55 Care of the intensive care unit patient in the pacu
Extended-Stay ICU Patients: Critically ill surgical patients who have recovered from anesthesia but need to stay in the PACU an extended or prolonged period of time because of the severity of illness or the need to be observed for complications.
Family Presence: Families are provided the opportunity to be present in the PACU with their loved one during life-threatening situations or at the end of life during cardiopulmonary resuscitation or codes.
Intensive Care Unit Boarders: Critically ill surgical patients who have recovered from anesthesia in the PACU. These patientshave been designated ICU status, but do not have an ICU bed and are boarding in the PACU.
Systemic Inflammatory Response Syndrome (SIRS): A systemic response to infection that involves the activation of the inflammatory response to include change in body temperature, elevated heart rate, respiratory rate, and white blood cell count.
The admission of intensive care unit (ICU) patients to postanesthesia care units (PACUs) is steadily increasing. In addition, the PACU also cares for another type of critically ill surgical patient population: ICU overflow patients, also known as ICU boarding patients. This terminology refers to a unique critical care patient population who recovers in the PACU and subsequently meets the PACU discharge criteria. However, these ICU patients are unable to be transferred because of the unavailability of inpatient ICU beds, subsequently theyremain in the PACU. This increase reflects a nationwide health care dilemma for emergency department and PACU patients who create a high demand for hospital beds. The American Society of PeriAnesthesia Nurses (ASPAN) Delphi Study identified ICU overflow patients and critical care competencies as the top research clinical, educational, and management priorities.1 Finally, these national patient safety priorities are strategic for ensuring safe, quality postanesthesia care to ICU patients and to the care environment.
As the science of perianesthesia nursing has evolved and become increasingly more sophisticated, nursing educators, managers, and administrators have realized the importance of an economically sound, evidence-based practice that continuously strives to provide safe quality care to the ICU patient in the PACU. However, recovery of the critically ill postoperative patient in the PACU often poses a myriad of challenges to the postanesthesia nurse and the PACU.
Throughout the United States, divergent postanesthesia practices have existed in the provision of care for the surgical intensive care unit (SICU) patient. Operationally, ICU recovery must occur on a routine basis, regardless of prognosis or acuity in the appropriate care setting. Some PACU care of the postsurgical critical care patient may be sporadic or an exception to the norm. From a clinical and an administrative position, however, the PACU must provide the optimal standard of care to SICU patients.2 This chapter discusses the historic significance of critical care recovery, administrative issues in extended ICU care, innovative educational opportunities to ensure competent staff, and clinical strategies in caring for complex, high-acuity, critically ill patients. Because patient safety is essential in providing care to low-volume high-risk patients, complex and highly specialized ICU nursing care concentrates on neurosurgical, burn, and septic management during the postanesthesia period. Ultimately, postanesthesia care must be focused on providing competent care while preventing harm and keeping critically ill patients safe. Finally, when the SICU patient’s condition becomes life threatening, family presence during resuscitation is introduced as an end-of-life nursing intervention that promotes patient-family–centered care.
During the late 1950s and early 1960s, ICUs emerged in hospitals for close monitoring of critically ill patients. Before that time, the critically ill postsurgical patients received care recovery rooms and inpatient wards. Critical care nursing was conceived to provide a setting in which the most acutely ill and injured patients received concentrated nursing care to enhance survival. Fifty years ago, ICUs were composed of a few specialized beds located at the end of or apart from an existing inpatient unit.3
Today, the design of the ICU is focused on individual rooms to promote an aesthetic therapeutic environment. The ICU provides patient privacy and is focused on highly technical care that can also be family centered. In comparison, the interior design of the PACU has not changed much in 50 years. It is usually one large room in which individual patient units are separated by curtains.
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.
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
• Prepare the family for the PACU care environment, especially the effects of patients emerging from anesthesia, respect for other PACU patients, confidentiality, PACU equipment (e.g., cardiac monitors, ventilators, infusion pumps), and purpose of the equipment.
Adapted from Norton C: The family’s experience with critical illness. In Morton PG, et al, editors: Critical care nursing: a holistic approach, ed 8, Philadelphia, 2005, Lippincott Williams & Wilkins.
The PACU nurses may express feelings of inadequacy related to critical care competencies. A PACU nurse may have no ICU nursing experience or outdated critical care experience. The critical care experience may have been generalized and not specific, or new technology may be foreign. Nurse-to-patient ratios may be exceeded for safe care. The PACU nurse may already be assigned one patient with simultaneous care for a newly admitted ICU patient with an unstable condition, and then family members (frequently numerous) want to be present and are upset because visitation is limited or not allowed. PACU nurses may find themselves in the midst of ethical situations that involve conflict between the needs of the ICU patient’s family members and the preferences of physicians and other health care providers. Consequently, this PACU environment may be chaotic and not conducive for healing. Visitors may perceive the PACU as a suboptimal environment for a loved one. When PACU nursing staff members perceive that safe patient care is becoming jeopardized or high risk, they should consult the nurse manager immediately.
As the nursing shortage in the United States has become more severe, placing ICU overflow patients in the PACU has become a standard of practice rather than being a series of isolated incidents.8 Reports from PACU nurses in different regions of the country have communicated unsafe practices. Postanesthesia nurses turned to their professional organization, the American Society of PeriAnesthesia Nurses (ASPAN), to voice their concerns about serious issues that affected the care they provided to recovering ICU patients in the PACU. The ASPAN Standards and Guidelines Committee conducted a special review of the evidence to identify current nursing practice issues. The following trends in the care of ICU patients in the PACU were identified:
4. When the need to send ICU overflow patients to PACU Phase I does not occur regularly, both the PACU and the hospital management may not be properly prepared to handle the admission and discharge of PACU Phase I and ICU patients.2,6
ASPAN invited the American Association of Critical Care Nurses (AACN) and the American Society of Anesthesiologists to address the practice trend of caring for the ICU overflow patient in the PACU and to strategize to promote safe quality care regardless of where the SICU patient recovers from anesthesia. A collaborative position statement was promulgated by these three powerful specialty organizations (Box 55-2).2
BOX 55-2 Joint Statement on ICU Overflow
A phase I postanesthesia care unit (PACU) is a critical care area that provides postanesthesia nursing care for patients immediately after operative and invasive procedures before discharge to the phase II ambulatory setting, the inpatient surgical unit, or the intensive care unit.
As professional societies involved in the provision of care for operative and invasive procedures and critically ill patients, the American Society of PeriAnesthesia Nurses (ASPAN), the American Association of Critical-Care Nurses (AACN), and the American Society of Anesthesiologists (ASA) collaborated to develop criteria for the purposes of maintaining quality care in the PACU, ensuring quality care for the intensive care unit patient, and promoting the safe practice of perianesthesia nursing and critical care nursing.
ASPAN exists to promote quality and cost-effective care for patients, their families, and the community through public and professional education, research, and standards of practice. ASPAN has the responsibility for defining the practice of perianesthesia nursing. An integral part of this responsibility involves identifying the educational requirements and competencies essential to perianesthesia practice and recommending acceptable staffing requirements for the perianesthesia environment.
AACN was established to provide the highest quality resources to maximize nurse contributions to care for critically ill patients and their families. AACN provides and inspires leadership to develop standards and guidelines that establish work and care environments that are respectful, healing, and humane.
ASA was established to raise and maintain the standard of the medical practice of anesthesiology and improve the care of the patient during anesthesia and recovery and is involved in the provision of critical care medicine in the intensive care unit.
In response to concerns expressed by perianesthesia nurses around the country, the ASPAN Standards and Guidelines Committee conducted a review of current literature and perianesthesia nursing practice to identify issues related to the care of critically ill surgical and nonsurgical patients in Phase I PACUs during times when all other ICU beds are full. The review identified the following trends:
2. The Phase I PACU nurse may be required to provide care to a surgical or nonsurgical ICU patient that the nurse has not been properly trained to care for or for which the nurse has not had the required care competencies validated.
4. Because the need to send overflow patients to the Phase I PACU does not occur regularly, both the PACU and the hospital management may not be properly prepared to deal with the admission and discharge of Phase I PACU and ICU patients.
Therefore, when admission of ICU overflow patients or prolonging the stay of the surgical ICU patient in the Phase I PACU is necessary, ASPAN, AACN, and ASA recommend that the following criteria be met:
2. Appropriate staffing requirements should be met to maintain safe competent nursing care of the postanesthesia patient and the ICU patient. Staffing criteria for the ICU patient should be consistent with ICU guidelines based on individual patient acuity and needs.
3. Phase I PACUs are by their nature critical care units, and as such, staff should meet the competencies required for the care of the critically ill patient. These competencies should include, but are not limited to, ventilator management, hemodynamic monitoring, and medication administration, as appropriate to the patient population.
4. Management should develop and implement a comprehensive resource utilization plan with ongoing assessment that supports the staffing needs for both the PACU and ICU patients when the need for overflow admission arises.
5. Management should have a multidisciplinary plan to address appropriate utilization of the ICU beds. Admission and discharge criteria should be used to evaluate the necessity for critical care and to determine the priority for admissions.
ASPAN, AACN, and the ASA committees (Anesthesia Care Team, Critical Care Medicine, and Trauma Medicine) recognize the complexity of caring for patients in a dynamic health care environment where reduced availability of resources and expanding roles for the registered nurse has an impact on patient care. Thus, we encourage all members to actively pursue the education and development of competencies required for the care of the critically ill patient in the perianesthesia environment. We also encourage members to actively identify strategies for collaboration and problem solving to address complex staffing issues.
From ASPAN, AACN and ASA’s Anesthesia Care Team Committee and Committee on Critical Care Medicine and Trauma Medicine: A joint position statement on ICU overflow patients, September 1999, in ASPAN: Perianesthesia nursing standards and practice recommendations 2010-2012, Cherry Hill, NJ, 2010, ASPAN.
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.
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.
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:
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.
The PACU nurses are required to use critical decision-making skills in daily practice. Advanced life support competencies are mandated for PACU nurses who care for all vulnerable patients who are emerging from surgery and anesthesia. The foundation of PACU and critical care nursing is an understanding of anesthesia agents and human physiology that guides the postanesthesia nursing assessments and interventions. Foremost, the PACU nurses must ensure that adequate oxygenation, ventilation, transport, and perfusion in the patient occur, regardless of unit: the ICU or the PACU. Impairment in oxygen delivery and utilization at the tissue level leads to global tissue hypoxia. Fundamental to recognition and treatment of global tissue hypoxia is knowledge of the principles of oxygenation, ventilation, transport, and perfusion and their etiologies and how they relate to postanesthesia care. The major differences lie in the complex pathophysiologic disease processes that occur in these critically ill patients. The following section discusses the pathophysiology and clinical strategies in management of the care for three highly specialized high-acuity low-volume populations: the neurosurgical, burn, and septic ICU patients.