Letter to the Editor: Reframing post-anesthesia care unit handover in gastrointestinal surgery - a missing link in enhanced recovery after surgery pathways

Abstract

We have read a recently article published in the World Journal of Gastrointestinal Surgery by Hu et al focusing on the handover management of gastrointestinal surgery patients during the post-anesthesia care unit (PACU) period. The study addresses a long-overlooked yet critically important “transition zone” in perioperative management. Within the perioperative management pathway of the enhanced recovery after surgery concept, PACU is often regarded as a “brief stopover area” rather than a genuine “management node”. In fact, PACU serves as the sole transitional point from anesthesia management to the surgical ward, where measures such as analgesia, antiemesis, and temperature management continue to be implemented. Any omission of information at this stage may undermine the effectiveness of prior enhanced recovery after surgery implementation. Additionally, the study introduces a “specialized mindset” into PACU handover management, consciously emphasizing the characteristics of gastrointestinal surgery patients within a standardized handover template. This is not merely about adding another handover template; it ensures that both parties involved in the handover reach a cognitive consensus on key issues, thereby reducing the risks arising from differences in information interpretation. In the future, this handover system could further transition toward digitalization to alleviate manual workload. Moreover, outcome indicators such as the incidence of adverse events could be used to more comprehensively evaluate its long-term effectiveness.

Key Words: Post-anesthesia care unit; Enhanced recovery after surgery; Gastrointestinal surgery; Handover; Comfortable medical treatment

Core Tip: Within the perioperative management pathway of the enhanced recovery after surgery concept, the post-anesthesia care unit is often regarded as a “brief stopover area” rather than a genuine “management node”. In fact, the post-anesthesia care unit serves as the sole transitional point from anesthesia management to the surgical ward, where measures such as analgesia, antiemesis, and temperature management continue to be implemented. Any omission of information at this stage may undermine the effectiveness of prior enhanced recovery after surgery implementation.

TO THE EDITOR

We read with great interest the study published in the World Journal of Gastrointestinal Surgery by Hu et al[1]. This study[1] focuses on handover management during the postoperative anesthetic recovery phase in gastrointestinal surgery patients in the post-anesthesia care unit (PACU). It addressed a long-neglected yet critically important “transitional zone” in perioperative management. In the current context, which emphasizes both patient safety and enhanced recovery, this topic clearly demonstrates clinical relevance and significant value from a patient safety perspective.

REFRAMING THE PACU FROM AN ERAS PERSPECTIVE: A CRITICAL BUT UNDERESTIMATED WINDOW

When the concept of enhanced recovery after surgery (ERAS) was introduced, it posed a significant challenge to the traditional perioperative care model, which primarily focused on preoperative preparation, intraoperative management, and postoperative care. Since then, ERAS has demonstrated clear benefits in colorectal, gastric, and hepatobiliary surgery and has been increasingly adopted. Although its implementation continues to evolve, growing evidence, including recent meta-analyses, shows that ERAS can significantly reduce hospital length of stay and postoperative complications[2,3]. International guidelines for ERAS have been established across various surgical specialties and continue to be updated. However, postoperative care within the ERAS perioperative management pathway remains focused on the ward phase[2,4]. In contrast, the PACU is often regarded merely as a site of “brief stay” rather than a true “management node”. This historical framing has, in practice, contributed to a persistent “structural blind spot” within ERAS pathways.

Actually, the PACU represents the only convergence point where anesthetic management transitions to surgical and ward-based care, serving as a watershed for the continuity of key interventions such as analgesia, antiemetic therapy, temperature management, and volume status optimization. For example, studies have shown that intraoperative hypotension is associated with the incidence of postoperative nausea and vomiting in the PACU[5]. Furthermore, intraoperative hypothermia may increase the occurrence of postoperative delirium in elderly patients in the PACU[6]. Consequently, any information loss or management discontinuity occurring during this phase may attenuate the effectiveness of earlier ERAS measures or expose patients to unnecessary pharmacologic treatments. Inadequate management in the PACU may even amplify the risk of postoperative complications.

Notably, hypoventilation events occurring within the first postoperative hour in the PACU have been shown to correlate with similar events occurring 48 hours after the patient returns to the surgical ward, with a positive predictive value of 100%[7]. From this perspective, although the PACU is the shortest phase temporally, it may represent the most critical transitional link within the ERAS pathway. Therefore, the PACU plays a critical role in ensuring the continuity of ERAS interventions and in identifying complications. By focusing on this specific node, the present study addresses an important theoretical gap and offers meaningful complementary value to existing ERAS frameworks.

INTRODUCING SPECIALTY-ORIENTED THINKING INTO THE PACU: CORRECTING THE “ONE-SIZE-FITS-ALL” MANAGEMENT PARADIGM

Another important contribution of this study lies in its introduction of a specialty-oriented approach to PACU handover management, offering a targeted refinement of long-standing standardized, template-based recovery room workflows. Current PACU handover processes predominantly emphasize universal safety elements, with relatively limited differentiation tailored to specific surgical types.

However, patients undergoing gastrointestinal surgery exhibit distinct perioperative characteristics, including the presence of multiple indwelling devices (such as nasogastric tubes, intra-abdominal drains, and central venous access), complex fluid management requirements, pronounced thermoregulatory fluctuations, and a relatively high risk of postoperative nausea and vomiting. This degree of “procedural heterogeneity” dictates that PACU management should not rely on generic templates alone but instead adopt focused priorities and content tailored to the surgical specialty during handover. The indicator system developed in this study represents a proactive response to this clinical reality, reflecting a shift in management philosophy from “general safety” toward “specialty-specific safety.”

HANDOVER CONTENT AND FORMAT: MORE THAN A CHECKLIST- A TOOL FOR COGNITIVE ALIGNMENT

From the perspective of specific interventions, the content design of this handover system clearly aligns with the ERAS objective of continuity of care. Its core intent is not to introduce additional interventions but to ensure that established strategies for analgesia, antiemesis, thermoregulation, and fluid management remain “unbroken” as care transitions between teams. From an ERAS standpoint, the quality of handover largely determines whether ERAS measures can be effectively translated into real-world clinical practice. Notably, despite variations in staffing models and patient populations across institutions, adequate staffing of both physicians and nurses remains essential to ensure safe and effective care.

In terms of format, the study adopts a structured handover form. Superficially, this tool resembles a checklist; however, its function extends well beyond simply documenting task completion. More importantly, through risk prompts, explicit visualization of key information, and bidirectional verification, it facilitates the establishment of a shared mental model among healthcare professionals from different roles during handover. Its value lies not in the number of items recorded but in its ability to align the cognitive focus of both parties on critical issues, thereby reducing risks arising from information misinterpretation and implicit assumptions.

METHODOLOGICAL PERSPECTIVE: NON-RANDOMIZED DESIGN AS A STARTING POINT FOR REAL-WORLD RESEARCH

From a methodological standpoint, this study employed a time-series grouping design without randomization or blinding, which objectively introduces the potential for selection bias and learning effects. This may weaken the strength of causal inferences and make ensuring the consistency of data quality difficult. This limitation should be acknowledged transparently. However, it is important to emphasize that a non-randomized design is not synonymous with a lack of scientific value. In studies of handover management that rely heavily on process coordination and team-based workflows, traditional randomized controlled trials are often impractical at the implementation level. The primary contribution of this study lies in demonstrating the feasibility of the proposed handover system in a real-world clinical setting, as well as its potential safety benefits. As such, it represents a feasibility or proof-of-concept study. This positioning is both reasonable and necessary, and it provides a practical foundation for subsequent large-scale implementation, refinement, and more rigorous evaluation. Matching participants in the experimental group with comparable controls may help reduce selection bias. In addition, a pilot phase could help minimize the influence of learning effects on study outcomes.

FUTURE DIRECTIONS: INTEGRATING HANDOVER INTO ERAS RATHER THAN TREATING IT AS AN ADDED BURDEN

Looking ahead, this system still offers room for further optimization. First, in terms of format, a gradual transition from paper-based to digital platforms could be pursued, with integration into anesthesia information management systems or PACU management systems. Such integration would allow automatic capture of key parameters - such as body temperature, mean arterial pressure, and fluid input - thereby reducing manual workload and enhancing scalability. Importantly, in routine practice, this system could be incorporated into existing PACU workflows without fundamentally increasing handover time by restructuring rather than expanding current communication processes. Second, with respect to study design, future research could consider stepped-wedge designs, multicenter before-and-after studies, or quality improvement frameworks, using outcomes such as adverse event rates, handover omission rates, and completion rates of key ERAS indicators to more comprehensively evaluate long-term effects. Third, the role of nurses is also very important. Studies have shown that the PACU nursing process based on ERAS can effectively accelerate the recovery speed of patients with gastrointestinal tumors and reduce complications[8].

However, several challenges remain. Healthcare institutions may be reluctant to depart from established PACU handover practices; adopting a new model may increase the learning burden for staff, and transitioning to electronic systems entails additional costs. Robust evaluation is also essential. Metrics such as handover completion rates, omission rates of critical items, and perioperative adverse event rates may support objective assessment and continuous improvement. With accumulating evidence of clinical benefit, integration of optimized PACU management into ERAS pathways may be further advanced.

Overall, this study does not seek to construct a more complex handover process; rather, through structuring and prioritization, it renders explicit those safety elements that were previously implicit and experience-dependent. The real challenge lies not in whether rigorous verification is necessary but in how to achieve high-quality, sustainable handover management without significantly increasing time or staffing burdens. We call for greater recognition of the PACU as a critical component of perioperative care and encourage further high-quality research to evaluate the role of PACU handover protocols within ERAS pathways. This work provides a valuable practical paradigm for formally incorporating PACU handover into the ERAS framework and lays the groundwork for future multicenter, quality improvement-oriented research.