Of all the things a surgical center can run out of, PACU beds might be the worst, right up there with patients, patience and patients. When they say that nothing can wreck a perfectly fine surgical schedule like a plugged-up PACU, here's what they mean:

The patient in OR 1 is done.

The next patient is prepped and ready to go.

But wait, the PACU's full. There's no place to move the patient in OR 1 to, so there's no place to move the prepped patient to.

You can hear the brakes pumping. Soon, your day comes to a screeching halt. The backup will stretch all the way to your waiting room and out into your parking lot and force you to play a losing game of catchup all day. Treat 'em and street 'em? Hurry up and wait is more like it.

I sat in on a roundtable discussion at the New York State Society of Anesthesiologists' Postgrad-uate Assembly in Anesthesiology last month. Vinod Malhotra, MD, the clinical director of operating rooms at New York Presbyterian Hospital, asked the doctors in attendance to write down on a piece of paper the No. 1 challenge they face in the operating room. All five anesthesiologists, including Dr. Malhotra, wrote down the same thing: not having a bed to discharge a patient to.

As you'll see in this month's cover story, "9 PACU Pick-me-ups" on page 24, poor PACU flow is a problem with many causes and many solutions. Here are a few ideas I overheard in New York.

• Have firm and fast discharge criteria. Sounds simple, but not every PACU does, said the doctors.
• Convert your morning holding area into an afternoon PACU to relieve bottlenecks.
• Bypass PACU whenever a patient who's stalled in the OR because there aren't any PACU beds available meets all discharge criteria.
• Don't recover inpatients and outpatients in the same PACU. Studies have shown that this results in a slower PACU than one that's outpatient-only.
• How do you rein in doctors whose patients are in PACU the longest or suffer the most PONV? Have them justify why they're not following your facility's evidence-based pre-emptive analgesia, anti-emetic and anesthesia guidelines. "Nobody wants to be the outlier," said one doctor.

Besides happier doctors, staff and patients, your reward for a streamlined PACU might be (gulp) more work. Dr. Malhotra said he'd created such efficient PACUs at New York Presbyterian that it let the hospital add ENT and plastics cases.

"This is ambulatory surgery. When you're finished, you're finished," said Dr. Malhotra. "What do you mean you don't have a PACU bed?"