Your post-anesthesia care unit - the last link in the patient care chain - can quite literally represent the bottom line in the surgical process as well as your schedule and budget. At our six-OR, multispecialty ambulatory surgical center, we've found that even seemingly small improvements can make a big difference in getting patients comfortable, on their feet and on their way home sooner. In this article, we've compiled some of the steps we've incorporated into this routine. Each step is common sense advice, of course, but taken together they boost PACU results, prevent bottlenecks from forming in your ORs and keep patients satisfied.

1 Infuse your staff with a sense of ownership
Cross-training your nursing staff is an integral part of seamless patient flow. A facility staffed by pre-op, OR and PACU nurses who can take on each other's tasks or fill a vacancy in the event of a busy schedule, an unexpected illness, planned time off or other personnel situations allows for immense efficiency.

Cross-training should include rotating nurses into a team leader role. This lets one person expedite personnel decisions and ongoing planning for the day. The leader looks at the big picture, staffing-wise, and assigns nurses to where they're most needed to take advantage of the flexibility that cross-training offers. The rotating team leader position lets the entire team understand the factors that dictate assignments and the opportunity to lead encourages individuals to develop leadership skills.

2 Appoint a PACU medical director
Every surgery center and outpatient department has a physician serving in the capacity of medical director. At our facility, we have a "PACU medical director," an anesthesiologist who is responsible for overseeing the post-op patient recovery process, patient discharge and QA follow-up on a daily basis. This task falls to the physician who's scheduled to leave the facility last at the end of the day. Many ASCs haven't assigned a physician to such a specialized medical director role, but we've found that patient outcomes measured by satisfaction scores and time to discharge are improved when we provide consistent patient care from arrival to discharge.

Our center's medical director, John Frenzel, MD, is an anesthesiologist, one of a team of anesthesiologists staffing our facility exclusively. Working with the same set of providers on a daily basis has fostered a positive working relationship between anesthesia and our PACU staff. This is an important aspect since patient outcomes can depend on their collaborative teamwork. Anesthesia responds quickly to address patient issues that the nurses raise, whether it's the need for routine blood pressure checks and pain relief or the emergence of unexpected concerns. Providers can also serve as a sounding board for nurses' ideas about process improvement, quality improvement and workflow efficiency.

3 Use short-acting anesthetics
A successful PACU depends on precise and effective anesthesia. Our anesthesia providers use paravertebral blocks for post-op pain relief in patients undergoing mastectomy, axillary lymph node dissection and breast reconstruction procedures. A short-acting general anesthetic lets patients wake sooner and a regional block means they'll be pain-free for several days after the procedure.

PVBs let us discharge our mastectomy patients soon after their procedures. We give patients the choice to stay overnight or to go home, and overwhelmingly these patients choose to be discharged. Additionally, as part of the PACU QI process, we contact these patients in the days following their surgery. When asked if they felt they made the right discharge decision, none has regretted their choice. This demonstrates a successful anesthesia - and PACU - outcome, considering the potential for intense pain resulting from that procedure.

4 Decrease nauseated patients
In addition to administering pre-emptive analgesia, our anesthesia providers have studied and decreased our incidence of PONV, since nausea significantly delays patient recovery and impacts patient satisfaction. Over the course of nine months, our nurses collaborated with our anesthesiologists to develop a comprehensive PONV prevention and treatment protocol. Based on the data we'd collected, we identified pre-op risk factors, created a standard order set and, as a result, reduced practice variability and improved outcomes. The results have been significant. Before this effort, our incidence rate of PONV averaged 16 percent among our post-op patients. Afterward it decreased to 3.2 percent. In addition to less post-op patient suffering, the standardization of treatment drugs reduced our medication expenses by more than 50 percent.

5 Maximize your space efficiencies
We also performed a comprehensive workflow analysis to keep waiting to a minimum. We standardized every PACU bed to maximize flexibility. Our center uses electronic medical records, so as soon as we arrive each morning, we turn on the PACU's computers. There's no reason to wait for patients to arrive before booting up.

For each patient scheduled to undergo surgery, we create a form on a three-by-five-inch index card. We affix the patient's label to it and write down the type of procedure, OR number and surgeon's name. When the OR nurse calls with the verbal handoff report, the PACU team leader fills in the key details of the patient's history, along with the PACU bed and staffing assignment on the card. Then they hand the card to the recovery nurse who's getting the case. That way, the information is delivered but the OR nurse doesn't have to hold on the phone waiting to talk with a PACU nurse during closing, one of surgery's busiest times.

Place equipment so that you maximize efficiency and minimize wasted time and motion. Observing and conversing with your nurses can uncover ways to reduce the number of walking steps, and the response time, between the patient and such discharge necessities as nutrition items and wheelchairs. Having enough wheelchairs on the floor prevents the problem of patients waiting in bed for discharge but lacking the transportation to take them there.

6 Invite relatives to bedside
As soon as a patient is out of surgery and stabilized in PACU, we invite a family member to spend time at the patient's bedside. Involving a family member in the post-anesthesia process motivates patients and acts as a resource toward understanding and recalling post-op care teaching and instructions.

7 Keep nurses at bedside
A PACU unit must be adequately staffed with patient transport support personnel to discharge patients in wheelchairs during the busiest times of the day. Either your PACU nurses can remain on the floor and at bedsides, free to focus on pain relief, warming, nutrition and other aspects of care, while transport personnel escort patients to the front door; or your patients can wait in bed for an available nurse to discharge them because their nurse is off the unit, pushing another patient's wheelchair to the door. In a busy PACU, the second option can be very costly. Your most valuable resource is a nurse at the bedside.

8 Free up PACU beds by jockeying patients
To leverage PACU beds and expedite discharges, we use a second level of post-anesthesia care - a phase-two chair unit. We also move patients who require a slightly longer recovery time to our observation unit for later morning discharges. We used to call it a "23-hour observation unit," but some patients were concerned they'd be billed for 23 hours of occupancy even if they were only there for a short time. We changed the name to the "short stay unit."

9 Ask your staff how to do it better
Lastly, and perhaps most importantly, empower your staff to suggest their own ideas for improving the processes in their work environment. This can only occur when you encourage employees to speak openly and you embrace change. At our facility, best practice is our goal, and this dialogue offers ownership of and accountability for those practices.

Until our better is best
When we opened our surgical center, our goal was to be recognized as a Center of Excellence. Achieving this will require participation from all of our staff. Through small improvements taken together, we can share that eventual success while creating a work environment that they're enthusiastic about along the way.