. As a result, effective pain management is essential to enable clear communication and cooperation with clinical staff during the postoperative period. University of Ghana http://ugspace.ug.edu.gh 27 Conventional monitoring systems including, noninvasive blood pressure, electrocardiogram, capnography and end tidal anesthetic analyzer are valuable and should be used to help assessment of these clinical signs. Some effective monitoring equipment include Bispectral Index Monitor, Narcotrend Monitor, AEP Monitor/ 2, PSA 4000 Monitor, Cerebral State Monitor, Entropy Module, DGA Monitors, Oxygen Analyser, Pulse Oximeter, Ventilation, Carbon Dioxide Monitor, Continuous Invasive Blood Pressure Monitor, Inhalational Anaesthetic Agent Monitor, Temperature Monitor, and Neuromuscular Function Monitor (Somchai, 2012). In the ideal situation, the healthcare centre is responsible for proving monitoring tools. Equipment for monitoring must be used in line with careful clinical observation (ANZCA, 2017). According to standards of The American Society of Anesthesiologist, post anaesthesia evaluation commences within 48 hours after procedure. The evaluation is not performed until the client is sufficiently recovered from anaesthesia. This enables the client to participate in answering questions appropriately, and performing simple tasks. The evaluation is conducted by an anaesthetist. While the evaluation has to commence at PACU, it may be completed after the client is moved to another inpatient location, if State law and hospital policy permits, after the client is discharged, as long as it is completed within 48 hours. The main component of the evaluation may include: respiratory function; cardiovascular function; mental status; temperature; pain; presence of nausea and/or vomiting; and post-operative hydration. Depending on the procedure performed, additional evaluation may be necessary. For a client who is unable to participate in the post anaesthesia evaluation, a post anaesthesia evaluation should be completed and documented within 48 hours with the report that the client was unable to participate. The American Society of Anesthesiologist indicated that evaluation for clients is based on criteria established by the medical staff based on State law and professional organizations recommended practices (ASA, 2019). University of Ghana http://ugspace.ug.edu.gh 28 Discharge assessments are conducted on client based on criteria established by the medical staff (ASA, 2019). In 2012, Kaur et al. developed a template form based on the post-anaesthesia evaluation standard set up by Medicare and Medicaid Services CMS and The Joint Commission. The form included all necessary elements of the evaluation and was added to the patient's medical record. Additionally, the authors modified the discharge process from the PACU by adding post- anaesthesia evaluation to the discharge criteria. They used a visual clue on the clients' stretchers and a systems-based team approach involving Anaethetists and PACU nurses to implement the template across all three campuses of UMass Memorial Medical Center and University of Massachusetts Medical School. The compliance with CMS revised guidelines was evaluated through random monthly chart audits by the Quality Department, and the report showed that the medical center achieved an average compliance rate of 82 to 93%. Post anaesthesia care is a critical phase of perioperative nursing that requires specialized knowledge and skills to ensure patient safety and recovery. However, there is limited evidence on the current state of post anaesthesia care in Ghana and the challenges faced by nurses in this area. One of the key studies conducted in Ghana is by Agyeman-Duah et al. (2018), which explored the knowledge and practices of nurses regarding post anaesthesia care in a tertiary hospital. The study highlighted the need for continuous education and training of nurses to enhance their skills in monitoring and evaluating patients after anaesthesia. Agyeman-Duah et al. (2018) used a descriptive cross-sectional design to collect data from 120 nurses working in the post anaesthesia care unit (PACU) of a tertiary hospital in Ghana. The data included demographic information, knowledge assessment, and self-reported practices of post anaesthesia care. The results showed University of Ghana http://ugspace.ug.edu.gh 29 that the majority of the nurses had inadequate knowledge and suboptimal practices of post anaesthesia care, which could compromise patient outcomes. The study also identified some factors that influenced the knowledge and practices of nurses, such as lack of standardized protocols, inadequate staffing, insufficient equipment, and poor supervision. The study recommended that the hospital should develop and implement evidence-based guidelines and policies for post anaesthesia care, provide regular in-service training and workshops for nurses, improve the staffing and equipment situation in the PACU, and establish a quality assurance system to monitor and evaluate the quality of post anaesthesia care. One of the recent studies that highlight the need for improving post-operative care in low-resource settings is the one conducted by Mensah et al. (2020). The authors implemented a post anaesthesia care unit (PACU) in a tertiary hospital in Ghana and evaluated its effects on various outcomes. They compared the data from 300 patients who received PACU care with 300 patients who did not, and found significant differences in several aspects. The PACU group had better monitoring of vital signs, oxygen saturation, and pain scores, as well as lower rates of post-operative complications, such as nausea, vomiting, hypothermia, and hypoxia. Moreover, the PACU group had shorter recovery times and length of hospital stay than the non-PACU group. The authors concluded that the introduction of a PACU facility in a low-resource setting can improve the quality and safety of post-operative care, and reduce the burden on the health system. This study demonstrates the importance of dedicated PACU facilities in enhancing post-operative care, and provides evidence to support the implementation of similar interventions in other settings. Furthermore, Amponsah et al. (2019) conducted a qualitative investigation on the difficulties encountered by healthcare professionals in post anaesthesia care units. The study revealed that the quality and safety of postoperative care were compromised by several factors, such as insufficient University of Ghana http://ugspace.ug.edu.gh 30 staff, inadequate equipment, and lack of uniform guidelines. These factors hindered the ability of healthcare professionals to monitor and evaluate the patients' recovery and respond to any complications that might arise. University of Ghana http://ugspace.ug.edu.gh 31 Figure 2.1: Eastern Regional hospital Anaesthesia protocol sheet University of Ghana http://ugspace.ug.edu.gh 32 2.6 Conceptual Framework In line with existing literature, it can be deduced that PACU is governed by policy to achieve the goal of delivering post-operative anaesthesia services. The policy is directed towards the ability of the unit to prevent post-operative pain. It is also set out to ensure that the service delivery does not cause harm to the client. Therefore, the policy provides a set of activities which are planned for, and implemented in a systematic and continuously manner to achieve this goal. In this case, the policy is set out to deliver a service which prevents the feeling of pain, throughout the recovery process (Bardiau, Taviaux, Albert, Boogaerts & Stadler, 2003). In the implementation process, the key areas the policy focuses on are management and monitoring of the clients. This requires inputs such as post-operative anaesthesia guidelines, facilities, and post-operative anaesthesia medication. Some of the facilities include: cardiac monitor, blood pressure cuff, oxygen, suction, pulse oximeter, and temperature monitor. Management processes entails the various activities that the anaesthetist undertakes to prevent post-operative pain on the client under recovery (Breivik & Stubhaug, 2008). These activities include: pain management, consciousness management, movement management, circulatory management, renal management and vomiting and nausea management, and complication management. Post-operative pain is managed with analgesics. University of Ghana http://ugspace.ug.edu.gh 33 Surgery and anaesthesia cause the clients vital indicators to change, therefore monitoring is an essential part of post-operative anaesthesia care. It leads to prevention, early recognition and treatment of possible complications. Through monitoring, feedbacks are also provided which re- inform the policy and improve the management and monitoring processes. The monitoring process includes: input monitoring, management monitoring, indicators (blood pressure, oxygen saturation, heart rate, temperature and electrocardiogram) monitoring, consciousness monitoring, pain monitoring, renal monitoring, movement monitoring, vomiting and nausea monitoring, complication monitoring, factors promoting PAC, and factors inhibiting PAC (Hoogervorst- Schilp, Boekel, Blok, Steegers, Spreeuwengerg & Wagner, 2016). Figure 2.2 : Conceptual Framework on PACU University of Ghana http://ugspace.ug.edu.gh 34 Proper management and monitory processes lead to the desired output, which in this case results in PAC service delivery. This ultimately results in the desired outcome, which means reduced postoperative complications & mortality, and early recovery. A client who feels well throughout the recovery period is guaranteed to be satisfied. Finally, the findings of the monitoring serves as a basis for evaluation. This determines the extent to which the PAC policy achieved it desired outcome. The conceptual framework is presented in the figure below. 2.7 Summary of Literature Review Literature review for this study comprised of the concept of post anaesthesia care, the concept of general elective surgery, post anaesthesia care after general elective surgery, post anaesthesia care monitoring and evaluation and conceptual framework. Post anaesthesia care refers to the period from the completion of anaesthesia and procedure until the client is discharged from the hospital. In other words, it is the management of a client after anaesthesia and surgery. This includes care given during the immediate postoperative period, both in the theater and PACU, as well as days following the procedure (Perry, Potter & Ostendorf, 2014). At PACU, the client’s condition must be continually assessed by appropriated methods. The assessment includes client’s, systemic blood pressure, heart rate/rhythm, airway patency, oxygen saturation and circulation, ventilatory rate/character, temperature, level of pain, and level of consciousness and/or sedation and documents these elements of the PACU admission. The post anaesthesia period is separated into three levels of care: Phase I, Phase II, and Phase III. Each phase of recovery may occur in one PACU or in multiple locations. Standards for post anaesthesia care refers to standards ensured during activities undertaken to manage the patient after completion of anaesthesia/surgical procedure and the concomitant University of Ghana http://ugspace.ug.edu.gh 35 primary anaesthetic. The purpose of these guidelines is to improve postanaesthetic care outcomes for patients who have just had anaesthesia or sedation and analgesia care. It is expected that these standards will be individualized according to patient needs. In the delivery of post anaesthesia care, the anaesthetist provides medical services before and after the client is transported to the PACU. Before the post-operative period, an essential part of the anesthesiologist’s work is to perform an initial evaluation. This is performed to assess risk and develop a post anaesthesia plan. By assessing risk, it uncovers hidden conditions that could cause complications during post anaesthesia care. Elements of the initial evaluation include: reviewing the client's medical history, pre anaesthesia data, intra anaesthesia data, and procedure data. A postoperative client is at risk of complications, and it is vital that this is minimized. Knowledge and comprehension of the key areas of risk and local policies help to reduce potential complications. Monitoring includes checking for client’s pulse, respiratory rate, systolic blood pressure, temperature, and level of consciousness. Additional monitoring may include pain assessment, capillary refill time, percentage of oxygen administered, oxygen saturation, central venous pressure, infusion rates and hourly urine output (Ahmed et al. 2013). In some practices, the National Early Warning Score (NEWS) has been developed to provide a national standard for monitoring, assessing, and tracking acutely and critically ill clients (Royal College of Physicians, 2012). Conventional monitoring systems including, noninvasive blood pressure, electrocardiogram, capnography and end tidal anesthetic analyzer are valuable and should be used to help assessment of these clinical signs. Some effective monitoring equipment include Bispectral Index Monitor, Narcotrend Monitor, AEP Monitor/ 2, PSA 4000 Monitor, Cerebral State Monitor, Entropy Module, DGA Monitors, Oxygen Analyser, Pulse Oximeter, Ventilation, Carbon Dioxide Monitor, University of Ghana http://ugspace.ug.edu.gh 36 Continuous Invasive Blood Pressure Monitor, Inhalational Anaesthetic Agent Monitor, Temperature Monitor, and Neuromuscular Function Monitor (Somchai, 2012). According to standards of The American Society of Anesthesiologist, post anaesthesia evaluation commences within 48 hours after procedure. The evaluation is not performed until the client is sufficiently recovered from anaesthesia. This enables the client to participate in answering questions appropriately, and performing simple tasks. University of Ghana http://ugspace.ug.edu.gh 37 CHAPTER THREE METHODS 3.0 Introduction This chapter describes the research design, research setting, study population, sampling technique and sample size, method of data collection, data analysis, ethical consideration, and expected outcome. 3.1 Research Design A mixed method study was conducted to evaluate post anaesthesia care after general elective surgery at Eastern Regional Hospital. This study type was chosen because it combines qualitative and quantitative research components in a single study (Schoonenboom & Johnson, 2017). This helps to expand and strengthen a study’s conclusions and therefore contribute to the published literature (Schoonenboom & Johnson, 2017). This study relied on quantitative and qualitative data. A quantitative approach was used to evaluate post anaesthesia care of clients after general elective surgery. Secondary data from patients’ anaesthesia protocol and PACU observational chart and used to evaluate post anaesthesia care of clients after general elective surgery. A qualitative approach was used to assess adherence to the use of standard protocol in post anaesthesia care of clients after general elective surgery and factors that hinder operationalization of post operative care of clients after general elective surgery. This is a study which analyzed the current situation to identify the starting point of a policy, programme or project. The Explanatory sequential design was the type of mixed method design employed in this study. This involved collecting and analyzing the quantitative data first, followed by qualitative data to explain and contextualize the quantitative findings. According to Schoonenboom and Johnson (2017), This design is useful when the researcher wants to explore the reasons or mechanisms University of Ghana http://ugspace.ug.edu.gh 38 behind the quantitative results, or when the quantitative data alone is not sufficient to answer the research question. 3.2 Research Setting The study was carried out at the Eastern Regional Hospital in Koforidua within New Juaben Municipality. Koforidua is the capital City of the Eastern Region of Ghana. It is made up of neighborhoods and settlements which includes Effiduase, Asokore, Oyoko, Jumapo, Suhyen, Dansuagya, Betom, and Srodae. It serves as a commercial center and the home of many Government Ministries, Departments, and Agencies at the Regional level. Figure 3.1: Map of New Juaben South Municipal University of Ghana http://ugspace.ug.edu.gh 39 The Eastern Regional Hospital was established in 1926. It operates under the Ghana health Service as the largest Hospital in the Eastern Region, and the main referral point. As a 340-bed facility hospital, it provides wide range of service in the area of Pediatrics, Obstetrics and Gynecology, Neonatology, Dermatology, Venereology, Anti-Retroviral Therapy, Surgery, Medicine, Dentistry, Ophthalmology, Physiotherapy, Ear, Nose and Throat, Pharmacy, Laboratory, X-ray, Ultrasound, Catering and Hospitality, Laundry and Primary Healthcare Services. The hospital also serves as an academic center for training interns, house officers, and residents as well as allied health students. 3.3 Study Population The study population was made up of all anaesthetists and PACU nurses at the Eastern Regional Hospital as well as patients who underwent general elective surgery in the last six months at the Eastern Regional Hospital. 3.3.1 Inclusion Criteria 1. All permanent anaesthetists and PACU nurses at the Eastern Regional Hospital. 2. Anaesthesia protocol and PACU observation chart of patients (18 years and above) who have undergone general elective surgery at Eastern Regional Hospital. 3.3.2 Exclusion Criteria 1. Anaesthetists who were not willing to participate in the study 2. PACU nurses who were not willing to participate in the study University of Ghana http://ugspace.ug.edu.gh 40 3.4 Description of Study Variables Study variables have been tabulated below. 3.4.1 Dependent variables Table 3.1 Dependent variables Variable Type of variable Operational Definition Scale of Measurement Protocol used at PAC, proper handoff, monitoring patient parameters, discharge measures at PACU Categorical Measures in place to ensure client safety during post anaesthesia care Nominal Adherence to Protocol in Post Anaesthesia Care Categorical The availability of standard protocol that guide PAC, its components and use for post anaesthesia care Nominal Factors That Hinder Operationalization of Post Operative Care Categorical Factors that prevent the use of standard protocol at PACU, policies governing the use of standard protocol for PAC and challenges encountered in the usage of the standard protocol for PAC. Nominal University of Ghana http://ugspace.ug.edu.gh 41 3.4.2 Independent variable Table 3.2: Independent variable Variable Type of variable Operational Definition Scale of Measurement PACU equipments Categorical The availability of medical equipments for ensuring client safety during post anaesthesia care Nominal PACU medications Categorical The availability of medications for ensuring client safety during post anaesthesia care Nominal Age Categorical Self-reported age Nominal Sex Categorical (binary) Self-reported sex Nominal Level of education Categorical Self-reported highest level of education attained Ordinal Residence or location Categorical Self-reported residence Nominal Occupation Categorical Self-reported occupation Nominal Marital status Categorical Self-reported Marital status Nominal University of Ghana http://ugspace.ug.edu.gh 42 3.5 Indicators for process evaluation of post-operative anaesthesia care. Table 3.3: Indicators for process evaluation of post-operative anaesthesia care. DESCRIPTION INDICATORS MEANS OF VERIFICATION OVERALL OBJECTIVE The main objective of the study is to evaluate post anaesthesia care after general elective surgery at Eastern Regional Hospital. 1. Percentage of PACU patients who developed post anaesthesia complicatios 2. Proportion of post anasthesia patients who died as a result of post operative complications 3. Percentage of patients who had surgeries and were discharged home 1. PACU admission and discharge register 2. Daily state ward state 3. PACU death certificate register 4. Incidence book 5. Ward admission and discharge register SPECIFIC OBJECTIVE 1. To assess the measures in place to ensure client safety during post anaesthesia care. 2. To assess adherence to the use of the protocol in post anaesthesia care of clients after general elective surgery 1. Availability of emergency drugs in the PACU 2. Availability and function PACU equipment 3. Percentage of PACU staff trained in critical care 1. Availability of postanaesthesia care protocol in the PACU 1. Physical check from PACU drug cabinet 2. Drug requisition book 3. Physical check of equipment 4. Form hospitals human resource records 1. Physical check of protocols in the PACU University of Ghana http://ugspace.ug.edu.gh 43 3. To determine factors that hinder operationalization of post operative care of clients after general elective surgery 2. Availability of discharge criteria protocol in the theater 3. Percentage of patients that protocols were used for 1. Number of nurses who do not like using the post operative care protocols 2. Factors that hinder post operative care 2. Physical check from PACU 3. From patient’s folder or documents 1. Response from nurses EXPECTED RESULTS 1. The result of the study is expected to improve post anaesthesia care at PACU at the Eastern Regional Hospital. 2. Percentage of post anesthesia patient who recovered and was trans out to the ward 3. Percentage of day care surgeries that were discharged home after surgery 1. PACU admission and discharge register 2. PACU admission and discharge register ACTIVITIES 1. Proper verbal and written handoff of patients by anesthetist to the PACU nurses 2. Applying monitors to the patients and monitoring the patient 3. Monitor vital signs (Blood Pressure, pulse. Electrocardiogram, temperature etc) till patient recovers for anesthesia 4. Use post-anesthesia care protocol to care for the patient 2. Availability of written handoff sheet in patients document or folder 3. Every patient received in the PACU attached to a monitor 1. Presence of handoff sheet in patient’s folder or documents 2. From post- anaesthesia care protocol 3. Presence of filled post-anaesthesia care protocol in patient’s folder or document 4. Patient’s monitoring chart/ protocol University of Ghana http://ugspace.ug.edu.gh 44 5. Assess the patient for pain using pain monitoring scale and act when appropriate 6. Watch out for signs of developing complications such as hypotension, difficulty in breathing, unconsciousness, excessive bleeding from operation site etc.) and act promptly 7. Use discharge criteria protocol to discharge the patient from PAC 4. Percentage of patients with protocols in their documents 5. Percentage of patients who developed post anaesthesia complications 6. Percentage of patients discharged with discharge criteria in their documents / folder 5. Patients’ folder/ documents 6. Admission and discharge register 3.5.1 Logical Framework The logical framework outlines the inputs, activities, outputs, and outcomes of the study on the evaluation of post-anaesthesia care after general anaesthesia at Eastern Regional Hospital. The inputs include the study protocol, research team, data collection tools, and the PACU unit at the hospital. The activities involve data collection from the PACU unit, analys