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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 is the definition of "responsible adult?"
If a patient does not have a responsible adult to accompany them at discharge, what do you suggest?
Q. What research has been done on temporal artery thermometers, and how accurate are they compared to tympanic thermometers?
Q. Can a PACU nurse extubate a patient? Must an anesthesia provider be present?
Q. What are the differences between Phase I, Phase II, and Extended Care (Extended Observation/Phase III)?
Q. What are the criteria for discharging a patient following spinal anesthesia?
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 is ASPAN’s recommendation regarding the role of the perianesthesia nurse during a preoperative peripheral nerve block?
Q. Does ASPAN have a position on dose ranging of medications? If so, what is it?
Q. What are the staffing recommendations for Phase I level of care? Is it necessary to have two nurses present?
Q. Can we put Preop patients in the same area that we have patients recovering from anesthesia?
Q. Does ASPAN have standards or recommendations guiding the use of perioperative leg compression therapy for VTE prevention?  What are some of the indications and contraindications for use? 

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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Q. What is the definition of "responsible adult?"
If a patient does not have a responsible adult to accompany them at discharge, what do you suggest?

A. The ASPAN 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements no longer refer to "responsible adults" but rather, "responsible individuals." The American Society of Anesthesiologists reports insufficient literature to suggest that there are fewer complications or adverse events when patients are accompanied home. However, the consensus of perianesthesia experts and anesthesia providers is that requiring a responsible individual to accompany a patient remains prudent practice.

Determinants of Responsible Individuals
When determining whether or not a person can be the responsible individual, 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 individual," even if the minor and his/her child live with parents or other adult relatives. The most important description of the responsible individual is one who can report any postprocedure/postanesthesia complications.(1)

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 individual" may be an acceptable option. A blind or deaf person can be the responsible individual. 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 individual" 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 individual? 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. If there is any question that the patient does not have home support, engage Care Management in finding solutions. 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 their 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. American Society of PeriAnesthesia Nurses. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2016:39.
  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. 
This FAQ has been reviewed and updated August 2017
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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. Normothermia is defined as a core temperature of 36° – 38° C (96.8° - 100.4°F).  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.(1) The recommendations include a section on temperature measurement and the class of supporting evidence.(1)

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.(2) 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.(3) 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.(3) 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.(4)

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. Therefore, the use of the temporal artery thermometer in the perianesthesia setting should be used with caution, and the knowledge that there may be significant differences between normothermic patients and those with hypothermia.(1)

References: 
  1. American Society of PeriAnesthesia Nurses. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. Available at: click here. Accessed August 15, 2017.
  2. Exergen Corporation. Available at: www.exergen.com  Accessed August 15, 2017.
  3. Fetzer SJ, Lawrence A. Tympanic Membrane Versus Temporal Artery Temperatures of Adult Perianesthesia Patients J Perianesthesia Nurs. 2008;23(4):230-236. 
  4. Barringer LB, Evans CW, Ingram LL, et al: Agreement Between Temporal Artery, Oral, and Axillary Temperature Measurements in the Perioperative Period. J Perianesthesia Nurs. 2011;26(3):143-150. 
This FAQ has been reviewed and updated August 2017
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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 the state nurse practice act, state board of nursing and/or professional registration requirements as well as state laws that prohibit the perianesthesia nurse 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 the Phase I PACU RN can extubate a patient. Most states are fairly vague when it comes to specific skills. Many state boards of nursing have statements in them saying that the nurse must be “deemed competent” in a skill to perform it independently. 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 Phase I 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 Phase I 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?” also lies in your policy. The policy should include criteria describing when 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 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. In some states and territories the perianesthesia nurse with proper education and training, can insert a laryngeal mask airway to protect the airway until help arrives. 

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; 2014. pp. 84-86. 
  2. Wright SM. Assessment and Management of the Airway. In: Odom-Forren J, ed. Drain’s Perianesthesia Nursing: A Critical Care Approach. 7th ed. St. Louis, MO: Saunders, an imprint of Elsevier Inc.; 2017: 417. 
  3. Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 3rd ed. St. Louis, MO: Saunders; 2016. Pp. 469, 475-476, 542-546,549-550. 
This FAQ was reviewed and updated August 2017 
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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 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 support for effective ventilation, progression toward hemodynamic stability, pain control, 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 physical 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, workflow efficiencies or for continuity of care. So, if a patient is ready to ambulate to 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 available inpatient 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 an inpatient 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 2017-2018 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 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, “Practice Recommendation 2-Components of Assessment and Management 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. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2016. Pages 7, 32-45
This FAQ was reviewed and updated August 2017
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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, the risk for a sympathetic block is diminished and the spinal 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 Trendelenburg position for any reason (e.g., 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 or placed with legs raised to increase preload.

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 the individual 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. 3rd ed. St. Louis, MO: Saunders; 2016. Pages 357-258, 1252-1253. 
  2. American Society of PeriAnesthesia Nurses. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2016. Pages 38-45.
This FAQ was reviewed and updated August 2017
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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. ASPAN Standards do not address where an ICU patient will be recovered or by whom. Ultimately, it is up to each hospital to decide based on staffing and staff competencies of both PACU and ICU. It really is imperative to consider the needs of the patient and how much care he/she will require in the immediate postanesthesia period. Since Phase I PACUs, by nature of the level of care that patients require, are considered critical care units, the staff should have competencies required for care of the critically ill patient. Collaboration between the two units can clearly benefit both the patients, the units, and patient flow in most hospitals.

Frequently, if the patient came from ICU and is returning to ICU, an ICU nurse recovers without a PACU nurse.  If the patient is hemodynamically unstable and the ICU has limited staff, an available Phase I PACU registered nurse may be called to assist in the recovery as needed.  This is particularly true if the patient has an advanced airway and remains on a ventilator.

If the patient is extubated, some anesthesia departments prefer that a PACU nurse care for the patient either in ICU or Phase I PACU. During the day, the ICU patients may come to the PACU as the Phase I PACU may have co-workers present to assist as needed. When Phase I PACU staff is on call, the preference may be 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. Phase I PACU staff cannot maintain 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 Phase I 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.

References: 
  1. American Society of PeriAnesthesia Nurses. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2016. Pages 38-45; 51-54.
This FAQ has been reviewed and updated August 2017
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Q. What is ASPAN’s recommendation regarding the role of the perianesthesia nurse during a preoperative peripheral nerve block?
A. The perianesthesia registered nurse may assist with the placement of the peripheral nerve block, but only credentialed practitioners, usually anesthesiologists, prescribe and insert these devices.  State nurse practice acts (NPA), state board of nursing and/or professional regulatory requirements 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 and board of nursing regulations for your state.(2,3)

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.(2)

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.(3) Frequency of vital signs ranges from every two to 15 minutes, depending on the patient’s response and overall condition.(3) Recognition of adverse reactions and timely intervention is critical.(2,3,4) Nurses assisting with blocks should maintain current ACLS/PALS credentials.

Depending upon state nurse practice act, board of nursing regulations, and facility policy, a nurse may inject local anesthetic through the peripheral nerve catheter under the direct supervision and instruction of the anesthesiologist.(3) 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.(2)

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.  Continuous close monitoring by the perianesthesia registered nurse assisting during the placement of the peripheral nerve block is integral to a successful outcome.(1)

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.(3) These competencies are necessary to ensure the patient’s optimal safety during the peripheral nerve block procedure.

References: 
  1. Clark M. Lipid Emulsion as Rescue for Local Anesthetic-Related Cardiotoxicity. J Perianesthesia Nurs. 2008; 23(2):111-121.
  2. Clifford T. Peripheral Nerve Blocks. J Perianesthesia Nurs. 2011;26(2):120-121.
  3. McCamant K. Peripheral Nerve Blocks: Understanding the Nurse’s Role. J Perianesthesia Nurs.  2006;21(1):16-26.
  4. Sandlin-Leming D. Resuscitation of Local Anesthesia-Induced Cardiac Arrest: Lipids to the Rescue. J Perianesthesia Nurs. 2010;25(6):418-420. 
This FAQ has been reviewed and updated August 2017
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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 http://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, intervention with 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 (WHO) 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.  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 August 29, 2017. 
  2. Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis, MO:  Mosby Elsevier; 2011. 
  3. American Society of PeriAnesthesia Nurses. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2016. Pages 102-105. 
  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. 
This FAQ has been reviewed and updated August 2017
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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 two questions can be found by going to the ASPAN home page,  http://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 2017-2018 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 August 29, 2017. 
  2. American Society of PeriAnesthesia Nurses. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012. Pages 33 
This FAQ has been reviewed and updated August 2017
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Q. Can we put Preop patients in the same area that we have patients recovering from anesthesia?
A. This question is frequently submitted to the ASPAN Clinical Practice network. Many nurses asking this work in facilities where the staff members of preop and PACU may be one and the same. The question also arises as facilities are trying to make the most of the available staff later in the day.

“Standard II- Environment of Care,” in ASPAN’s 2017-2018 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 waiting area; a distinct area set aside for patients and families, outside of the areas used to prepare patients for their procedures, perform procedures, or recover from procedures.”(2)  42 CFR 416.2 defines an ASC as “a distinct entity that operates exclusively for the provision of surgical services. An ASC may not share space with another entity when the ASC is open.”(3) We consider a "recovery room" to be an area where patients are brought to recover from procedures and are not yet discharged. Medicare regulations do not address specific requirements for a preop area.

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. 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2016. Page 21. 
  2. &3. Retrieved from Department of Health & Human Services, Centers for Medicare & Medicaid Services https://www.cms.gov/ August 29, 2017
This FAQ has been reviewed and updated August 2017
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Q. Does ASPAN have standards or recommendations guiding the use of perioperative leg compression therapy for VTE prevention?  What are some of the indications and contraindications for use? 
A. ASPAN does not have a standard or recommendation that specifically addresses who utilizes leg compression therapy for VTE prophylaxis.  However, the ASPAN 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations, and Interpretive Statements includes Practice Recommendation 2, Components of Assessment and Management for the Perianesthesia Patient, and Practice Recommendation 4, Recommended Competencies for the Perianesthesia Nurse, that stress integrating relevant patient data to individualize care, to maximize patient safety, and improve outcomes as they navigate through the perianesthesia experience.(1)  

Integrating these recommendations into nursing practice requires critical thinking and analysis and should reflect evidence based knowledge about patient selection for VTE prophylaxis, physiologic variables (risk factors) leading to thrombus formation, and effective leg compression prophylaxis.

Venous thromboembolism (VTE) is the combination of deep vein thrombosis (DVT) and pulmonary embolism (PE).  Studies indicate that in the absence of prophylaxis, as many as 10% to 40% of hospital acquired DVT occur in medical and general surgical populations and 40% to 60% occur in the orthopedic surgery population.(2)

Three physiologic variables, Virchow’s Triad, lead to thrombus formation:  1.) Disturbance in blood flow causing stasis, 2.) Hypercoagulability, and 3.) Vessel wall damage.(2) Physiologic conditions predisposing individuals to this triad are considered to be high risk for VTE. High risk conditions for VTE include: trauma, orthopedic surgery, burns, procedures lasting more than 30 to 45 minutes, positioning that constricts blood vessels, use of tourniquets, varicosities, obesity, smoking, HRT, pregnancy or postpartum, CHF, COPD, dehydration, hypovolemia, ethnicity, immobility or sedentary lifestyle, personal history or a family history of clotting disorders, DVT, PE, blood clots.(2) Research has shown that emptying the deep veins of the legs (preventing stasis) reduces thrombus formation.  Stasis prevention can be achieved through early mobilization and compression therapy with intermittent pneumatic compression (IPC) and/or graduated compression stockings (GCS).(3,4)

Correctly applied IPC that includes three locations, foot, calf, and thigh, has been shown to be the most effective (using current technology). Ideally, IPC sleeves should sense each leg independently and provide compressions to match postcompression venous refill times.(4) GCS can be knee or thigh length. Thigh length GCS are associated with wrinkling, rolling, and a tourniquet effect. Hilleran-Listerud (2008) concluded that knee length GCS and IPC were equally effective in reducing VTE, were more comfortable for patients, were associated with greater compliance and ease of use, were more cost effective and posed less injury risk related to poor fit and wrinkling.(4)

While GCS and IPC are highly effective in VTE prevention, there are potential contraindications for their use:  peripheral vascular disease, arterial insufficiency, leg deformity, excessive (> 3+) edema, pulmonary edema, peripheral neuropathy, and preexisting skin conditions.(5,6)  Here is a 2012 updated VTE prophylaxis reference tool:  http://ebookbrowsee.net/uhs-vte-prophylaxis-guidelines-update-2012-pdf-d430193366.

In summary, each patient should be properly assessed for both indications and contraindications for VTE prophylaxis. Some patients will require anticoagulation along with compression therapy. Others may only require early ambulation and performing “ankle pumps” (ankle flexion and extension) during immobile periods. Many will require compression therapy, either alone or combined IPC and GCS. Some patients will be discharged to home wearing GCS and/or with a home IPC unit. All should be educated to the risks of VTE and how they are an equally important link in prevention.

References: 
  1. American Society of PeriAnesthesia Nurses, 2017-2018 Perianesthesia Nursing Standards, Practice Recommendations, and Interpretive Statements, Cherry Hill, NJ, 38-45, 51-54.
  2. AORN Guideline for Prevention of Venous Stasis (2007), AORN, 85, (3), 607 – 622.
  3. Comerota, A. J. (2011), Intermittent pneumatic compression for DVT prophylaxis, supplement to Endovascular Today October 2011.
  4. Hilleren-Listerud, A. E., (2009), Graduated compression stocking and intermittent pneumatic compression device length selection, Clinical Nurse Specialist, 23, (1), 21-24. Doi: 10.1097/01.NUR.0000343078.73085.75

UHS VTE Prophylaxis Guidelines Update 2012 courtesy of University Health System retrieved on July 28, 2013 from http://ebookbrowsee.net/uhs-vte-prophylaxis-guidelines-update-2012-pdf-d430193366

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