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Rev Up Your Recovery Room
Here's a snapshot of today's PACU, gleaned from a survey of more than 200 surgical facilities.
Mary Ann Kelly
Publish Date: November 4, 2008   |  Tags:   Anesthesia

To find out if your recovery room is running as smoothly as it can, Outpatient Surgery Magazine and I teamed up last month to create an online reader survey that took the pulse of PACUs in both hospital outpatient departments and ambulatory surgical centers across the country. Here's a report on what we found out about nurse-to-patient ratios, pain management practices, discharge instructions, snack offerings and more.

Here's the snapshot
Most of the 221 recovery rooms that we surveyed quench pain with fentanyl (morphine was a close second, Demerol a distant third), thirst with juice and hunger with crackers — although I was shocked to see that some post-surgical patients eat better than airline passengers, enjoying such treats as chicken noodle soup, sandwiches, applesauce, toast, muffins, pudding and cookies soon after emergence (see "What's On Your PACU Menu?" on page 36). While I applaud the effort for customer service, keep efficiency and cost in mind if you opt to expand your offerings.

Fentanyl (46.4 percent) was the preferred PACU drug over morphine (33.3 percent) and Demerol (20.3 percent). Because fentanyl has a rapid onset and shorter duration, the patient can be comfortable and get his first dose of PO narcotics before he's discharged. Fentanyl also doesn't have the histamine reaction that morphine has, so it's less of a risk for children with asthma. We observe that the use of fentanyl for immediate post-op pain is superior for patient outcome and recovery. I'm surprised at the amount of Demerol responses; we don't use it much here at our ASC, except for post-op tremors.

Which agent do you use primarily for post-op pain control?

Fentanyl

46.4%

Morphine

33.3%

Demerol

20.3%

What is the most frequent cause of prolonged recovery?

Uncontrolled pain

45%

PONV

33.5%

Extended observation

16%

Hemodynamic instability

5.5%

SOURCE: Outpatient Surgery Magazine Reader Survey, October 2008, n=221

Families at bedside?
Most PACUs (58.4 percent) allow family members at the bedside, not only because it's therapeutic for patients — especially children, our respondents noted — but also because it's an opportune time to review discharge instructions. Many respondents say having family at the bedside lets them begin discharge instructions earlier and thereby shorten the time patients are in the PACU. It also eliminates later questions and calls and gives patients initiative to go home sooner, say our respondents.

"People seem more ready to go home when there is a loved one at the bedside," says Sharon D. Bowen, CASC, a vice president of operations with ASCOA in Hanover, Mass. "If there is no one, they tend to sleep and stay longer."

With the push to involve patients in their own care, I don't know how you can't allow families in to see their loved ones. We limit the age to 14 years and allow up to two at the bedside. With the outpatient surgery market so competitive, anything to give a center an edge is worth considering. We have found through patient surveys that allowing visitors in post-op results in a positive customer experience.

The Fairfield (Conn.) Surgery Center lets family in after the initial assessment is completed. "They assist feeding and dressing the patient. Usually it's a help," says supervisor Billie Carney, RN, PACU.

"Family members help to keep an eye on the patient, which frees up the nurse to assist others," adds Trey Sampson III, MBA, administrator of the Jackson Surgery Center in Montgomery, Ala.

Our survey also uncovered much disagreement and debate over whether family members at the bedside in PACU slow things down instead of speeding things up. A sizable number of respondents (39.1 percent) don't allow families in recovery, many citing privacy concerns for other patients.

"If we could figure a way to protect patient privacy in the very open PACU, we would have more family members at the bedside," says Margo Mynderse-Isola, RN, BSN, MBA, the CEO of the Surgecenter of Palo Alto, Calif.

Many facilities set limits on PACU visits, for example, allowing only one visitor, limiting visits to five minutes or only letting relatives see patients in Phase II recovery, after staff have taken initial vitals and moved the patient to a recliner.

"It can be a burden, because some patients seem to be in ???more' pain when family is at bedside," says Evelyn DeMoss, ADN, the pre-op/PACU charge nurse and risk manager at North Austin Surgery Center in Austin, Texas.

One often-overlooked advantage to having family members at bedside: You'll know exactly where the family is — not in the cafeteria or outside on their cell phones — when it's time for discharge, says Linda Phillips, RN, administrator of the Southgate Surgery Center in Southgate, Mich.

Average length of stay
For 59.3 percent of our respondents, the average length of stay for Phase I Recovery is 30 minutes to one hour. I'm assuming many of these are GI and pain procedure patients who get propofol. Our survey uncovered pretty standard recovery times: Another 31 percent stay one to two hours, 7.4 percent stay less than 30 minutes and 2.3 percent stay more than two hours. Consider anything more than two hours prolonged stays — unless specifically ordered by a physician. Pediatric ENT cases typically spend one hour (58.9 percent) and sometimes one to two hours (24.4 percent) in recovery.

Most facilities we surveyed follow AORN PACU staffing standards. The average nurse-to-patient ratio is 1:2 for Phase I recovery (55.7 percent) and 1:3 for Phase II recovery (36 percent). AORN standards are 1:1 in Phase I with an unconscious patient or pediatric patient (sometimes 2:1 with a pediatric patient if they are combative when they wake up) and 1:2 with an awake patient and an unconscious patient.

Our survey also confirmed what we already knew: that uncontrolled pain (45 percent) and PONV (33.5 percent) are the most frequent causes of prolonged recovery. This points to an even greater need to have an aggressive pre-op and intraop anesthesia pain management plan. If PONV is a recurring issue in delaying recovery, evaluate the preventative medications being used, especially for patients with a history of PONV.

What's On Your PACU Menu?

While patients in some recovery rooms eat and drink well, others are sent home hungry and thirsty, according to our survey. Some PACUs serve such wholesome and nutritious snacks as chicken noodle soup, turkey sandwiches, bagels and cream cheese, buttered toast, applesauce, pudding and Jell-O, while others serve nothing more than ice chips and caffeine-free soda in Styrofoam cups.

"The smell of the toasting bread makes patients hungry and they love it," says Kecia Rardin, RN, the administrator and director of nursing at Northwest ASC in Portland, Ore.

"Depending on what our patients have done, they receive a full liquid or soft diet meal before discharge from the [PACU]," says one facility manager.

One New York Hospital offers recovery patients nothing. "We do not give anything to eat or drink in PACU," says the manager of surgical services.

Here are the most popular PACU snacks served by the readers we surveyed:

  • juice, 87.4%
  • crackers, 85%
  • water, 79%
  • soda, 72%
  • coffee or tea, 66.4%
  • popsicles, 50.5%
  • muffins, 17.3%

"Treat ???em and street ???em"
The single most important benchmark for any recovery room is the safe turnover of patients. Most of our colleagues say that the keys to getting patients in and out of the PACU as safely and as efficiently as possible are anesthesia providers who control pain intraoperatively (52.3 percent) and having adequate PACU staff (30.7 percent). Yes, it's no secret that a comfortable post-op patient is more likely to be discharged in a timely manner, but anesthesia's role in the equation bears mentioning. Our anesthesia providers are in control of pain management. Aggressive anesthesia involvement — from pre-operative antiemetics to intraoperative pain management and using designer gases like desflurane that provide for faster elimination — makes for a comfortable post-op patient. And, of course, regional blocks lead to faster discharge.

"Our anesthesia providers are great teammates when it comes to discharge and giving the appropriate drugs pre-op, intraop and post-op," says Dana Yocum, RN, CASC, CNOR, administrator of the Mid Rivers Surgery Center in St. Peters, Mo. Key word: teammates.

Respondents also cited giving adequate pre-op instructions (20.6 percent) as a factor that makes fast-tracking possible in the PACU. But when is it optimal to give discharge instructions? There is some difference of opinion. More than half (56.8 percent) give patients discharge instructions as soon as the family gets to the bedside. "We specifically wait until the family is at the bedside, but we may wait longer if the patient is still feeling groggy," says a hospital perioperative director.

For the other 44.1 percent, giving discharge instructions is a continuum, beginning at the first contact with the patient, continuing at pre-op and ending with the family and take-home instructions. "We begin our discharge instructions pre-operatively, reinforce them to the patient and family post-op, and send written instruction home with the patient," says Lynn Lillie, ADN, BSN, director of surgical services at Fort Madison Community Hospital in Fort Madison, Iowa.

Some facilities (9.5 percent) take patients to a separate discharge room. Only 5.9 percent of respondents assign an additional nurse to give discharge instructions. Consider using the same nurse to give discharge instructions. There's less risk for oversight — especially with the new medication reconciliation standards — to make sure patients don't go home with a prescription that is contraindicated or repetitive of something they're already taking.

Staffing issues
A few facilities have their staff float back and forth between Phase I and Phase II. This speaks volumes for cross-training staff. More than three-fourths of respondents (76.8 percent) stagger PACU staff's start times to prevent overtime. Some managers' ideas for making this work:

  • "Bring one RN in to open at 7:30 a.m., two at 8 a.m. and two at 8:30 a.m. The last two are the closers."
  • "We have a 7 a.m. to 3:30 p.m. nurse and an 8 a.m. to 4:30 p.m. nurse."
  • "Individuals rotate start times from 5:45 a.m. to 11 a.m. It's expected and known on hire."
  • "PACU start times change daily according to the surgery schedule. Nurses know this at hire."
  • "Our per diem staff members receive their arrival time the day before so we can individualize their start time according to the schedule. If it's a light day, they may come in at 8:30 a.m. If it's a heavy day, they may not come in until 10 a.m."
  • "We have a per diem nurse come in mid-morning and stay until the end of the day."

The bottom line: If you can staff your PACU with RNs who are willing to flex their time and cross-train staff from other departments to help with lunch reliefs, you've truly maximized your resources.

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