Patient classification

Most PACUs have some type of patient classification system (PCS) either formal or informal. The most accurate PCSs are those that base the patient classification on length of stay in the PACU and intensity of the care required. The PCS can be used to justify budget for staffing and supplies as well as space requirements and charges for the PACU stay. For example, a patient with a classification of 1 has a lower charge than a patient with a classification of 3.

Developing a PCS for the PACU is difficult. Many variables must be considered and addressed when developing a PCS. Length of stay and anesthesia patient classification are starting points for PCS, but length of stay of each patient may vary significantly, and the acuity of a patient can change within a short period of time. Moreover, patient populations can range from pediatric to geriatric and can include minor to extensive surgical procedures, depending on the makeup and mission of the institution.

The advantages of a PCS include a more accurate assessment of the nursing time and energy needed for each patient, which helps a manager to estimate staffing requirements on the basis of the next day’s schedule. Other advantages can include knowledge of the highest workload time periods each day, allowing the manager to flex staff accordingly. This allows PACU nurses the knowledge that the type of workload in the PACU, with its peaks and valleys, is acknowledged and management is responsive to their unique staffing needs.

Visitors

The merits and benefits of visitation in the PACU are well documented. Patient visitation lowers anxiety and decreases stress for both the patient and the family. The result is an increase in patient and family satisfaction and increased adherence to the recovery plan.^1,2 In the past, PACU visitation was restricted for reasons such as the lack of privacy, the acuity of the patients, and the fast turnover that is common to the PACU. Visitation may have been allowed only if staffing and the physical structure of the unit permitted. In many institutions a change in culture surrounding PACU visitation has shown that the positive outcomes from visitation have outweighed the real and perceived drawbacks. A main catalyst behind the change has been the lack of available postoperative beds, thus extending the stay in the PACU for many patients. Some patients may have a prolonged stay in the PACU while they await critical care, telemetry, or surgical beds in the nursing unit. As the frequency of morning admissions increases, the incidence rate of extended PACU stays also increases because of lack of postoperative bed availability.^1,3

Part of the challenge with a change in the organizational culture to allow visitation in the PACU is that nursing care historically has concentrated on the care of the patient only. However, many family members also need nursing interventions, such as explanations of the PACU care provided to their loved ones, and require time and effort on the part of the nurses. However, PACU visitation can provide an excellent opportunity to start postoperative education with families.

Visitation times vary greatly, with some PACUs that still do not allow visitation and others that have adopted policies originally designed for other critical care units. Some PACUs may include a 5-minute visit each hour or a 20-minute visit every 4 hours, whereas other institutions have open visitation that is restricted only during the timeframe when a critical event is occurring in the PACU. Other criteria may include a limited number of family members at one time, the patient’s desire for visitors, the unit needs, and the patient’s condition. Privacy of other patients in the PACU must always be a consideration and priority.

Situations in which visitation should be encouraged include the following:

As facilities renovate or build new surgical suites, the design of the perianesthesia area should accommodate patients and families. In addition, patient privacy and visitation must be considered. The PACU needs to allow for the comfort and privacy of the patient population who may need an extended PACU stay, including the ability to allow for family members to have extended visits in the PACU setting.

Patient records

The postanesthesia care record is essential for every patient admitted to the PACU. Many institutions have evolved to total electronic documentation or a hybrid of computerized and paper documentation. Whether traditional paper documentation or electronic format is used, the record should be an accurate account of the patient’s postanesthesia stay and the care that was provided. Anecdotal notes should detail admission observations. The assessment, planning, and implementation phases of the nursing process should be documented, and an evaluation of the patient’s response to the care should be provided. A discharge summary should also be included.

The trend in many institutions is toward a fully electronic medical record, which allows multiple users in remote locations to have access to the medical record at the same time. The fully computerized record for the surgical patient begins in the preoperative evaluation phase and follows the patient through the PACU period to the ambulatory surgery unit or an inpatient unit. One of the important advantages of a computerized medical record includes immediate access by other health care practitioners involved in the patient’s care. It can also be a time saver for nurses, because data entry is often accomplished with drop-down menus much like a checklist as well as documentation prompts for critical areas that must be completed before the record is closed, thus ensuring all required documentation has been completed. Disadvantages include the cost of installation and education and the time necessary to orient the staff to the system, as well as staff resistance to change from paper to computer charting.

Discharge of the patient from the PACU

Written criteria for discharge of the patient from PACU must be available. At a minimum the criteria should include:

The criteria for discharge of a patient from the PACU vary by the unit, location of transfer, anesthetic technique, and physiologic status. Ultimately the physician is in charge of the patient’s discharge from the PACU. Predetermined criteria can be applied if the criteria have been approved by the physician staff members.

The use of a numeric scoring system for assessment of the patient’s recovery from anesthesia is common. Many institutions have incorporated the postanesthesia recovery score as part of the discharge criteria. Box 3-2 shows an example of two discharge scoring systems. The Aldrete Scoring System was introduced by Aldrete and Kroulik in 1970 and was later modified by Dr. Aldrete to reflect oxygen saturation instead of color. Clinical assessment must also be used in the determination of a patient’s readiness for discharge from the PACU. This scoring system does not include detailed observations such as urinary output, bleeding or other drainage, changing requirements for hemodynamic support, temperature trends, or patient’s pain management needs. All these criteria should be considered in the determination of readiness for discharge. The unit policy and the established PACU discharge criteria determine the appropriate postanesthesia recovery score and physical condition for discharge from the PACU. The patient must have a preestablished score to be discharged from the PACU. Scores or conditions lower than the preestablished level necessitate evaluation by the anesthesia provider or surgeon and can result in an extension of the PACU stay or possible disposition to a special care or critical care unit.

Because patient conditions vary with surgical procedure, anesthesia used, use of analgesics, and patient response, no specific time requirements for the PACU stay can be stated. Professional judgment is needed to determine when the patient is ready for discharge from the PACU. A complete accurate report is required from the PACU nurse to the nurse who will be responsible for the care of the patient. Hand-off communication has been identified as an area in which patient safety can be compromised if not performed accurately.

When ambulatory surgical patients are discharged to home, other criteria should be assessed. These criteria may include the following: pain control to an acceptable level for the patient, control of nausea, ambulation in a manner consistent with the procedure and previous ability, and a responsible adult present to accompany the patient home. Some Phase II PACUs require the patient to void or tolerate oral fluids before discharge to home. The Post Anesthetic Discharge Scoring System is often used for assessing the readiness of the patient to be discharged home or to an extended observation area.⁴

Phase II patients should receive a follow-up visit by the anesthesia provider and be released as appropriate, or as in phase I where the nursing staff of the Phase II PACU are appropriately educated, a discharge by criteria policy that defines discharge parameters and allows the nurse to discharge the patient may be in effect. Discharge criteria should be developed to meet appropriate standards, but should be individualized to each PACU.

Home care instructions should be taught to the patient and responsible adult, both of whom should verbalize an understanding of the instructions. Written instructions should be given to the patient to take home. Information on what to do if a problem or question arises should be addressed, and emergency and routine telephone numbers must be included in the instructions.