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Clinical Practice: 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 the ASPAN Clinical Practice Network or post it on the ASPAN Forum.
Q: At what temperature should you maintain blanket warmers and fluid warmers? Q: Does ASPAN have a position on dose ranging of medications? If so, what is it? Q. What does ASPAN say about the standards of L&D nurses obtaining and maintaining ACLS certification? Q: What is the definition for Phase I and Phase II? Q: What are the criteria for discharging a patient following spinal anesthesia? Q: Must a registered nurse accompany patients being transferred from PACU? Q: What does ASPAN say about families visiting in PACU? Q: How many PACU beds should there be for each OR? Q: Is it necessary for a cardiac rhythm strip to be recorded and placed with the PACU record? Q: Looking for guidelines from ASPAN for recommended frequency of vital signs in Phase I level of care. Q: What are the recommendations for PACU nurses regarding ACLS and PALS?
Q: At what temperature should you maintain blanket warmers and fluid warmers?
A: The ASPAN Clinical Guideline for the Prevention of Unplanned Perioperative Hypothermia emphasizes the importance of warming techniques for surgical patients. There are currently a number of options available to promote and maintain normothermia. Common methods of passive insulation include the application of warmed thermal blankets, socks, head coverings, intentional limitation of skin exposure, circulating water mattresses and the appropriate regulation of ambient room temperature.11
Traditionally aimed at patient safety measures, a recent trend in clinical practice questions suggests that regulatory surveys have additionally targeted medical equipment which provide a direct impact on patient care and outcomes. Specifically, the safety of thermal warming units has come into question. The Joint Commission environment of care (EC 6.10 and 6.20) standards require that institutions provide written plans concerning the effective, safe and reliable operation of medical equipment. While the Joint Commission currently does not have any required range settings for the temperature of blanket warmers it does endorse the recommendations of the manufacturers of such devices.2-3
In 2006 the Emergency Care Research Institute (ECRI) issued a warning that while some warming cabinets may be designed with a wide range of temperature settings allowing a variety of temperature settings, patient safety and the prevention of thermal burns should be a primary concern.4-5 The ECRI report suggests there is evidence of patient injury related to overheated supplies and that maintaining all fluid and blanket warming cabinets at 110°F will prevent injuries, ultimately promoting patient safety. Temperatures above this level unnecessarily increase the risk of burns while providing no added clinical benefit. Some perianesthesia staff have reported that limiting the temperature settings of blanket warmers also limits the therapeutic benefits of warming blankets and solutions. Subjectively they report that the items do not feel warm enough to be used to affect patient comfort.
The ECRI (Emergency Care Research Institute) has responded to the concerns of clinical staff with the following recommendations::4-5
REFERENCES
1. 1 The American Society of PeriAnesthesia Nurses. Clinical Guideline for the Prevention of Unplanned Perioperative Hypothermia. 2006-2008 Standards of Perianesthesia Nursing Practice. ASPAN: Cherry Hill, NJ, 22-31, 2006. 2. Enthermics. Blanket Warming Temperature Standards and The Joint Commission. Last accessed February 10, 2008. Available at www.enthermics.com/learn/pdfs/Temperature%20Standards.doc. 3. Subhan A. JCAHO. Ascend Media, January 2007. Last accessed February 9, 2008. Available at http://www.24x7mag.com/issues/articles/2007-01_05.asp. 4. ECRI Institute. Limiting the Temperature of Warming Cabinets Remains a Good Safety Practice. Health Devices Alerts Action Item. Accession Number : A8073, 1-4, 2006. 5. ECRI Institute. ECRI Institute Upholds Recommendations on Warming Cabinet Temperatures. Risk Management Reporter – The Newsletter of the Healthcare Risk Control System, 26(2), 9 – 10, 2007. -------------- 6. Leslie K, Sessler DI. Perioperative hypothermia in the high-risk surgical patient. Best Practice & Research Clinical Anaesthesiology Vol. 17, No. 4, pp. 485–498, 2003
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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 2006-2008 Standards of Perianesthesia Nursing Practice, states: "Personnel and visitor dress codes are determined by proximity and frequency of access to operating rooms."1 Unfortunately, no other recommendations in the Standards address attire worn by perianesthesia personnel.
In 1999, the Centers for Disease Control and Prevention (CDC) published a "Guideline for the Prevention of Surgical Site Infection". This guideline indicated there were no well controlled studies relating surgical site infections to laundering of scrubs. Where and how to launder scrubs was described as an unresolved matter, and no specific recommendation was issued.3 This implies that scrubs laundered at home and worn from home do not pose a risk to patients. It also suggests that, at the end of the day, those same scrubs do not pose a health threat to 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 contaminate clothing founded in hygienic principles, common sense, and consensus.2 When clothing becomes contaminated with blood, emesis, urine, or any other body fluid, the clothing should be immediately removed and laundered at the healthcare facility. 2
The Association of periOperative Registered Nurses (AORN) does not support home laundering of surgical attire, citing a lack of evidence related to safety of healthcare workers, their families, and patients.4 AORN recommends that all reusable surgical attire, such as scrubs, cloth hats, and warm-up jackets be laundered after daily use in a facility approved and monitored laundry.4 AORN further advises that when healthcare workers are required by a facility to launder surgical scrubs at home, suggested measures for laundering the items should be observed. These include, but are not limited to: use of an automatic washer and hot air dryer; washing the scrubs separately and as the last load of wash; promoting microbial kill with a water temperature above 110° F; and the appropriate use of detergent and chlorine bleach.4
Regarding the use of scrubs by the perianesthesia nurse, a general survey of clinical practice constituents from across the country revealed wide variations in opinion and practice related to scrubs. 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. Clearly, the current state of the evidence offers an expansive opportunity for studies on the implications of laundering methods. Such studies are needed to further support the decision process related to the question, “home scrubs or hospital scrubs?”
REFERENCES
1. The American Society of PeriAnesthesia Nurses. Standard II: Environment of care. 2006-2008 Standards of Perianesthesia Nursing Practice. ASPAN: Cherry Hill, NJ, p. 13, 2006. 2. Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee. Guidelines for environmental infection control in health-care facilities. Available at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Enviro_guide_03.pdf. Accessed June 11, 2007. 3. Belkin NL. Home laundering of soiled surgical scrubs: Surgical site infections and the home environment. American Journal of Infection Control, 29(1): February 2001. 4. Association of periOperative Registered Nurses. Recommended practices for surgical attire. AORN Journal, 81(2): February 2005.
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Q: What research has been done on temporal artery thermometers, and how accurate are they compared to tympanic thermometers?
A. This is definitely a hot topic. The current research is primarily funded and conducted by the device manufacturer and industry. When searching the manufacturer's Web site, one finds that the company has a medical division with several articles listed on the site. Several articles are presented, and one summary article refers to a number of studies. One pilot study was presented by Steve Baumgart, M.D and colleagues, in May 2001 at the American Pediatric Society and the Society for Pediatric Research.1 This study compared infrared thermometry scanned over the temporal artery to digital axillary thermistor in premature neonates, and concluded that infrared temporal artery scanning makes repeated temperature assessment during incubation and rewarming easy to perform and it better reflects premature babies’ true core temperature while being less invasive than deep rectal or esophageal temperature monitoring.1
Another study conducted at Children's Hospital in Boston compared the temporal artery thermometer with the tympanic thermometer, and found the temporal method significantly more accurate. 1 A Massachusetts General Hospital study favorably compared the temporal artery thermometer with temperatures measured using a pulmonary artery catheter in adults.1
One reason for abnormal readings most frequently cited with the use of temporal artery thermometer is user error. Moving the thermometer too quickly across the patient's forehead or breaking contact with the skin may result in erroneous readings. If your unit is using the temporal artery thermometer, your biomedical department may need to purchase a calibration kit in order to routinely check temporal artery thermometers for accuracy.
Based on the electronic mail exchanged among our ASPAN members writing to the Clinical Practice Committee, it appears that most perianesthesia nurses currently using temporal artery thermometers do not want to give them up. While we acknowledge that more studies on the accuracy of infrared temporal artery thermometry in the perianesthesia patient population are required in order to validate this method as an evidence based practice, we nurses do like the relative ease and noninvasive features.
Thanks to Susan Russell, BSN, RN, JD, CPAN, CAPA, for her contribution to this response.
REFERENCE 1. Exergen Corporation. (2005). Independent Assessment of Temporal Artery Thermometry: Summary. Accessed November 18, 2006 at http://www.exergen.com/medical/eductr/clinicallyproven.html.
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Q: Regarding the standard about when to implement medical-surgical restraints -- when does the standard apply?
A. From what we understand, if the use of restraint is part of the customary post procedure care the standard for restraint does not apply. 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 containing 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.11.10 through PC.11.100.” 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 the staff may try to avoid the application of restraints. This is often accomplished by staying at the bedside, talking with the patient, and offering some pain medication and/or sedation. Once a patient emerges from anesthesia, but continues to need restraint to keep from pulling at lines or tubes, some institutions may require the initiation of restraints protocols.
Thanks to Clinical Practice Committee member Jan Lopez, BSN, RN, CPAN, CAPA, for her contribution to this response.
REFERENCES 1. The Joint Commission. Revision to the Introduction to the Standards for BHC Restraint and Seclusion. Available at http://www.jcrinc.com/6653/. Accessed March 28, 2007. 2. The Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Critical Access Hospitals, 2nd ed. Joint Commission Resources: Oakbrook Terrace, IL. PC-22, 2005.
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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. Resource 7, titled “ASPAN Pain and Comfort Guideline”1 recommends a multimodal approach for pain management in Phase I PACU. This subject is a challenge because regulatory agencies, boards of nursing, and hospital policies usually address this issue and thus ASPAN has a broad statement in Resource 7 stressing the importance of assessment, intervention in multimodal therapy, and reassessment. In addition, ASPAN offers “A Position Statement on the Safe Administration of Medication.” This statement is posted for reference on the ASPAN Web site (http://www.aspan.org/PosStmtsSMA.htm).
The ASPAN Standards do not describe specific interventions, such as correlating medication doses to pain scales. ASPAN’s pain guidelines basically follow the World Health Organization pyramid of mild to moderate and moderate to severe, and stress the importance of a multi-modal approach. In a recent article, 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.2 However, it could not be determined whether range orders contributed to the events, or in what environment of care the errors occurred.
Manworren2 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.
Special recognition goes to Maureen McLaughlin, MSN, RN, CPAN, CAPA, for her contributions to this response.
REFERENCES 1. American Society of PeriAnesthesia Nurses, Resource 7, 2004 Standards of Perianesthesia Nursing: 38-41. ASPAN: Cherry Hill, NJ, 2004. 2. Manworren R. A call to action to protect range orders: A consensus statement supports this important nursing responsibility, American Journal of Nursing, 106(7): p. 65, 2006.
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Q: Can LPNs work in the PACU if they are qualified (such as having BLS, ACLS, hemodynamic courses, arrhythmia courses, starting IVs, drawing blood, and working PACU for years)?
A. In reference to the question regarding what functions LPNs are allowed to do, ASPAN does not have a standard or position statement specific to the role of LPN in the PACU setting, regardless of the type of surgical facility. We do recommend that you look at your state board of nursing Website for some guidance. Each state has specific rules and regulations regarding the use of practical nurses, so this would be your best resource. The functions the LPN would be allowed to perform would be dictated by the state board regulations, as well as your facility's policies.
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Q: How long do you need to observe a patient who has had reversal of a benzodiazepine with flumazenil (Romazicon)?
A: Your question surrounded standards regarding discharge of Phase II patients after receiving flumazenil. The Standards of Perianesthesia Nursing Practice does not address this specifically. There is a resource in the standards that addresses "The Role of the Registered Nurse in the Management of Patients Undergoing Sedation for Short-Term Therapeutic, Diagnostic or Surgical Procedures". It covers management and monitoring, but really does not discuss specific medications.
The single point that needs to be kept in mind is the half-life of all the medications that were administered. According to Michael Kost, in his book Moderate Sedation/Analgesia, flumazenil has a half-life of 30-45 minutes. The duration of action for the benzodiazepines that flumazenil reverses can last hours equal to the patient’s age (diazepam), or one to five hours for midazolam. In determining the appropriate length of time to monitor the patient who received flumazenil, the age of the patient and renal and liver function need to be taken into consideration. Dosages of the administered benzodiazapines will also need to be considered as well as why the flumazenil was administered. Was it because of respiratory depression or was it to wake the patient up a bit more quickly to move them to the recovery area and free up the procedure room for the next patient?
There is no easy answer for the length of time the patient needs to be monitored in the Phase II area. Your facility policy will give you some guidance and, when in doubt, seek input from the anesthesia provider and obtain an evaluation regarding the safety of releasing the patient to a responsible party. Another good resource is Cecil Drain’s book, Perianesthesia Nursing: A Critical Care Approach. Lastly, try the 2005 edition of the Practical Guide to Moderate Sedation/Analgesia, written by Jan Odom-Forren and Donna Watson and published by Elsevier. Your hospital library may have these books if you don’t keep reference copies on your unit.
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Q: What does ASPAN say about the standards of L&D nurses obtaining and maintaining ACLS certification?
A. ASPAN is the Society that represents perianesthesia nurses working in the preanesthesia phase, postanesthesia care units, ambulatory settings, extended observation settings, special procedures (cardioversion, ECT, endoscopy, invasive radiology), pain management, etc. The assumption is that the above question refers to L&D nurses who recover patients that have had general or regional anesthesia after a C-section. However, relative to L&D nurses who care only for the laboring patient or a patient who has delivered normally under regional anesthesia, ASPAN has no such requirement (to obtain/maintain ACLS?).
ASPAN's Standard III addresses Staffing and Personnel Management. With regard to ACLS/PALS certification it states: "The professional perianesthesia nurse providing Phase I level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status as appropriate to the patient population served."
ASPAN’s Standard III also: “recommends that the professional perianesthesia nurse providing Phase II level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status as appropriate to the patient population served."
Phase I is defined as "the immediate postanesthesia period" during which time "basic life-sustaining needs are of the highest priority and constant vigilance is required ... as the needs of the patient are neither minimal nor episodic." “Phase II level of care focuses on preparing the patient/family/significant other for care in the home, extended observation, or care in extended care environment” (i.e. admission in this case). It is not the "1-hour" time frame, but the meeting of criteria that is essential.
Could this standard be met in another way? Yes, it can: when a CRNA or physician ACLS provider stays in the room with the L&D nurse the entire time until the patient reaches the predetermined criteria for discharge.
Thanks to Nancy O’Malley, MA, RN, CPAN, CAPA, for her contribution to this response.
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Q: Looking for a method to calculate IV fluid replacement for children and adults for the NPO hours, operative and post anesthesia period?
A. Adult fluid replacement:
Three part formula for deriving amounts of fluid to be replaced:
A. Deficit is defined as the time the patient is NPO to the time surgery begins 1. 4 ml/kg/hr for the first 0-10 kg10 kg10 kg10 kg 2. 2 ml/kg/hr for the next 11-20 kg 3. 1 ml/kg/hr for weight greater than 21 kg
B. Maintenance is defined as the time of incision to closure (dependent on the type of surgical procedure) 1. Eye surgery, extremity procedure 5 ml/kg/hr 2. Mastectomy 8 ml/kg/hr 3. Minor abdominal procedure 8-10 ml/kg/hr 4. Laparotomy/resection, thorocotomy 12 ml/kg/hr 5. Extensive procedure 15-20 ml/kg/hrkg/hr
C. Blood replacement: ml/ml for blood replacement plus 3 ml/ml crystalloid to estimated blood loss or 1 ml/ml of volume expander such as albumin
Schedule for replacement during the surgical procedure: A. First hour: ½ the deficit + maintenance + blood replacement B. Second hour: ¼ the deficit + maintenance + blood replacement C. Third hour: ¼ the deficit + maintenance + blood replacement
REFERENCE ASPAN, Redi-Ref 2004: Ambulatory/PACU/Pediatric (Ireland, D, Ed.). 10 Melrose Ave, Suite 110, Cherry Hill, NJ, p. 72, 2004.
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Q: How can patients with multi-drug resistant organisms (MRSA, VRE, etc.) be cared for in PACU? Do they need to be in an isolation room, recovered in the OR, returned to the patient room for Phase I level of care?
A. ASPAN's Resource 14 for Infection Control is in the 2006-2008 Standards of Perianesthesia Nursing. The Resource offers general guidelines and stresses throughout that each facility must have an infection control plan. The perianesthesia area must follow that plan while using Resource 14 as a reference for adaptation to the PACU and Pre-op setting as appropriate.
Regarding contact isolation, it is a given that Standard Precautions are used on all patients. According to Resource 14: ”Contact Isolation should be instituted for patients known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact during procedures that require touching the dry skin or indirect contact with items in the patient's environment. (VRE, enteric infections, contagious skin infections such as impetigo, abscesses, scabies, and MRSA when institution policy considers it to be of special or epidemiological significance)”. This statement allows each institution to make its own policy and determine if these infections are of special significance requiring special precautions and handling.
Resource 14 further states: "Place the patient in a private room when department or facility policy mandates. Wear gloves when entering the room and remove gloves before leaving. Wear a gown when entering the room if clothing will have contact with the patient or any items in the patient's environment . . . etc.”
The Resource recommends using disposable equipment or dedicating equipment to the patient. It also recommends that you ensure that multiple use patient items are cleaned using the facility approved disinfectant method.
Resource 14 states: "If the policy (facility) allows patients in main PACU, follow the same precautions using gloves and gown with one nurse to one patient initially. Nurse may have a second patient if the acuity of the two patients allows time for the nurse to remove gloves and gown, and wash hands between patients."
Thanks to Helen Buss, BSN, RN, CPAN, for her contribution to this response.
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Q: What is the definition for Phase I and Phase II?
A: The best resource for this question is the 2006-2008 ASPAN Standards of Perianesthesia Nursing Practice, which you can purchase from the ASPAN Website. Having said that, Phase I and Phase II are defined as follows in Resource 3 of the 2006-2008 Standards of Perianesthesia Nursing Practice, “Patient Classification/Recommended Staffing Guidelines” (also available on the ASPAN Website):
Phase I Level of Care: The professional perianesthesia nursing roles during this phase focus on providing postanesthesia nursing care to the patient in the immediate postanesthesia period, and transitioning them to Phase II level of care, the inpatient setting, or to an intensive care setting for continued care.
Phase II Level of Care: The professional perianesthesia nursing roles during this phase focus on preparing the patient/family/significant other for care in the home, extended observation level of care or the extended care environment.
Thanks to Terry Clifford, MSN, RN, CPAN, for her contribution to this response.
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Q: What are the criteria for discharging a patient following spinal anesthesia?
A: The question about discharging patients that have received spinal anesthesia surfaces frequently. This is a concern in today’s healthcare world of: increased caseload volume from more patients requiring surgical intervention; a shortage of competent PACU nurses; limited bed space in Phase I and II; concerns for adequately addressing patients’ comfort and safety; and managing our financial budgets. In reviewing recent literature, it was interesting to note that the first question we must answer is, to where are we planning to discharge the patient?
If it is to an in-house nursing unit, there are recent studies that suggest patients can be discharged when the following criteria are met: sensory blockade lower than T10, minimal movement of the lower extremities, and no need for fluid resuscitation. However, most of us are still following the standard discharge criteria of stable adult patients, able to stand, walk and void following spinal anesthesia if they are going home or to another nursing unit.
If you do not use a patient classification scoring system to determine “Readiness for Discharge” for all patients in your units, I would suggest that your unit consider doing so, beginning with Resource 4 “Criteria for Initial, Ongoing and Discharge Assessment and Management” found in the 2006-2008 ASPAN Standards of Perianesthesia Nursing. There are several other scoring systems (other what? Resources?) [PC2]that are commonly utilized by many PACUs as they were published by their authors or adapted to meet the specific needs of a unit’s patient population. The Postanesthesia Recovery Score of Aldrete and Kroulik1 is an excellent Discharge Scoring System, as is The Short-Stay Surgery Discharge Score (SSSDS) noted in that same article. 1 For optimal safe patient care your unit needs to adopt or develop a patient discharge scoring system and have it approved by your facility for all patients that receive care there, including patients receiving spinal anesthesia.
Thanks to Barbara Hannah, EdD, MSN, RN, CPAN, for her contribution to this response.
REFERENCE Mortensen M. Discharge score for surgical outpatients. American Journal of Nursing, 86(12): pp. 1347-1349, December 1986.
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Q: Must a registered nurse accompany patients being transferred from PACU?
A: Resource 10, Safe Transfer of Care in the 2006-2008 Standards of Perianesthesia Nursing Practice states, among other things:
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Q: What does ASPAN say about families visiting in PACU?
A: ASPAN has taken the position to support family visits in PACU. Guidelines certainly need to be in place to assist with incorporating family visits in the Phase I level of care. There is a Position Statement included in the 2006-2008 Standards of Perianesthesia Nursing Practice that is available on the ASPAN Home page. It can be found under Clinical Practice and is titled “A Position Statement on Visitation in Phase I Level of Care.”
In units that have adopted family visitation practices the results have been positive for all. It is reassuring to family members to see their loved ones and patients also find it comforting. This practice requires education for the family and measures taken to provide patient confidentiality and privacy.
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Q: What are the staffing recommendations for Phase I level of care? Is it necessary to have two nurses present?
A: The answer to these questions can be found by returning to the ASPAN home page. Click on the Clinical Practice button at the top of the page and “pull down” to Patient Classification. In Resource 3 of the 2006-2008 Standards of Perianesthesia Nursing Practice, “Patient Classification/Recommended Staffing Guidelines”, you can read the Resource in its entirety and print if off for reference.
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Q: How many PACU beds should there be for each OR?
A: In Cecil B. Drain’s fifth edition of Perianesthesia Nursing: A Critical Care Approach you will find some recommendations. It states: “For an inpatient hospital PACU that serves a combined patient population of inpatients and same-day admission patients, a ratio of 1.5 to 2 PACU bays per OR is necessary to safely care for the patient”. For a same day surgery setting “with a limited number of surgical services and types of procedures, 2.5 to 3 PACU Phase I and PACU Phase II (combined) bays are necessary”.
Things to keep in mind are the type of surgeries done and the type of anesthesia generally preferred by the anesthesia providers. Will most of the patients have a high acuity and require prolonged monitoring and observation? Will most of the anesthetics be regional blocks with sedation and be “fast tracked” to the Phase II level of care? When these questions can be answered, it becomes easier to determine the number of beds needed for a particular institution.
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Q: What are hospital PACUs doing regarding sending patients back direct to ICU from the OR, especially if the patient came from the ICU? If the patient goes back to ICU must a PACU RN recover the patient there?
A: This issue has been debated for years, and ultimately, it is up to each hospital to decide based on staffing of both PACU and ICU. ASPAN Standards cannot dictate where the ICU patient will be recovered or by whom. It really is imperative to consider the needs of the patient and how much care he/she will require. Collaboration between the two units can clearly benefit both units in most hospitals.
Frequently, if the patient came from ICU and is returning to ICU intubated, the ICU nurse recovers without a PACU nurse unless the patient is very unstable and ICU has limited available staff. If a PACU nurse is available, the PACU nurse can help as needed.
If the patient is extubated, some anesthesia departments prefer that a PACU nurse care for the patient either in ICU or PACU. During the day, the ICU patients may come to the PACU as PACU staffs have co-workers present to assist as needed. When on call, most prefer to recover the patient in the ICU as there are more resources immediately available.
There are discussions about having ICU nurses recover all ICU patients. There are two drawbacks that will arise:
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, safest, most qualified person to 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 post anesthesia care.
Thanks to Nancy O’Malley, MA, RN, CPAN, CAPA, for her contribution to this response.
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Q: Is it necessary for a cardiac rhythm strip to be recorded and placed with the PACU record?
A: Resource 4 in the ASPAN Standards states that the cardiac monitor rhythm must be documented. The Standards do not elaborate as to the specifics of how the rhythm is documented, i.e., a rhythm strip. Many facilities place a rhythm strip in the flow sheet, as well as document the rhythm. If the rhythm changes, the nurse can then place a second strip in the flow sheet showing the different rhythm as well. If there is an issue with placing a rhythm strip in the chart, you might ask how the nurses have demonstrated competency in ECG interpretation so that nurses’ interpretation of the rhythm without the actual rhythm strip can be validated.
Anesthesia providers will often bring strips from the monitor obtained during surgery, especially if some change occurred. Rhythm strips are frequently obtained upon arrival in the PACU. The timing element of the obtaining a rhythm strip postoperatively is that anesthesia can have harmful cardiac side effects, especially in elderly patients, and the rhythm strip may capture the effect. It is also helpful for documentation purposes. When a nurse is relieved for a break or handing over his/her assignment, it is helpful to have documentation to compare with the present monitor pattern in case some change has occurred during the postoperative course.
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Q: Looking for guidelines from ASPAN for recommended frequency of vital signs in Phase I level of care.
A: ASPAN’s 2006-2008 Standards of Perianesthesia Nursing Practice does not specify how frequently vital signs need to be taken. Frequency is patient specific according to stability of condition and degree of variance from baseline. Most institutions have a policy to take vital signs every five minutes for the first 15 minutes, and then every ten to fifteen minutes for the duration of the stay depending on patient stability and return to baseline. If the patient is very unstable, perhaps on vasoactive drips, etc., the frequency will be at least every five minutes until the patient is more stable. It is unusual to find a time span greater than fifteen minutes in Phase I PACU unless the patient is a boarder or awaiting transfer to another area.
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Q: What do we need to do to be in compliance with standards for follow-up phone calls after outpatient surgery?
A: The Joint Commission standards do not require a follow-up phone call. Standard PC.2.20 from the 2007 Comprehensive Accreditation Manual for Hospitals and the 2006 Comprehensive Accreditation Manual for Ambulatory Care allows an organization to define what data and information is gathered during assessment and reassessment. PC.2.150 allows organizations to determine timeframes for reassessment based on patient needs and the care, treatment and services provided. The organization must be able to justify the efficacy of the mechanism chosen based on the patients it serves and the services or care provided.
In practice, most organizations, especially those performing surgical and/or invasive procedures on an outpatient basis, find the post-procedure phone call follow-up to be helpful from both a timeliness and patient-focused perspective. Organizations that have chosen to adopt the phone call reassessment must also consider how it will be accomplished for patients requiring follow-up on weekends or at other times when staffing is an issue.
Additionally, LD.3.20 from the same manuals, requires that patients with comparable needs receive the same level of care, treatment, and services throughout the organization. The question an organization must ask in that situation is whether or not the intensity of reassessment for outpatient surgical patients is comparable to that for other patients in similar situations (e.g., inpatients, post-procedure outpatient interventional radiology)?
In the 2006-2008 Standards of Perianesthesia Nursing Practice, Resource 4 “Criteria for Initial, Ongoing, and Discharge Assessment and Management” states: “Discharge Assessment: Extended Observation - The Registered Nurse will adhere to institutional policy for patient reassessment following discharge. How this is done will be determined by institutional policy and procedure.”
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Q: What are the recommendations for PACU nurses regarding ACLS and PALS?
A: This is addressed in Standard III in the 2006-2008 Standards of Perianesthesia Nursing Practice, “Staffing and Personnel Management”. It states, “The professional perianesthesia nurse providing Phase I level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served.”
At one time, the phrase “or equivalent” was included in this statement, but this was deleted in the 2002 Standards. The decision to delete was made when the AHA ACLS protocols were based on evidence. Research is ongoing, with changes made in the protocols as evidence supports new recommendations for practices, making it difficult for institution developed programs to reflect these changes in a timely fashion.
Page updated June 30, 2008
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