Financial constraints

The 1990s brought increased financial constraints on hospitals and increased competitiveness among hospitals. The focus in the 1990s on controlling costs led to a dramatic shift in the types of patients who were admitted to hospitals. Only the sickest patients were eligible for admission, and the length of stay was compressed to the shortest possible time.⁴ Although hospital population dropped, ICU patient volumes were steadily increasing. Hospital mergers and closings occurred in many cities. During this same time, two significant changes developed: (1) patient acuity of critically ill patients admitted to hospitals increased and (2) the shortage of ICU nurses prompted hospital administrators to close ICU beds. ICU bed closures have had a serious effect on PACUs. PACUs were naturally chosen for critical care overflow because the environment of care included highly technical monitoring and many critical care–educated nursing staff. In addition, the retention of staff in the PACU was much higher with fewer vacancies. This choice seemed the ideal answer to a complex problem. Consequently, the PACUs were increasingly requested for recovery of SICU patients, and in many hospitals the PACU was designated an ICU overflow unit until an ICU bed became available.

Management dilemmas

Nurse managers encounter numerous challenges between competing health care providers that relate to patient placement priority for ICU beds. These challenges are affected by decisions of senior administrators (e.g., chief operating officers, chief nursing officers, departmental medical officers of medicine and surgery, emergency or trauma physicians). The dilemmas faced by managers affect ancillary staff, families, patients, and the PACU staff nurses. The PACU manager is obligated to follow hospital policies and protocols. When senior administrators make decisions in the best interest of the hospital to keep the emergency departments and operating rooms open and to perform surgery for elective surgical cases regardless of high hospital population, the PACU becomes the relief valve for medical center admissions. Often the hospitalized patients who occupy beds in the ICU are not ready for transfer to a lower level of care. This gridlock has a domino effect on the PACU beds. Emergency department patients who need critical care may be given priority status for ICU beds, as may “code” call patients from inpatient units. Some ICUs actually hold beds open for potential code call situations. As the inpatient and ICU surgical cases are completed, they too compete for the PACU available beds. Complications arise if the PACU is still holding ICU patients from the day before or from earlier in the morning. Eventually, the operating room (OR) schedule may grind to a halt because of the ensuing gridlocked beds. In some hospitals, the OR continues to perform surgery on critical care patients, with admission of more ICU overflow patients to an already stressed PACU. These SICU patients become known as boarders, extended stay, or ICU overflow. Patients and families may voice intense dissatisfaction when the PACU is designated for ICU care.²

Recovery of the ICU patient who has an extended stay in the PACU may have serious physician repercussions. Anesthesia providers and surgeons become frustrated because they want to complete the elective surgical schedule. At times, their behaviors may strain relationships with the nurse manager. The lost surgical and anesthesia revenue can threaten the viability of the hospital if surgical cases continue to be delayed or cancelled. University hospitals also have graduate medical education and need to perform a required number of surgical or anesthesia cases per year to qualify for accreditation of the programs.

Other challenges encountered by medical staff may be the following issues that place the care of the ICU patient at risk. Medical intensivist management of the SICU patient may be delayed because of the physical location of the PACU or other commitments to patients in the ICU. Confusion may exist regarding whom to contact for medical or surgical problems. Another issue that frequently surfaces is the need to have medical consultations. PACU staff may believe that lack of timely medical care not only increases the stress of the nurse, but ethically affects the professional duty to provide safe timely quality care. Further delays in treatments can critically affect a patient’s condition. Finally, the surgeon may become upset with the hospital administration because the order was for the ICU patient to be admitted to the ICU for postoperative care and management.

The physical location of the PACU is always adjacent to the OR; however, the ICU is usually in a different area of the hospital. This situation can create delays in diagnostic care or treatment that otherwise is more expeditious if the patient is in the ICU. For example, respiratory therapy, pulmonary services, blood bank, and the critical care laboratories may be actually located in the ICU. Advanced practice nurses and physician assistants assigned to the ICU may not be available for ICU patients in the PACU. The PACU may have to wait for the hospital’s respiratory therapist or laboratory technician to come to the unit. If a computed tomographic scan or magnetic resonance imaging scan is needed, the PACU nurse might not be able to transport the ICU patient in a timely manner because of assigned care of another postanesthesia patient. The ICU patient may need special medications or vasoactive intravenous drips that are not immediately available to the nurse. Ancillary services have a vital role in the care and management of the ICU patient.

ICU patients emerging from anesthetic agents frequently request that their families visit in the PACU. Traditionally, PACUs have been considered large open units in which family visitation is severely limited because of other patients emerging from anesthesia. This type of policy can create intense conflict between the nurse and the family. Family expectations of a private room in which families can visit freely are not met. Furthermore, the family’s anxiety increases when the surgeon speaks about the critical nature of the surgery and the need to place the patient in the ICU. Families frequently worry and may perceive the ICU as a sign of impending death, based on past experiences or those of others.⁵ Understanding what critical care means to patients and families helps the nurse promote positive coping skills. Depending on the patient’s physical condition, effective communication with the ICU patient may be challenging. Barriers to communication can relate to emergence from anesthesia; the patient’s physical status; the existence of endotracheal tubes, which inhibit verbal communication; medications; or other conditions that alter cognitive function.^5,6 The critical care patient’s anxiety can increase the stress response and further complicate the patient’s recovery. Patients may consider that they have a right to see and visit with their family and may find significant emotional support for well-being.

Managing and communicating with the ICU families in the PACU can be challenging. Depending on each patient’s diagnosis and acuity, the SICU patient’s family may be in crisis. If the patient’s condition is critical, the family may exhibit a high degree of stress, anxiety, blame, or other disturbing behaviors. Families may be emotional and act out or exhibit disruptive outbursts. The staff nurse may believe that one’s first duty is to provide care to the patient, not to the family. Time can pass quickly for the PACU nurse and not afford the family timely visits. Anxiety and worry mounts for the waiting family as a result of little or no communication and fear of the unknown. The PACU nurse needs to make a conscious effort to effectively communicate with the family in a manner that promotes coping, personal growth, and adaptation to the ICU patient’s critical condition (Box 55-1).⁷

Critical care educational competencies

The postanesthesia nurse must have in-depth knowledge of anesthesia agents, normal physiology, pathophysiology, and current surgical management to plan appropriate nursing interventions and to care for the postanesthesia patient. Depending on the PACU nurse’s critical care experience, competencies, skills, and available medical and nursing resources, the care and management may prove to be frustrating or threatening. However, one should remember that the PACU nurse is recognized for possessing critical care competencies and skills when caring for the vulnerable patient recovering from anesthesia and surgery. Likewise, the challenge of caring for the complex SICU patient can be a rewarding opportunity to use one’s critical thinking skills in making a difference in the outcome of the critically ill patient.

Orientation and basic critical care competencies

The first steps in planning an orientation to the PACU is the interview process and subsequent hiring of the nurse who is motivated to learn many new skills. In addition, the nurse who seeks to be professionally challenged on a daily basis inspires and motivates the critical care preceptor. The PACU should never be viewed as a place to wind down or retire, because nurses with that goal in mind are often immediately disappointed and dissatisfied with their new jobs. Many PACUs prefer to hire nurses with critical care experience. Medical-surgical nurses are also hired, provided that an adequate support system of nursing education exists during orientation and the length of orientation is such that the nurse without prior critical care experience has ample time to master the myriad new skills essential to the new role.

Orientation to the PACU must focus on anesthesia and complications related to anesthetic agents, comorbidities, and surgery, because this subject area encompasses almost the entire patient population in the PACU. But what about the critical care patient? All patients who arrive in the PACU, regardless of invasive lines and mechanical ventilation, must be viewed as having the potential to be a critically ill patient. Even a patient who has had a hernia repair or an appendectomy can become gravely ill. In addition to this fact is the matter of the critically ill patient who arrives in the PACU before the final destination of the ICU. Orientation and education must also focus on the following essentials:

Orientation should include the essentials of how to care for the patient who has all or some of the invasive monitoring equipment mentioned previously and how to assemble such equipment in preparation for insertion in the PACU. The PACU should have the necessary equipment readily available in the event that a patient’s condition worsens and invasive procedures are to be performed in the PACU.

The main challenge in orienting the newly hired nurse to the critical care element of the PACU is access to these patients. A day in the operating room with an anesthesia provider who inserts a PA catheter and manages a critically ill patient, such as with a cardiac bypass case, can be helpful. An immersion in the ICU is another option, with the PACU registered nurse (RN) spending 1 week or more in the ICU shadowing an ICU nurse. A cardiothoracic ICU is ideal because this type of ICU admits patients frequently, similar to the PACU, and the orientee can learn the tasks of detangling lines, managing the newly ventilated patient, weaning the patient, initiating and titrating vasopressor medications, and other needed skills. The leadership team of the PACU should closely collaborate with the leadership team of the ICU to ensure that the PACU RN has an orientation that is similar or identical to the orientation of the new nurse in the ICU. If the ICU educator or clinical nurse specialist is providing education for the ICU staff members, the PACU RNs should be encouraged to attend as well. Some ICUs use the online orientation program sponsored by the AACN. This program is called Essentials of Critical Care Orientation, which is a computer-based standardized orientation of critical care nursing. If the ICUs in the facility use this type of orientation program, the PACU nurse might be helped by using it as well. If the ICU orientation consists of critical care courses, then the PACU trainee should attend as well, after the essentials of perianesthesia nursing and PACU core competencies have been mastered.

But what about the experienced PACU nurse who is suddenly confronted with the increasing volume of critical care patients? Collaboration with the ICU leadership team is helpful, with the possible outcome of an opportunity to shadow an ICU nurse for 1 week or more to learn the basic care and management of the patient with both mechanical ventilation and invasive monitoring equipment that requires vasopressor support.

A competency-based orientation checklist should be completed for the new nurse and the experienced PACU RN who receives any education in critical care. The PACU leadership team must develop a standardized educational process with the requisite paper trail to safeguard the PACU RN, the hospital, and the PACU leadership team in the event of an untoward outcome.

In addition, if the facility sponsors an annual skills fair day, the PACU RN should complete or show similar competencies to the ICU RN, based on the patient population that the PACU cares for, even if that critical care population is rare. The care of a patient who is high risk and low volume is the most challenging for the RN.

The PACU RN should also be expected to complete the same annual competence assessment that is required of the ICU nurses. For example, if a dysrhythmia competency is developed for the ICU RN, the PACU RN should also be expected to complete it, and documentation of completion should be placed in the education folder.

Advanced critical care concepts

Understanding key advanced critical care concepts assists the PACU nurse in refining critical decision-making skills. The ICU patient who remains in the PACU for an extended period of time poses an enormous challenge in many aspects. Both the nursing and physician management of these patients can be difficult. The standards of care that are developed by the ICU and the facility and that are in place in the ICU should be readily available and implemented in the PACU. These standards include:

Creating A specialized critical care resource for the PACU

Many PACUs across the country care for ICU patients sporadically. This situation occurs when the hospital census is high or when a surgical emergency presents. Specialized critical care educational resources strategically provide the PACU nurse with expert advisors when the critical time arises. This resourceful method can be accomplished in several ways. First, the PACU can recruit expertise from the unit. Second, the nurse manager may elect to request key leadership staff to orient and become competent and proficient in managing the care of specific patient populations.

Another innovative concept to achieving critical resources is cross training the PACU staff to the ICU and critical care nurses to the PACU. When the PACU admits a highly complex high-acuity SICU case and the primary nurse does not possess the knowledge or skill to provide care, an opportunity may exist to exchange nurses rather than patients to appropriately match the patient severity with the nurse’s knowledge and competencies.