The PACU may be the patient's last stop, but it's also where your day can grind to a halt if you don't adjust your staffing levels for those peak periods in your OR schedule. If you've tried everything to ease the gridlock of an overflowing recovery room, here's an idea that may finally help.

Scaling the peaks
If post-op patients are arriving in recovery faster than staff can deal with them, you likely don't have enough staff during peak times. Track when patients enter and exit PACU — periods with lots of overlaps are your peak times — and how many patients there are per nurse. The patient-to-nurse ratio is usually two patients for every one PACU nurse, but it can be 3 to 1 in a phase II recovery room. You're short-staffed when the patient-to-nurse ratio is higher than the norm for an extended period.

Once you've plotted your PACU's traffic patterns for a few months, you can determine how many nurses you need for each hour of the workday. Ideally, you want nurses' shifts to overlap during your peak periods. Each recovery room nurse could work from 7 a.m. to 3 p.m., 8 a.m. to 4 p.m., 9 a.m. to 5 p.m. or even a 12-hour shift. Use a computer spreadsheet such as Excel to determine which arrangements will give you enough personnel for each hour of the day.

Mixing up the cases
At this point you're ready to handle the peaks in your PACU, but you should also work to reduce how busy these times are to improve the patient flow. This comes down to how well you sequence your cases according to how long they're expected to take.

For example, let's say you're in a three-OR facility with one surgeon in each OR. Each surgeon has six hours' worth of cases on his schedule and he does the cases in order of longest to shortest. Each has a three-hour case scheduled in the morning, followed by a two-hour case and then a one-hour case. This will give you three hours in the morning when no one is in the PACU, three hours when you have three patients, an hour when you have six patients in there and then an hour with three patients.

Now let's say that you talk to your surgeons about rescheduling their cases. Instead of doing the three-hour case first, each will do his one-hour case, followed by the three-hour case and then the two-hour case. This will smooth out your schedule because the one-hour case patients will be ready to leave when the three-hour case patients are going into the PACU, and when they're ready to leave the two-hour case patients will go in. With a schedule such as this, you'll never have more than three patients in the PACU at a time. Assuming a 2-to-1 patient-to-nurse ratio, this can mean the difference between having three nurses for an hour to only needing two throughout the day. That's quite a difference.

You'll find that many surgeons rarely mind making this change. As long as there are no concerns with the patients' health or other factors, there's no reason they can't make the adjustments. There will also be no effect on the OR nurses and anesthesia providers.

Sharpen those pencils
If you're willing to do the math, there's no reason you can't keep your PACU from getting crowded. The end result will be a much smoother patient flow and potential cost-savings if you can reduce the number of PACU staff you need during the day.