Surgical Recoveries in ICU?

hollykate · Jan 13, 2001

Hi Zee,

We always have a 2:1 ratio and PACU has been trying to push this with us as well. If they are still intubated, we will take the pt, but if they are extubated, it is up to PACU to recover them. PACU (especially if it is late at night) still tries to roll them over-so far the ICU super. has put a stop to it, but we'll see how this year unfolds. I agree with you, it is very un safe- and thats why there is a specialty unit- the PACU, to recover these patients.

McIndia · Jan 14, 2001

We don't really have a "policy" yet...but we have been going back and forth with the anesthesia dept. and the PACU staff and the surgeons about recovering patients in the CCU. So far, if a nurse is going to have to recover a patient in the unit, the charge nurse will try to shuffle assignments...so you will have a transfer patient or a cath lab patient...not another unstable vent patient or someone that is crashing, along with the PACU patient. Noone has had to take a PACU patient along with 2 others...yet. If the patient is not reversed in the OR, then the PACU will send someone up with them for the first 30'or hour(if they can spare anyone...usually they can for the first 30'). It all comes down to what kind of surgery the patient had...so far we only take the ones that are intubated(whether they were in CCU before the surgery or intubated during surgery and not extubated after). We do not feel comfortable doing this because we are not really oriented to PACU procedures...but that is not really an issue with the powers that be, so we do the best we can. We are all afraid this is a trend we will not be able to stop.

Jacci59 · Jan 14, 2001

There are good and bad points to this idea of ICU recovering pts. I am a retired PACU nurse, and we were not ICU nurses where I worked. There many facets of ICU care that we were not that familiar with, such as ART lines etc. For that reason, most patients that were going to ICU after surgery, went directly to the unit. If a patient was still intubated from the surgery, because they were not reversed, they never left the OR until they were at least breathing on their own. A pt who is still intubated is much safer than a patient who is not, under those conditions. So it shouldn't matter to ICU if they are or are not intubated. Our theory was that the patient would receive better care by the ICU nurse who knows about all the different lines. The person performing Anesthesia should be in close contact with you anyway, as far as any medications are concerned, and should leave you orders for any meds needed. Many of the meds we used in the PACU were also used in the ICU, with the possible exception of Fentanyl, a very short acting drug, for pain, but also used sometimes with induction.

I must add that ours was a fairly small, but growing Community Hospital. Our ICU nurses always liked to get their own patients, they felt that they could take better care of them than we could.!!

OC_An Khe · Jan 14, 2001

Many smaller hospitals use thei ICU's as recovery rooms when PACU is closed. The issue is twofold. The first is that the hospital is following ASPAN's standards of care and the ICU staff is oriented to that level. Secondly that it doesn't impact on the nurse patient ratio in the ICU. Look to the specialties standards of care and use them to setparameters for PACU patients in ICU's. As a matter of course it is not unusual for the PACU to have patients with a-lines, vents, etc. In fact when ICU is gridlocked they want to use PACU as an overflow for ICU patients.

Marilou26RN · Jan 14, 2001

Zee-RN: I am currently working in PACU in a trauma hospital. The anesthesiologist has the final word on whether the pt goes directly to ICU or comes to PACU, then to ICU (naturally, the surgeon has written the order for ICU bed). They stay w/ us for 1 hr. unless further complications arise. We are not ICU-trained RN's..any complications, anesth. dr are the ones that issue the orders. We don't have the staff comparable to ICU. We may have 3-4 pts coming in at the same time. All fresh,anesthesized surgical pts are high risk for any complications. An ICU pt that may be intubated in OR or PACU is a 1:1.

Zee_RN, BSN, RN · Jan 14, 2001

Thank you all for your replies. We just had a recovery here that was just awful. The RN had 3 ICU patients--the fresh laryngectomy post-op, a 6-hr extubated pt who was starting to crash and a pt returning from the GI lab s/p procedure. The recovery returned with a heart rate in the 40s and BP 220/110. No anesthesiologist came up with patient. We had no MD in the ICU. We placed call to anesthesiologist--he said "I can't come up! I'm in middle of a nephrectomy!" Order given to give apresoline (not a stock med here). Run around, get med. Place more calls to anesthesiologist. He says call me back. We call back--he's left the building. Call surgeon--surgeon says 'not my department, call anesthesiologist.' It was just horrible. Other nurses managed to take care of this nurse's crashing respiratory failure (who did get reintubated) and GI lab patient who also had to have central line inserted during all this fal-da-ral. With 3 patients each, our nurse patient ratio is not conducive to safe care during a recovery. Especially considering the lack of support from anesthesiology.

Jenny P · Jan 14, 2001

Zee, the situation you just described is horrible! Your hosptial has to have a risk management department; if it was me, I would send incident reports to your manager, supervisor, medical director of your unit, head of anesthesia, risk management, and whoever else may be in the chain of command at the hospital (also the docs involved). If you are a member of your state nurses association, send them a "concern for unsafe practice" form also. What those docs did risked that patients' life and the nurses' license--- and your unit being so short staffed is dangerous to every critical patient there. There are standards of care for ICU's; get them from AACN and ANA and give them to your manager. I'd probably pass them out to every nurse who works there also. We are NURSES, NOT DOCTORS, and I'm tired of docs blowing us off when we call them. I work CV-ICU and am very assertive when it comes to my patients' life being endangered by a doc who doesn't want to come in or hasn't given the right orders for the patient (I work nights and some docs don't make sense when you call them. I hang up and call them back; and they may be p*$#ed off, but they will give decent orders because they ARE awake- and angry. My defense is that my patient needed the doc's attention, and his previous order was inappropriate).

[This message has been edited by Jenny P (edited January 14, 2001).]

Jacci59 · Jan 15, 2001

Dear Zee, It sounds like you do not have musch cooperation from your anesthesia department. I would call what that anesthesiologist did, abandoment !! If he could not respond, he should have sent another one of the anesthesia staff up to the unit, with the needed drugs, if you did not have it on the unit.

When I retired from the PACU, we were starting to be inserviced on ART lines, which is actually the only thing that we were not that familiar with. We did take care of patients on vents, etc. I truly believe that each hospital must set standards of care for patients following anesthesia, who are ICU bound. Each unit must work together in this matter. There will be times when acuity of either unit may change these standards. One such case int eh Unit was mentioned by you. In that case, if PACU was not up to their a-- in alligators, then they should have been able to keep that patient who was fresh post op. We had a situation in PACU where we had 3 of our 4 nurses tied up with a patient who developed Malignant Hypertension. A case like this takes at least 3 nurses to care for the patient until the crisis is over. There really needs to be a general understanding between the 2 units, and a commeraderie,so that the 2 units can work together. It seems that in too many hospitals there is just the opposite. We need to put ourselves in each others shoes, and show a little understanding of each others problems. Hope that this helps a little..........Jacci

Margy · Jan 15, 2001

Hi all.... I work in a recovery unit here in Aus and our policy is that if the patient is deemed to need ICU care post op ( either due to the type of surg,complics or previous med hx) they go straight to ICU and bypass us in the PACU REC. I feel that this is correct procdeure as if the pt needs intensive care they should be there for the duration of their stay. Staffing should reflect these needs,and be appropriate to take these pts.

Cheers, Marg

grammied50 · Feb 22, 2001

KNOW THIS A LATE REPLY,BUT I AMA PACU RN. WITH NOC CASES IT WOULD BE MOST HELPFUL IF THE PT. WENT TO ICU POST OP. SEV. PLACES WHERE I HAVE WORKED BEFORE THIS WAS STANDARD.THEY HAD RECOVERY EXPERICENCE. IN OUR PACU THE SAME NURSE AT NIGHT IS PROBABLY THE SAME NURSE TO WORK DAYS. THE ICU DIRECTOR HAS BEEFED UP HER STAFFING TO ACCOMODATE THIS. IF ICU IS FULL,WE ARE EXPECTED TO FUNCTION AS AN ICU HOLDING AREA. IN MY EXPERIENCE IT IS BETTER FOR THE PT. TO BE MOVED ONLY ONCE! ALOTS OF THOUGHTS,SOME HAS TO DO WITH STAFFING AND NOT BEING ABLE TO WORK ALL DAY AND THEN ALL NIGHT!

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