1 Space planning and basic equipment systems
From the birth of the recovery room in the 1940s to the postanesthesia care unit (PACU) of the twenty-first century, the look and function of this room (or unit) have been in a state of continual evolution.1 Throughout the last six decades, surgical procedures have become more extensive and complex and thus require more specially prepared nursing staff and equipment for care of the patients.
The first recovery rooms were established for centralization of patients and personnel. The PACUs of today have evolved from general care to intensive care specialty units that provide a spectrum of nursing care, from neonatal to geriatric and from outpatient or same-day surgery to inpatient surgery. The modern PACU must be flexible to serve all perianesthesia phases and patient acuities. The design of the space is critical to the ability of the staff to care safely and efficiently for a variety of patients.2
Many factors are considered in the design of a PACU. Before the architect or design firm is consulted, the users of the space (i.e., perianesthesia nurses, anesthesia providers, clerical staff) should meet to answer the following questions regarding the function of the space:
Flexibility is an important consideration. One of the first factors for consideration is how the space will be used. Will the bays be used strictly for postoperative care, or will the unit need the flexibility of preoperative use? Many institutions have a separate area dedicated to preadmission testing or screening. This area is best located near the surgical clinics and testing areas (i.e., blood draw station, radiology and cardiology [electrocardiography] departments). However, consideration should be given to how the preoperative holding area will be designed and used. Because of the cost of construction and the limited hours of use, many administrators are reluctant to build space that has only a single function and that does not lend itself to change as the users or programs evolve. Therefore all disciplines that use or expect to use the area need to engage in the discussion related to space usage so that future needs can be anticipated.
Perianesthesia nurses have knowledge of the entire process from preadmission testing to discharge the day of surgery. The staff members in the surgery department need to have input regarding types of operations, new surgical techniques, and the need for prolonged observation before discharge. The anesthesiology department medical staff members will have input regarding preoperative needs (e.g., a preadmission testing or screening area, day-of-surgery preoperative procedures area). Clerical services personnel should have input related to the flow of patients and record and paperwork systems. Input from environmental services personnel is related to needs of janitorial space and house cleaning supplies and equipment. Central supply personnel should be consulted regarding the space needed for storage of disposable supplies and linen for ready availability on the unit. Patient equipment personnel should give input regarding space needed to deliver and store reusable equipment, such as stretchers, beds, wheelchairs, infusion pumps, intermittent or sequential pneumatic compression devices, patient-controlled analgesia pumps (intravenous [IV] or epidural), and implantable cardioverter defibrillators.
Adequate time for consultation with all of the potential users and ancillary personnel who will use or provide services in the space is wise. One needs only a brief conversation with staff who have had to work in a poorly designed space to understand the importance of this first step in the design process.
The same factors that influence the building of a housing development or retail shops in one place versus another can be applied to this discussion of perianesthesia space needs. A new construction design typically offers greater probability of optimization of design than remodeling does. The first consideration before construction should be ease of access for the patients and families. Parking should be easily accessible and plentiful, and the entrance should be located adjacent to the parking garage or lot. The patient reception and waiting area should be near the entrance to decrease the patient anxiety and frustration that results from searching for an area.
The second consideration should be egress. A logical patient flow—with adjacent areas that naturally follow the patients’ transit through the unit—should be established for maximization of staff efficiency and decreased steps between areas. The waiting area should be adjacent to the preoperative holding area. PACU Phase I and PACU Phase II should be adjacent but with separate entrances from the ORs for safety and efficiency. In an inpatient setting, a separate elevator is ideal for patients of the OR to be transported to general care and intensive care units (ICUs). This separate elevator is a matter of safety for patients going to an ICU, and it maximizes staff efficiency for patients going to general care. With remodeling, great care should be taken to determine that the design shows consideration of these factors and incorporation whenever possible.
Several key components must be incorporated into the design of the space. The first element that needs determination is the number of patient bays. Before this number can be calculated, consideration must be given to several key factors that influence that number.2,3
• Does the PACU service other procedure areas of the hospital (i.e., cardiac catheterization, electrophysiology laboratory, electroconvulsive therapy treatments, medical procedures [endoscopy, bronchoscopy], radiology and angiography, anesthesia pain service [chronic and acute])? If so, how many cases per day and at what time of day?
For an inpatient hospital PACU that services a combined patient population of inpatients and same-day admission patients, a ratio of 1.5 to 2 PACU bays per OR is necessary to safely care for the patients and not back up the OR. For an ambulatory surgery center with a limited number of surgical services and types of procedures, 2.5 to 3 PACU Phase I and PACU Phase II (combined) bays are necessary. The shorter surgical procedures necessitate an increased number of PACU slots because the recovery time may be two to three times the length of the procedure. If pediatric patients receive care in either setting, the number of bays may need to be increased, because this patient population necessitates 1:1 nursing care for a longer time than does a solely adult population.
Cases of antibiotic-resistant organisms and tuberculosis infections have been on the rise over the past several years. As a result, the need for negative pressure isolation or body substance isolation should be considered in the design. Geographic location and patient population demographics should be reviewed to determine the number of isolation rooms needed. Every PACU should have at least one negative pressure room. However, more rooms may be necessary if the institution services a more susceptible population. Consultation with the institution’s infectious diseases department is advisable to ensure that the design meets institutional policy and is prepared to serve the patient population.4
Another consideration in the design of patient bays is size and means of separation. Most states have building codes that define the minimum square footage of each bay (e.g., Minimum Design Standards for Health Care Facilities in Michigan requirement is 80 square feet).5 However, consideration should be given to how the bays are to be used. If they are strictly for patients requiring a PACU Phase I level of care, the minimum required square footage may be adequate. If the bays are to be used for anesthesia preoperative procedures or anesthesia pain procedures that necessitate equipment such as fluoroscopy or bronchoscopy, the size may need to be increased (to as much as 150 square feet). Also, if the bays are to be used alternatively as PACU Phase I or PACU Phase II levels of care and then as observation for 23-hour admissions, they may need to be large enough to accommodate a patient bed, table, lounge chair, or other equipment. Building some of the bays larger to accommodate these future needs may also be wise, but it is important to realize that the size of the bays affects the configuration of the space.
Patient privacy needs to be considered in determination of the means of separation between patient bays. Typically, PACU bays are open spaces defined only by a curtain that can be pulled for privacy. The open floor plan maximizes patient safety and staff efficiency in the higher acuity PACU Phase I setting. With preoperative and PACU Phase II care, patient acuity is typically lower and continual observation of patients is usually not necessary. Patients are more alert and families are generally present; therefore the need for privacy is increased. Half walls may be considered in these spaces. A half wall (i.e., floor-to-ceiling wall one third to half the depth of the bay) gives more privacy to the patient and family from the sights and sounds of the adjacent bays. However, this configuration still allows the clinicians to observe patients and be readily available for acute needs.
The bays should be carefully arranged for maximized staffing efficiency within the constraints of the American Society of PeriAnesthesia Nurses (ASPAN) staffing resource guidelines.4 The PACU Phase I staffing recommendation is a maximum of two patients per registered nurse (RN)—less for an unstable condition or a pediatric patient. For PACU Phase II staffing, the recommendation is a maximum of three patients to one RN—less for a patient with an unstable condition who needs transfer or a pediatric patient without family or staff support. Grouping of slots in multiples of two or three allows the most efficient, safe staffing. Careful consideration should be given to how the space will be used (i.e., as preoperative care, PACU Phase I or PACU Phase II, or interchangeably).
The ASPAN Perianesthesia Nursing Standards and Practice Recommendations do not define staffing ratios for preoperative cases.4 Ideal safe staffing ratios are determined by individual institutions on the basis of the particular patient population, the number of ORs, the OR turnover time, and the number of preoperative procedures performed with anesthesia. The amount of nursing time necessary to prepare for surgery depends on the patient’s age, the amount of preparation done in the surgery clinic, and the patient’s knowledge and anxiety level. Patients who are well prepared when they arrive for surgery may require less preoperative nursing time. The number of ORs, the average length of procedures, and turnover time affect how many patients are in the preoperative area at one time and how much time they wait before going into the OR. In a small ambulatory surgery center, one or more rooms may be used for quick procedures that necessitate little equipment or cleaning to ready the OR for the next patient. In this case, two patients for that same OR may need to be in the preoperative area at the same time. Another factor that affects preoperative staffing is the number and type of anesthesia preoperative procedures. Again, in a small ambulatory surgery center, most procedures can be performed with a general anesthetic or sedation; therefore the preparation time is shorter. Conversely, a teaching institution may have a patient population with significant comorbid conditions that necessitate monitoring lines (e.g., pulmonary artery catheters, arterial lines, central lines). In addition, many institutions have a pain service that offers patients epidural catheters or extremity blocks for postoperative pain management. These patients occupy the preoperative holding area bay for a longer period and may need nursing assistance for sedation or monitoring during and after the procedure until they go into the OR. In these situations, a ratio of three to five patients to one RN is safe and efficient. However, staffing should be flexible to decrease the number of patients per RN as the patient acuity rises or the need for nursing care and monitoring increases.
For space that is flexible for any need, preoperative or postoperative care, all the headwalls should be designed uniformly to allow flexibility day-to-day or in the future as institutional needs change. During new construction, when the walls are open, the addition of piped-in medical gases and vacuum for suction at each bay is simple and cost effective. For the care of critically ill patients in PACU Phase I, each bay should have a minimum of two oxygen outlets, one air outlet, and three vacuum outlets for suction. In a freestanding ambulatory surgery center that never serves a critically ill inpatient population, it may be more prudent to decrease the number of oxygen and vacuum outlets. However, consideration should be given to the possibility of a patient with a surgical or anesthesia complication that necessitates more intensive care. The other elements of the headwall design include electrical outlets and data and telephone jacks. Again, whether the unit is new construction or renovation, a plan for maximum care and future needs is wise. Each bay should have adequate electrical outlets to service a variety of pieces of equipment, including a patient bed, a forced air warming and cooling device, multiple infusion pumps, a ventilator, a physiologic monitor, a computer, a compression device, and a patient-controlled analgesia machine. Telephone and data jacks should be installed to service the current standard of practice and future needs. Most physiologic monitors are computers that need a data jack. Technology development has brought online data entry to the bedside. Planning for adequate data jacks to support this need is wise and necessary. In addition, wireless networking capability should be considered when designing the space to allow for the use of smartphones, wireless local area network–enabled computers, and other technology in the unit.
Another important component of the design of the patient care bay is lighting. Adequate light needs to be available for admission assessment and emergency situations. Large overhead lights provide the best source of light to meet this safety need. Consideration should be given to the patient in stable condition for whom bright lighting is not a safety concern. Wall-mounted lights, overhead canned lights on a dimmer, or low-wattage lighting provide the appropriate ambience for the patient and still allow the nurse to provide safe care.
Storage in the patient bay is also essential. Some emergency equipment must be stored at each bay for ready availability to the practitioners. However, careful planning should occur to avoid clutter that would hamper the nurses’ ability to quickly access equipment. Many different systems are available to service this need. Before any system is purchased, the items to be stored and the space needed must be assessed. Another point for consideration is what constitutes emergent equipment and what is at the bedside for convenience.4 Figure 1-1 shows one example of a bedside cart storage system. The carts are mobile, are stocked with essential bedside supplies, and contain an interior locked space. A larger storage cart complements this system; it contains items that need to be readily available for efficiency but are not needed emergently. The ability to care for patients in the PACU safely and efficiently depends on the layout of the room. Beyond the confines of the patient bay and its components, immediate access to supplies, equipment, and service areas is essential. Box 1-1 contains a list of the space and service areas needed for the function of the preoperative holding area and PACU. Many of the supplies, pieces of equipment, and service areas overlap, which should be considered in the design. If service areas are strategically placed, they can service two units and thus increase staff efficiency while decreasing the cost of building and maintenance.