Medical Decisions Asked of PACU Nurses?

Clark A. Fenn

To the Editor

I write to the APSF Newsletter regarding a situation that has been recurrently discussed in the risk management circles of Massachusetts.

Concern has been raised as to whether the practice of allowing registered nurses in the Post Anesthesia Care Unit (Recovery Room) to educate patients should be continued in light of our increasing litigious society.

In conversations with various Risk Managers from a variety of different-sized hospitals, it is becoming increasingly apparent that supervision of the Recovery Room staff by the responsible anesthesiologists is varied depending upon the type of hospitals surveyed.

For example, large teaching hospitals with residency programs in anesthesia tend to have available anesthesiologists in the recovery room at all times. However, mid to small-sized hospitals who practice with two to three staff anesthesiologists at best, rarely have an anesthesiologist immediately available to the recovery room. In most cases, the anesthesiologist transfers the intubated patient to the PACU and then begins another case. This leaves the extubation of patients to the discretion of the nursing staff based upon criteria taught to them usually on the job by the department anesthesiologist.

At a recent symposium sponsored by The Society for Post Anesthesia Care Nurses, a key note speaker felt that extubation by registered nurses was a duty above and beyond what is allowable under the Nurse Practice Act and in fact places the registered nurse, the anesthesiologist, and the hospital at risk if complications were to ensue. She further stated that if registered nurses practice extubation, it places them at the same level of duty of an anesthesiologist in that they should have the ability to handle complications and reintubation.

Again, in the informal survey conducted of various hospitals regarding this topic, it is dear that most Post Anesthesia Care Nurses cannot readily intubate nor have they been trained or educated to do so.

I would appreciate the thoughts of involved anesthesia providers concerning this matter. The position taken to date by some hospitals in Massachusetts are to:

1. Not allow recovery room staff to extubate, requiring increased anesthesia staff or increased time for the patient to be discharged from the operating room suite; or

2. To continue to allow recovery room staff to extubate after having been through an educational process developed and implemented by usually the Chief of Anesthesia for the involved hospital.

Clark A. Fenn Risk Manager Holyoke Hospital, Inc. (MA)

Editors note: Replies are welcome, either directly to Mr. Fenn or to the APSF Newsletter for publication.