Volume 5, No. 2 • Summer 1990

Is This PACU Practice Patient Abandonment?

Lee A. Balaklaw, M.D.

To the Editor

I have been following the controversy of “abandoning” patients in the OR under various circumstances. My practice circumstances are perhaps not unique I would appreciate comments and guidance l am part of a three physician group with three operating rooms. Ordinarily we work with two nurse anesthetists and there is a supervising anesthesiologist free to deal with emergencies. However at certain times of the year we are without nurse anesthetists. At that point no anesthesiologist is free except between cases, and each anesthesiologist is committed one-on-one to an operating room. Similar situations would exist in an all-M.D. group.

Our current practice mode is to only bring patients who are extubated and breathing well and maintaining their own airway to the recovery room. Our problem rate in the recovery room is very low, and usually revolves around giving medications for pain or nausea or discharging patients from the recovery room. On rare occasion we may have to order vapoepinephrine or humidified oxygen for a “croupy” post tonsilectomy patient. We endeavor to only bring stable patients to our recovery room, and we will if necessary stay with our patients in the operating room until we judge them to be stable

My understanding of the standards of care in the recovery room is that once the anesthesia personnel have turned over a stable patient to the appropriately trained and credentialed operating room nurse and given an appropriate turnover report, they are free to return to the operating room. Under such circumstances we do not have an anesthesiologist free to deal with an emergency in the recovery room until another case ends. Most of our cases are fairly short with rapid turnovers, until the afternoon, by which time when we are involved in longer cases, one of our colleagues are free. Does this meet the standard of care?

As a secondary consideration to prior discussions of this issue, I would never consider leaving an operating room to go to the recovery room to deal with a cardiac arrest, unless I had trained anesthesia personnel to relieve me. Even a patient who is awake having cataract surgery under local anesthesia can get into trouble at a moment’s notice. We have had sudden cardiac dysrhythmias or ST segment changes develop without warning, which required immediate intervention. We have also had patients develop panic attacks under the same circumstances. Furthermore, should a cardiac arrest develop in the recovery room, while I am in the operating room with another patient, the cardiac arrest team could always be called. In our institution, the team is lead by an emergency physician who can intubate, as well as ICU nurses, a nursing supervisor, and respiratory therapists (and a recovery room nurse) who are all skilled at basic airway management techniques.

I still consider leaving a patient in the operating room to attend to a patient in the recovery room abandonment, and I will not do it unless there are trained anesthesia personnel to take my place. I have been known, however, to run (and I do mean run) into our operating room’s central core to pull in supplies that I need. I only do so on stable patients. Under those circumstances I am away from the head of the table for under thirty seconds. I do not necessarily consider this to be abandonment since our central core and supplies am only a few feet away. By the same token when I am doing a spinal I am at times of necessity facing away from my monitors for periods far longer than thirty seconds. I do not consider this to be a breach in the standard of care since I know all of our colleagues are in the same boat.

I would think that our practice mode meets the standard of care. It has allowed us to function in what I think is a safe and effective manner. I do not think we meet Dr. Fletcher’s standards (APSF Newsletter, Sept., 1989). However, I do not think based on my understanding of current standards that not having anesthesia personnel immediately physically available in the recovery mom is a breach of care when trained recovery room nurses are present to care for stable patients. We are immediately available for consultation with the recovery room nurses from the operating room. Do all M. D. groups in private hospitals always have an M. 0. free to care for recovery mom problems? That may be financially feasible in a large group, but it is not in small hospitals such as ours.

Any thoughts, comments, or guidance your readership can provide would be greatly appreciated.

Lee A. Balaklaw, M.D. Cortland, NY