discharge criteria for pacu patients

[dsainz]

I have recently budded heads with an anesthesiologist I work with in PACU. I was told it was fine to discharge a patient with o2 sats in the mid 80's on rm air. this patient had no history of lung disease. she came in with a sat of 97%. upon discharge her lungs had heavy rhonchi through out. the women ended up in the ED 2 days later diagnosed with pneumonia. I have only worked in PACU for less than 2 years and could use some help handling this type of situation in the future. the doctor was advised multiple times of breath sounds and low sats with no orders given. he now complains to others that I do not respect his judgement.

[Perpetual Student]

Ha, it sounds like you have good reason to not respect his judgment. Effective documentation is important. I would also be sure to inform him that I was writing that it was OK to discharge home with SpO2 in the 80s as an order.

In the situation you mention there I would've likely contacted the surgeon and seen if he wanted to convert the patient to inpt or outpt observation. Not so much to go around the anesthesiologist, but because it is generally the surgeon who orders the final disposition of the patient in my facility. The outpatient order sets we use state that if the patient is unstable/does not meet discharge criteria to contact the surgeon for further orders.

As far as what to do now, that depends a little upon your environment. Talking it out with this guy, perhaps with some mediation from department leadership may be helpful.

[djmatte, ADN, MSN, RN, NP]

First and foremost as stated, document the hell out of that. It varies with each facility, but if we feel a patient is less than stable then we contact the surgeon or residents (if the MDA doesn't want to bother with the patient). Typically its rare in my experience that an MDA will just boot an unsatting patient out and ours seem alot more conservative in their vitals before allowing the pt to go home. But I have seen where MDA's are less than willing to admit a patient either and would rather keep em in recovery a bit longer and hope for an improved outcome.

[GHGoonette, BSN, RN]

That sounds very suspicious...did the patient vomit, either in PACU or in theater? Sounds like she might have aspirated, especially given the pneumonia diagnosis.

If she vomited in theater, and it wasn't reported to you, the anaesthesiologist was grossly negligent. What type of airway did she have in ? ET tube or LMA?

[meandragonbrett]

Our PACU d/c criteria is Spo2> 90% on room air unless they have lung pathologies and an alderete within 2 points of preo-op baseline.

If anesthesia wouldn't have given me orders/taken care of what needed to be done, I would have contacted the surgical team to get the patient admitted.

[nmnurse05]

I would have definitely went over this anesthesiologists head before d/c'ing this pt. There is always someone you can go to. The chief of anesthesia, the PACU supervisor, anyone. Don't let someone else's title over run your good judgement. In these times your policies and procedures can be your best friend.

[NVCW]

I would notify the surgeon as they would possibly have a different opinion and admit the patient for further monitoring and evaluation.