section epub:type=”chapter” id=”c0015″ role=”doc-chapter”> Sarah Marie Independence Cartwright; Susan M. Andrews All management procedures, clinical practices, and policies of the PACU should be established through joint efforts of the PACU staff, nurse manager, CNS, and medical director of the unit. These procedures and policies should be written and readily available to all staff members working in the PACU and to all anesthesia providers, surgeons and other physicians using the area for care of patients. Changes in the clinical situation of the facility and advances in science and technology make revision of policies and procedures a continuous challenge. governance; orientation; organizational structure; policy; procedure All management procedures and policies of the postanesthesia care unit (PACU) should be established through joint efforts of the PACU staff, the nurse manager, and the medical director of the unit. These procedures and policies should be written and readily available to all staff members working in the PACU and all advanced practice nurses or physicians using the area for care of patients. Policies are guidelines that give direction and have been approved by the administration of the institution. Procedures specify how a policy is to be implemented and are either managerial in scope or specific to clinical nursing methods. The PACU policies and procedures should be reviewed periodically so that appropriate changes can be made when necessary. Policies and procedures must always reflect the actual practice of the unit. The PACU is designed and staffed for intensive observation and care of patients after a procedure for which an anesthetic agent is necessary. Criteria for admission to the PACU should be clearly outlined, and exceptions to the policy should be explicitly delineated. The effects on staffing and the use of PACU beds for a multitude of services—such as cardiac catheterization, arteriography or specialized radiologic tests, electroconvulsive therapy, other special procedures, or observation of patients who have undergone special procedures—have created special concerns in PACU management. Additional use of the PACU for patients of the intensive care unit, telemetry, emergency departments, or medical-surgical inpatient units when no beds are available in those areas of the hospital, also puts constraints on resources. A shortage of hospital medical and surgical beds has also turned the PACU into a holding area for surgical patients awaiting inpatient bed availability. Specific policies and procedures addressing any special procedures performed in the PACU and nursing care of these nonsurgical and post-PACU patients need to be developed and in place before these situations arise. A list of potential PACU policy and procedure titles can be found in Box 3.1. One person should have ultimate responsibility for the management of the PACU. Typically, the title of this role is nurse manager, director, supervisor, clinical leader, or head nurse. For clarity, this person with direct responsibility will be referred to here as the nurse manager. The nurse manager is responsible for the administrative control of the PACU and typically reports directly to the perioperative leadership, either nursing or surgical services, although in an ambulatory surgery center it is possible that the nurse manager will report to anesthesia services or a combination of surgery and anesthesia services. The reporting structure depends on the institution’s organizational structure. The chief of anesthesiology is usually the medical director of the PACU. In large institutions, if the chief of anesthesiology cannot fill this role because of other duties, the chief may appoint a designee to this position. The medical director works closely with the nurse manager to develop policies and procedures and to assist with continuing education activities for the nursing staff. The director may also be involved in the development and implementation of continuous quality improvement activities in the unit. Maintenance of a good working relationship between the perianesthesia nurse manager and the medical director of the unit is essential so that areas of concern can be addressed in a collaborative and productive manner. Most PACUs have some type of patient classification system (PCS),1,2 either formal or informal. The most accurate PCSs are those that base the patient classification on PACU length of stay 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 for the PACU stay 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. However, the 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. An advantage of a PCS includes a more accurate assessment of the nursing time and energy needed for each patient, which helps a manager estimate staffing requirements based on the next day’s schedule. Another advantage can include knowledge of the highest workload time periods each day, allowing the manager to flex staff accordingly. This gives 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. Understaffing in the PACU can result in adverse outcomes.3 A decrease in staff to save money for a facility can result in increased costs due to adverse events.3 Kiekkas et al.4 investigated the reasons for missed nursing care in the PACU and found that the three most common reasons were inadequate nursing staff, unexpected rise in patient volume or acuity, and heavy admissions or discharges. Ramarapu and Cook5 used the Rapid System Review (RSR) score in an attempt to predict the number of interventions required during a patient’s stay in the PACU. They found that as the RSR score increased, the number of required interventions increased as well. One outcome of the RSR score may be the ability to anticipate adequate staffing.5 The merits and benefits of visitation in the PACU are well documented. The American Society of PeriAnesthesia Nurses’ (ASPAN) Practice Recommendation on Family Presence in the Perianesthesia Setting endorses visitation in the PACU based on the patient status, patient wishes and activity in the unit, and nurses’ availability to provide time with the patient and family members.6 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.7,8 In the past, PACU visitation was restricted for reasons such as lack of privacy, acuity of the patients, and the fast turnover 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 shows that the positive outcomes from visitation outweigh 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 a lack of postoperative bed availability.6,7 Part of the challenge with a change in the organizational culture allowing PACU visitation 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, requiring 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; some PACUs still do not allow visitation, and others 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 time frame when a critical event occurs in the PACU. Other criteria may include a limited number of family members at one time, the patient’s desire for visitors, the unit’s 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 family members to have extended visits in the PACU setting. The postanesthesia care record is essential for every patient admitted to the PACU. Most 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 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. A fully electronic health record (EHR) 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. The electronic record can also be a timesaver for nurses because data entry is often accomplished with drop-down menus, much like a checklist. Additionally, in many systems, documentation prompts for critical areas must be completed before the record is closed, thus ensuring that all required documentation has been completed. Disadvantages include the cost of installation and a secure network, as well as education and time necessary to orient the staff to the system. There could also be staff resistance to change from paper to computer charting; however, as electronic record keeping is normalized, perception of the use of paper records has shifted to the foreign process. As with all technology-based applications, the PACU must develop a policy and procedure for scheduled and unscheduled downtime procedures in the event electronic documentation systems are not available. Written clinical criteria for discharge of the patient from the PACU must be available. At a minimum, the criteria should include: Nonclinical reasons for delay of PACU discharge should be addressed. These nonclinical reasons for delayed discharge include lack of available transport, bed availability on the unit, and the receiving registered nurse’s (RN) readiness to accept a patient and handover from the PACU.10 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 oversees the patient’s discharge from the PACU. Predetermined criteria can be applied if the anesthesiologist and medical staff members have approved the criteria. 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 (inclusion in electronic documentation is license dependent as obtained by the EHR provider per tools selected). 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.
3: Management and Policies
Abstract
Keywords
Purpose of the pacu
Organizational structure
Patient Classification and Acuity
Visitors
Patient Records
Discharge of the Patient From the PACU
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