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.