PACU Staff Research Articles

Who's Who in the PACU? Role Designation During Emergencies

<h3>Introduction</h3> There is ample evidence that high performance teams are vital to patient survival during emergency events. Role designation among clinicians is key for high-performing emergency response teams. <h3>Identification of the problem</h3> Poor team dynamics and communication breakdown is often the cause of preventable errors with patient mortality/morbidity occurring more often when team dynamics fail. Lack of role designation may lead to adverse patient outcomes during emergency events. <h3>EBP Question/Purpose</h3> Does role designation strategy impact PACU staff team dynamics during emergency situations? <i>Databases/Resources Utilized</i>: CINHAL PubMed UpToDate ASPAN 2021 Scope and Standards AHA 2020 Pediatric Advanced Life Support Guidelines finding 12 articles and selecting <i>Mayo High Performance Teamwork Scale.</i> Synthesized findings support role designation as an effective strategy for high performing emergency response teams and simulation as a learning tool to improve knowledge confidence and clinical skills. <i>Purpose</i>: Implement and evaluate the effectiveness of an evidence-based role designation strategy for PACU staff during emergency situations with aims to improve staff confidence staff knowledge and team dynamics. <h3>Methods/Evidence</h3> <i>Pre-intervention</i>: Survey distributed to PACU staff to assess knowledge of emergency skill/concepts with 5-point Likert scale measuring confidence of role assumption and skills needed for each role. Team dynamics evaluated using the validated <i>Mayo High Performance Teamwork Scale</i> during unit mock codes. <i>Intervention</i>: Education via skill stations for the following roles/concepts: Effective Team Dynamics Airway Management Crash Cart Compressions & Documentation. Roles and Designation Tool implemented during education. <i>Post-intervention</i>: Repeated survey of knowledge and confidence with staff. Comparative team dynamics evaluated with <i>Mayo High Performance Teamwork Scale</i> during unit mock codes. <h3>Significance of Findings/Outcomes</h3> Implementation of an evidence-based Role Designation Tool with education improved role delineation among PACU staff. Consistency in understanding assumed role during emergencies improved from 0% role-consistency (0/10 simulated events) to 87.5% role-consistency (7/8 simulated events) (p < 0.001). <h3>Implications for perianesthesia nurses and future research</h3> Implementation of a role designation tool in the PACU provides PACU staff with a clear plan for emergencies. This clear plan improves communication team dynamics and comfort among PACU staff during emergencies positively impacting patient outcomes.

Discharge Scoring Tool in Ambulatory PACU

<h3>Introduction</h3> Patient safety is imperative and objective scoring systems like the discharge scoring tool (DST) are used to help nurses determine when a patient is ready to be discharged home after surgery. Once the DST score has been deemed acceptable and all criteria are met, the patient may safely be discharged home. <h3>Identification of the problem</h3> DST discrepancies are occurring in the following areas: Missing Parameters, Multiple Back Entered Columns and No Discharge Post Assessment, as well as applying the DST tool in practice. <h3>QI question/Purpose of the study</h3> The purpose of our QI plan is to form a quality improvement strategy to standardize practice in the usage of the DST. Also, to improve the use of the DST through education to help ambulatory patients move from PACU I to PACU II in a timely manner and discharge to home safely and efficiently. <h3>Methods</h3> From April 2021 until the present, we have been tracking staff infractions from daily compliance reports, completing chart audits and collecting data that will be used prior to the ASPAN national conference. This data was then utilized to educate staff on the proper use of the DST. <h3>Outcomes/Results</h3> With creation of our DST Superuser group and thorough staff education, the data is supporting that there has been continued and sustained improvement in discharge documentation each month by PACU staff. Notably, we've observed a 70% decrease in overall infractions. <h3>Discussion</h3> Providing staff with monthly updates in the staff meetings has brought awareness to improvements that are needed within our documentation. Individual feedback has also helped staff members to find their own ability to improve. Limitations include the DST must be entered in a certain sequence to function properly. If the logic is not correct, the system will not pull in data, which then leads to infractions. <h3>Conclusion</h3> Staff education and feedback has helped the actualization of the implementation of the improvement plan. Based on the data, it has helped optimize patient readiness for discharge and standardize practice throughout the perianesthesia area. <h3>Implications for perianesthesia nurses and future research</h3> Even with objective data, critical thinking skills and nursing judgement of the paranesthesia nurse are still required to determine if the DST tool is accurate. Findings from this improvement plan has helped guide the nurse's ability to use the DST more efficiently.

Nurse Initiative Driven Project Results in Increased Patient Satisfaction Scores

<h3>Introduction</h3> Since acquiring Interventional Pulmonary procedures within the last year, patient satisfaction scores showed consistent opportunities for improvement in discharge preparedness. <h3>Identification of the problem</h3> During Shared Governance discussions, it was determined that electronic medical record discharge instructions did not include procedure specific information. This lead to frustration amongst the staff due to being unable to answer the patient's questions. <h3>QI question/Purpose of the study</h3> The purpose of the study was to increase patient preparedness for discharge, including questions specific to what to do for bleeding, infection, pain, and patient perception of being prepared for recovery/discharge. <h3>Methods</h3> The Post Anesthesia Care Unit nurses collaborated with Endoscopy procedure nurse to develop specific procedure discharge instructions. The discharge instructions were then given to the head of the Interventional Pulmonology department for approval. Once approved, the discharge instructions were uploaded into the EPIC EMR system. A tip sheet was developed on how to attach the new discharge instructions to the patient After Visit Summary as a reference. Additionally, the Endoscopy procedure nurse developed and provided education to the PACU staff to increase understanding of the Interventional Pulmonary procedures. <h3>Outcomes/Results</h3> Patient satisfaction scores in the below categories increased within the three month implementation period: - Prepare for Recovery: 75 percent to 100 percent - Bleeding: 75 percent to 84.2 percent - Pain 58: percent to 100 percent - Infection: 58.3 percent to 88.9 percent Additionally, our post- procedure phone calls and surveys reported less concerns. <h3>Implications for perianesthesia nurses and future research</h3> Our Shared Governance reviews patient satisfaction scores and reports on a regular basis, thus leading to this idea for interdisciplinary collaboration. We are looking to further review other specialties that would benefit from enhanced discharge education for patients.

PACU Education Standardization for PACU Protocols

Background Information New PACU staff nurses are assigned two preceptors for a three-month orientation. It was noted that a lot of variation existed in the education of orientees regarding various protocols in the PACU. Pre-survey results showed that 47% of staff felt as though there were inconsistencies from preceptor to preceptor. Furthermore, we discussed with new staff and orientees areas where they felt discrepancies existed in their orientation, which included documentation and checking of patient-controlled analgesia (PCA), frequency of vital signs, documentation of assessments, and various competencies, such as arterial lines. Objectives of Project The objective of this project is to streamline the education and orientation process so that each new PACU staff nurse receives consistent information from both preceptors. By standardizing education, the PACU staff nurse would be able to improve workflow and compliance with PACU policies, also allowing for consistent documentation throughout the duration of their time in PACU. Process of Implementation A ten question anonymous survey monkey was sent out to all staff regarding PACU policies and documentation to evaluate which areas re-education was needed for PACU nurses. All PACU nurses were then in-serviced on PACU policies and documentation on the topics highlighted in the survey results. We educated on six different topics and then conducted a post-education survey to determine the effectiveness of the in-services. Statement of Successful Practice On pre-survey there was a large gap in the knowledge surrounding various protocols utilized in the PACU. On average nurses answered 64.7% of the questions correctly prior to in-services. After education on protocols, post-survey results showed an improvement to 89.2%. Implications for Advancing the Practice of Perianesthesia Nursing Standardization of the practices and implementation of hospital wide protocols allows for consistent and streamlined care of patients throughout their hospital stay, beginning with their arrival to the PACU and then transitioning to their destination. This allows for consistent and specific care for the large variety of disciplines and acuity of patients seen in this and other similar PACUs. New PACU staff nurses are assigned two preceptors for a three-month orientation. It was noted that a lot of variation existed in the education of orientees regarding various protocols in the PACU. Pre-survey results showed that 47% of staff felt as though there were inconsistencies from preceptor to preceptor. Furthermore, we discussed with new staff and orientees areas where they felt discrepancies existed in their orientation, which included documentation and checking of patient-controlled analgesia (PCA), frequency of vital signs, documentation of assessments, and various competencies, such as arterial lines. The objective of this project is to streamline the education and orientation process so that each new PACU staff nurse receives consistent information from both preceptors. By standardizing education, the PACU staff nurse would be able to improve workflow and compliance with PACU policies, also allowing for consistent documentation throughout the duration of their time in PACU. A ten question anonymous survey monkey was sent out to all staff regarding PACU policies and documentation to evaluate which areas re-education was needed for PACU nurses. All PACU nurses were then in-serviced on PACU policies and documentation on the topics highlighted in the survey results. We educated on six different topics and then conducted a post-education survey to determine the effectiveness of the in-services. On pre-survey there was a large gap in the knowledge surrounding various protocols utilized in the PACU. On average nurses answered 64.7% of the questions correctly prior to in-services. After education on protocols, post-survey results showed an improvement to 89.2%. Standardization of the practices and implementation of hospital wide protocols allows for consistent and streamlined care of patients throughout their hospital stay, beginning with their arrival to the PACU and then transitioning to their destination. This allows for consistent and specific care for the large variety of disciplines and acuity of patients seen in this and other similar PACUs.

Same-Day Total Joint Discharges: A Collaborative Effort for Patient Safety

<h3>Background Information</h3> Previously, both knee and hip replacement patients had been admitted to the hospital for several days on average. Our orthopedic surgeons began booking them as same day discharges. In navigating this new plan of care, we identified a lack of knowledge of the PACU RN regarding discharge instructions for these patients. The required home discharge information included: antibiotics, anticoagulation therapy, home visits with nursing, and physical therapy. Coordinating these therapies, same day, was identified as a new process for the PACU RN. <h3>Objective of Project</h3> The objective and goal of this project was to ensure our patients have a safe discharge on post-op day zero with adequate preparation for medication management and the necessary services at home. <h3>Process of Implementation</h3> Our team identified the key stakeholders to accomplish our objective. These stakeholders included: Orthopedic surgery, Orthopedic Nurse Practitioner, Case Management, Physical Therapy, PACU management, and PACU staff members. Multiple meetings occurred between these multidisciplinary team members to discuss each member's expectations for a safe discharge, potential roadblocks, and solutions. Issues identified were Case Management coverage for PACU, proper lovenox teaching, and physical therapy evaluation equipment needed in the PACU. These issues were addressed and resolved. To assure that the complex criteria for discharge was met, the PACU RN's created a tool to assist with this process. This tool listed all the activities to be completed prior to discharge. <h3>Statement of Successful Practice</h3> The identification of proper discharge requirements and the creation of the "Orthopedic Same-Day Surgery Tip Sheet" streamlined the discharge process. This tip sheet provided guidance to RN's to ensure each patient was being sent home with the correct teaching and tools for a safe same-day discharge. During the post-operative phone call the patients confirmed that the discharge instructions were complete and the home visits were scheduled. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> The identification of a knowledge deficit led to a multidisciplinary group collaborating on best practices. The creation of a PACU "Tip Sheet" gave the RN's the necessary tool and knowledge to care for the same day discharged total joint patient. Our patients are going home with proper education and resources needed for a successful and safe recovery at home.

“BLOCKED” Sign to Prevent Patient Falls Due to Peripheral Nerve Blocks

<h3>Introduction</h3> Multimodal analgesia is a practice used at the Kaiser Permanente Ambulatory Surgical Units (ASU). Preoperatively, patients are given different types of analgesic medications such as acetaminophen, gabapentin, NSAIDS plus a peripheral nerve block, and the like. This practice decreases post-operative opioid use and shortens the PACU length of stay. <h3>Identification of the problem</h3> The increase of the use of peripheral nerve blocks in an ASU increases the risk of a patient fall. There have been 2 falls, and 1 near-miss at the Kaiser Permanente Otay Mesa ASU in 2016 and 2018 due to peripheral nerve blocks such as femoral, and interscalene nerve blocks. The PACU staff work as a team, that although there is one primary nurse for a patient, all staff are there to help any patient in need. The danger of this is that the staff helping might not know that the patient is a fall risk due to the block and that led to the patient's falling. <h3>QI question/Purpose of the study</h3> What can be done to alert the perioperative/perianesthesia staff that the patient is a fall risk due to a peripheral nerve block? <h3>Methods</h3> Placing a bright "BLOCKED" sign on the gurney's IV pole on every patient that received a peripheral nerve block. The sign will only be removed after the patient has been discharged. <h3>Outcomes/Results</h3> Since implementation of the "BLOCKED" sign in September 2018, there have been no patient falls due to peripheral nerve blocks at the Kaiser Permanente Otay Mesa ASU. <h3>Discussion</h3> This simple sign alerted the perioperative staff that a patient is a fall risk due to the block and to take special care to prevent a patient fall. <h3>Conclusion</h3> The "BLOCKED" sign implementation alerts the staff that a patient is a fall risk due to the block. <h3>Implications for perianesthesia nurses and future research</h3> Spreading this QI project to the other Kaiser ASU's in San Diego will help with its sustainability. In fact, one of the ASU's has already adopted this practice with the same results.

Managing PACU Workflow on the Integrated Procedural Platform (IPP)

<h3>Background Information</h3> From 1996 to 2018 there were 2 separate OR locations supported by 2 PACU locations. Each 15 bed PACU had unique staffing schedules, RN assignments, and patient flow patterns. Surgical procedures were specific to the OR locations with staff knowledge specialized in those patient populations. The new 44 bed PACU opening in the fall of 2018 required all staff to care for all patient populations. <h3>Objectives of Project</h3> Develop a new workflow that includes best practice from each PACU. Create a physical flow pattern and communication system that allows for smooth transition from OR/procedural rooms to the PACU. Develop education ensuring all staff are competent in caring for all patient populations. Include all staff in the change process by encouraging their input through surveys and unit representatives. <h3>Process of Implementation</h3> Staff were surveyed and encouraged to provide best practice from their home PACU. We created an IPP workflow team including nurses from both PACUs, the manager and educators. Over the eight months prior to opening the combined PACU we considered all aspects of workflow including staffing, RN assignment, patient arrival through two entrance points, and impact on OR/Procedural staff. The new workflow process was communicated via staff meetings and emails. <h3>Statement of Successful Practice</h3> PACU staff rotate through 5 PACU pods and 1 Pre-op pod. Impending PACU admissions are called to the charge RN who then pages the appropriate pod. Staff self-assign patients and support each other with cares, lunch relief and getting out of work on time, decreasing overtime to the unit. A charge nurse and unit clerk support all staff. Reevaluation changes included an adjusted 8 week to 16 week schedule, thereby increasing staff satisfaction by allowing the opportunity to work with a wider variety of team members. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> We found that it is possible to bring two cultures of PACU nursing together by focusing on best practice from each unit. Staff input during the initial planning, implementation, evaluation and revision process was key to our success.

Live from New York – It’s Pre-Op Instructions!

Breast surgery patients go to a myriad of appointments unseen by the PACU staff. Nuclear Medicine, Mammography, Ultrasound, Seed Placement, Clip Placement, Imaging, Biopsies and consultative appointments all occur prior to being booked for surgery. In a time where the patient experience matters most, focus needs to be given to the patient population undergoing the most amount of pre-surgical, stressful appointments.

Readiness for Discharge After F&amp;A Surgery Using Peripheral Nerve Blocks

Category: Other Introduction/Purpose: Neuraxial anesthesia is often viewed as superior to general anesthesia (GA), but there are concerns that it may prolong length of stay (LOS). Most studies comparing the two anesthesias were performed in the absence of peripheral nerve blocks (PNBs), which when used as an analgesic adjunct may overcome the associated negative side effects of GA and allow decreased LOS. We hypothesized that patients given PNBs and GA would be discharged sooner than patients given PNBs and spinal anesthesia plus sedation, without increased incidence of adverse side effects such as pain, opioid administration and nausea. Methods: A single-center triple-blinded randomized controlled trial of 36 consecutive patients receiving elective F&amp;A surgery predicted to take 1-3 hours under planned PNB with either spinal or GA was performed (see table 1. for demographics).The primary outcome was time to meet criteria for home discharge. The a priori clinically relevant difference with 80% power was determined to be 45 minutes. Patients were assessed after admission to the PACU and at 15-minute intervals thereafter. Once an Aldrete score=9 (scale signifying patient no longer needs intensive monitoring) was obtained, patients were transferred to Phase II and assessed until the post anesthesia discharge scoring system, a home readiness scale, was =9. Actual time to discharge was also recorded.Additional outcomes included a series of baseline characterizations which were assessed pre-and post-operatively, and again during Phase II.The primary outcome was compared using multivariable unconditional quantile regression. Various regressions were performed on secondary outcomes. Results: After adjustment for age and surgical duration, patients given GA plus PNB were ready for discharge from PACU 39 minutes prior to patients given neuraxial anesthesia plus PNB, but this difference did not reach the clinically relevant a priori selected difference of 45 minutes (Table 1). However, the adjusted median time to meet ambulation discharge criteria was 52 minutes fewer (p = 0.003) (Table 1). Patients met discharge criteria substantially sooner than their time until actual discharge which was not different between groups (Table 1). Pain scores at rest were higher among GA patients at 1 hour in the PACU (adjusted difference in means [95% CI]: 2.1 [1.0, 3.2], p &lt; 0.001). Subsequent pain scores and all other secondary outcomes were not different. Conclusion: GA with PNB patients were ready for discharge 39 minutes earlier, but that difference may not be clinically significant. Although patients met criteria for discharge sooner due to a significantly more rapid ability to ambulate, they were not discharged sooner because PACU staff was not acclimated to the earlier readiness and so did not push for earlier discharge. These findings suggest that GA plus PNB leads to earlier discharge with similar side effects as spinal plus PNB. Therefore, the use of GA with PNB for foot and ankle surgeries could save the hospital and the patient time and resources.

Pain Control Without Over-sedation is Poss-able. From PACU Ebp Question to System Wide Change: Implementing The POSS

Based on the Joint Commission Sentinel Event Alert, hospitals need to focus on safe opioid administration and vigilant monitoring of the effects of opioids. The PACU lacked a standardized policy to determine when the non-ventilated patient is ready for discharge based on pain and level of sedation. PACU staff has varying levels of experience leading to inconsistency in treating pain and the risk of opioid-induced oversedation and/or respiratory depression.

Postictal Agitation After Electroconvulsive Therapy

Postictal agitation (PIA) after electroconvulsive therapy (ECT) is a major medical problem. This observational study investigated the incidence and severity of PIA and evaluated propofol as a treatment option in a patient population. The study included 14 patients that underwent a series of ECTs performed either with or without an approximately 0.5-mg/kg propofol bolus after the end of an electroencephalography (EEG) seizure. Among other values, we documented PIA incidence and severity as rated by a simple score; orientation to person, time, place, and situation; transfer times to the postanesthesia care (PACU) and inpatient unit; nurses' and patients' rating of recovery period, and others and tested for significant differences. Five minutes after the end of ECT, the patients showed moderate to severe PIA in 8 of 37 ECT sessions. Incidence was significantly lower when patients had received propofol (3/37). Transfer time to the PACU was longer, but transfer time to the inpatient unit was shorter after administration of propofol. The recovery period was rated significantly better after propofol administration by nurses and patients. A single bolus of propofol administered after the end of the seizure reduced the incidence of post-ECT PIA. The PACU staff and patients rated the emergence period significantly better when propofol was administered.

Using Evidence-Based Practice to Implement Standardized Anesthesia-to-PACU Handoff Tool and Improve PACU Staff Satisfaction

Using Evidence-Based Practice to Implement Standardized Anesthesia-to-PACU Handoff Tool and Improve PACU Staff Satisfaction

Improving Communication and Patient Comfort When Stay Is Extended in PACU

Wait time for inpatient beds for PACU patients can cause decrease productivity and patient satisfaction. The Operating Room is affected as patient flow comes to a halt. PACU staff experience frustration and confusion related to staffing ratios.

Peer Review Panel Pilot

The purpose of the PEER Panel Pilot was to assess staff satisfaction with the peer review as a part of the overall performance evaluation process. The PACU staff had elected a panel of staff to provide meaningful, constructive, consistent, positive peer review feedback for all staff. Anonymous surveys were given to all staff.

PACU/Transport Relations Project

The purpose of this project is to assess satisfaction and effectiveness between PACU staff and transport team regarding use of transport for patient transport instead of PCA's. Both departments elected to trial using transport team for patient transport while using PCA's for their certified duties in PACU. Anonymous surveys were distributed to department staff.

TAP Into Pain Control

A multidisciplinary team approach was implemented in the educational process for the care of the patient with Transversus Abdominis Plane (TAP) blocks. Coordinating pharmacy, surgeons, PACU, OR and Surgical floor staff to facilitate optimal care for the patient receiving TAP blocks was imperative to the success of our process.

Cutaneous Capnography in the PACU: Immediate Assessment of Respiratory Status Emerging From Anesthesia

The team met for one 6-hour day and one 3-hour day. The team developed a workplan andmet each month until the room opened. A core group of nurses from the PACU volunteered and were chosen to learn how to provide the care needed for pre-, intraand post-care. The PACU staff went to the CPC to learn how to pull sheaths and to learn about the supplies, process and monitoring. The core group of nurses also attended additional training to learn the new computerized documentation system. Standard operational procedures were developed. When the room construction was completed, the PACU and OR staff did rehearsals of the process. They walked through each step to ensure that when the first patient was scheduled for a procedure, the process would be smooth and safe. Evaluation and Outcomes: The first day and first patient’s procedure went safely and effectively. The OR and PACU staff truly worked as a team to provide excellent care. The vascular physicians were pleased with how smooth and on time the process was and continues to be.

Hybrid Room: PACU Staff Working in the OR

Hybrid Room: PACU Staff Working in the OR

The Impact of Unit Design and the Need for Patient Advocacy

PACU staff recognized the impact of environmental stressors that directly correlated to poor unit design and created daily frustration. Providing quality nursing care in an outdated architecturally designed department lead to growing concerns for patient safety and privacy, an inefficient unit flow, and an unprofessional environment of care we felt reflected on nursing. Administrative allocations for redesign had been delayed over several years. Staff determined their concerns must be taken directly to the hospital CEO and proactively planned a meeting to present their case. Peer input was compiled and a summary of concerns was formulated. The presentation incorporated ASPAN Standards of Care, JCAHO requirements, HIPAA regulations, PeriAnesthesia Nursing literature, specific Press Ganey results, including patient safety concerns, new requirements for design and research studies finding's on effect of noise on staff and patient outcomes. The meeting was strategically held in the PACU to allow an enactment of nurse-patient interactions. Following the presentation the CEO requested staff to report any other safety concerns immediately to the Day Surgery Committee, and a new unit could be realized within 18 months. A positive outcome was achieved by presenting our concerns as a group with written, verbal and visual tools promoting patient advocacy.

“Changing the Safety Culture Through Hand Washing”

The Centers for Disease Control (CDC) Prevention cited that hand washing is the single most effective way to prevent the transmission of disease. Despite the proven health benefits of hand washing, many people have poor hygiene practice including PACU staff. The goal of this safety project was to improve hand washing adherence through access and staff education. The objectives were to assess baseline hand washing compliance, implement strategies, monitor, report findings and recognize staff. The process included: baseline data, staff education, training of observers, Purell bottles at each bedside and around the unit, weekly random audit, feedback, and recognition.