Question for PACU Nurses

  1. I'm newly appointed Charge Nurse in ICU, having work there as a staff nurse for >3 years. Had an event yesterday that I need input on.

    We sent a patient to the OR for a lap chole. He was in a SR and on room air (88-years-old). The PACU nurse called me and said they were sending him straight up to ICU post-op because he was ventilated, on dopamine, neo and epi. OK, fine (? happened?!) but fine. Nearly immediately she called back and said "you need to send a nurse to the OR; he's crashing." Ummm...never heard of that! ICU send a nurse to the OR?! We couldn't do that and she said "OK, he's coming up right now." So this patient comes into the ICU with an ABP systolic of 50. Never got it any higher. We poured blood products and fluids and added levophed to the routine and desparately tried to get a central line in him (they sent him up with a 22g in his left hand and a 14 gauge angio cath in his neck!). After about 90 minutes of this (ABP never higher than 50) with blood pouring out of his JP drain requiring constant (every minute) emptying, we took him back to the OR where they found a bleeder (big surprise) and fixed it. He came back and we were able to wean some of the pressors off (down to dopamine 6 and levophed 16).

    My question: doesn't PACU handle these types of crises? I thought that was the purpose of PACU--so they could send them back to the OR urgently if needed, under the supervision of the anesthesiologist. We DO NOT have an intensivist in our unit. We have family practice residents--on call. We just happened to have the pulmonologist there on the unit yesterday and HE managed the case while the patient was crashing in ICU and inserted the triple lumen. The surgeon paced uselessly back & forth.

    I'm honestly looking for advice; I'm new to charge (only 6 shifts under my belt!) and I'm not sure what to expect from ancillary departments. The charge nurse who followed me said "did you write it up?!" Ummm, well, no. Didn't realize it was "write-up-able." What do you think?
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  2. 19 Comments

  3. by   shodobe
    I don't work in the PACU, I work in the OR but it does seem the PACU was wrong in sending this patient to you in that condition. Our PACU would have NEVER even considered doing this. Patients are supposed to be sent back in stable condition, your's wasn't. They should be trained well enough to know this and not "dump" a problem on your shoulders and to call for help from you is really ridiculous. The bleeding issue should have been addressed in the PACU by the surgeon. Do you have more than your fair share of incompetent surgeons and anesthesia? It sounds like it. Not to put your hospital down but these are simple issues and where I work it would have never led to the problems you describe. That patient would have been left in PACU all night if necessary and no one would have questioned it. I would be talking to the PACU charge to find out what the problem was concerning her people. What made them feel this was something they couldn'e handle. Our PACU nurses are just as well trained as the ICU nurses we have upstairs and they can handle anything. Maybe a newer nurse on the floor or whatever. Definitley something to look into. Good luck! Mike
  4. by   nowplayingEDRN
    Speaking from both worlds....I am a ICU nurse and a PACU nurse (our facility is so small that the ICU and the PACU staff are combined and ICU does after hour recoveries). We are all ACLS/PALS trained. And PACU nurses are trained to handle crises and emergencies. ...we have a crash cart and emergency drugs to use in just such an event. Sometimes if a CODE is called...(during the day when there is both an ICU and a PACU nurse) the ICU nurse will go to assist in PACU. However, if there was blood pouring out of the JP, my question would be: Why was this not picked up on in PACU. After all there is criteria that a patient must meet to leave PACU. It seems that something like a JP drain rapidly filling with blood would be an indication that there is something amuck and the surgeon needs to be called, like yesterday. What were the qualifications of the staff working on PACU?? Was the staffing appropriate for the number of patients in PACU? Why did the surgeon wait so long to take the pt back in and do an exploratory to find the source of bleeding?? As shodobe said if the pt was not stable enough to leave PACU....he should have never been transfered to the ICU. Except here, we primarily do ambulatory procedures and and any inpatient surgeries surgical cases are scheduled during regular business hours. I realize that we don't do a ton of major surgeries but here if they are not fit for the floor....they get admitted to the ICU because all of the ICU nurses are trained to function in PACU and our unit is tiny (2 beds) so...the staffing and care is more than adequet. General rule of thumb here is, if they can not be stable enough to go to the med-surg floor, the surgeon is called and orders are obtained to admit the pt to ICU where PACU protocol is continued. They would spend 24 hr in ICU and the surgeon comes in the am to re-evaluate.

    Sounds like risk management needs to get involved to evaluate the events that transpired so that the area where the break down occured can be re-evaluated and measures can be developed and taken to correct the problem so that it does not become a fatal problem the next time around.

    Good luck and let me know how you make out, Zee.

    Christie
  5. by   Zee_RN
    He never made it into PACU; they rushed him right up to ICU, the PACU nurse in attendance along with anesthesiologist. Both of whom piddled around while the pulmonologist and two ICU nurses managed the care of the patient (which meant four other ICU patients were not seen by their nurses--the nurse assigned to the patient had TWO other patients and the nurse who helped her had two ICU patients of her own). The surgeon is one who rarely operates at our facility (and will certainly never touch a member of MY family!) and I was unfamiliar with the anesthesiologist too. Maybe because it was Saturday? The surgeon, as I said in the first post, truly just walked around--with his hands clasped behind his back--while the pulmonologist managed the case.

    So the general rule is--patients leave PACU when stable? Even when it is an ICU patient (although the patient was not in any way in a critical state when LEFT ICU to go to the O.R.).? Thanks for helping me understand this issue.
  6. by   sharann
    Our PACU would never do this. We would stabilize as best we could in recovery. However, your PACU nurses may not have the training to handle such a critical pt.?
    We are competent to handle these and do, but some nurses may freak at this. Now I don't know how "Stable" you want th pt, but your patients are critical are they not. I've had ICU nurses freak at me for bringing up a pat with a systolic of 84. Well, considering what the pressure HAD been (60's) I think they were lucky to get such a stable pt. Does ER send you all your patients nice and stable?
    My main point is that something is wrong with your PACU staff, either their competence or their communication skills. UNLESS, that RN was ALONE in PACU after hours with no backup. In that case, she/he would be doing exactly the RIGHT thing.
  7. by   Charity
    In our facility, all ICU patients bypass PACU. Of course, in our facility, family medicine residents are not allowed in our ICUs. It is obvious that this patient should not have left the OR in the first place. If the patient is expected to remain on all the drugs, vent, etc, it would make sense to transport directly to the unit. Get them settled once for the day. From what you describe, however, they were not ready for transport. Somebody panicked.
  8. by   storey
    I know that we would not have done the same thing at our hospital. Our PACU RN's are expected to be able to handle this type of situation. However we are a LEVEL 1 trauma center. We are ACLS and PALS certified and deal with crashing pts frequently.
    I guess there are a few things that would need to be looked into...
    1. what was the pacu staffing and rn/pt ratios at the time--maybe there were no open slots for the pt at that time.
    2. Why was the pt even allowed to leave the OR if this unstable with blood continually running from JP? The OR staff is also trained for this. And what Anesthesiologist even consented that the pt leave OR/PACU to begin with? They are responsible for stabilizing pts. before taking pt. to another floor?
    3. Was this pt. transferred with a transport moniter to watch VS on way to unit?
    After looking into some of this I would definately write up some sort of incident report-- Bottom line is this pt. was placed at great risk here.
    Let us know how this turns out--Best of luck to you.
  9. by   ratchit
    I think it should be written up- obviously something went wrong. Any unexpected event or death should be investigated by risk management- they are notified of these events primarily by incident reports.

    I agree that the patient should not have left the OR- that kind of bleeding can't be stopped by nurses in any unit- that patient needed to go back to the OR. But we cannot refuse patients out of the OR for any reason other than no space in PACU. When the surgery is done is the surgeon's scope of practice only. We can make suggestions, though... Did anesthesia protest? Did the PACU nurse protest?

    I have an idea why they went to the unit- it sounds like the PACU nurse was on call alone. If the surgeon brought the patient out of the room like that, I would sure as heck not want to be alone in the PACU with that situation. When you're on call you have to make the calls, get the supplies, hang the IVs, mix the drips, send the labs, deal with the phone, everything. Sounds to me like she wasn't dumping on you but asking for your help- she came up to deal with this with the help of other nurses around.

    Write down everything you remember now for the sake of your own memory. Write the incident report. Ask the PACU nurse and anesthesiologist for their thoughts on what happened and why the pt came to the ICU.

    Sounds like you did well under fire, though. Congrats.






    Originally posted by Zee_RN
    I'm newly appointed Charge Nurse in ICU, having work there as a staff nurse for >3 years. Had an event yesterday that I need input on.

    We sent a patient to the OR for a lap chole. He was in a SR and on room air (88-years-old). The PACU nurse called me and said they were sending him straight up to ICU post-op because he was ventilated, on dopamine, neo and epi. OK, fine (? happened?!) but fine. Nearly immediately she called back and said "you need to send a nurse to the OR; he's crashing." Ummm...never heard of that! ICU send a nurse to the OR?! We couldn't do that and she said "OK, he's coming up right now." So this patient comes into the ICU with an ABP systolic of 50. Never got it any higher. We poured blood products and fluids and added levophed to the routine and desparately tried to get a central line in him (they sent him up with a 22g in his left hand and a 14 gauge angio cath in his neck!). After about 90 minutes of this (ABP never higher than 50) with blood pouring out of his JP drain requiring constant (every minute) emptying, we took him back to the OR where they found a bleeder (big surprise) and fixed it. He came back and we were able to wean some of the pressors off (down to dopamine 6 and levophed 16).

    My question: doesn't PACU handle these types of crises? I thought that was the purpose of PACU--so they could send them back to the OR urgently if needed, under the supervision of the anesthesiologist. We DO NOT have an intensivist in our unit. We have family practice residents--on call. We just happened to have the pulmonologist there on the unit yesterday and HE managed the case while the patient was crashing in ICU and inserted the triple lumen. The surgeon paced uselessly back & forth.

    I'm honestly looking for advice; I'm new to charge (only 6 shifts under my belt!) and I'm not sure what to expect from ancillary departments. The charge nurse who followed me said "did you write it up?!" Ummm, well, no. Didn't realize it was "write-up-able." What do you think?
  10. by   ratchit
    PS- sending patients back to the OR emergently is actually pretty rare. The point of PACU isn't to be near the OR. It's to have nurses specially trained in managing patients after their anesthesias (which have their own set of potential complications) and to provide closer monitoring than a floor can provide during the patient's potentially unstable period. With anesthesias getting faster and safer, I think the real reason for PACU is the lower staff ratio- we can get that patient settled with new orders, pain control, airway monitoring, etc much better than the floors can because we're a 1:2 ratio unit. It's also safer to have the direct visualization of your patient while they can't be trusted to guard their airways or tell you if they are vomiting. <g>

    I only worked in one ICU that did not recover their own postop patients- ICU provides the same ratio and monitoring capability as PACU. I don't see a reason for an ICU patient to come to PACU at all most of the time.
  11. by   PACU_Lily
    Our PACU is not a large one, and patients who are intubated and attached dopamine infusions etc, go directly from the OR to ICU, bypassing recovery completely. We do occasionally receive pts destined for ICU, but they are not ventilated, and stay only a short time before proceeding to ICU. Sometimes we call for ICU to send their nurse to collect the patient but otherwise we NEVER call them to ask them to send a nurse to help resus a patient. Patients who are going down the plughole like the one you described, should not be sent to you from OR that way, and certainly the surgeon shouldn't be walking around with his hands in his pocket watching the proceedings.
    Did this happen on a weekend when perhaps a specialist anaesthetist was not around, and the case was being done by a registrar? [ I am talking in Australia here, after hours anaesthetics are often done by senior staff studying anaesthetics as a specialty, the specialist anaesthetist not called in unless needed. ]
    Whatever, this sounds like a real botch up from the surgeon/anaesthetist in theatre.
  12. by   flowison
    Hey all,
    We are a Level 1 Trauma Center also. My question is: What is the policy of the OR?? PACU??
    If this patient was so unstable in the OR, why didn't they try to assess the situation a bit better?
    Our PACU doesn't take ABP's, there is also the "time" constraint that at PACU faces. Yes we are qualified to take care of patients with critical issues. However, I think the investigation needs to start in OR, the physician who made the decisions, and your policies first. If there are none, this could be an opportunity to put one in place, it's not to blame---it's to fix the situation to protect the patient with best practice insights.
    It is our policy that patients on ABP's, go directly to the Cardiac ICU for their care.
    Good luck, let me know how it plays out!
    flowison
  13. by   prmenrs
    It does sound a bit peculiar. And probably not the standard of practice in you facility or icommunity.

    And that's what you should think about regarding "writing it up": a deviation in quality of care. Not blaming, but fact finding. Where was the breakdown in the system, not the people. How can the system be tweaked so that the patient is better protected? Focus on the process, not the personnel.

    Congratulations on your new responsibilities! I know you will do well, Miss Zee!
  14. by   carcha
    sounds like a mixture of poor management, inexperience, poor communication and panic. This patient should never have left the or room, let alone be rushed further away from the one area he needed to be in the or. I would certaintly write up a "near miss" form and recommend in it that the medical and nursing staff who dealt with this patient, reflect on their actions and decisions and without blaming anyone, come to an agreement on what course of action should have been taken and should be taken in the future.

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