Episode #128 Are We in the PACU or the ICU?

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Have you ever been in an overflow situation at your hospital? Where you had more patients that needed critical care than the number of critical care beds? What did you do? Maybe you have never been in this challenging situation before, but all anesthesia professionals are familiar with caring for patients in the post-anesthesia care unit or PACU and in the ICU as well. Stay tuned as we talk about an alternate use for the PACU and the role of the anesthesia professional.

Before we dive into the episode today, we’d like to recognize Fresenius Kabi, a major corporate supporter of APSF. Fresenius Kabi has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Fresenius Kabi – we wouldn’t be able to do all that we do without you!”

Our featured article today is once again from the October 2022 APSF Newsletter. It is “Risks and Benefits of the Use of the Postanesthesia Care Unit as an Intensive Care Unit and Special Considerations for Anesthesia Professionals” by George Tewfik and colleagues. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the Current Issue, October 2022 and then scroll down until you get to our featured article today. I will include a link in the show notes as well.

Before we get into the article, we are going to be hearing from one of the authors. I will let him introduce himself now.

[Tewfik] “Hi, my name is George Tewfik and I’m an associate professor of anesthesiology at Rutgers New Jersey Medical School in Newark, New Jersey.”

[Bechtel] To kick off the show today, I asked Tewfik why he feels so passionate about this topic? Let’s take a listen to what he had to say.

[Tewfik] “The post-anesthesia care unit or PACU is a versatile location in the hospital that can be used in a variety of ways beyond its original intention, which is to care for patients who have received anesthesia care.

One of these important ways to use a PACU is as an intensive care unit. Using a PACU as an ICU can create great benefits to patient care, including the use of an under-utilized area of the hospital and taking advantage of the care provided by a group of highly trained nursing staff. But it is very important for anesthesiologists to understand this use of the PACU and to be involved at each institution with the decision to proceed with its use as an ICU in order to ensure appropriate patient care.

To facilitate a clear line of leadership and patient management and to improve perioperative patient safety while maximizing efficiency. Though it can be a net positive for patient care in an institution, if it is not approached thoughtfully, using a PACU as an ICU may negatively impact patient safety and perioperative outcomes.”

[Bechtel] And now, it’s time to get into the article and explore the risks and benefits. So, let’s head into the recovery room. The article starts out with some background information. It may be necessary to use a postanesthesia care unit for intensive care unit patients when the demand for ICU level care exceeds the availability of critical care beds. In fact, this occurred in institutions in the United States geographic areas that had high concentrations of early coronavirus outbreaks in the spring of 2020. Hospitals saw a dramatic increase in critically ill patients that exceeded the ICU bed capacity leading to the creation of makeshift ICUs and to help meet the demand.

So, what did these make-shift ICUs look like? Some were created in PACUs and staffed by physicians, nurses and advanced practice providers trained in ventilator management. Remember, at the beginning of the COVID-19 Pandemic, elective surgeries were on hold which meant that PACUs were open and available for ICU overflow. Other hospital locations including general hospital floors and emergency department rooms were converted into ICUs as the demand for critical care increased. Operating rooms that stood empty from elective surgeries on hold had a new use as ICU rooms with anesthesia machines turned into ICU ventilators.

As these new critical care units were quickly created to meet the demand and provide care for patients who required airway management and ventilatory support, there were additional modifications that included establishing isolation rooms with temporary partitions and anterooms with HEPA filtration and changing from positive pressure ventilation to negative pressure ventilation in the operating rooms. All of this was accomplished with support from organizations including the Army Corps of Engineers and local, state, and federal authorities who provided specialized medical equipment, triage tents, and clinical/logistic manpower to withstand the surge of critically ill patients.

Now, let’s start at the very beginning. What is the purpose of a PACU? This is a unit designed to provide the necessary care for postanesthesia patients and support the capacity of the operating room. Before the pandemic, was the PACU ever used for ICU overflow at your institution? Go ahead and raise your hands if you have seen this. I’m raising my hand now too. PACU beds may have been converted to ICU beds as a result of increased hospital surgery volume and increased patient acuity. For example, if the surgical intensive care unit is full, the PACU may be used for overflow surgical patients who need critical care after surgery or for surgical intensive care unit patients who are more stable to make room for another more critically ill patient who need to be in the unit to receive specialized care such as ECMO or continuous renal replacement therapy. The PACU was not designed to be a back-up intensive care unit. It serves a specialized purpose in the hospital with perioperative nurses working to keep patients safe following surgery and anesthesia. In addition, just like there may be a shortage of beds in the ICU, bed shortages in the PACU may also occur which can affect the operating room schedule since patients may be delayed moving out of the OR and into the PACU while waiting for an open bed.

The American Society of PeriAnesthesia Nurses, American Association of Colleges of Nursing, and American Society of Anesthesiologists issued a joint statement in 2000 to address ICU overflow patients in the PACU which recommended a multidisciplinary approach to optimize ICU bed utilization to decrease the need for ICU overflow in remote locations. I will include a link to the article in the show notes so that you can check it out too.

Over the past twenty years, there have been many examples from around the world of PACUs used for ICU overflow and several articles that support this practice. The PACU may be one of the safest places to provide care for overflow ICU patients. Beds may be available since many surgical procedures have moved to outpatient surgical centers. There are appropriate resources to provide safe patient care including ability for advanced monitoring and appropriately trained staff. Use of a PACU as an intensive care unit depends on the impact of the three major stakeholders – the ICU overflow patients, the regularly scheduled postoperative patients requiring postanesthesia care, and the perioperative nurses who provide this care. To assess the impact on these groups, there are important questions to address. Is there a higher morbidity and mortality for ICU patients managed in the PACU compared to the ICU? What is the impact of the increased workload on PACU nurses who must provide care for routine PACU patients and overflow ICU patients? Do the routine PACU patients still get the necessary and timely care that is required in the immediate postoperative period?

Let’s continue the conversation today by discussing the advantages of using a PACU as an ICU. First, the geographic location of the PACU next to the operating rooms is an ideal location for overflow surgical ICU patients who may require a quick transfer back to the operating room or who may need repeat surgical procedures. If there are no available beds in the surgical ICU, a transfer to the nearby PACU may be a great alternative with nurses already trained to provide care during the immediate postoperative period. Whereas the medical ICU may not be ideal for overflow surgical ICU patients if it is located far from the operating rooms and the team is not familiar with providing postoperative and postanesthesia care. The next consideration is the nursing staff in the PACU who are trained to provide care for one or more high-acuity patients including intubated patients on ventilators, patients with invasive monitoring and central lines requiring hemodynamic support with IV fluids, blood transfusions, and vasoactive medication infusions, and more. With the goal to keep patients safe following anesthesia care, the PACU emerges as a safe place to provide postoperative ICU level care. Check out the article by Callaghan and colleagues published in 2005, “Overnight intensive recovery: elective open aortic surgery without a routine ICU bed.” This study is a retrospective case analysis of patients who underwent elective open aortic surgery and were preoperatively identified as candidates for extubation in the operating room followed by overnight recovery in the PACU compared to planned ICU admission which revealed no excess mortality or morbidity in patients managed in the PACU overnight. I will include the citation in the show notes as well.

It’s time to review the disadvantages of using the PACU for overflow ICU patients. This practice can have an impact on patient safety as well as operating room scheduling and utilization. The first disadvantage is also related to location. T his time it is the ICU physicians and advanced practice providers who may be in different physical location than the PACU and not immediately available to come to the PACU if they are busy taking care of critically ill ICU patients on a different floor or part of the hospital. Another disadvantage is related to staffing since PACU nurses may not be appropriately trained to manage every aspect of ICU care. This is particularly important for patients who would otherwise be managed in a special ICU such as a neuro-intensive care unit or the cardiothoracic intensive care unit or even the pediatric intensive care unit. There are also logistic considerations such as the admission history, releasing order sets, and documentation workflow that differs in the PACU compared to the ICU. This can lead to delays in medication availability and administration. Also, remember that the purpose of the PACU is to provide postoperative care, so if the PACU fills up with overflow ICU patients there may be downstream effects of decreased operating room efficiency, threats to postoperative patient safety, and decreased clinician and patient satisfaction. One of the significant disadvantages of using the PACU for overflow ICU is the impact on PACU nurses’ expectations, workflow, and stressors. PACU nurses who have been interviewed about their experience in the PACU with overflow ICU patients report feelings of distress and concerns about providing substandard ICU-level care. ICU patients may remain in the PACU for a longer duration than typical postoperative PACU patients. In addition, there may be concerns from patients and their families about the care team since PACU patients often receive care from anesthesia professionals in collaboration with the surgical team while ICU patients receive care from a critical care physician and a multidisciplinary team who are not always present in the PACU. Visiting hours and access for multiple family members may be limited in the PACU which can be an additional stress for patients and their families.

We have covered the advantages and disadvantages of using the PACU for overflow ICU patients, but there is still more to talk about. We hope you will join us next week for the exciting conclusion. We will be reviewing the infrastructure of the PACU compared to the ICU, the impact of the Covid-19 pandemic, the standards for postanesthesia care from the American society of anesthesiologists, and so much more.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Have you considered applying for the joint APSF-FAER Mentored Research Training Grant? The Letter of Intent submissions for the 2023 grant opened December 1^st and will close on January 1, 2023, so there is still time. This is a two-year, $300,000 award to help anesthesiologists develop skills and preliminary data in order to become independent investigators in the field of anesthesia patient safety. The first step is the letter of intent prior to submitting a full application. So, what are you waiting for? Get your letter of intent in! I will include a link to the submission page in the show notes as well. You might be the next anesthesia patient safety researcher!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation