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Frequently Asked Questions

Welcome to the ASPAN’s Clinical Practice Committee “FAQ” page.

Scroll down the page to read answers to some of the most frequently asked clinical practice questions received by ASPAN. These questions will be modified periodically as practice issues change.

If you do not find the answer to your question, please feel free to submit it to ASPAN's Clinical Practice Network or post it on the ASPAN Forum.

Q: What is ASPAN’s recommendation regarding the role of the perianesthesia nurse during a preoperative peripheral nerve block?
Q: What is the definition of "responsible adult?" "If a patient does not have a responsible adult to accompany him at discharge, what do you suggest?"
Q: Do the ASPAN standards require, or simply recommend, ACLS for nurses working in a preop and phase II setting? Is BLS sufficient?
Q: Is Capnography required in Phase I PACU?
Q: What discharge scoring system does ASPAN recommend?
Q: What are the requirements for preoperative pregnancy testing?
Q: Can a PACU nurse extubate a patient? Must an anesthesia provider be present?
Q: Is there an acuity system that ASPAN recommends to help in daily staffing?
Q: Can a patient ambulate to the car or is it required that we take them out in a wheelchair?
Q: What is ASPAN’s standard for vital sign frequency in Phase I and Phase II and Extended Care?
Q: Do all outpatients need to void prior to being discharged?
Q: Can we put Preop patients in the same area that we have patients recovering from anesthesia?
Q: What are the differences between Phase I, Phase II, and Extended Care (Extended Observation/Phase III)?
Q: Can I give oral pain medications in Phase I?
Q: How long should we keep patients in the PACU after they have received a narcotic?
Q: Is ECG interpretation necessary in the PACU, along with running and mounting an ECG Strip?
Q: At what temperature can we set our blanket and fluid warmers?
Q: What is the national trend for being able to wear personal, home-laundered scrubs to work in the PACU?
Q: What research has been done on temporal artery thermometers, and how accurate are they compared to tympanic thermometers?
Q: Regarding the standard about when to implement medical-surgical restraints -- when does the standard apply?
Q: Does ASPAN have a position on dose ranging of medications? If so, what is it?
Q: Can LPNs work in the PACU if they are qualified (such as having BLS, ACLS, hemodynamic courses, arrhythmia courses, starting IVs, drawing blood, and working PACU for years)?
Q: How long do you need to observe a patient who has had reversal of a benzodiazepine with flumazenil (Romazicon)?
Q: What does ASPAN say about the standards of L&D nurses obtaining and maintaining ACLS certification?
Q: Looking for a method to calculate IV fluid replacement for children and adults for the NPO hours, operative and post anesthesia period?
Q: How can patients with multi-drug resistant organisms (MRSA, VRE, etc.) be cared for in PACU? Do they need to be in an isolation room, recovered in the OR, returned to the patient room for Phase I level of care?
Q: What are the criteria for discharging a patient following spinal anesthesia?
Q: Must a registered nurse accompany patients being transferred from PACU?
Q:

What does ASPAN say about families visiting in PACU?

Q: What are the staffing recommendations for Phase I level of care? Is it necessary to have two nurses present?
Q: How many PACU beds should there be for each OR?
Q: What are hospital PACUs doing regarding sending patients back direct to ICU from the OR, especially if the patient came from the ICU? If the patient goes back to ICU must a PACU RN recover the patient there?
Q: What do we need to do to be in compliance with standards for follow-up phone calls after outpatient surgery?
Q: What are the recommendations for PACU nurses regarding ACLS and PALS?

Q: What is ASPAN’s recommendation regarding the role of the perianesthesia nurse during a preoperative peripheral nerve block?
A:

The ASPAN Perianesthesia Nursing Standards and Practice Recommendations 2010-2012 include Resource 3, the “ANA Position Statement: Role of the Registered Nurse in the Management of Analgesia by Catheter Techniques (Epidural, Intrathecal, Intrapleural or Peripheral Nerve Catheters).1 The American Nurses Association (ANA) states that RNs may not insert the device, administer a test/initial dose of medication through the device, confirm placement, or establish the dose parameters necessary to achieve analgesia/pain relief.1 Only credentialed practitioners, usually anesthesiologists, prescribe and insert these devices. State nurse practice acts (NPA) may differ in how the RN’s scope of practice is defined regarding participation during insertion. Before developing facility policies, procedures and competencies, review the applicable nurse practice act for your state.3,4

In many facilities, nurses do assist during insertion of peripheral nerve blocks. Minimally, the RN should facilitate patient safety. Safety factors include completing a preprocedure checklist, and also verifying informed consent, IV access and patency, procedural timeout, and emergency equipment availability.3

When assisting with the procedure, a 1:1 nurse/patient ratio applies. Duties may include gathering supplies such as ultrasound equipment, administering physician-ordered moderate sedation, monitoring the patient, and in some cases, adjusting the stimulator’s amplitude at the direction of the anesthesiologist.4 Frequency of vital signs ranges from every two to 15 minutes, depending on the patient’s response and overall condition.4 Recognition of adverse reactions and timely intervention is critical.3,4,5 Nurses assisting with blocks should maintain current ACLS/PALS credentials.

Depending upon state nurse practice act and facility policy, a nurse may inject local anesthetic through the peripheral nerve catheter under the direct supervision and instruction of the anesthesiologist.4 The anesthesiologist should maintain the position of the needle and the catheter while the nurse injects the medication. The nurse effectively serves as the anesthesiologist’s extra pair of hands.3

Nursing documentation reflects the nurse’s participation in the procedure. Note the patient’s condition on arrival and departure from the procedure area. Complete the preprocedure checklist and timeout. Chart vital signs with oxygen saturation. Document the cardiac rhythm, and where possible, include rhythm strips. Record medications administered and the response of the patient. Note adverse reactions. Document neurovascular and neurological checks. Include the patient’s position, noting protective devices used as well as padding. The anesthesiologist should complete a physician procedure note.

Nursing competencies should include ACLS/PALS, moderate sedation, intralipid protocol, recognition of signs and symptoms of toxicity including cardiac arrhythmias and seizures, pharmacology of local anesthetic agents, and neurovascular/neurological checks. Nurses should be familiar with each type of block performed, its therapeutic effects, associated side effects, possible adverse reactions associated with the specific block performed and any indicated emergency interventions.4 These competencies are necessary to ensure the patient’s optimal safety during the peripheral nerve block procedure.

REFERENCES:

  1. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ: ASPAN; 2010:139-140.
  2. Clark M. Lipid Emulsion as Rescue for Local Anesthetic-Related Cardiotoxicity. J Perianesthesia Nurs. 2008; 23(2):111-121.
  3. Clifford T. Peripheral Nerve Blocks. J Perianesthesia Nurs. 2011;26(2):120-121.
  4. McCamant K. Peripheral Nerve Blocks: Understanding the Nurse’s Role. J Perianesthesia Nurs.  2006;21(1):16-26.
  5. Sandlin-Leming D. Resuscitation of Local Anesthesia-Induced Cardiac Arrest: Lipids to the Rescue. J Perianesthesia Nurs. 2010;25(6):418-420.
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Q: What is the definition of "responsible adult?"
"If a patient does not have a responsible adult to accompany him at discharge, what do you suggest?"
A:

The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements do not include a definition of "responsible adult." The dictionary defines ‘responsible’ as an “individual who is able to answer for his conduct and obligations; someone who is trustworthy; someone who knows right from wrong; someone who is accountable.”1 An "adult" is an individual 18 years or older. There are facilities where the word "adult" has been changed to "party" or "person."

Determinants of Responsible Adult
When determining whether or not an individual can be the responsible adult, age is not the only factor. Sometimes, it is the relationship of the parties. Parents are presumed to have authority to act on behalf of their minor children. A minor who is a parent caring for his/her own child may be the "responsible adult," even if the minor and his/her child live with parents or other adult relatives.

The ability to drive is not a prerequisite, although it may be necessary to ascertain whether the mode of transportation is safe for the patient. The patient cannot be the driver after sedation, but taking a taxi when accompanied by a non-driving "responsible party" may be an acceptable option. A blind or deaf person can be the responsible person. Discharge instructions may be carried out through an interpreter. In today's society, many people live alone or are single parents. If the patient's "responsible adult" is a teenage child, you must consult the facility's policy regarding the discharge. It may be reasonable to discharge the patient with a teenager who understands the discharge instructions, and is willing and able to provide the necessary care.

Caregiver Support
What if the patient is not accompanied by a responsible adult? It is best to verify discharge arrangements prior to the procedure. At the time of admission, ask who will be caring for the patient after discharge, and what transportation arrangements are planned. Make sure the designated caregiver understands that the patient should not be left alone for the first 12-24 hours, depending on the procedure and the type of sedation.

Occasionally, the person driving the patient home is not the designated caregiver. If possible, contact the caregiver to review the discharge instructions and to answer any questions. If the caregiver does not comprehend the discharge instructions, or is unable to perform the tasks necessary to care for the patient, it may be necessary to consult the physician and obtain an order for home healthcare. Occasionally, unaccompanied patients state they have someone to help them at home. Some facilities allow patients to leave via taxi with a physician’s order. Consider notifying the caregiver when the taxi leaves the facility. Document the telephone number, the name, and the relationship of the individual.

Discharge  
It may be necessary to obtain an order for the patient to spend the night in the facility (if that is an option). If no alternatives can be identified, the physician may need to cancel the procedure. When discharging a patient to a group home, review the discharge instructions with the group home supervisor. When discharging a patient to assisted living, contact the caregiver to determine what arrangements can be made for overnight care if a family member or friend is not going to be with the patient. With elderly patients, the accompanying spouse may require more care than the spouse having the procedure. When the patient is the spouse's caregiver, determine who else may be available to assist the couple after the procedure.

Never hold a patient against his will. False imprisonment is not an option. The patient could file both civil and criminal charges, depending on state laws. Consult the facility risk manager or administrator regarding leaving Against Medical Advice (AMA). AMA departures should be carefully documented in the medical record. 

REFERENCES:

  1. Merriam-Webster Dictionary. Available at: click here. Accessed June 30, 2012.
  2. Chinnappa V, Chung F. What Criteria Should Be Used for Discharge after Outpatient Surgery? In: Fleisher L, ed. Evidence Based Practice of Anesthesiology. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2009:310-311.
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Q: Do the ASPAN standards require, or simply recommend, ACLS for nurses working in a preop and phase II setting? Is BLS sufficient?
A:

The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements do not require ACLS/PALS for nurses working in Preop or Phase II perianesthesia care. ACLS and PALS recommendations are addressed in “Standard III, Staffing and Personnel Management” with the following statement: “It is recommended that the perianesthesia nurse providing Phase II level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served.”1

“Practice Recommendation 4, Recommended Competencies for the Perianesthesia Nurse,” includes  ACLS,  and PALS or PEARS (Pediatric Emergency Assessment Recognition Stabilization) training for nurses working in either preanesthesia or Phase II settings, depending on the scope of services provided in the unit.1 “Practice Recommendation 5, Competencies of Perianesthesia Support Staff,” recommends that even unlicensed personnel maintain BLS.1

Facility Considerations
In determining whether preop and phase II nurses are required to maintain ACLS and PALS/PEARS, it may be best to assess the patients and community served. Age and acuity are only two factors. Other factors include the type and location of the facility, ancillary staff on site, and types of procedures performed. Are ACLS/PALS trained staff available to respond to a code in preop and Phase II whenever patients are present in those areas? In a unit or facility where critically ill children are rarely admitted, would PEARS, if available, be a reasonable choice for preanesthesia and phase II nurses caring for pediatric patients? PEARS trains healthcare providers to recognize and respond appropriately to pediatric emergencies such as respiratory distress, shock, and cardiac arrest until advanced life support providers arrive. ACLS, PALS, and PEARS courses are offered through the American Heart Association.2

Economic factors also affect the decision to require ACLS/PALS/PEARS. These include course cost and availability, access to qualified instructors, and the expense of scheduling extra staff to cover during classes. Outpatient facilities may not have ancillary staff, such as respiratory therapists, to assist in emergencies. Ambulatory surgery center (ASC) RNs are frequently cross-trained to work in more than one perioperative area. Competencies in every facility should reflect all cross-training, including the requirement for ACLS/PALS.

Conclusion
ASPAN’s 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements do not require ACLS/PALS for nurses working in preop or phase II perianesthesia care. Each facility should evaluate their preoperative and phase II scope of service to determine whether to require nurses to maintain ACLS/PALS.

REFERENCES: 

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 19, 48-52.
  2. American Heart Association. Available at: www.heart.org Accessed May 29, 2012.
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Q: Is Capnography required in Phase I PACU?
A:

ASPAN Standards
The American Society of PeriAnesthesia Nurses (ASPAN) does not currently have a practice recommendation requiring continuous monitoring of etCO2 in the Phase I PACU. “Practice Recommendation 2, Components of Assessment for the Perianesthesia Patient,” states that vital signs are monitored, including “end-tidal CO2 (capnography) monitoring if available and indicated,” and to monitor, maintain, and/or improve “airway and respiratory/ventilation status.”

ASA Standards
Monitoring etCO2 has long been a standard of care for anesthesiologists delivering general anesthesia for intubated patients in the operating room.2 This practice has expanded to areas outside of the operating room. The American Society of Anesthesiologists (ASA) recently updated their standards for Basic Anesthetic Monitoring.3 The Standards state that “the adequacy of ventilation will be continuously evaluated……...continual monitoring for the presence of expired carbon dioxide shall be performed.”3 The ASA goes on to state that “during moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide.”3 This applies to nurse monitored sedation as well.2

The ASA state in the Standards for PostAnesthesia Care that “particular attention should be given to monitoring oxygenation, ventilation, level of consciousness and temperature.”4 The ASA does not specifically state that capnography is required in the post anesthesia care unit, but that ventilation is monitored. The most effective way to monitor ventilation is through capnography.

Future of Capnography
Capnography can be valuable in the post anesthesia care unit for heavily sedated patients, those receiving high doses of opioids, and those with diagnosed or undiagnosed obstructive sleep apnea. “Practice Recommendation 10, Obstructive Sleep Apnea in the Adult Patient,” in the 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretative Statements, discusses Phase I and II care as including “routine monitoring and the addition of capnography when available” for obstructive sleep apnea patients.”1  In situations where the patient’s respiratory status has been compromised, capnography monitoring and assessment may prompt the PACU nurse to intervene for patient safety as the patient transitions from PACU care. He/she may advocate for a higher level of care when the patient is discharged from the PACU.5

Capnography may be also useful for a period of time after the patient leaves the PACU. Post anesthesia nurses are aware that medical/surgical  floors have  increased  nursing work loads which limit  the frequency of the nurse’s presence at the bedside. A trend is for patient-controlled analgesic pumps to incorporate both pulse oximetry and capnography into the pump mechanics. These additional monitors alarm to give earlier warnings of potential respiratory issues and/or a potential crisis.2

Trends in perianesthesia nursing are regularly discussed as potential additions to the ASPAN Standards. Capnography increases safety and has proven its value in better patient outcomes in anesthesia and sedation venues. With the increasing vigilance needed in Phase I PACU for patients in such a vulnerable state, capnography is a monitoring tool that may be beneficial and recommended in the very near future.5

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretative Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 38-39, 69.
  2. Odom-Forren J. Capnography and Sedation: A Global Initiative. Journal of PeriAnesthesia Nursing. August 2011; 26(4):221-224.
  3. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. Effective Date of July 1, 2011. Available at: click here. Accessed August 7, 2011.
  4. American Society of Anesthesiologists. Standards for PostAnesthesia Care. Effective Date of October 21, 2009. Available at: click here. Accessed August 7, 2011.
  5. Godden B. Where Does Capnography Fit Into the PACU? Journal of PeriAnesthesia Nursing. December 2011; 26(6): 408-410.

Barbara Godden, MHS, RN, CPAN, CAPA
Revised November 11, 2012

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Q: What discharge scoring system does ASPAN recommend?
A:

ASPAN’s Non-Endorsement Statement:
The American Society of PeriAnesthesia Nurses (ASPAN) does not endorse any specific postanesthesia scoring tool or system. ASPAN’s 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements includes "Practice Recommendation 2, Components of Assessment for the Perianesthesia Patient.”  This recommendation states that a component of postanesthesia assessment includes “Postanesthesia scoring system if used.” Practice Recommendation 8, Fast Tracking the Ambulatory Surgery Patient, includes the following statement in the recommendations for bypassing the Phase I PACU, “Scoring systems are one way of assessing readiness for Phase II level of care and can include White’s Fast Tracking Scoring System, Modified Aldrete, or the Post Anesthetic Discharge Scoring System (PADSS).”

What the ASPAN Standards State
The use of a scoring system is not required by ASPAN Standards. Each facility should develop assessment and discharge criteria for each level of postanesthesia care and may include a postanesthesia scoring system as a component of the assessment and discharge criteria. Facilities are encouraged to work with the Department of Anesthesia to develop and implement appropriate discharge criteria which meets the needs of the population served.

Common Scoring Systems
Scoring systems commonly used include Aldrete, Modified Aldrete (also known as PARSAP), PADSS, and White, to name a few. Aldrete scoring is traditional, was developed in 1970, and includes scoring for activity, respiration, circulation, consciousness and color, now changed to oxygen saturation. The maximum score for Aldrete is 10. The Modified Aldrete was developed in response to ambulatory surgery trends. This scoring system includes 10 elements consisting of activity, respiration, circulation, consciousness, oxygenation, dressing, pain, ambulation, feeding, and urine output. The maximum score for Modified Aldrete is 20. This scoring system is useful where Phase I and Phase II are combined units. The White scoring system was developed in 1999 to use for fast-tracking patients. The elements for the White scoring system include level of consciousness, activity, hemodynamic stability, respiratory stability, oxygen saturation, pain, and emetic symptoms. The White system has a maximum score of 14.2,3 Many facilities use the Post Anesthetic Discharge Scoring System (PADSS) for Phase II patients. The elements include vital signs, activity, nausea and vomiting, pain, and surgical bleeding. The maximum score for this system is 10.3 Policies addressing the total discharge score for each scoring system should be established in consultation with the anesthesia department.1,4  Deviations from the established discharge scores should be addressed in the facility policy and may require a specific order from the anesthesia provider for discharge to the next level of care.

Individual Facility Practices
The use of scoring systems varies widely across perianesthesia practice. Many facilities use one or more of the above mentioned scoring systems. Still others do not use a scoring system at all, but instead use defined discharge criteria from each phase of care. Many other facilities use a combination of a scoring system along with defined discharge criteria.

ASPAN Clinical Practice Committee members are ASPAN volunteers working in a variety of perianesthesia settings and for many different employers. Because of the variety of settings and work-related affiliations, individual committee members may have experience with specific scoring systems and may answer questions about scoring systems based on personal experience. This does not constitute an endorsement from ASPAN.

Additional Considerations
Additional questions ask how to score certain elements. One example is how to score activity for a patient with a history of stroke. It may be helpful to have a preoperative score to establish a baseline. Another common question is how to score a patient who is drowsy but arousable. Do you score the patient as a 1 or a 2? An assessment that is helpful in determining this score and readiness for discharge to the floor is, does the patient arouse on his own, look around, and go back to sleep? This would be a score of 2 and would indicate that the patient could progress to the next level of care if all other criteria are met. If the patient is going to a floor bed, the nurse wants the patient comfortable, but not necessarily wide awake and hurting. If the patient is going to Phase II, the discharge policy  regarding the assessment  may require that patients be more awake, off supplemental oxygen, comfortable, and have stable vital signs.

Conclusion
The bottom line is that the discharge criteria are developed in consultation with the anesthesia department.1,4  A scoring system should not be used exclusively as the discharge criterion for a postanesthesia patient. If using a scoring system, clinical assessments must also be considered. Because each patient’s condition varies and must be assessed individually, time frames for discharge cannot be stated and are not prescribed by ASPAN. Critical thinking and nursing judgment are essential factors in determining readiness for discharge.3,4

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretative Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 39-41, 60-61.
  2. Fetzer SJ. Phase I Discharge Criteria. In: Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO: Saunders; 2010: 615-622.
  3. Ead H. From Aldrete to PADSS: Reviewing Discharge Criteria After Ambulatory Surgery. Journal of PeriAnesthesia Nursing. August 2006; 21(4): 259-267.
  4. Andrews SM, Cartwright SMI. Management and Policies. In: Odom-Forren J, ed. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders,an imprint of Elsevier Inc; 2013: 21-23.

Barbara Godden, MHS, RN, CPAN, CAPA
Susan Russell, BSN, RN, JD, CPAN, CAPA
Revised November 11, 2012

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Q: What are the requirements for preoperative pregnancy testing?
A:

To state it simply, there is no definitive answer to this question. Practices vary from facility to facility, and should be driven by a preoperative testing policy that is developed in conjunction with the anesthesiology department.

American Society of Anesthesiologists
The American Society of Anesthesiologists (ASA) includes in its Statement on Routine Preoperative Laboratory and Diagnostic Screening Standard that “No routine laboratory or diagnostic screening test is necessary for the preanesthetic evaluation of patients. Appropriate indications for ordering tests include the identification of specific clinical indicators or risk factors (e.g., age, pre-existing disease, magnitude of the surgical procedure). …. Anesthesiologists, anesthesiology departments or health care facilities should develop appropriate guidelines for preanesthetic screening tests in selected populations after considering the probable contribution of each test to patient outcome. Individual anesthesiologists should order test(s) when, in their judgment, the results may influence decisions regarding risks and management of the anesthesia and surgery. Legal requirements for laboratory testing where they exist should be observed. The results of tests relevant to anesthetic management should be reviewed prior to initiation of the anesthetic. Relevant abnormalities should be noted and action taken, if appropriate.“1 In other words, tests should only be conducted when there is a clinical indication to do so.

Individual Facility Practice
Some facilities have policies that state that all females from menarche to menopause require a pregnancy test. Other facilities state that the only exemptions from being tested are those women who have had sterilization such as a tubal ligation or a total hysterectomy. Still other facilities have a policy that has nursing staff ask the patient if there is any chance that they could be pregnant. If the patient states “no”, they accept the patient’s word and document as such. While many facilities do not require pregnancy tests, many individual anesthesiologists may require one in their specific preoperative orders for a particular patient.

Additional Considerations
Even among individual anesthesiologists, the issue of preoperative pregnancy testing remains highly controversial. Randomized control trials will never be done due to ethical considerations.2  For this reason, some physicians feel that all patients should be tested. According to some literature, there is insufficient evidence to support that a single exposure to modern anesthetics causes teratogenic effects on a fetus.3 Additionally, if all patients are tested, there may be issues related to legal requirements for patients who are minors, HIPAA considerations, and potential financial considerations.3 Some physicians believe that informed consent of all females to conduct testing is the best option. Some physicians will write the order for preoperative pregnancy testing if their own personal practice patterns dictate that the test be completed, no matter what the facility policy states.

Conclusion
There is no national standard for preoperative pregnancy testing. The ASA Position Statement indicates that the anesthesiologist needs to consider each individual patient, patient needs, and individual risk factors when ordering preoperative tests. Each facility needs to develop a preoperative pregnancy testing policy in collaboration with the Department of Anesthesiology.

REFERENCES

  1. ASA. Available at: click here. Routine Preoperative Laboratory and Diagnostic Screening, Statement on (2008). Accessed July 2, 2011.
  2. Kahn RL, Liguori GA, Stanton MA, Levine DS, Edmunds CR. Letters to the Editor: Routine Pregnancy Testing Before Elective Anesthesia is Not an American Society of Anesthesiologists Standard. Anesth Analg. May 2009; 108(5): 1716.
  3. Palmer SK, Van Norman GA, Jackson SL. Letters to the Editor: Routine Pregnancy Testing Before Elective Anestheia is Not an American Society of Anesthesiologists Standard. Anesth Analg. May 2009; 108(5): 1715-1716.
Reviewed November 11, 2012
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Q: Can a PACU nurse extubate a patient? Must an anesthesia provider be present?
A:

The answer to the first question is yes, depending on several things. First of all, are there any restrictions in your state Nurse Practice Act that prohibit nurses from extubating patients? Second, do you have a policy in your department that states whether you can extubate patients in the PACU? And third, do you have an extubation competency in place that all PACU nurses must complete before they can extubate a patient?

These three items must all be present before you can consider whether or not you can extubate a patient. Most state Nurse Practice Acts are fairly vague when it comes to specific skills. Many practice acts have statements in them saying that the nurse must be “deemed competent” in a skill to perform it. With this criteria met, the next step is to work with your anesthesia department to develop a policy. Extubation policies can be very simple and straight forward, stating that a PACU nurse may extubate a patient once they have been checked off on a unit competency. Other extubation policies actually include the policy along with the procedure, step by step. And the third piece is to have a competency in place for ensuring that PACU nurses know how to extubate a patient correctly and safely. There are several resources available to assist in developing a competency for extubation. In addition to the extubation criteria and skills, the competency should include post extubation assessment skills, including monitoring for complications such as hypoventilation, respiratory stridor, and  laryngeal edema.1,2,3

The answer to the second question, “must an anesthesia provider be present?”, lies in your policy. Your policy needs to include criteria in which an anesthesia provider needs to be present. In many facilities, it is not mandatory for an anesthesia provider to be physically present in the PACU when a patient is extubated, provided that the criteria for extubation are very strict and the nurses adhere to these criteria. However, in all situations, there must be someone who can re-intubate the patient if complications arise after extubation. In dire situations, the nurse can “ambu” (bag/valve/mask) the patient until an anesthesia provider is available, This is not ideal, nor the safest option for the patient. Again, in most facilities, the practice is to have an anesthesia provider available within a couple of minutes  to re-intubate the patient if necessary.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses; 2009. Pages 74-78, 92.
  2. Wright SM. Assessment and Management of the Airway. In: Odom-Forren J, ed. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders,an imprint of Elsevier Inc; 2013: 423.
  3. Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO: Saunders; 2010. Pages 581, 677-678, 682, 1366.

Reviewed November 11, 2012

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Q: Is there an acuity system that ASPAN recommends to help in daily staffing?
A: ASPAN does not have an acuity system, nor do they endorse any particular acuity system. This question is one of the topics posted on the ASPAN Forum. For anyone looking for a more formal system, it may be possible to obtain a form from someone by visiting the ASPAN Forum and posting a request.

The ASPAN Standards  define factors that should be considered when determining the acuity of a patient. Acuity is defined as the “clearness or sharpness of perception.”1 In the nursing world, acuity is the complexity, time requirements, and interventions needed for a particular patient.

In the ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, the Standards include acuity elements when discussing staffing ratios. These can be found in “Practice Recommendation 1, Patient Classification/Staffing Recommendations.”2

In the preanesthesia area, acuity is difficult to define as these departments function in so many different ways. Some preanesthesia patients may require extensive day of surgery preparation, especially if they are not prepared through preadmission testing or a preoperative phone call. If patients are not prepared prior to the day of surgery, their “acuity” could be considered more intense. A patient with significant co-morbidities may have a higher preop acuity. Patients may need assistance changing clothes or ambulating to the bathroom. The patient may require multiple interventions in addition to obtaining the history, such as lab work, ECGs, a preoperative block, or an epidural placed prior to surgery. All of these interventions may increase the acuity.2

For the postanesthesia patient, the ASPAN Standards include elements of acuity in the staffing ratios. The general ratio of 1 nurse to 2 patients in Phase I allows for appropriate care based on the complexity and requirements of a particular patient. Acuity in a postanesthesia patient often revolves around the stability of an airway and the level of consciousness. Critical elements must be met for a patient to be considered stable and less acute. The ASPAN Standards define “critical elements” as “report has been received from the anesthesia care provider, questions answered, and the transfer of care has taken place; patient has a stable/secure airway; initial assessment is complete; patient is hemodynamically stable, and patient is free from agitation, restlessness, combative behaviors”2 The Standards further define an unstable airway as “requiring active interventions to maintain patency such as manual jaw lift or chin lift or an oral airway; evidence of obstruction, active or probable, such as gasping, choking, crowing, wheezing, etc.; and symptoms of respiratory distress including dyspnea, tachypnea, panic, agitation, cyanosis, etc.”2

Other elements that should be considered in determining acuity of a patient are pain management requirements, interventions for hemodynamic stability, PONV, restlessness, anxiety, and other interventions specific to the patient’s procedure.

It is difficult to determine a patient’s acuity prior to his arrival to the preanesthesia area or the PACU. We all know that a simple case can come out of the OR as a train wreck or develop problems some time after arriving in the PACU. Consequently, it is difficult to define acuity or use a specific acuity system in the pre or post anesthesia period with any predictability.

REFERENCES
  1. Anderson KN, ed. Mosby’s Medical, Nursing, & Allied Health Dictionary. St. Louis, MO: Mosby; 1998.
  2. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 30-35.
Revised November 11, 2012
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Q: Can a patient ambulate to the car or is it required that we take them out in a wheelchair?
A:

This question comes up frequently through the questions sent into the Clinical Practice Network.

One of the recommended assessments prior to discharge per the ASPAN Standards is “arrangement for safe transportation from the institution.”1 The Registered Nurse also determines the “mode, number and competency level” for transport personnel and method of transportation from the institution.1

With these practice recommendations and after considering facility policy, it is up to the RN to use his/her nursing judgment to determine if a patient can ambulate to the car or should be discharged via wheelchair. Patients having general anesthesia may still be drowsy upon discharge and may require a wheelchair. If a patient has only sedation or monitored anesthesia care, they may be capable of ambulating to the car. In all cases whether discharge is via wheelchair or ambulation, it is important for a nurse or tech to accompany the patient. Again, per the ASPAN Standards, the RN determines the mode of transportation from the facility as well as the competency level of the accompanying facility personnel.1 Often, having a patient ambulate to the car is a way to assess steadiness of gait and the patient will do at home. Part of the regular discharge instructions should include having someone with the patient the first few times he ambulates at home. If necessary, additional instructions can be given for safe ambulation at home when the patient is escorted to the car. Instructions may include telling the patient to get up at regular intervals and walk around to get his “sea legs” back. Another example is a patient who had local infiltration into an inguinal hernia site where ambulation prior to discharge is important to ensure that the local anesthetic did not cause weakness or numbness in the lower extremities, limiting the ability to ambulate. Following a  laparoscopic procedure, ambulation may enhance elimination of the carbon dioxide used in the procedure. Ambulation also enhances oxygenation and elimination of  inhalation anesthetics.

Other patients may require a wheelchair. Examples are lower extremity orthopedic procedures, the elderly, patients who are still a little drowsy, patients who have pre-existing respiratory or cardiac conditions, or facilities where the exit is a long way from the recovery area.

In summary, the decision regarding mode and method of discharge ultimately falls within facility policy and procedure. The ASPAN Standards allow the registered nurse to use his/her patient assessment and clinical judgment  regarding mode of discharge for the patient.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 36-42, 53-55.
Revised November 11, 2012
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Q: What is ASPAN’s standard for vital sign frequency in Phase I and Phase II and Extended Care?
A:

This question comes up almost weekly through the questions sent into the Clinical Practice Network. In fact, this question is asked so frequently, that ASPAN reviewed the literature to see if there was any evidence to support a recommendation or define how frequently vital sign should be obtained during perianesthesia care. The result of the search was presented at the Fall 2009 Standards Strategic Work Team revision meeting.

Team leaders from the Standards and Guidelines Strategic Work Team and members from the Evidence Based Practice Strategic Work Team met face to face in October 2009. In preparation for this meeting, the question put to the Evidence Based Practice Strategic Work Team was “How often should vital signs be taken?” The team reviewed 521 articles, including 2 abstracts. Rankings and consensus were completed. No evidence at all was available to guide the practice of how often to take vital signs to promote optimal outcomes.1

The discussion continued. Perianesthesia nurses want to know what is best practice related to vital sign frequency. Clinical judgment is the essential element in determining frequency of vital signs. Expert opinion from perianesthesia nurses indicates that most units take vital signs every five minutes for the first 15-30 minutes of patient stabilization, and then decrease to once every 15 minutes for the duration of the patient’s Phase I stay. If the patient is placed into a “holding pattern”  for some reason such as waiting for an inpatient bed, the frequency of vital signs can be the same as the standard used on the destination nursing unit. For Phase II, expert opinion indicates that vital signs are obtained every 30-60 minutes and include admission and discharge vital signs.1

Because of this discussion and the lack of evidence and specific literature stating what the vital sign frequency should be, the ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, “Practice Recommendation 2- Components of Assessment for the Perianesthesia Patient”, states the following:

“Frequency of adult vital sign assessment during Phase I is institution specific. Practice varies across the country with frequency ranging from every five to every fifteen minutes. Expert opinion recommends that the frequency of vital sign assessment occurs a minimum of every fifteen minutes during Phase I as clinical condition requires."

With regard to pediatric vital sign assessment, the ASPAN Pediatric Specialty Practice Group was surveyed. Survey responses revealed:

“In terms of postoperative pediatric assessment, close to 74% of survey respondents admitted that an initial blood pressure is always obtained from the pediatric patient on arrival to Phase I.”

REFERENCES

  1. American Society of PeriAnesthesia Nurses. Standards and Guidelines Meeting minutes, Batesville, Indiana. October 23, 2009.
  2. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 36-42.
Revised November 11, 2012
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Q: Do all outpatients need to void prior to being discharged?
A:

This question has been debated since the advent of ambulatory surgery over 20 years ago. Varying opinions continue as to whether patients should void prior to discharge. At this time, there is little research and evidence pointing one way or another. If a patient does not void prior to discharge, does this alter the outcome for him? Or does requiring the patient to void an unnecessary practice that merely prolongs his hospitalization and may add to his bill?1

Postanesthesia patients are often not well-hydrated when they arrive in the PACU. This results from their NPO status, limited amounts of intravenous fluid, and third spacing, even in routine and seemingly small procedures. These patients have not had time to produce adequate urine. Another factor to consider is that most people void every four to six hours. This amount of time may not have passed by the time they are ready to be discharged. Couple that with the potential dehydration, and they do not have enough urine to stimulate voiding.

On the other hand, certain conditions may predispose a patient to urinary retention, such as prostatic hypertrophy. Some surgical procedures may stun the bladder or the nerves surrounding the bladder. Urological procedures may result in hematuria with the potential for clots which may obstruct urinary flow. Other procedures which place patients at risk for urinary retention include rectal procedures, inguinal herniorrhaphy, and lower abdominal and pelvic procedures. These patients often  have no urge to void because of manipulation of the nerves surrounding the bladder, and consequently may be at higher risk for urinary retention. Therefore, voiding under these conditions is advisable, according to experts.1, 2

Spinal or epidural anesthesia is another factor to consider when determining if a patient should void prior to discharge. Recovery from a blockade is in the reverse order from onset. Therefore patients regain first motor, then sensory, and finally sympathetic. The sympathetic nervous system controls bladder function. So the ability to void indicates total resolution of the block. Prior to this, patients usually cannot tell whether their bladder is distended.1,2

Many PACUs now have bladder scanners as standard equipment. This tool can be used in conjunction with other assessments to evaluate patients for bladder volume and potential urinary retention prior to discharge home.3 In addition, if patients are not required  to void, they and their care providers should be instructed on symptoms which might indicate a full bladder, the importance of avoiding over distention of the bladder, and how long to wait before seeking care for a full bladder.4

REFERENCES

  1. Burden N, Quinn D, O’Brien D, Gregory-Dawes B. Ambulatory Surgical Nursing 2nd ed. Philadelphia, PA: WB Saunders; 2000.
  2. Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO: Saunders; 2010.
  3. Feliciano T, Montero J, McCarthy M, Priester M. A Retrospective, Descriptive, Exploratory Study Evaluating Incidence of Postoperative Urinary Retention After Spinal Anesthesia and Its Effect on PACU Discharge. Journal of PeriAnesthesia Nursing, 2008; 23(6): 394-400.
  4. O’Brien D. Care of the Gastrointestingal, Abdominal, and Anorectal Surgical Patient. In: Odom-Forren J, ed. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders,an imprint of Elsevier Inc; 2013: 585.
Revised November 11, 2012
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Q: Can we put Preop patients in the same area that we have patients recovering from anesthesia?
A: 

This question comes up frequently in the ASPAN Clinical Practice network. Many nurses asking this question work in facilities where the staff members of preop and PACU may be one and the same. The question also arises when facilities are trying to make the most of the available staff later in the day.

“Standard II- Environment of Care,” in ASPAN’s 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements states that “Preanesthesia patients are separated from patients undergoing procedures and/or recovering from anesthesia/sedation.”1

In addition, this requirement for separation comes from the Centers for Medicare and Medicaid Services (CMS). “The conditions for coverage at 42 CFR 416.44(a)(2) state that an "ASC must have a separate recovery room and waiting area.” We consider a "recovery room"  to be an area where patients are brought to recover from procedures and are not yet discharged. A "waiting area" is considered to be the area set aside for patients and families outside of the areas used to prepare patients for their procedure, the procedure area itself, or recovery from their procedure. Each ASC must have a distinct "waiting area" and distinct "recovery room" that are not used by patients for other purposes. Medicare regulations do not address specific requirements for a preop area.” 2

The implementation of this requirement can take several different forms. The most common scenario involves a setting where the number of staff is decreasing for the day and it is desirable to combine resources. In this case, preoperative patients may be in the same physical space as patients recovering from anesthesia or sedation. But they should be cohorted and separated as far away as physically possible from postanesthesia patients. Curtains should be used for privacy for the patient and family, and the level of noise should be kept down in the postanesthesia section of the room, so that patients waiting for their procedures do not hear activity related to patients waking up. It is also desirable to have separate staff, that is, a preop nurse is not also caring for a postanesthesia patient. These methods allow the facility to meet the standard while making practical use of resources and providing the appropriate environment for the patient.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Page 17.
  2. Pelovitz SA. Clarification of CMS Policies Regarding Ambulatory Surgical Centers. Centers for Medicare and Medicaid Services. Baltimore, MD. 2002. Available at: click here. Accessed February 28, 2010.
Revised November 11, 2012
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Q: What are the differences between Phase I, Phase II, and Extended Care (Extended Observation/Phase III)?
A:

This is a very frequent question that comes through the Clinical Practice network. The questions range from “What are the differences between Phase I, Phase II, and Phase III?” to “Can I get a patient up in Phase I?” to “Can I discharge a patient home from Phase I?"

The ASPAN Standards define Phase I, Phase II, and Extended Care (Extended Observation / Phase III) as levels of care, not physical places. Therefore, the care that is provided is dependent on where the patient is in their physical recovery, not the physical location that they are in.1

Postanesthesia Phase I – The nursing roles in this phase focus on providing postanesthesia nursing in the immediate postanesthesia period, transitioning to Phase II, the in-patient setting, or to an intensive care setting for continued care. Basic life-sustaining needs are of the highest priority. Constant vigilance is required during this phase.”1

Postanesthesia Phase II – The nursing roles in this phase focus on preparation for care in the home or an extended care environment.”1

Extended Care – The nursing roles in this phase focus on providing care when extended observation/intervention after discharge from Phase I or Phase II is required.”1

Phase I is the level of care in which close monitoring is required, including airway and ventilatory support, progression towards hemodynamic stability, pain management, fluid management, and other acute aspects of patient care. When the patient has progressed beyond these elements of care, they can progress to Phase II level of care. Phase II is the level of care in which plans and care are provided to progress the patient home. This may be in the same location as Phase I care. Many PACU’s are providing blended levels of care, in which all levels of care are provided in the same location. This is often done for staffing reasons or for continuity of care. So if a patient is ready to go the bathroom and is awake and stable enough, they are not necessarily a Phase I patient anymore. They have progressed to Phase II level of care, even if they are in the same location. The same goes for discharging a patient home from Phase I. If a patient is ready to go home, they have progressed beyond Phase I level of care, into Phase II level of care, and may go home if they meet discharge criteria. Again, the Phases are NOT locations, but LEVELS of care.

Extended Care, previously Extended Observation / Phase III, may also occur in the same physical location as care provided to Phase I and Phase II patients. This phase is for patients who have met criteria to leave Phase I, but are not able to go to another place. The most common reason for this is that there is no floor bed. In this case, the patients may stay in the location where they received Phase I level of care if there is nowhere else to move them. The difference is that these patients are basically a medical-surgical patient at this point, and the assessments and care required are different from that of a Phase I patient. The staffing expectations would also be different, as defined in the ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, Practice Recommendation 1 – Patient Classification/Staffing Recommendations.1

The elements to consider for assessments as well as discharge from Phase I, Phase II, or Extended Care levels of care are found in the ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, Practice Recommendation 2-Components of Assessment for the Perianesthesia Patient.”1 These elements help determine the patient’s phase of care and whether the patient is ready to progress to the next level, regardless of where the care will be provided.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 7, 30-42.
Revised November 25, 2012
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Q: Can I give oral pain medications in Phase I?
A:

The simple answer to this question is yes. The belief that oral pain medications are reserved for Phase II PACU or for when the patient reaches the postoperative unit, is one of those sacred cows often found in PACUs.

Many years ago, when anesthetic agents had a longer duration, the inhalation agents given were stronger and more often caused nausea and vomiting in the postanesthesia patient, so oral pain medications were avoided. Patients were not usually awake enough, nor did they feel well enough to take oral medications in Phase I PACU. The postanesthesia nurse avoided giving oral medications and withheld oral fluids hoping to prevent or minimize postoperative nausea and vomiting (PONV).

With the advent of propofol and newer inhalation agents such as Sevoflurane and Desflurane, patients awaken quickly, often have little or no nausea, and are ready for oral fluids and medications in Phase I. Many patients are pre-treated with antiemetics. Preemptive treatment is a result of education on best practices related to PONV.1 Patients are usually able to tolerate ice chips, juice or soda shortly after they wake up. These interventions are also helpful in addressing rehydration.

Another advantage of giving oral pain medications in Phase I is that it promotes early evaluation of the patient who is going home. By giving the oral pain medication in Phase I, often the medication the patient will take at home, along with  crackers or other light food, the nurse has time to evaluate whether the oral pain medication will work for the patient. In addition, there is time to observe for adverse reactions if this is the patient’s first experience with the medication. Timing the oral medication shortly after the last IV dose of narcotic allows time for the oral medication to start taking effect. The patient can then be transferred to Phase II for further care, observation, and discharge instructions.

Oral medications do have a place in the Phase I PACU. Each patient should be evaluated for this intervention, as it can be an effective method for transition to the next level of care.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. The American Society of PeriAnesthesia Nurses (ASPAN) Evidence-Based Clinical Practice Guideline for the Prevention and/or Treatment of Postoperative Nausea and Vomiting and Postdischarge Nausea and Vomiting in Adult Patients. Available at: click here.   Accessed November 11, 2012.
Revised November 11, 2012
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Q: How long should we keep patients in the PACU after they have received a narcotic?
A:

When evaluating a patient for discharge from Phase I or Phase II after a narcotic, several factors need to be kept in mind. These factors include what is the dosage, what is the route, what is the onset of action, when does the medication’ peak, what is the duration of the medication, and what is the half-life of the medication.1,2,3

With IV medications, obviously there is a quicker onset and a shorter duration of action. Most IV medications, including Morphine, Dilaudid, and Fentanyl, have an onset of action of 1-5 minutes and peak within 5-20 minutes. The duration of action with Morphine and Dilaudid is 2-4 hours, while the duration of action of Fentanyl is 30 minutes to 1 hour. Morphine and Fentanyl have a half-life of 3-4 hours, while Dilaudid has a half-life of 2 hours.1,2,3

Oral narcotics have an onset of 30-60 minutes, and peak in 60-90 minutes.1,2,3

With this information in mind, the nurse must consider what is safe in terms of when the patient can transition to the next level of care. Since IV medications peak in 5-20 minutes, it is prudent for the nurse to use this interval to assess the patient  for  adverse respiratory effects. The nurse should also monitor the patient without any stimulation to determine how the patient may respond when moved to a quiet patient room without  the added PACU environmental stimuli. Patients will generally desaturate when unstimulated. Ensuring that the patient can handle a narcotic without episodes of oxygen desaturation is a key to determining when it is safe to discharge/transfer a patient.

With oral narcotics, the nurse should ask the patient if he has taken the medication previously and if it was effective. If yes, the nurse can give the patient the narcotic with relative assurance that the patient will not suffer adverse effects and that it will provide pain relief. If the patient has not received the oral narcotic previously, the nurse can give it shortly before transitioning to Phase II. This allows time for the narcotic to take effect over 30-60 minutes and time for the nurse to evaluate the patient’s response.

So with this information in mind, what is the time frame for discharge after narcotics? Since most IV narcotics peak in 20 minutes, 30 minutes should allow sufficient  time to observe for adverse respiratory effects. Waiting 30 minutes is generally a safe post administration interval before discharge from Phase I. With oral narcotics, the nurse can observe for effectiveness within 30-60 minutes of administration and the patient can transition home. These time frames allow the patient to progress to the next phase of care in a safe and effective manner.

REFERENCES

  1. Odom-Forren J, ed. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders,an imprint of Elsevier Inc; 2013: 236-252, 427-449.
  2. Physicians Desk Reference. 2011.
  3. Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO: Saunders; 2010.
Reviewed November 21, 2012
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Q: Is ECG interpretation necessary in the PACU, along with running and mounting an ECG Strip?
A:

The 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements speak to assessments that are recommended in Phase I PACU. The Standards state in “Practice Recommendation 2-Components of Assessment for the Perianesthesia Patient” that “Cardiac monitor rhythm [is] documented per institutional protocol.”1

Many experienced nurses can look at a monitor and quickly tell what rhythm is displayed. To accurately interpret the rhythm, it is necessary to calculate the PR and QRS intervals, along with the rate. These calculations can be performed by running a six second strip and doing the measurements. Some monitors have built in calculators for performing these functions; the monitor may need to be “instructed” to perform these functions on a specific segment of the patient’s rhythm strip. “Mounting a strip” is an individual facility policy and many facilities still subscribe to the motto that if it’s not documented, it’s not done. Stating the rhythm in the nursing notes is fine, but the “proof” is not in written words, it is in the visual documentation of the actual ECG strip.

With electronic documentation, many ask, “where do I put the strip?” The best advice is to use a blank sheet of paper for mounting, if there is no hard copy of the PACU record.

Another frequently asked question is why ECG rhythm interpretation is even necessary. “We just need to be able to tell that something isn’t right” some nurses say.

As critical care nurses, we need to be able to accurately assess the patients, and then share that information with the anesthesia provider. Perianesthesia nurses know that anesthetic agents affect the cardiac muscle and can slow cardiac conduction and/or cause increased ventricular excitement. Medications such as catecholamines and anticholinergics can alter the balance between the sympathetic and parasympathetic nervous systems. Lighter anesthesia during emergence can cause cardiac dysrhythmias. Research indicates that about 60% of all patients undergoing anesthesia develop some type of dysrhythmia in the perianesthesia period.2

Fluid status affects heart rate and rhythm. One of the most common causes of tachycardia in the PACU is hypovolemia. Premature ventricular contractions are often a sign of hypoxia in the PACU patient. Pain and bleeding can affect cardiac rate and rhythm as well. The perianesthesia nurse must recognize the rhythm and intervene appropriately. Some interventions may not require additional physician orders.3

Along with respiratory assessment and airway management, cardiac assessment is one of the most important elements of perianesthesia nursing practice. Hemodynamic stability is a component of safe discharge. Thorough cardiac assessment, including interpreting the ECG rhythm, is one of the best ways to assess patient status.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Page 38.
  2. Cosco L, Burkard JF. The Cardiovascular System. In: Odom-Forren J, ed. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders,an imprint of Elsevier Inc; 2013: 128-149.
  3. American Society of PeriAnesthesia Nurses. A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses; 2009. Pages 101-129.
Revised November 21, 2012
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Q: At what temperature can we set our blanket and fluid warmers?
A:

The Emergency Care Research Institute (ECRI) changed the temperature setting recommendations for cabinet blanket warmers in 2009. Cabinet blanket warmers can now be set up to 130º F (54ºC). Fluid warming cabinets should continue to be limited to 110º F (43ºC).1

The change to the recommendation stems from recognition in the healthcare community that blankets and fluids should be warmed separately. The original 2005 recommendations from ECRI  for 110º F for both blanket and fluid warmers were based on information that many facilities placed blankets and fluids in the same warmer simultaneously. As a result of this dangerous practice, some patients sustained burns from the fluids which hold significantly more heat than blankets and present a greater burn risk. To promote safe practice for all patients, in 2005  ECRI recommended the lower temperature of 110º F for both blankets and fluids.1

Discussions with healthcare facilities over the past several years indicate a growing awareness and recognition that  separate cabinets should be used to warm fluids from those used to warm blankets. ECRI and healthcare facilities also recognized a concern for patient comfort related to warming blankets. Because of this concern,  ECRI changed its recommendations for blanket cabinet warmers to 130º F (54º C).1

The ECRI recommends separate warming cabinets for blankets and fluids. For facilities using one cabinet with 2 compartments, each compartment must have its own temperature control. If a facility chooses to use the same cabinet/compartment for both blankets and fluids, the temperature should be limited to 110º F (43º C).1

Perioperative normothermia is critical in promoting the well-being and comfort of all perianesthesia patients. ASPAN updated its Clinical Guideline on Hypothermia, now entitled ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia.2 The guideline includes new evidence for warming practices and promotion of optimal outcomes for patients. The reader is directed to the clinical guideline, which can be accessed on the ASPAN Web site at  www.aspan.org

REFERENCES

  1. ECRI Institute. ECRI Institute revises its recommendation for temperature limits on blanket warmers (hazard report). Health Devices. July 2009; 38(7): 230-231.
  2. Hooper VD, Chard R, Clifford T, Fetzer S, Fossum S, Godden B, Martinez EA, Noble KA, O’Brien D, Odom-Forren J, Peterson C, Ross J. ASPAN’s Evidence Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. Journal of PeriAnesthesia Nursing. October 2009; 24(5): 271-287.
  3. American Society of PeriAnesthesia Nurses. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. Available at: click here.   Accessed November 23, 2012.

Revised November 23, 2012

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Q: What is the national trend for being able to wear personal, home-laundered scrubs to work in the PACU?
A:

“Standard II - Environment of Care,” found in the 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, states: "Personnel and visitor dress codes are determined by proximity and frequency of access to operating rooms."1 Unfortunately, no other recommendations in the Standards address attire worn by perianesthesia personnel.

In 1999, the Centers for Disease Control and Prevention (CDC) published a "Guideline for the Prevention of Surgical Site Infection." This guideline indicated there were no well-controlled studies relating surgical site infections to laundering of scrubs. Where and how to launder scrubs was described as an unresolved matter, and no specific recommendation was issued.2 At the time this guideline was published, it implied  that scrubs laundered at home and worn from home did  not pose a risk to patients. It also suggested that, at the end of the day, those same scrubs posed no health threat in the home environment.

In 2003, the CDC and the Healthcare Infection Control Practices Advisory Committee issued guidelines for infection control in healthcare facilities. Although clothing contact is not known as a significant mechanism for transmission of pathogens, the guidelines recommend control measures to prevent healthcare associated infections related to contaminated clothing, i.e., clothing soiled by blood or body fluids while at work. These control measures were founded in hygiene principles, common sense, and consensus,3 and recommended that when clothing is contaminated  with blood, emesis, urine, or any other body fluid, the clothing should be immediately removed and laundered at the healthcare facility.3

The Association of PeriOperative Registered Nurses (AORN) does not support home laundered attire being worn in the operating rooms,  citing a lack of evidence related to safety of healthcare workers, their families, and patients during surgical procedures.4 In revised practice guidelines published in 2011, AORN  took a stronger stand on surgical attire. AORN now recommends that surgical attire be laundered in a healthcare accredited laundry facility.4

As to laundering scrubs worn by perianesthesia nurses, a general survey of clinical practice constituents from across the country revealed wide variations in opinion and practice.  It is obvious that each healthcare institution has a tailored approach to handling scrubs based on knowledge of related research, associated costs, perceptions of staff and consumers, and cost/benefit breakdowns. Some perianesthesia staff function in expanded clinical roles, including but not limited to providing occasional clinical support for bedside invasive procedures and emergency support in the operating room. The possible exposure of staff and/or patient to potentially infectious contaminates must also be considered. Clearly, the current state of the evidence indicates an opportunity for further studies related to  laundering methods. Such studies are needed to further support the decision process related to the question, “home laundered or hospital laundered scrubs?”

REFERENCES

  1. The American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Page 18.
  2. Belkin NL. Home laundering of soiled surgical scrubs: Surgical site infections and the home environment. American Journal of Infection Control, 29(1): February 2001.
  3. Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee. Guidelines for environmental infection control in health-care facilities. Available at: click here.  Accessed August 3, 2011.
  4. Association of periOperative Registered Nurses. A Stronger Stand on Surgical Attire. Available at: click here. 2010News/ATTIRE.  Accessed August 3, 2011.
Theresa Clifford, MSN, RN, CPAN
Revised August 3, 2011

Revised November 24, 2012
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Q: What research has been done on temporal artery thermometers, and how accurate are they compared to tympanic thermometers?
A:

Perioperative hypothermia has been associated with increased morbidity and mortality. Promoting normothermia in the perioperative setting is a designated quality measure under the Surgical Care Improvement Project.1 Normothermia is defined as a core temperature of 36° – 38° C (96.8° - 100.4°F). Achievement of this core measure is met when a patient is normothermic within 30 minutes before or 15 minutes after anesthesia end time.1 Because maintaining core temperature is associated with better patient outcomes, the accuracy of the instrument used to obtain the measurement is of concern to perioperative nurses. 

On April 19, 2009 the ASPAN Representative Assembly adopted a Clinical Practice Guideline, ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia.  The guideline can be accessed on the ASPAN Web site at www.aspan.org.2 The recommendations include a section on temperature measurement and the class of supporting evidence.2

Perianesthesia nurses began using the temporal artery thermometer in their practice settings several years ago. ASPAN began fielding questions related to the accuracy of this device compared with other types of thermometers as perianesthesia nurses were introduced to the technology. The popularity of the temporal artery thermometer has grown because it is quick, relatively easy to operate, noninvasive, and can be used for pediatric and adult populations. Both tympanic and temporal artery thermometers use infrared technology to assess temperature.  The temporal artery reading is obtained by scanning the thermometer across the patient’s forehead. Tympanic temperatures are obtained by inserting a probe tip into the ear canal. The tip does not fit into the ear canal of smaller patients, limiting their use in pediatric populations. Tympanic thermometers should not be used on patients after head, neck and facial surgeries which alter blood flow to the area.  User error is the most commonly cited cause of temperature inaccuracy for both tympanic and temporal artery instruments.

Early studies evaluating the accuracy of the temporal artery thermometer were funded by the device manufacturer.3 Subsequently, studies have compared the accuracy of measurements  taken with the temporal artery, tympanic, digital axillary, digital oral, and chemical dot thermometers as well as more invasive methods such as esophageal, bladder, and rectal measurements.4 In 2008, S. Fetzer and A. Lawrence published their prospective study on temporal artery and tympanic instruments in the perianesthesia setting. The authors stated that their intent was not to determine superiority of one instrument over another and no bias or preference was reported. They did recommend that perianesthesia nurses use the same temperature measurement method consistently rather than switch from one method to another.4 L. Barringer, et.al, conducted a study comparing temporal artery, oral, and axillary temperature measurements in the perioperative period. This study was conducted in part, to determine whether or not the temporal artery thermometer was an acceptable replacement for electronic oral/axillary thermometers.  The authors concluded that the temporal artery thermometer provided a first attempt reading on all subjects. They also concluded that temporal artery measurements more closely correlated with electronic oral temperatures than with electronic axillary temperatures.5

In conclusion, current evidence supports the use of a consistent route of temperature measurement in the perianesthesia setting. Temporal artery thermometers are relatively safe and easy to use although they require some staff training. Temporal artery thermometers may not be as reliable in patients who are outside normothermic parameters. Tympanic thermometers are not recommended in perianesthesia settings.2

REFERENCES

  1. Joint Commission, Surgical Care Improvement Project (SCIP Inf-10), Surgery Patients with Perioperative Temperature Management. Accessed July 19, 2011 at www.jointcommission.org.
  2. American Society of PeriAnesthesia Nurses. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. Available at: click here.  Accessed November 24, 2012.
  3. Exergen Corporation. Available at: www.exergen.com  Accessed July 19, 2011.
  4. Fetzer SJ, Lawrence A. Tympanic Membrane Versus Temporal Artery Temperatures of Adult Perianesthesia Patients J Perianesthesia Nurs. 2008;23(4):230-236.
  5. Barringer LB, Evans CW, Ingram LL, et al: Agreement Between Temporal Artery, Oral, and Axillary Termperature Measurements in the Perioperative Period. J Perianesthesia Nurs. 2011;26(3):143-150.
Thanks to Susan Russell, BSN, RN, JD, CPAN, CAPA, for her contribution to this response.
Revised July 28, 2011

Revised November 24, 2011
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Q: Regarding the standard about when to implement medical-surgical restraints -- when does the standard apply?
A:

From what we understand, if the use of restraint is part of the customary post procedure care, the standard for restraint does not apply. For example, devices employed during medical, diagnostic, or surgical procedures that are considered a regular part of the procedure are not considered restraints. These would include the restraining of an arm when undergoing intravenous therapy, the placement of a body restraint during surgery, and restraint during recovery from anesthesia that occurs in the critical care or post anesthesia care unit. It is advisable to visit The Joint Commission (TJC) Web site (www.jointcommission.org) to review their restraint standards. Type “restraint” into the search box, then select the “Restraint and Seclusion” link, which leads to a ‘frequently asked questions’ page which includes restraint use information.

The Joint Commission lists some exceptions to the applicability of the Behavioral Health Care Restraint and Seclusion Standards. According to TJC, “The standards for restraint and seclusion do not apply to the following: The use of restraint associated with acute medical or surgical care, which is covered under standards PC 12.10 through PC 12.190.”1

Regarding the use of restraints for protection of surgical and treatment sites in pediatric and adult patients, TJC indicates the standards do not apply to usual “practices that include limitation of mobility or temporary immobilization related to medical, dental, diagnostic, or surgical procedures and the related post-procedure care processes.”2 Examples of the usual practices include: protection of surgical and treatment sites in pediatric patients; radiotherapy procedures; intravenous arm boards; and surgical positioning.2

Many facilities consider short term use of restraint to protect tubes and lines during the recovery process to be medical immobilization, and in this situation do not implement the Behavioral Health Care and Seclusion Restraints standard and interventions. However, in many perianesthesia settings staff may try to avoid the application of restraints at any time. This is often accomplished by staying at the bedside, talking with the patient, and offering pain medication and/or sedation. If a patient emerges from anesthesia and continues to need restraints to keep him from pulling at lines or tubes or harming himself, some institutions may require the perianesthesia staff to initiate restraint protocols and adhere to facility policies regarding application of restraint devices including physician orders and assessments.

The use of restraints is strictly regulated and should be limited as much as possible. Patients in restraints require frequent monitoring and specific documentation related to monitoring and assessments. In some facilities, restraints are permitted only in an ICU setting where appropriate monitoring can be assured. Use of restraints in the post anesthesia care unit should be reviewed with the facility’s Risk Management department. Individual facility policies should address the permissible use of restraints in the PACU.

REFERENCES

  1. The Joint Commission. Revision to the Introduction to the Standards for BHC Restraint and Seclusion. Available at: click here. Accessed November 24, 2012.
  2. The Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Critical Access Hospitals, Joint Commission Resources: Oakbrook Terrace, IL. PC 12.10 through PC 12.190.
Thanks to Clinical Practice Committee member Jan Lopez, BSN,, RN, CPAN, CAPA for her contribution to this response.

Revised November 24, 2012
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Q: Does ASPAN have a position on dose ranging of medications? If so, what is it?
A:

The ASPAN Standards do not specifically address this issue. Dose ranging is a topic of review with regulatory agencies, and the reader is directed to regulatory resources and their facility risk management experts for direction on dose ranging. What ASPAN does discuss in its "Pain and Comfort Clinical Guideline" is a  multimodal approach for pain management in Phase I PACU. This Clinical Guideline can be accessed on the ASPAN Web site at www.aspan.org. 1 Pasero and McCaffery also discuss multimodal pain management as an effective means for treating postoperative pain.2
 Dose ranging is a challenge in many facilities, and consequently, regulatory agencies, boards of nursing, and hospital policies are  addressing  this issue., Because of the regulatory requirements and changes, ASPAN has several broad statements in "A Position Statement on Safe Medication Administration”  stressing the importance of assessment, interventionwith  multimodal therapy, reassessment, and adherence to regulatory and facility standards and policies.3

The ASPAN Standards also do not describe specific interventions, such as correlating medication doses to pain scales. ASPAN’s pain guidelines basically follow the World Health Organization pyramid of mild to moderate and moderate to severe, and stress the importance of a multimodal approach. In an article by Manworren,  a discussion concerning data reporting between 1995 and 2003 indicated that 276 sentinel events involved a 21% medication error rate related to opioids administration, and the overwhelming majority of these opioid errors resulted in death.3 However, it could not be determined whether range orders contributed to the events, or in what environment of care the errors occurred.4

Manworren also cites a consensus paper published by the American Society for Pain Management Nursing and the American Pain Society. This document stresses the importance of the critical judgment and empirical knowledge of a nurse in determining the right dose of the right drug to relieve the patient’s pain.4

REFERENCES

  1. American Society of PeriAnesthesia Nurses Pain and Comfort Clinical Guideline. Available at: click here.  Accessed November 24, 2012.
  2. Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis, MO:  Mosby Elsevier; 2011.
  3. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 87-89.
  4. Manworren R. A call to action to protect range orders: A consensus   statement supports this important nursing responsibility, American Journal of Nursing, 2006;106(7):  65.

Revised November 24, 2012

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Q: Can LPNs work in the PACU if they are qualified (such as having BLS, ACLS, hemodynamic courses, arrhythmia courses, starting IVs, drawing blood, and working PACU for years)?
A: In reference to the question regarding what functions LPNs are allowed to do, ASPAN does not have a standard or position statement specific to the role of LPN in the PACU setting, regardless of the type of surgical facility. We do recommend that you look at your state board of nursing Web site for some guidance. Each state has specific rules and regulations regarding the use of practical nurses, so this would be your best resource. The functions the LPN would be allowed to perform would be dictated by the state board regulations, as well as your facility's policies.

Reviewed November 24, 2012
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Q: How long do you need to observe a patient who has had reversal of a benzodiazepine with flumazenil (Romazicon)?
A: The most important factor when determining discharge readiness is knowledge of the half-life of all the medications that were administered. According to pharmacological references, Flumazenil is extensively distributed in the extravascular space with an initial distribution half-life of 4 to 11 minutes and a terminal half-life of 40-80 minutes. The duration of action for benzodiazepines reversed by flumazenil can be the number of hours equal to the patient’s age (diazepam), or for midazolam, one to five hours. In determining the appropriate length of time to monitor the patient who received flumazenil, the age of the patient, renal and liver function, as well as clinical signs of resedation, need to be considered.

Factors determining the length of time the patient needs to be monitored in the Phase II area are multifaceted.

Theresa Clifford, MSN, RN, CPAN
Revised August 3, 2011

Reviewed November 24, 2012
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Q: What does ASPAN say about the standards of L&D nurses obtaining and maintaining ACLS certification?
A:

ASPAN is the Society that represents perianesthesia nurses working in the preanesthesia phase, postanesthesia care units, ambulatory settings, extended observation settings, special procedures (cardioversion, ECT, endoscopy, invasive radiology), pain management, etc. Regardless of the environment of care, the patient undergoing anesthesia for surgical interventions require the same standards of care provided by like-competent staff.

The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements  “Standard III - Staffing and Personnel Management,” addresses ACLS and PALS. With regard to ACLS/PALS certification,  the Standard states: "The  perianesthesia registered nurse providing Phase I level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served."1

The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements “Standard III, Staffing and Personnel Management,” also states that  “It is recommends that the  perianesthesia nurse providing Phase II level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served."1

Phase I is defined as "the immediate postanesthesia period" during which time "basic life-sustaining needs are of the highest priority and constant vigilance is required ... as the needs of the patient are neither minimal nor episodic." “Phase II level of care focuses on preparing the patient/family/significant other for care in the home, extended observation, or care in extended care environment” (i.e. admission in this case). It is not the "1-hour" time frame, but the meeting of criteria that is essential.1

Having stated ASPAN’s position, we acknowledge the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) which provides standards of practice for labor and delivery nurses. AWHONN suggests that the requirement for L&D nurses to have ACLS should be guided by factors such as “the acuity of the patient population served, the availability of the code team within a facility, and the frequency with which ACLS skills may actually be used by those nurses.”2 This position poses the question, is this standard being met in another way? One suggestion is having a CRNA or physician ACLS provider stay in the room with the L&D nurse continuously until the patient reaches the predetermined criteria for discharge.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 7,19-20.
  2. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Advanced Cardiac Life Support in Obstetric Settings. JOGNN. 2010; 39:606-607.

Theresa Clifford, MSN, RN, CPAN
Revised August 3, 2011

Revised November 24, 2012

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Q: Looking for a method to calculate IV fluid replacement for children and adults for the NPO hours, operative and post anesthesia period?
A:

ADULT FLUID REPLACEMENT

Three part formula for calculating fluid to be replaced intraoperatively:

  1. Deficit—defined as the time the patient is NPO to the time surgery begins
    Formula is the maintenance rate X the number of hours the patient has been NPO
    Also account for fluid losses from NG suctioning and bowel preps
  2. Maintenance—defined as the time of incision to closure:
    Based on the 4 – 2 – 1 formula
    4 ml/kg/hr for 0-10 kg weight
    2 ml/kg/hr for the next 10 kg weight
    1 ml/kg/hr for each kg > 20

    Example:
    Weight in kg = 70
    4 ml/kg/hr for the first 10 kg = 40
    2 ml/kg/hr for the next 10 kg = 20
    1 ml/kg/hr for each kg > 20 = 50
    40 + 20 + 50 = 110 ml/hr

    A shortcut for patients weighing > 20 kg is weight in kg + 40
    Example:
    Weight in kg = 70 + 40 = 110 ml/hr
  3. Surgical losses
    • Blood
      • Replace 3-4 ml crystalloid/ml blood loss or 1 ml colloid/1 ml blood loss
      • Replace blood at 1 ml/1 ml loss + crystalloid or colloid
    • Evaporation from open wound
    • Third-spacing from fluid redistribution

Estimation of Evaporation and Third-Space Losses—additional maintenance fluid based on amount of tissue trauma

  1. Minimal procedure, e.g. herniorrhaphy 2-4 ml/kg/hr
  2. Moderate procedure, e.g. cholecystectomy 4-6 ml/kg/hr
  3. Major procedure, e.g. bowel resection 6-8 ml/kg/hr
Schedule for Replacement During the Surgical Procedure:

 

First hour:  1/2 the deficit + maintenance + replacement for blood loss
Second hour:  1/4 the deficit + maintenance + replacement for blood loss
Third hour:  1/4 the deficit + maintenance + replacement for blood loss

Example:
80 kg patient scheduled for total hip replacement, NPO for 10 hours
Deficit = 10 hours NPO X 120 = 1200 ml
Maintenance = 120 ml/hr
Blood loss replacement (EBL = 300 ml) = 3 ml crystalloid X 300 = 900 ml

1st hour = 600 (1/2 the deficit) + 120 (maintenance*) + 300 ml LR (blood loss replacement) = 1020 ml
2nd hour = 300 (1/4 the deficit) + 120 (maintenance*) + 300 ml LR (blood loss replacement) =  720 ml
3rd hour = 300 (1/4 the deficit) + 120 (maintenance*) + 300 ml LR (blood loss replacement)  = 720 ml
                 Total = 2460 ml
 *Additional fluid may be added to the hourly maintenance to account for evaporation and tissue trauma losses

Estimated adult blood volumes
Male = 70-75 ml/kg
Female = 55-67 ml/kg
  

PEDIATRIC FLUID REPLACEMENT

Fluid Resuscitation Guidelines

  • Start fluid resuscitation
    • 20 ml/kg of isotonic crystalloid (Normal saline or Lactated ringers)
    • Bolus over 5-20 minutes
    • Repeat boluses of 20 ml/kg as needed to restore blood pressure and perfusion 
    • Adjust rate according to cause of shock state
  • Do not administer fluids containing glucose
  • Blood and blood products are recommended for replacement of volume loss in pediatric trauma patients with inadequate perfusion despite administration of 2-3 boluses of 20 ml/kg of isotonic crystalloid  (PALS, 2006)
HOURLY MAINTENANCE FLUID REQUIREMENTS FOR INFANTS AND CHILDREN
Body Weight (kg)  Hourly Requirement
1-10 kg 4 ml/kg/hr for each kg body weight
11-20 kg 40 ml/hr + 2 ml/kg/hr for each kg 11-20 kg
> 20 kg 60 ml +1 ml/kg/hr for each kg > 20 kg

Based on 1 ml of fluid per 1kcal of calorie expenditure.
Estimated blood volume (EBV)
Infant  80-90 ml/kg
Child  70-80 ml/kg
Maximal allowable blood loss should not exceed 20% of EBV, depending on pre-op hematocrit

REFERENCES
  1. American Society of PeriAnesthesia Nurses. Fluid and Electrolytes. In: Redi-Ref for Perianesthesia Practices. Cherry Hill, NJ: ASPAN; 2010:65-67.
  2. American Society of PeriAnesthesia Nurses. Perianesthesia Care of the Pediatric Patient. In: Redi-Ref for Perianesthesia Practices. Cherry Hill, NJ: ASPAN; 2010: 142-144.

Revised November 24, 2012

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Q: How can patients with multi-drug resistant organisms (MRSA, VRE, etc.) be cared for in PACU? Do they need to be in an isolation room, recovered in the OR, returned to the patient room for Phase I level of care?
A:

ASPAN's 2012-2014 Perianesthestia Nursing Standards, Practice Recommendations and Interpretive Statements has a Practice Recommendation for the care of patients on isolation precautions.” Practice Recommendation 1A, Staffing Recommendations and Management of the Patient on Precautions, (PR1A)”  offers general guidelines and stresses throughout that each facility must have an infection control plan. The perianesthesia area must follow that plan while using this Practice Recommendation  as a reference for adaptation to the PACU and Pre-op setting as appropriate.

Regarding contact isolation, it is a given that Standard Precautions are used on all patients. According to PR1A: "When a patient known or suspected to be infected with epidemiologically important or highly transmissible pathogen, the appropriate transmission precaution is utilized.”1  This statement allows each institution to make its own policy and determine if these infections are of special significance requiring special precautions and handling.

PR1A  further states that “in the event that a facility allows patients in main PACU, the best way to prevent the spread of organisms it to follow standard infection control measures.”  In addition, “Nurse to patient ratios should be one to one upon arrival of the patient. Ratios may advance based on ASPAN’s recommended staffing guidelines, providing that the preoperative or Phase I or Phase II care needs of the patients allow sufficient time for donning and removing respiratory protection and other protective barriers, and washing hands between patients.”1

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 34-35.

Theresa Clifford, MSN, RN, CPAN
Revised August 3, 2011

Revised November 24, 2012

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Q: What are the criteria for discharging a patient following spinal anesthesia?
A: The question about discharging patients after spinal or epidural anesthesia surfaces frequently. This question has been researched by the Standards and Guidelines Strategic Work Team and the Evidence Based Practice Strategic Work Team. There is currently no evidence which supports a better outcome or result  from waiting to discharge a patient until the patient achieves one predetermined dermatome level over another predetermined dermatome level.

Inpatient Discharge
Perianesthesia nurses know from experience that  patients with a dermatome level of T10 which is receding are generally safe for discharge to an inpatient unit. A T10 level indicates that the spinal/epidural anesthetic is resolving and will continue to recede after discharge.1 When discharging a patient with this level to an inpatient unit, it is important that the receiving nurse unit knows not to place the patient in trendelenberg position for any reason (i.e.,for  hypotension) since the level of the spinal/epidural could ascend if the patient is in that position. Instead, hypotensive patients post spinal or epidural are treated with fluid resuscitation.

Perianesthesia nurses need to know whether there are facility policies defining specific discharge criteria for patients receiving spinal/epidural anesthetics. Some anesthesiologists may include such criteria as patient bending knees, lifting buttocks, stable blood pressure in a lateral position, etc., prior to discharge to an inpatient unit.

Outpatient Discharge
When patients are being discharged home or to another facility, there may be a policy which stipulates that the spinal/epidural should be fully resolved. Patients should be able to walk with a steady gait to ensure that they are safe at home. A fully resolved spinal/epidural includes Level S3, the perineal level. If this dermatome level is present, the patient should be able to void and should sense the urge to void.
 
Whether or not a patient is required to void prior to being discharged after a spinal/epidural is left to theindividual facility policy and practice. There are anecdotal stories of patients reporting incontinence in their private vehicles when they are discharged prior to full resolution of the spinal/epidural. Patient dissatisfaction may be one reason some facilities require full resolution of the spinal/epidural before discharge.

The bottom line is discharge criteria should be developed in consultation with one’s anesthesia department and facility policies need to be followed.2

REFERENCES
  1. Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO: Saunders; 2010. Pages 418-424, 619.
  2. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 36-42.
Revised November 25, 2012
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Q: Must a registered nurse accompany patients being transferred from PACU?
A:

“Practice Recommendation 6, Safe Transfer of Care: Handoff and Transportation” in the 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements states, among other things:

  • "A policy exists to ensure safe transportation of patients.
    • The perianesthesia registered  nurse determines the mode, number and competency level of accompanying personnel based on patient needs
    • The perianesthesia registered  nurse assures the availability of appropriate transportation of the patient from the institution
    • The patient will be discharged with a responsible adult
    • A plan exists for those patients who do not have an accompanying responsible adult or reliable transportation
    • An appropriate means of transportation from a freestanding institution to a full service hospital will be used in emergent and non-emergent situations.
  • A perianesthesia registered  nurse should accompany patients who:
    • Require continuous cardiac monitoring
    • Require evaluation and/or treatment during transport (e.g.,, vasopressor infusions or pulse oximetry
  • The  perianesthesia registered nurse determines the appropriate equipment and supplies needed for transport
  • Transport personnel will remain with the patient until the receiving unit personnel are at the bedside to assume responsibility for the care of the patient. 
  • Patient identification is verified per institutional protocol."1
REFERENCES
  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 53-55.

Revised November 25, 2012

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Q: What does ASPAN say about families visiting in PACU?
A:

ASPAN supports family visits in PACU. Guidelines certainly need to be in place to assist with incorporating family visits in the Phase I level of care. The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements discuss family visitation in “Practice Recommendation 9 – Visitation in the Perianesthesia Care Unit.”1

This practice recommendation is evidence-based, and the supporting literature can be found in the reference section of this practice recommendation. In units that have adopted family visitation practices, the results have been positive for all. It is reassuring to family members to see their loved ones and patients also find it comforting. This practice requires education for the family and nursing staff, and requires measures be taken to provide patient confidentiality and privacy.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 63-66.
Revised November 25, 2012
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Q: What are the staffing recommendations for Phase I level of care? Is it necessary to have two nurses present?
A:

The answer to these questions can be found by going to the ASPAN home page at www.aspan.org. Click on the Clinical Practice tab at the top of the page and “pull down” to Patient Classification. Here, you can read the staffing recommendations in its entirety.1 This is “Practice Recommendation 1 – Patient Classification/Staffing Recommendations” that can also be found In the ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements.2 

In a nutshell, the Standards state that “Two registered nurses, one of whom is an RN competent in Phase I postanesthesia nursing, are in the same room/unit where the patient is receiving Phase I level of care.”2

REFERENCES

  1. American Society of PeriAnesthesia Nurses. Practice Recommendation 1 – Patient Classification/Staffing Recommendations. Available at: click here. Accessed November 25, 2012.
  2. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 30
Revised November 25, 2012
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Q: How many PACU beds should there be for each OR?
A:

In Drain’s Perianesthesia Nursing: A Critical Care Approach, the sixth edition, space planning is discussed:  “For an inpatient hospital PACU that services a combined patient population of inpatients and same-day admission patients, a ratio of 1.5 to 2 PACU bays per OR is necessary to safely care for the patients and not back up the OR”. For an ambulatory surgery center with a limited number of surgical services and types of procedures, 2.5 to 3 PACU Phase I and PACU Phase II (combined) bays are necessary.”1

Other considerations listed are how the bays will be used, that is, for preoperative, Phase I or Phase II care, how many surgical cases per day, are they short or long cases, how many other procedural areas send patients to PACU for care (e.g., endoscopy, cardiac catheterization patients, ECTs, pain services, chronic and acute, etc.). What kind of procedures are done in the facility, is the facility a high acuity/level 1 trauma center, is there a large pediatric population, what is the bed capacity and the average wait time for an inpatient bed? When these questions can be answered, it becomes easier to determine the number of beds needed for a particular institution.

REFERENCES

  1. Smith BA, O’Brien D. Space Planning and Basic Equipment Systems. In: Odom-Forren J, ed. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders,an imprint of Elsevier Inc; 2013: 1-5.
Revised November 25, 2012
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Q: What are hospital PACUs doing regarding sending patients back direct to ICU from the OR, especially if the patient came from the ICU? If the patient goes back to ICU must a PACU RN recover the patient there?
A:

This issue has been debated for years, and ultimately, it is up to each hospital to decide based on staffing of both PACU and ICU. ASPAN Standards cannot dictate where the ICU patient will be recovered or by whom. It really is imperative to consider the needs of the patient and how much care he/she will require. Collaboration between the two units can clearly benefit both units in most hospitals.

Frequently, if the patient came from ICU and is returning to ICU intubated, the ICU nurse recovers without a PACU nurse unless the patient is very unstable and ICU has limited available staff. If a PACU nurse is available, the PACU nurse can help as needed.

If the patient is extubated, some anesthesia departments prefer that a PACU nurse care for the patient either in ICU or PACU. During the day, the ICU patients may come to the PACU as PACU may have co-workers present to assist as needed. When PACU staff is on call, some prefer to recover the patient in the ICU as there are more resources immediately available.

There are also discussions in some facilities about having ICU nurses recover all ICU patients. There are two potential drawbacks:

  1. The PACU staff cannot maintain their advanced ICU skills (PACU is a critical care unit) unless they care regularly for ICU patients.
  2. ICU nurses must possess the same level of expertise in managing the immediate postanesthesia patient as the PACU staff (PACU is also a specialty) so ICU nurses must have specialized education and competency assessments related to Phase I level of care.
It is difficult to give a straight-forward response to this question as there are many variables that caregivers must consider. Who is the best qualified and can provide the safest care for each patient at that particular point in time? The anesthesia provider, and sometimes the surgeon, will determine where the patient ultimately receives immediate postanesthesia care.

Thanks to Nancy O’Malley, MA, RN, CPAN, CAPA, for her contribution to this response.

Reviewed November 25, 2012

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Q: What do we need to do to be in compliance with standards for follow-up phone calls after outpatient surgery?
A:

“Postoperative phone calls are not a requirement of any regulatory agency, including The Joint Commission. What The Joint Commission requires is that reassessment is done on all patients at intervals determined by the facility.”1 Reassessment is necessary in order to evaluate patient treatment and response to treatment.

How this reassessment is performed should be defined in writing by each institution. Policy can also define whether calls are done “the following day” or the “next business day,” which covers the time frame when nurses may not be scheduled to work, such as over the weekend.

Some facilities do follow-up with a survey or postcard. Most continue to do follow-up phone calls as their means of reassessment. These calls not only serve to evaluate the patient, but can be helpful in answering patient questions that have come up since discharge regarding their care. The calls also provide an opportunity to obtain feedback regarding the care and services provided, can lead to accolades for staff, and provide opportunities for improvement.1

There is varying research on the best time to do the postoperative calls. Some research suggests waiting a day or two, as that is when the patient is feeling a little better, and questions may have come to mind. Other data suggests that if calls are delayed, the patient may be unavailable, leading to lack of opportunity for feedback or  the ability to answer questions.1

Time is usually the major barrier to getting calls completed. It is generally best to assign the calls each day to one or two staff members to ensure that this important element of patient care is completed.1

REFERENCES

  1. Godden B. Postoperative Phone Calls: Is There Another Way? J Perianesthesia Nurs. 2010;25(6):405-408.
Revised November 25, 2012
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Q: What are the recommendations for PACU nurses regarding ACLS and PALS?
A:

This is addressed in “Standard III-Staffing and Personnel Management” in the 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretative Statements. It states:

Phase I
“The perianesthesia registered nurse providing Phase I level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served,”1

Phase II
“It is recommended that the perianesthesia nurse providing Phase II level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served.”1

REFERENCES

  1. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Page 19.
Revised November 25, 2012
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