Episode #129 Using the PACU for Overflow ICU Patients, Part 2

December 20, 2022

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

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.

Table 1. Potential Advantages and Disadvantages to the Use of the PACU for Patients in Critical Condition.

Advantages

  • Proximity to the operating room
  • Highly trained nursing staff
  • Available respiratory therapists and ventilators
  • Advanced equipment readily available
  • Use of an under-utilized critical care unit

Disadvantages

  • Decrease in nursing availability for OR cases
  • Use of physical space reserved for OR cases
  • Limited availability of nursing to cover more than one patient
  • Potential misuse by services which prefer patients near OR
  • Potential cause for cancellation or delay of surgical cases
  • Unclear delineation of physician responsibility for patients
  • Potential need for additional training/continuing education for nurses
  • Differences in documentation required for patients

Plus, we are reviewing the Standards for Postanesthesia Care published by the American Society of Anesthesiology. This was originally approved in 2004 and last amended in 2019. Keep in mind that these standards apply to postanesthesia care in all locations and the goal is to promote quality patient care. There are times when additional support or care is necessary following anesthesia depending on the surgery or patient.

We hope that you will consider applying for the joint APSF-FAER Mentored Research Training Grant. The Letter of Intent submissions for the 2023 grant open December 1st, 2022, and close on January 1, 2023. 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!

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© 2022, The Anesthesia Patient Safety Foundation

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. We are talking about overflow ICU patients in the PACU once again today. Last week, we discussed pre-pandemic use of PACUs for ICU patients as well as the advantages and disadvantages of providing critical care for patients in the post-anesthesia care unit.

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

Let’s crack open the October 2022 APSF Newsletter and return to our featured article, “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.

To kick off the show today we are going to review Table 1 from the article, Potential Advantages and Disadvantages to the Use of the PACU for Patients in Critical Condition. I will include the table in the show notes as well. We are going to start with the advantages which include the following:

  • Proximity to the operating room
  • Highly trained nursing staff
  • Available respiratory therapists and ventilators
  • Advanced equipment readily available
  • Use of an under-utilized critical care unit

Here are the disadvantages.

  • Decrease in nursing availability for OR cases
  • Use of physical space reserved for OR cases
  • Limited availability of nursing to cover more than one patient
  • Potential misuse by services which prefer patients near OR
  • Potential cause for cancellation or delay of surgical cases
  • Unclear delineation of physician responsibility for patients
  • Potential need for additional training/continuing education for nurses
  • Differences in documentation required for patients

In order to discuss the use of the PACU for ICU patients, it is important to consider the infrastructure differences. ICUs often have space, beds, seating, and amenities for patients’ families. PACUs often do not have the space or resources to accommodate patients’ families. In addition, the layout of the PACU means that there is less patient privacy and ambulatory patients may be exposed to the sickest ICU patients. There are other ICU resources that may not be available on site in the PACU including on-unit staffed satellite pharmacies, social/pastoral service points, and patient movement/positioning equipment.

The authors provide several recommendations in their article. These are important considerations for any institution that is considering using the PACU for ICU patients. It is critical to review the potential advantages and disadvantages and develop a plan to maintain patient safety with efficient utilization of resources. This requires constant evaluation of available capacity and resources which serve as the foundation for developing a plan for efficient deployment of resources and the use of units with excess capacity for overflow patients including the PACU.

Where is the anesthesia professional in all of this? Once again, there is an opportunity for anesthesia professionals to be leaders when deciding on how to utilize PACU resources. This is critical since anesthesia professionals are responsible for managing the PACU, keeping patients safe, and maintaining operating room efficiency. The conversation is different when considering routine use of the PACU for ICU-level care in patients who require postoperative mechanical ventilation for a short period of time which is common in the United States compared to using the PACU regularly for overflow ICU patients which requires different staff responsibilities and allocating available resources. When anesthesia professionals are involved in the planning, it can help minimize the impact on the operating room schedule and keep patients safe. We often talk about how important communication is for patient safety. The authors highlight that clear lines of communication are necessary to ensure that ICU patients located in the PACU are managed by the most well-trained clinical staff. Appropriate training for all nurses managing these ICU-level patients is an important consideration for keeping patients safe in the PACU. Resource availability including IV pumps, ventilators, and monitoring equipment needs to be assessed and managed appropriately as well. Finally, it is important to make sure that support staff including respiratory therapists, nursing assistants, and transporters, have access to the PACU and are available to provide care to ICU overflow in the PACU.

Throughout the Covid-19 pandemic, there have been numerous examples of increased demand for ICU bed space and this demand has been met with available PACU bed space when elective surgeries were on hold. Reports have described staff training, equipment availability, and physical space modifications including airflow and pressure systems and construction of isolation rooms. What we don’t know at this time is the impact of using the PACU for overflow ICU patients on critically ill patient outcomes. What about patients who undergo emergency surgery and need routine postanesthesia care? We also still don’t know about the psychological impact of providing ICU care in these overflow units on healthcare professionals, patients, and their families.

Let’s return to the article and the conclusion. The authors remind us that using the PACU as an ICU may help during times of increased ICU demand and relieve the stress on facilities management, hospital administrators, and critical care physicians. On the other hand, there are important threats to patient and healthcare professional safety that may impact patients, physicians, nurses, advanced practice providers, and ancillary staff. The authors leave us with a call to action that I will read now:

“Though emergency conditions may render its use necessary at times, careful thought and planning of PACU care for ICU patients should involve anesthesia professionals to potentially mitigate the adverse consequences to patients and operating room efficiency by deploying this valuable resource in a unique manner.”

We made it to the end of the article, but not the end of the show. Before we wrap up for today, since we have been talking about postanesthesia care, we are going to review the Standards for Postanesthesia Care published by the American Society of Anesthesiology. This was originally approved in 2004 and last amended in 2019. Keep in mind that these standards apply to postanesthesia care in all locations and the goal is to promote quality patient care. There are times when additional support or care is necessary following anesthesia depending on the surgery or patient. Okay, here we go. Standard 1 states the following:

“ALL PATIENTS WHO HAVE RECEIVED GENERAL ANESTHESIA, REGIONAL ANESTHESIA OR MONITORED ANESTHESIA CARE SHALL RECEIVE APPROPRIATE POSTANESTHESIA MANAGEMENT.”

The PACU or an appropriate ICU is highlighted in this standard since all patients who receive anesthesia care must then be admitted to one of these locations unless there is a specific order from the responsible anesthesia professional. In addition, the patient care policies and procedures in the PACU must have oversight from the Department of Anesthesiology and the design, equipment, and staffing of the PACU needs to meet the requirements of the facilities accrediting and licensing bodies.

Next up is Standard II which states the following:

“A PATIENT TRANSPORTED TO THE PACU SHALL BE ACCOMPANIED BY A MEMBER OF THE ANESTHESIA CARE TEAM WHO IS KNOWLEDGEABLE ABOUT THE PATIENT’S CONDITION.  THE PATIENT SHALL BE CONTINUALLY EVALUATED AND TREATED DURING TRANSPORT WITH MONITORING AND SUPPORT APPROPRIATE TO THE PATIENT’S CONDITION.”

This one is pretty straightforward. All anesthesia professionals are familiar with transporting patients from the operating theatre to the PACU. It is important to keep patients safe during transport with appropriate monitoring and treatment if needed.

Standard III states that “UPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE RE-EVALUATED AND A VERBAL REPORT PROVIDED TO THE RESPONSIBLE PACU NURSE BY THE MEMBER OF THE ANESTHESIA CARE TEAM WHO ACCOMPANIES THE PATIENT.”

Let’s look at some of the details of this standard. It is important to document the patient’s status when they arrive in the PACU. The PACU handoff must include information about the preoperative condition as well as the surgical and anesthetic course. Finally, a member of the anesthesia care team needs to remain in the PACU until the PACU nurse is available to provide patient care.

The fourth standard involves continuous evaluation of the patient’s condition in the PACU. Appropriate observations and monitoring depend on the patient’s medical condition and surgical procedure. Monitoring oxygenation with pulse oximetry as well as monitoring ventilation, circulation, level of consciousness, and temperature is vital to keep patients safe. There needs to be a written report of the patient’s PACU course and an appropriate PACU scoring system may be used on admission, at regular intervals, and just prior to discharge. An anesthesiologist shall be responsible for general medical supervision and patient care coordination in the PACU. In addition, there needs to be a physician available to help manage any complications and provide cardiopulmonary resuscitation if needed in the PACU as well.

The final standard states that a physician must be responsible for patient discharge from the PACU. Discharge criteria may be used when approved by the Department of Anesthesiology and the medical staff and depends on the patient’s discharge location which may be hospital room, ICU, short stay unit, or home. If there is no physician responsible for discharge, the PACU nurse may determine when the patient meets discharge criteria with the name of the discharge physician noted on the record.

I will include a link to the postanesthesia standards in the show notes as well. And it looks like we have met the discharge criteria for this show. 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 on December 1st 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