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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 does ASPAN say about staffing after hours and on call? 
Q: Should PACU or ICU recover ICU patients on ventilators?
Q: What is the standard for handoff report from the PACU to the receiving unit? 
Q: Is Capnography required in Phase I PACU?
Q. What is the national trend for being able to wear personal, home-laundered scrubs to work in the PACU?
Q. Regarding the standard about when to implement medical-surgical restraints -- when does the standard apply?
Q. Can licensed practical nurses (LPNs) or vocational nurses (VNs) 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: What does ASPAN say about staffing after hours and on call?
A: The CPC receives questions related to call coverage after hours and on weekends on the majority of weekly rosters. This is a hotly debated subject and a source of concern for many perianesthesia nurses. The same staffing requirements apply when patients are in the PACU after hours as during regular business hours. Each facility and unit should develop a written plan to define how safe staffing standards will be achieved in these situations. Patient safety should always be the priority. Management should consider the number and type of cases admitted to PACU after hours, patient acuity, number of qualified staff eligible to take PACU call and number of on-call hours to be covered. Additional considerations may include location of the PACU, whether special procedure areas also rely on PACU for after hours recovery and whether on-call staff are also assigned for preop and phase II patients.

The 2017-2018 ASPAN Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements address staffing for each level of perianesthesia care in several areas:
  • Standard III, Standard and Personnel Management
  • Practice Recommendation 1 Patient Classification/Staffing Recommendations
  • Practice Recommendation 4 Competencies for the Perianesthesia Registered Nurse
  • Practice Recommendation 5 Competencies of Perianesthesia Support Staff
  • ASPAN’s Position Statement 2 “On Call/Work Schedule.”

Specialty organization standards are not mandatory and no facility can be forced to follow them. However, they are persuasive and are frequently cited by attorneys and experts when analyzing malpractice/negligence cases. In facilities which profess to follow ASPAN standards, exceptions should not exist just because a case occurs “after hours.” Every patient deserves the same level of care provided by an appropriate number of qualified personnel no matter what time of day or night that care is delivered. On-call staff should have the same competency requirements as staff working during regular business hours. While it is acceptable to have a RN who is not cross-trained to PACU serve as the 2nd RN after hours, the staffing ratios cited in PR 1 for Phase I PACU still apply. The 2nd RN should not be providing care to patients without the requisite competencies. If the nurse to patient ratio requires the presence of a 2nd fully qualified PACU nurse, there should be a plan in place to call in additional qualified staff.

There are as many solutions to staffing on call as perianesthesia nurses can imagine. Common solutions include using preop/phase II, OR, house supervisors, prn perianesthesia staff and ICU RNs as the 2nd nurse. Some facilities transfer postop patients to other nursing units for phase I recovery where care is provided by a PACU RN or critical care RN. Wherever PACU care is provided, the monitoring equipment, emergency equipment and medications appropriate for the patient’s level of care should be immediately available to the same extent as in the actual PACU. The RN providing phase I care should have the same competencies as the PACU RNs, including ACLS/PALS. Discharge criteria from phase I level of care should remain consistent with that required in PACU.

The requirement that the 2nd RN be in the same room or unit means that the backup RN is immediately available and is physically present in the PACU. It is not acceptable to designate the OR circulator as the backup RN if duties require his/her presence in another area of the facility including the OR, central core, sterile processing, etc. The RN designated to provide PACU backup must not have any other assigned responsibilities which require the RN to be in another physical location.

In some states, laws prohibit mandatory overtime for healthcare workers. State law and/or BON rules may address the maximum number of hours a healthcare worker may be scheduled to work. This may be expressed as the number of consecutive hours in a 24-hour period or in hours worked per week.  In 2007, ASPAN developed a Fatigue Self-Assessment which includes a checklist. This resource may be helpful to perianesthesia nurses concerned about their fitness for duty and factors influencing job performance and safety.

In summary, ASPAN recognizes that providing safe perianesthesia care after hours can be challenging for staff members and for management. Patient safety should not be compromised because of the time of day or day of the week. Would we condone substituting a scrub tech for the OR circulator in the OR? All of our patients are vulnerable during emergence from anesthesia. Every patient deserves a qualified Phase I RN at the bedside as well as a backup RN committed to providing support to the Phase I PACU RN charged with their care.  

References:
  1. 2017-2018 ASPAN Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements.
  2. ASPAN Fatigue Resource at http://www.aspan.org/ClinicalPractice/FatigueChecklist accessed July 17, 2017.  

This FAQ was reviewed and updated July 2017

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Q: Should PACU or ICU recover ICU patients on ventilators?
A: The topic of recovering the ICU patient comes up frequently in questions submitted to the Clinical Practice Committee. Ventilated patients feature prominently in the debate about where to recover these patients.

ASPAN has no Standard specifically addressing where ICU patients should be recovered. The debate rages on as to which nursing specialty is better suited to provide immediate postop care to this patient population. PACU nurses care for myriad populations, from the ASA I patient to the critically ill patient who likely will not survive the day. The ASPAN Standards are applicable to all of these patients.

The ASPAN 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretative Statements include Practice Recommendation (#8) that addresses bypassing Phase I PACU and taking patients directly to Phase II recovery (p. 65-67). There is no parallel practice recommendation describing criteria for bypassing Phase I PACU with critical care patients who may require mechanical ventilation or other advanced monitoring. In some facilities ventilated patients go directly to ICU from the OR. In others, Phase I PACU nurses recover ventilated patients on a regular basis. In still other facilities, some ventilated patients go to the PACU for care and observation until they meet criteria for extubation while others who will not be extubated within a short time go directly to ICU. Who decides? Is the decision based on space available or is it resource oriented?

When determining what will work in your facility, another resource that might provide guidance is Position Statement 3, “A Joint Position Statement on ICU Overflow Patients” developed by ASPAN, AACN, ASA’s Anesthesia Care Team Committee and Committee on Critical Care Medicine and Trauma Medicine. This Position Statement recognizes:

The primary goal when determining the postoperative setting for the critically ill surgical patient is to ensure the best environment for the patient, aligning both nurse and physician characteristics and competencies…
Management should develop and implement a comprehensive resource utilization plan with ongoing assessment that supports the staffing needs for both the PACU and ICU patients when need for overflow admission arises… (p.96-98)

The important issues to keep in mind are: 1. The same standard of care must be met for the patient recovering from anesthesia, regardless of where that process occurs. 2. Patient safety issues must always be at the forefront when considering the best location for the patient’s recovery.

That being said, there are times when ventilated post-operative patients become the focus of “turf wars.” Many organizations have established policies to help guide and direct care givers in making appropriate decisions for patient placement in these situations. Input from the Anesthesia Provider, Phase I PACU charge nurse, and ICU charge nurse can be valuable in determining where care can best be provided. PACU nurses generally contend that the patient will not be “recovered” if he is to remain intubated, while ICU nurses’ argue staffing issues: one-to-one care for a specified length of time (ICU nurses may not be as well versed on anesthetic agents and recovery).  Finally, anesthesia providers need to weigh in on the issue. Anesthesiologists often feel more comfortable when Phase I PACU nurses are directly involved in providing the initial postanesthesia care for all their patients, including those who will ultimately transfer to ICU. 

Summary: Developing a written policy to address the recovery of ICU patients helps resolve the criteria for transferring critical patients from OR to ICU and/or PACU. An existing policy promotes open communication and helps guide caregivers in determining the safest and best patient placement.

References:
  1. A joint position statement on ICU overflow patients developed by ASPAN, AACN, and ASA’s anesthesia care team committee and committee on critical care medicine and trauma medicine. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. ASPAN. 2012. Cherry Hill, NJ (p.96-98).
  2. Practice recommendation 8: Fast tracking the ambulatory surgery patient. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. ASPAN. 2016. Cherry Hill, NJ (p. 65-67).
This FAQ was reviewed and updated July 2017
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Q: What is the standard for handoff report from the PACU to the receiving unit? 
A: In 2005, the Joint Commission identified communication errors during handoff as a contributory cause in at least half of sentinel events. The 2017–2018 ASPAN Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements describe the handoff communication process in Practice Recommendation 6, Safe Transfer of Care: Handoff and Transportation (p. 58-60). Perianesthesia nurses are responsible for their patients’ safe transfer of care and for employing an appropriate and reliable method of communicating with the next healthcare provider. A structured handoff process reduces errors and omissions of pertinent information, eliminates confusion and redundancy, and increases the effectiveness of the handoff. Minimally, the handoff report should include:
  1. Patient’s name and age
  2. Patient’s pertinent history: allergies, precautions, surgeries, hospitalizations, medical history and physical limitations
  3. Surgeon’s name and procedure performed
  4. Type and tolerance of anesthesia/sedation
  5. Unusual events during procedure
  6. Estimated blood loss and fluid replacement
  7. Clinical history and physical assessment to minimally include: 
  • Level of consciousness/orientation
  • Vital signs, including temperature
  • Status of dressings/surgical site, drainage tubes
  • Amount and type of IV fluids infused and amount remaining in present bag
  • Medications given and effects, (if appropriate)
  • Previous pain management interventions, effects, present pain score, patient goals 
  • History of recent opioid use or requirement/tolerance
  • Previous comfort measures, comfort status (e.g. PONV), patient comfort and function goals
  • Tests and treatments performed (labs, x-rays, aerosols, etc.)
  • Other assessment findings (e.g., breath sounds, neurovascular status, abdominal distention, bowel sounds)
  • Review of postoperative orders as applicable
  • Valuables/sensory aids disposition (eyeglasses, hearing aids)
  • Social support (family, significant others, caregivers)

Advance notice of transfer allows the receiving provider the opportunity to prepare for the patient’s arrival. Handoff report should be completed before or at the time of transfer. There should be an opportunity for the provider assuming care of the patient to ask the transferring nurse questions. Keep in mind that responsibility for effective handoff communication belongs to both providers. Not only does the current caregiver have a responsibility to cover all of the pertinent information, the receiving caregiver has the duty to actively listen to the handoff report or to read it carefully and request clarification as needed. Whether handoff report is in verbal or written format, it is a critical process which requires each individual caregiver to be fully engaged.

In summary, each institution should hardwire the handoff communication process. Using a standardized system, or tool, discourages miscommunication or failed communication. Guidelines designed to meet the needs of the population optimize a safe transition of care. 

References:

  1. Practice recommendation 6: Safe Transfer of Care: Handoff and Transportation 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements: 2017-2018. ASPAN. 2016. Cherry Hill, NJ (p. 58-60).
This FAQ was reviewed and updated July 2017
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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 and Management for the Perianesthesia Patient,” states that vital signs are monitored, including “end-tidal CO2 (capnography) monitoring if available and indicated,” and for “initial and ongoing assessment of airway patency, respiratory status, breath sounds and oxygen saturation”.

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 “Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated……...continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient.”(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 2017-2018 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 also be useful for a period of time after the patient leaves the PACU. Post anesthesia nurses are aware that medical/surgical floors have increased nursing workloads 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 with 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. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretative Statements. Cherry Hill, NJ: ASPAN; 2016. Pages 41-42, 73. 
  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 October 28, 2015. Accessed July 17, 2017. 
  4. American Society of Anesthesiologists. Standards for Postanesthesia Care. Effective Date of October 14, 2014. Accessed July 17, 2017. 
  5. Godden B. Where Does Capnography Fit Into the PACU? Journal of PeriAnesthesia Nursing. December 2011; 26(6): 408-410. 
This FAQ was reviewed and updated July 2017 
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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 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, states: "Personnel and visitor dress codes are determined by institutional policies."(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?” 

The AANA published an article in 2016 which offered a brief checklist of recommendations when laundering scrubs at home.(5)  These include, but are not limited to:
  • Use a machine that can reach water temperatures of at least 60ºC
  • Use bleach-based detergents when not contraindicated by the garment’s features
  • Use the highest settings for heat on the dryer and iron scrubs immediately after washing
  • Use separate laundry loads for scrubs
  • Protect materials from contamination within the home environment by placing them in a secured bag and don them only after arriving at work.
References: 
  1. The American Society of PeriAnesthesia Nurses. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2016:22. 
  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. Updated 2017. Available at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf.   Accessed July 17, 2017. 
  4. Association of periOperative Registered Nurses. Guideline at a Glance: Surgical Attire. AORN J. 2016. Available at: http://www.aornjournal.org/article/S0001-2092(16)30610-X/pdf. Accessed July 17, 2017. 
  5. Vera CM, Umadhay T, Fisher M. Laundering methods for reusable surgical scrubs: A literature review. AANA J. 2016;84(4):246-252.
This FAQ was reviewed and updated July 2017
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Q. Regarding the standard about when to implement medical-surgical restraints -- when does the standard apply?
A. In general, 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 oneself, 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. 
Bibliography:
  • The Joint Commission. Standards FAQ Details. Restraint and Seclusion: Side Rails. Available at: click here. Accessed July 17, 2017.
This FAQ was reviewed and updated July 2017
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Q. Can licensed practical nurses (LPNs) or vocational nurses (VNs) 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 the role of LPNs in the perianesthesia setting, ASPAN does not have a standard or position statement that specifically addresses this, regardless of the type of surgical facility. 

The ASPAN standards regarding nurse:patient ratios for Phase II state that two competent personnel should be available in the same room as a patient receiving Phase II level of care, one being an RN competent in Phase II nursing. In many facilities the second competent personnel is often a nurse’s aide or other non-RN personnel, including the LPN.  It is important to remember the scope of practice for the RN defines the ultimate standard of care for a patient, including the assessment, planning of care, implementation and evaluation of outcomes.

Each state board of nursing has specific rules and regulations regarding the use of practical nurses and determines which tasks fall under the RN license and which can be performed by the LPN. In terms of the scope of practice for the LPN, the LPN provides direct patient care and functions in a task-oriented manner. The scope of practice for the RN is more multifaceted and involves more complex assessments and procedures. The critical difference is that the actions of the LPN ought to be delegated by the RN rather than be independent of the RN. Each facility also describes the role of the LPN on an institutional basis.

Bibliography:
  • American Nurses Association. Registered Nurses as Professionals, Advocates, Innovators, and Collaborative Leaders: Executive Summary. 2017. Available at: click here.  Accessed July 20, 2017.
  • Practical Nursing.org. Working as a Licensed Practical Nurse (LPN). 2017. Available at: click here. Accessed July 20, 2017.
This FAQ was reviewed and updated July 2017
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