Postanesthesia Care Unit Nurses Research Articles

Feasibility, implementation, and outcomes of in situ simulation-based curriculum to manage common emergencies in the pediatric post-anesthesia care unit

PurposeStudies have shown that most critical events that occur in the post-anesthesia care unit (PACU), including cardiac arrests, are preventable and respiratory in origin. Admission to the PACU necessitates transfer of care from anesthesiology staff to PACU nurses. The aim of the study is to assess a) feasibility in implementing an in-situ curriculum for PACU nurses to manage common pediatric emergencies, b) the effectiveness of the curriculum in improving self-confidence of the PACU nurses in performing essential skills c) nurses’' perception of such an offering. Design and methodsThis was a single center curricular evaluation study. Anonymous surveys were used to assess curriculum effectiveness by comparing self-reported confidence in the execution of key technical skills and application of knowledge in a real clinical environment at three time points: baseline, immediately post-simulation, and 3 months later. ResultsOf 50 PACU nurses, 80%, 98% and 58% responded to the targeted needs assessment, post-simulation and follow up (at 3 months) survey respectively. Self-reported confidence levels for most of the essential skills were significantly increased immediately after simulation and at 3 months. Most of the participants responded that the simulation training helped them improve care of hypoxic (83%) and hypotensive (62%) patients in the PACU. ConclusionImplementation of in situ curriculum for PACU nurses was feasible. The self-reported confidence in performing essential skills increased significantly and the nurses could apply these skills in real clinical environment. Practice implicationsInterprofessional simulation should be implemented in all high risk units to optimize safety of children.

Documenting urine output for pediatric urology patients in the post-anesthesia care unit: A quality improvement initiative

Close monitoring and documentation of urine output (UOP) after urologic surgery is a nursing standard of care in the post-anesthesia care unit (PACU). UOP is a critical piece of information for surgeons and anesthesiologists to provide safe quality patient care. The electronic medical record (EMR) is used to communicate this information between members of the care team. Initial review at our institution confirmed only 31.3% of children recovering in the PACU after urologic surgery had a numerical value for UOP documented in the EMR. The aim of this project was to improve compliance of UOP documentation in the EMR for pediatric urologic patients in the PACU from 31.3% to 80% by August 2021, using quality improvement methodology. Patients undergoing urologic surgery with planned post-operative hospital admission were identified in the EMR by admission status and Current Procedural Terminology (CPT) code. UOP documentation data during the patients' PACU stay was retrieved from the EMR. Traditional QI methods were used to develop a key driver diagram, identify barriers, and implement targeted interventions. Statistical process control charts tracked the outcome measure (percentage of patients with UOP documented in the PACU) and balancing measure (average PACU length of stay). The project began in July 2019, and four interventions started between July and October 2019. These interventions resulted in a centerline shift of our outcome measure, UOP documentation rate, from 31.3% to 76.2% (p<0.001). Patient volumes were stable with the exception of March, April, and May 2020 during the Covid-19 pandemic. An X-bar chart tracked PACU LOS, the balancing measure, in average minutes per patient without any trends. This quality improvement initiative sought to improve urine output (UOP) documentation for pediatric urologic patients during the immediate post-operative period. Targeted interventions leading to this improvement included educating nursing staff, establishing direct communication expectations for the surgical team, and improving the availability of UOP measurement tools. Limitations include reliance on education and behavioral change, only including urologic surgery patients, and our institution's robust focus on quality improvement work. This performance improvement initiative successfully increased the rate of UOP documentation by PACU nurses for pediatric urology patients through a combination of interventions. The next phase is to expand these interventions throughout the hospital to improve UOP documentation for all post-operative patients.

Nurses' Perceptions of Patient Participation in the Postanesthesia Care Unit—A Qualitative Focus Group Study

PurposeTo explore postanesthesia care unit (PACU) nurses' experiences and perception of patient participation during PACU care. DesignQualitative focus group study based on a phenomenological hermeneutic approach. MethodsWe conducted three focus group interviews with 18 nurses from three different PACUs. Themes were created based on interpretive theory inspired by Ricoeur. FindingsFour themes and 11 subthemes were found. Patients’ clinical condition and situation, time management, ethical aspects, and the patient-nurse relationship all had a high impact on postanesthesia nursing practice and conditions for involving patients. ConclusionsPACU nurses want patients to participate in their own treatment and care in the PACU; however, nurses perceive patient participation differently. Nurses experience challenges including patients’ impaired autonomy, absence of a holistic approach, and lack of time and resources. Nurses highlight that these barriers should not become an excuse for noninvolvement.

Adaptations and Evolution during COVID-19 in a Pediatric Satellite Setting

Background InformationThe global Covid-19 pandemic has required the rapid development and implementation of processes that support safety and quality of care. Prior to this unprecedented challenge, our satellite pediatric ambulatory surgical center consisted of four units: a preoperative unit (Preop), six operating rooms, a Post Anesthesia Care Unit (PACU), and an Inpatient Short Stay unit. Although the Preop and PACU nurses were cross-trained to cover both areas, Inpatient nurses maintained a distinct skill set and were a standalone unit. In effort to support virus containment, including social distancing, a flexible staffing model required the integration of Preop, PACU, and Inpatient nurses into one cohesive team.Objectives of ProjectDevelopment and implementation of changes to perioperative processes that support quality care and safety during Covid-19.Process of ImplementationInpatient areas were converted to support the preop care of patients/families and facilitate the adoption of COVID safety regulations. Inpatient nurses were oriented to the Preop nurse role, Preop Covid test screening, and Visitor/Employee lobby screening. This cross-training educational program included in-services on Preop documentation and procedures and one to one orientation with a Preop nurse. Presently, nurses may care for the same patient/families preoperatively and during their inpatient stay which promotes quality care and an improved surgical experience. Changes to staffing models were evaluated through staff survey, analysis of Press Ganey patient satisfaction feedback and surgical throughput data.Statement of Successful PracticeA majority (83.3%) of nurses agreed or strongly agreed that the new flexible staffing model promoted team cohesion and ensured safety and quality throughout the surgical experience. Between May and September 2020, our integrated perianesthesia team cared for 1206 perioperative patients. Press Ganey scores were overwhelmingly positive. One family stated “Before surgery the nurse kept us calm, engaged, & informed. After surgery that nurse did the same thing & was also a great teacher regarding home care”.Implications for Advancing the Practice of Perianesthesia NursingAs ambulatory surgical centers, continue to adapt during the pandemic, it is imperative that perianesthesia nurses design and implement flexible staffing models that promote team cohesion and ensure safety and quality during surgery.

Nurse Discharge by Criteria Decreases Post Anesthesia Care Unit (PACU) Length of Stay

Background Information The PACU nurses noted that when a patient was ready for discharge, an Anesthesiologist was not always immediately available to evaluate and discharge the patient. This led to both nurse and patient frustration as well as an increased length of stay (LOS) for the patient. Objectives of Project The objective is to facilitate the safe discharge of patients from Phase I PACU while decreasing the LOS. Process of Implementation • Literature review performed to identify best practices supporting this type of initiative. • Visitation to an affiliate hospital who had previously implemented this practice. • Consultation with Department of Anesthesiology to determine support for this initiative: ○ In the electronic medical record the Anesthesiologist orders indicate if the patient is eligible for discharge by criteria or an Anesthesiologist sign out. ○ If a patient is initially ordered for discharge by criteria, but the nurse has concerns, the nurse has the option to call the Anesthesiologist for an evaluation and sign out. • The PACU Nurse Manager and Nurse Educator discussed how to best implement this initiative, scheduled for January 7, 2019. • The Manager introduced this initiative to the nurses at unit staff meetings. • The Educator developed a program focusing on the Aldrete Score and our PACU Discharge Policy. At this session a case study type knowledge test was administered, and once completed, responses were reviewed with each nurse. A competency tool was developed for the Anesthesiologist to document that each nurse demonstrated proficiency in our Phase I PACU Discharge Criteria. Statement of Successful Practice The average length of stay for ambulatory surgery patients (974) in our Phase I PACU prior to this initiative (September- November 2018) was 119.17 minutes. After the implementation of this initiative (May - July 2019) the LOS for this patient population (935) decreased to 112.96 minutes. This reflects a 6.21 minute decrease in PACU LOS. At a cost of approximately $13.33 per minute of recovery time for 935 patients for this period, $77,399.30 was saved. Implications for Advancing the Practice of Perianesthesia Nursing PACU nurses can safely and independently discharge Phase I patients by criteria while demonstrating a decrease in the LOS for the Phase I PACU. The PACU nurses noted that when a patient was ready for discharge, an Anesthesiologist was not always immediately available to evaluate and discharge the patient. This led to both nurse and patient frustration as well as an increased length of stay (LOS) for the patient. The objective is to facilitate the safe discharge of patients from Phase I PACU while decreasing the LOS. • Literature review performed to identify best practices supporting this type of initiative. • Visitation to an affiliate hospital who had previously implemented this practice. • Consultation with Department of Anesthesiology to determine support for this initiative: ○ In the electronic medical record the Anesthesiologist orders indicate if the patient is eligible for discharge by criteria or an Anesthesiologist sign out. ○ If a patient is initially ordered for discharge by criteria, but the nurse has concerns, the nurse has the option to call the Anesthesiologist for an evaluation and sign out. • The PACU Nurse Manager and Nurse Educator discussed how to best implement this initiative, scheduled for January 7, 2019. • The Manager introduced this initiative to the nurses at unit staff meetings. • The Educator developed a program focusing on the Aldrete Score and our PACU Discharge Policy. At this session a case study type knowledge test was administered, and once completed, responses were reviewed with each nurse. A competency tool was developed for the Anesthesiologist to document that each nurse demonstrated proficiency in our Phase I PACU Discharge Criteria. The average length of stay for ambulatory surgery patients (974) in our Phase I PACU prior to this initiative (September- November 2018) was 119.17 minutes. After the implementation of this initiative (May - July 2019) the LOS for this patient population (935) decreased to 112.96 minutes. This reflects a 6.21 minute decrease in PACU LOS. At a cost of approximately $13.33 per minute of recovery time for 935 patients for this period, $77,399.30 was saved. PACU nurses can safely and independently discharge Phase I patients by criteria while demonstrating a decrease in the LOS for the Phase I PACU.

Administering Ketamine Infusions for Depression: Embracing Change in the Post Anesthesia Care Unit

<h3>Background Information</h3> Ketamine infusions are emerging as a novel treatment therapy for patients with severe treatment resistant depression. Across the country, there are limited options for receiving ketamine infusions outside of an academic based medical research center. A 171-bed community hospital in the northeast United States wanted to provide ketamine to carefully evaluated patients with severe treatment resistant depression. Since ketamine is traditionally used as an anesthetic agent, it was determined that the Post Anesthesia Care Unit (PACU) would be the appropriate setting to provide this treatment. <h3>Objectives of Project</h3> To educate and engage post anesthesia care nurses to implement a non-traditional treatment procedure, Ketamine Infusions, in the PACU setting. <h3>Process of Implementation</h3> Following the leadership decision to initiate ketamine Infusions, PACU nurse champions were identified and became members of the interdisciplinary task force charged with leading the change process. PACU nurses identified specific practice changes required to successfully implement this new treatment including a dedicated ketamine infusion room with new equipment, updates to the electronic health record, development of new standing orders to ensure availability of medications needed to treat adverse events, and establishment of pre and post infusion huddles with the attending psychiatrist. The nurse champions collaborated with the educator to develop a comprehensive multi-modal education plan to ensure competency for this new practice. <h3>Statement of Successful Practice</h3> Since May 2019, a total of 92 ketamine infusion treatments have been administered without serious adverse events. PACU nurses have embraced the practice change as demonstrated through recent survey results. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> The successful implementation of ketamine infusions is a result of PACU nurses being directly involved in the planning, implementation, and on-going evaluation of this initiative. As organizations across the country explore options to meet patient health care needs, PACU nurses will play an important role in addressing strategic initiatives by embracing treatment therapies.

The Rolling Refresher Cart (RRC): Improving the Level of Preparedness in PACU Nurses in Caring for Patients and their Specialized Surgical Drains

<h3>Introduction</h3> Patients with specialized surgical drains can be a high-risk occurrence in the post anesthesia care unit (PACU) if PACU nurses (RNs) mishandle these drains. Disproportionate opportunities to care for particular patient drains have contributed to RNs feeling unprepared. Research studies have shown that frequent education has a positive impact on RN's performance and preparedness level. <h3>Identification of the problem</h3> Absence of frequent education sessions have negatively impacted PACU RNs' level of preparedness to care for patients and their specialized drains. <h3>QI Question/Purpose of Study</h3> Will using a mobile teaching cart (aka RRC) that provides monthly in situ "refresher" sessions increase the level of preparedness in PACU RNs by 15% after each session? <h3>Methods</h3> PACU RNs were selected to participate in monthly 20-minute RRC sessions in their unit for 11 months. A needs assessment questionnaire was used to identify the 3 surgical drains for this project. One drain was reviewed per month and repeated quarterly. The hospital's policies and subject matter experts were consulted for the teaching points. A re-purposed utility cart was used during RRC sessions to store, transport, and display teaching materials. During each session, participants were provided a quick lecture and hands-on practice. Pre and post data for the nurses' preparedness level were collected immediately before and after each session via questionnaires. <h3>Outcomes/Results</h3> The goal was met. Self-reported data from PACU nurses show that monthly RRC sessions have increased the RNs' preparedness level to manage specialized surgical drains by at least 15%. 98% of the participants agreed to participate in future RRC sessions. <h3>Discussion</h3> Monthly RRC sessions were successful in improving the level of preparedness in PACU RNs. Buy-in from these RNs ensured future opportunities to use the RRC again for in-situ training. <h3>Conclusion</h3> Results from this project highlight the promising role of RRC in improving and maintaining knowledge, preparedness level, and skills set in PACU nurses. The absence of a control group in this project limits the generalizations that can be made. <h3>Implications for perianesthesia nurses and future research</h3> The RRC is optimal for in-situ training because it is easily accessible, readily available, uses minimal space, and can be used for just-in-time training. The RRC should be considered for use in other departments for RN training.

Diffusion of Successful Same Day Discharge Practice for Total Joint Arthroplasty Patients to a Select Population of Mastectomy Patients

<h3>Background Information</h3> Reimbursement guided by the Centers for Medicare & Medicaid Services (CMS) inpatient-only list continues to evolve with advancements in technology, care and coordination. Hospitals face business and quality imperatives of adjusting care pathways to allow for safe, high quality discharge of surgical patients earlier than ever. A 171-bed community teaching hospital in the northeast United States wanted to develop a novel care pathway to discharge patients undergoing mastectomy without reconstruction from the post anesthesia care unit (PACU) on the day of surgery. Current practice was to discharge them from the post-op floor. With the recent success of a novel pathway for same day discharge of joint replacement patients developed on this unit, staff were quickly able to translate effective practices to this new population. <h3>Objectives of Project</h3> To develop and implement a novel care pathway to discharge same day mastectomy without reconstruction patients from the PACU while maintaining high quality and patient satisfaction. <h3>Process of Implementation</h3> Following the leadership decision to initiate PACU discharge of select mastectomy patients, a PACU nurse champion was named. She identified needed changes and collaborated with multiple members of the interdisciplinary team to create a novel care pathway. Enhancements put in place included a new standard order set developed in collaboration with the surgical Advanced Practice Provider (APP) to support top of license nursing practice, customization within the electronic health record to clarify discharge materials for patients, collaborating with the Chief of Anesthesia to develop and disseminate a post-operative pain management protocol and a dedicated physical therapy pager and space to facilitate the most efficient care. <h3>Statement of Successful Practice</h3> Since June 2020, 3 patients have been discharged via the PACU pathway. None have required change to the traditional pathway. Mean length of stay has decreased for this population from overnight stay to approximately 6 hours. Patient and surgeon satisfaction for this group is high and there has been no impact to quality metrics. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> The successful implementation of PACU discharge of mastectomy patients is a result of PACU nurses leading collaborative innovation. As organizations across the country explore options to decrease length of stay, PACU nurses will play an important role in addressing strategic initiatives by embracing novel care pathways.

An Evidence-Based Approach to Nursing Recognition and Management of Early Sepsis in Percutaneous Transhepatic Biliary Drainage (PTBD)

<h3>Introduction</h3> Percutaneous Transhepatic Biliary Drainage (PTBD) is an interventional radiology (IR) procedure indicated for relief of biliary obstructive symptoms: pruritus, jaundice ang cholangitis cause by benign or malignant conditions. Gallstones, cholangiocarcinoma and hepatobiliary malignancy are frequently seen to cause sepsis. <h3>Identification of the Problem</h3> Although PTBD is generally a safe procedure, significant complications manifest as systemic inflammatory response syndrome (SIRS) that leads to mortality. Early post anesthesia care unit (PACU) nursing recognition is critical in effectively managing these high risk patients. <h3>EBP Question/Purpose: PICO question. Databases utilized</h3> What is the best practice for patients post biliary drain placement presenting symptoms of systemic inflammatory response syndrome (SIRS)? (P) Patients post PTBD; (I) Early recognition of SIRS; (C) Prompt/early management of SIRS compare to standard care in alleviating sepsis (O). The evidence-based practice (EBP) searches were conducted using PUBMED/CINAHL databases. <h3>Methods/Evidence</h3> The evidence reviewed from PUBMED/CINAHL ranged from 2013 to 2019. Mesh terms were: interventional, biliary drainage, PTBD, pathophysiology, cholangitis, symptoms, complications, sepsis and SIRS. The first search yielded eight out of 36 articles that met PICO criteria. The second and final search included eight additional articles with terms of mortality and patient outcomes. <h3>Significance of Findings/Outcomes</h3> EBP appraisal revealed compelling science for recognizing and managing early SIRS in PTBD patients. Team created an EBP algorithm (see poster) that was effective for PACU nurses in early recognition of SIRS and prompt PACU nursing management to mitigate deteriorating symptoms of increased heart rates and rigors followed by fevers to improve quality patient care. <h3>Implications for perianesthesia nurses and future research</h3> Post PTBD SIRS can be challenging for PACU nurses to manage life-threatening complications. Evidence supports the development of an algorithm tool that focuses on recognition, assessment, and appropriate management of SIRS in this population. The science recommends easy accessibility of standing physician order sets, including medications, such as intravenous (IV) fluids, IV antibiotics, and acetaminophen as SIRS management in PACU strategies to facilitate positive patient outcomes.

Post Anesthesia Care Unit Nurses’ Experience Caring for Opioid Tolerant Patients

<h3>Introduction</h3> Nearly 20% of same-day surgery patients regularly consume opioids, with the majority undergoing orthopedic or neurosurgery procedures for relief from chronic pain. Many have become opioid intolerant and subsequently, experience more pain and consume more opioids postoperatively than opioid naïve patients. Despite higher dosing, their pain is often unrelieved. Evidence-based guidelines include <i>preoperative identification</i> of opioid tolerant patients; however, postoperative nurses often learn of their patient's tolerance only after the patient exhibits an extreme reaction to pain. These experiences can be stressful and lead to nurse compassion fatigue and moral distress, particularly in a fast-paced post anesthesia care unit (PACU). <h3>Identification of the problem</h3> Several studies examine perioperative nurses' experiences with opioid tolerant patients in managing pain, though none explore the day-to-day personal challenges faced by nurses in the care of these patients. <h3>Purpose of the Study</h3> To explore PACU nurses' experiences in caring for opioid tolerant patients. <h3>Methodology</h3> A narrative research design was used. Six full-time PACU nurses with one or more years of PACU experience were recruited in Fall 2020. Subjects were asked to discuss an experience caring for an opioid tolerant patient and how they felt afterward. They were also asked to identify supports that would help them care for these patients. <h3>Results</h3> Interviews will be analyzed inward, outward, back in time, and forward in time to understand the participants' experience through five contexts – personal (feelings, reaction), social (environment, other people), past, present, future, and situation (professional practice). <h3>Discussion</h3> Narrative threads and their interpretation will be discussed to better understand how nurse's feelings are expressed and directed in professional practice. <h3>Conclusion</h3> This study made it possible to think about nursing practice in a new light through honoring experiences that are difficult to share yet are an important source of knowledge. <h3>Implications for perianesthesia nurses and future research</h3> Insights into the nature, causes, and strategies used to handle experiences caring for opioid tolerant patients will be identified as well as ways to better support nurses in the practice environment.

Oh Baby! There's a Pregger in My PACU…

<h3>Background Information</h3> With a trending increase in patient volume and acuity in the Post-Anesthesia Care Unit (PACU)s in a large academic medical center, it was noted that one of the demographics fostering this growth is the Obstetric (OB) population. It is important to note that the OB patients presenting to the PACUs required post-anesthesia care for non-OB procedures and interventions with the exception of OB procedures requiring general anesthesia. Hospital leadership and nursing staff noticed that caring for the OB patient in a non-OB PACU setting offered some distinct challenges related to the special considerations unique to the OB population. Instead of viewing OB patients in the PACU as a quagmire, the PACUs viewed this as an opportunity to collaborate with the OB department, promulgating maternal care in the PACU. <h3>Objectives of Project</h3> The objective was to create a program increasing knowledge related to the care of the OB patient in the PACU. <h3>Process of Implementation</h3> Collaborative gap analyses by the PACU and OB educators revealed that fundamental knowledge, skills, and adherences to professional organization recommendations regarding standards of care were opportunities for improvement. "Special Population Considerations: The OB Patient" was created and added to the existing PACU Residency/ Transition to Practice and PACU Preceptor curriculums which offer didactic and simulation activities to facilitate learning. Topics addressed included OB assessment, fetal monitoring (FM) expectations, postpartum hemorrhage care, and OB emergencies and equipment guided by professional practice guidelines and recommendations. Further, the OB department committed to collaborative care for FM and additional resources as needed, easing the anxiety of PACU nurses. Knowledge assessment was performed pre and post offering to measure changes in knowledge and program evaluation. <h3>Statement of Successful Practice</h3> After completion of the program by five cohorts, the average preassessment score of 30.6% increased to 85.6% post assessment showing an increase in knowledge and program success. Further, 100% of participants found the program beneficial. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> In addition to the new OB curriculum being offered, OB learning enrichment opportunities should be added to unit in-services, yearly skills and drills, and/ or unit-based competencies to ensure that PACU nurses are retaining knowledge regarding the care of the OB patient in the PACU.

Capnography monitoring in the Post Anaesthesia Care Unit (PACU)

Problem identification Capnography monitoring has been identified as a valuable monitoring tool to assist in the early detection of respiratory adverse events in post-operative patients in the PACU who are receiving supplemental oxygen. This integrated review of literature aims to identify the usefulness of implementing capnography monitoring in the PACU as standard practice to ensure safe patient outcomes. Literature search A search was undertaken of Scopus, Cumulative Index Nursing and Allied Health Literature (CINAHL) Complete, Health Source: Nursing and Academic Edition, Clinical Key, PubMed and MEDLINE Complete electronic databases. Articles (n=12) were selected for this review including a randomised control trial (RCT), quality improvement projects, a prospective observation study, a prospective cross-sectional study, an evidence summary and a systematic review and meta-analysis study. Data evaluation synthesis The main indicators for the use of capnography in the PACU included patients on assisted oxygen, patients receiving opioid analgesia, patients with obstructive sleep apnoea and paediatric patients. All articles related to capnography presented complimentary findings regarding the usefulness of capnography monitoring and its implementation in the PACU. Implications for perioperative nursing practice or research Capnography is effective in identifying compromised ventilation in post-operative patients who are receiving supplemental oxygen in the PACU, compared to the use of pulse oximetry alone. The literature recommends the combined use of pulse oximetry and capnography in the post-operative period to provide clinicians with a complete assessment of a patients ventilatory status. Nursing education is indicated to improve respiratory assessments and monitoring skills of PACU nurses combined with further research to ensure the effective implementation of capnography in the PACU.

Minimising the number of cancellations at the time of a severe lack of postanesthesia care unit beds or nurses

A deficiency of the postanesthesia care unit (PACU) beds or nurses may cause delays in the operating rooms (ORs) and increase the number of cancellations. Some disruptions like the COVID-19 pandemic may cause this deficiency. This paper investigates two integrated OR and PACU scheduling problems; one with few PACU beds, and the other with few PACU nurses. For each problem, a mathematical model and a matheuristic are proposed for minimising the number of cancellations. To the best of our knowledge, it is the first study that investigates the implications of a severe lack of the PACU beds or nurses on the number of cancellations. The matheuristics hybridise the decomposition of each instance into some small-sized sub-instances with a variable neighbourhood search algorithm. The main advantages of these methods are their flexibility to incorporate many problem details (such as a step-wise demand for the PACU nurses) and to solve any large-scale problem. Numerical results for a data set with 22 ORs show that with an increasingly severe lack of PACU capacity there is progressively greater benefit of the matheuristics than their initial solutions. Moreover, these results show the influence of the overtime and the recovery in ORs on improving the situation.

Developing and Implementing an Ambulatory Postanesthesia Care Unit Hand-Off Tool

PurposeThe purpose of this research study was to improve communication and reduce critical information loss between the ambulatory postanesthesia care unit (PACU) and ambulatory surgical center (ASC) nurses by developing, piloting, and evaluating a hand-off communication tool. DesignDescriptive study. MethodsThis pilot study was conducted in an outpatient surgery unit located at a large Magnet university hospital in New Jersey. Twenty ASC registered nurses (RNs) evaluated the hand-off tool developed for this study. Descriptive statistics were used to analyze the data from the 20 ASC RNs using three Likert-scale questions. FindingsThree Likert-style questions guided the rating of this tool. Using correlation analysis, the results support that the tool may be perceived as an instrument that was simultaneously easy to use, helpful, and communicated relevant patient data. The calculation of the reliability coefficient was 0.89. ConclusionsThis standardized hand-off tool relayed the pertinent and relevant patient data needed to support handoff from the ambulatory PACU to the ASC. Only ASC RNs rated the tool in this study. A planned second phase will evaluate PACU nurse's perception of the tool.

Sugammadex Effects on Hormonal Contraception Effectiveness: Implementation of Uniform Postoperative Teaching

PurposeThe purpose of this quality improvement project was to improve consistency of discharge teaching in women who used progesterone-containing hormonal contraceptive medications and received sugammadex during general anesthesia, as there is a risk of unintended pregnancy for 1 week after administration of sugammadex. DesignThis project used a predesign and postdesign using two separate sample groups of patients and postanesthesia care unit (PACU) nurses. MethodsThe sample consisted of 31 total women of childbearing age and 59 PACU nurses. Simplification of sugammadex discharge instructions was achieved by incorporating evidence-based recommendations for electronic discharge instructions and nursing education. PACU nurses were educated and surveyed before and after regarding frequency of discharge teaching, clarity, and comprehension of the after-visit summary and knowledge of sugammadex. Patients were called via telephone postoperatively to assess recall of sugammadex discharge teaching. FindingsPostoperative patient phone calls identified a small increase in patient recall of discharge instructions from 5 of 14 patients (35.7%) before implementation to 7 of 17 after implementation (41.2%). PACU nurse surveys indicated an increase in self-reported frequency of sugammadex discharge teaching (34.8% vs 64.2%, P = .024) and that new discharge instructions contained more clear, comprehensive information as compared with previous instructions (29.4% vs 75.5%, P = .001). ConclusionsThis quality improvement project successfully implemented more consistent and comprehensive discharge instructions for women who receive sugammadex intraoperatively. Limitations of the project included a small sample size and short implementation intervals. As a result of switching to uniform discharge instructions, more patients received important discharge teaching from PACU nurses, and the percentage of patients who recalled this information increased.

Retrograde Bladder Filling after Laparoscopic Gynecologic Surgery: A Double-blind Randomized Controlled Trial

Study ObjectiveTo evaluate whether retrofilling the bladder on completion of elective laparoscopic gynecologic surgery for benign indications has an effect on the timing of the first postoperative void and the timing of discharge from the hospital.DesignDouble-blind randomized controlled trial.SettingSingle academic surgical day hospital.PatientsPatients undergoing outpatient laparoscopic gynecologic surgery, excluding hysterectomy or pelvic reconstructive surgery.InterventionsOn completion of surgery, patients were randomized to either retrograde filling of the bladder with 200 mL of saline before catheter removal or standard care (immediate catheter removal). Patients and postanesthesia care unit nurses (outcome assessors) were both blinded.Measurements and Main ResultsThe primary outcome was the time to first void. The secondary outcomes were time to hospital discharge, postoperative urinary tract infection, and patient satisfaction. Over a 3-month period, 47 patients were approached on the day of surgery, 42 consented and were randomized (21 to intervention and 21 to control). There were no significant differences in baseline demographics between the groups. The median time to first void was significantly shorter for patients in the intervention arm than controls (104 ± 75 minutes vs 162 ± 76 minutes, p <.001). Patients who had retrofilled bladders were discharged faster from post-anesthesia care unit compared to controls (155.0 ± 74 minutes vs 227 ± 58 minutes, p = .001). There were no urinary tract infections in either group, and the proportion of satisfied or very satisfied patients was high (93.8% vs 88.2%, p = .512).ConclusionRetrograde filling of the bladder after outpatient laparoscopic gynecologic surgery is a safe, effective method that significantly reduces the length of hospital stay.

Critical Obstetric Patients During the Coronavirus Disease 2019 Pandemic: Operationalizing an Obstetric Intensive Care Unit.

Critical Obstetric Patients During the Coronavirus Disease 2019 Pandemic: Operationalizing an Obstetric Intensive Care Unit.

Navigating Uncertainty in Respiratory Assessment: The Interaction of Culture and Technology During Phase I Postanesthetic Recovery

PurposeTo explore postanesthesia care unit (PACU) nurses' interactions with technology during the critical Phase I recovery period. DesignInterpretive description was used to understand nurses' experiences. MethodsNine PACU nurses were recruited from three mid-sized hospitals within the same health authority in a Western Canadian province. Nurse participants were interviewed using a semistructured interview guide. FindingsNurses' interactions with technology were significantly influenced by PACU culture, as they constantly navigated a level of uncertainly about their patient's respiratory status. Three themes from the study are described. Theme 1 described nurses' confidence and trust in a visual sensory respiratory assessment process and the influence of anesthesia providers. Theme 2 described PACU nurses' guarded trust or rationalized mistrust in technology. Theme 3 highlighted the contextual influences, which sustained nurses' approach to respiratory assessment. ConclusionsPACU nurses practiced their intuitive sensory assessments with a projected strong sense of expert practice and minimal dependence on technology. PACU nurses expressed frustrations with current PACU bedside technology, particularly the respiratory module and described some experiences with delayed identification of hypoventilation and hypoxia. Rationalized behaviors with technology and alarm suppression were commonplace. Workplace culture sustained PACU nurses' respiratory assessment practices.

Experiences from the epicenter: an observational report on converting a post anesthesia care unit to a COVID-19 intensive care unit

Experiences from the epicenter: an observational report on converting a post anesthesia care unit to a COVID-19 intensive care unit

Respiratory depression in the post-anesthesia care unit: Mayo Clinic experience.

The anesthesia recovery is a complex physiologic process as systems recover from the effects of surgery and anesthesia. Inadequate recovery of respiratory physiology can lead to severe hypoxemia-induced end-organ damage and even death. Emerging evidence suggests that signs of respiratory depression during early anesthesia recovery may portend increased risk for future severe adverse events. This article briefly reviews the Mayo Clinic research experience and advances in clinical practice. From the implementation of a step-down model of discharge criteria in the post-anesthesia care unit (PACU), consisting of PACU nurses monitoring patients in predetermined periods for signs of respiratory depression, and delaying PACU discharge for patients who exhibit signs of respiratory depression, and early intervention in high-risk patients. Subsequent studies found that even a single episode of respiratory depression in the PACU was strongly associated with subsequent respiratory complications. Further, patient baseline characteristics found to be associated with respiratory depression included obstructive sleep apnea and low body weight, and surgical factors associated with increased risk included the use of preoperative sustained-release opioids, perioperative gabapentinoid use, higher intraoperative opioids, isoflurane as the volatile anesthetic, and longer surgical duration. Based in part of Mayo Clinic research, the FDA issued a warning in 2019 on gabapentinoids use and respiratory complications, increasing the recommended level of respiratory vigilance in patients using this medication. Understanding the complex nature of postoperative respiratory events requires a range of translational and clinical research and constant update of practice.