Recovering Patients

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    For all you PACU nurses please give me your input on this situation. Should patients be recovered in an ICU by nurses who have never been oriented to PACU nursing. A battle is being waged at my place of work as my colleagues and I refuse to recover patients in the ICU as we have no training in PACU nursing. Last week a patient was brought to the ICU intubated, unrecovered, with a systolic of 217. The ICU nurse refused to take report, and before you knew what was happening all the big chiefs were on the floor, and the argument ensued. Come to find out, our boss agreed to this new policy with the head of anesthesia, without notifying the ICU staff. The only problem they are having is that we refuse to take these patients, owing to the fact that patient safety is compromised, as we are not PACU nurses. Our ICU is not an open plan. Every patient has their own room, and the unit is massive. Our ratio is 2:1, and sometimes 3:1. We would not be able to stay in the room continuously with the unrecovered patient. What are your feelings on this issue. I have printed the standards of care for PACU nursing which I obtained from the ASPAN website for my boss. I will be giving this to him in the morning.

    Thanks
  2. 9 Comments so far...

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    We have had the same battle at our hospital as well. As a PACU nurse I believe that some critically ill patients need to go directly to the ICU after surgery. Many times they are just too unstable and critical to make the stop in the PACU before going to ICU. It is also an added expense to this patient when we in the PACU wouldn't actually be recovering them. In our facility if the patient is going to be vented post-operatively and kept immobile for 12 hours or more the ICU staff takes them directly from the OR. If the staffing in the ICU is such that they cannot take this patient a PACU nurse will come up to assist. However on the night shift this practice gets abused. There are problems with equipment that isn't the same in both units, ICU staff claiming they are too busy but are sitting at the desk while the PACU nurse is busy and no assistance is offered. I think this is a dilemma in many facilities around the country. There is no easy answer. I think you have to look at it as what you are trying to do for the patient. Are you actually recovering the patient or are you stablizing them? Recovering from anesthesia has specific criteria and many of these patients aren't going to meet this criteria so are you really recovering them? At our facility Diprivan drips are used in the ICU to keep critically ill patients down while vented. Diprivan is an anesthetic agent. I think we all have to keep an open mind and do what is best for our patients at the moment and not refuse to do something. The patient is the one who needs us. Ask for more education, information, and get specific criteria as to what is expected of you. Ask that the PACU nurses/educator or Nursing education come in and teach you what you need to know. Knowlege is power and the more knowlege you have the more valuable you are.
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    I am a PACU nurse and our ICU takes their OR pts. directly unless they are filled and then they stay in PACU until a bed opens up, but this is rare. We do recover the CCU pts. because those nurses are not trained in standards of PACU care. It is a hassle to take care of the CCU pts. with drips like Amidarone(sorry if I spelled it wrong). We were going to ICU at night to recover OR pts. just as a place to stay so we would not be alone in PACU instead of having 2 nurses come out at night because we are on call and work that day and the next day and we got abused by ICU expecting us to stay all night and recover their pts. so this ended.
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    Our argument is that we do not object to recovering patients if we have been given adequate training. Our trainining was a two page paper listing the drugs used for anesthesia. Two weeks ago we were given a pt during the night straight from the OR with a systolic B/P of 58, an anesthesiologist who could not wait to leave the patient, no vent orderes or med orders. It took three ICU nurses to attempt to stabilize the pt. By the way the pt died the next day! During this time who was taking care of the rest of the ICU patients? With adequate training, staffing, and specific policies and protocols we have no problem taking the pt. We also have a PACU nurse who is on call for 40 hours a week for night shift. She gets paid for forty hours whether she works for ten hours or fifty hours. We do not do that many surgeries during the night so we belive that she should be made to earn her pay.
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    London 88: You have just described a scenario that all PACU nurses deal with every day, anesthesia rushing to start another case and not back up the OR schedule; plus having a wide awake SDS pt waiting impatiently to go to their room; plus having a family member visiting the other pt. because there is no admit bed for the inhouse pt and no where to put an awake stable pt. who has been in PACU at least 3 hours. We do have curtains and pull them around but a lot of privacy is given up.
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    london 88

    I find it hard to believe why an icu nurse cannot deal with a hypertensive / hypotensive pt.

    if you have one pacu nurse on call at night, how would that person handle the case alone, when it took 3 nurses in your dept to handle the pt.

    would that be safe for one nurse?????
    what would be BEST for the pt???? your extra work aside.

    do you think i received extra training from anesthesia when i became a pacu nurse. hahahaha.
    two drugs : morphine, phenergan. and fluid bolus.

    there is no real reason why a pt that is intubated (that will not be extubated soon) needs to stop in pacu. recovery is about waking up, orienting the patient. making sure that the patient is safe on a med surg floor, ie can call for help, or will not vomit and aspirate.

    level I trauma accreditation looks at this point exactly. any multisystem trauma pt from OR should go straight to icu whenevr possible.

    if it is really a hardship on your dept. call the on call pacu nurse in to HELP recover the pt. i have no problem with helping out another dept.
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    Thanks Dan for the post. I totally agree with you. For days I have been thinking that we in PACU recover then often BOARD CCU/ICU patients for hours waiting for a bed to open up. I have had NO ICU training, and yet, I manage to care for these pts. WHY? Because PACU is a critical care area, as is ICU/CCU and ER. If you need more education in recovering patients I am all for you asking to go spend a shift with PACU RN's for a day or 2. This is how I learned it. It's the same all over... AIRWAY, BREATHING and CIRCULATION, the rest is comfort, pain control, nausea control and dysrythmia management. Same stuff you do in ICU. Oh yeah, keeping the patient warm is really important, as OR is freezing (and certain procedures use cold blankets on purpose and cold saline....)
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    At our hospital, a couple of PACU nurses come and recover the pt in the ICU for at least an hour. I don't know of any problems we've had. Basically, the ICU nurses are happy the PACU nurses are there, and the PACU nurses are happy to be in ICU, where help is readily available.
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    Sharran,
    You have stated my point. We have no objections if we are allowed to go to PACU for one or two shifts to get a feel for what PACU nurses do. Maybe it is the same as what we do but we do not know that. In terms of the PACU nurse being with the pt by herself, well that is not what we are advocating. What we are saying is bring the pt to ICU with a PACU nurse, and an ICU nurse will assist. However the situation became a mute point yesterday as the issue went to the vice president, who agreed that a PACU nurse must come to ICU to recover the pt because of the dynamics of the ICU, and that the ICU must assist. The issue is about the dynamics of our ICU. We have a 20 bed ICU where every pt has their own room. The unit is huge and covers a lot of area. It is not possible to remain in the room with an unrecovered pt continuously, and to maintain some of the standards set by ASPAN such as a vented unrecovered pt needing 2:1. If you dispute what it is I am saying, go to ASPAN website and look at the standards of care. I am not naive to believe that all hospitals maintain those standards, but it is worth aiming for owing to pt safety, and not because of extra work for the ICU nurses. It is also worth mentioning that we have a PACU nurse who is on call for forty hours a week, who gets a full salary regardless of what hours she works. We only do emergency surgeries during the night, so there is not that many surgeries during the night. This also influenced the vice presidents decision.
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    London,

    I understand what you mean. Our experience however has been to be treated terribly by ICU. They don't help us and they expect us to stay far past the "recovery" period. Some pts just won't get more stable...that's why the ICU bed. I do believe the ASPAN citation, have read it, and follow it as much as possible(too bad the hospital does not). Certain pts are 1:1 and if no ICU nurse able to, then you need PACU. Why don't facilities cross train? I see so many RN's in ICU who are freaked out because the were floated from tele or ER. This is NOT the same type of nursing! I myself would refuse to float to ICU without training....so you are correct in trying to "refuse" recovering, until properly trained.

    Take care


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