DISCHARGE from PACU? Who does this?

RN34TX · Dec 26, 2006

This has been attempted several times in the PACU I work in.

I resist it and make it as difficult as possible in order to discourage it.

PACU is an inappropriate place to D/C patients home.

Ours doesn't even have a bathroom for patients to use. It's a bedpan, urinal, or forget it.

In addition, our off shifts have only two nurses working the room. No unit clerk, no charge, no aides or other support staff.

The last time it was attempted was about 6-8 months ago by an MD who didn't want to deal with post-op orders on the floor and tried to make me D/C the patient from PACU.

He did a completely routine non-emergent case on a saturday and was frustrated because day surgery is closed on the weekends so he tried to get out of sending the patient to the floor by writing "D/C from PACU" orders.

He kept saying "The patient's condition doesn't warrant her going to the floor, she needs to go home and I can't help it that day surgery is closed on weekends so she needs to be D/C'd from here."

To which I informed him that the PACU is open 24 hours for emergent cases that can't wait until monday morning, not for cases that a surgeon doesn't feel like waiting for and gets a wild hair to perform on a saturday.

The administrator on that day tried to back him up and guess who ended up having to come down to PACU and D/C the patient herself?

The administrator.

Needless to say, she no longer thinks it's a great idea anymore since it inconveniences her now as well.

I just can't stand anyone that tries to bend rules or get around something in order to take a load off their own backs and place additional burden on others.

The MD tried to lighten his own load by making mine heavier and the administrator had no problem with it initially because she was under the impression that it wouldn't give her any extra work to do either.

And that doesn't even speak to the safety issues involved that you mentioned, particularly in peds cases.

gentle_ben_RN, ASN · Dec 29, 2006

We have had to dc patients home after SDC closes on several occasions and I agree that it is not a good practice. Especially when it's 1030PM and I'm the only RN on the unit and I have to get this hip reduction dressed and in a wheelchair while there is another case going in the OR that will be finished at any time. Often with limited resources, as you could imagine.

RN34TX · Dec 30, 2006

We have had to dc patients home after SDC closes on several occasions and I agree that it is not a good practice. Especially when it's 1030PM and I'm the only RN on the unit and I have to get this hip reduction dressed and in a wheelchair while there is another case going in the OR that will be finished at any time. Often with limited resources, as you could imagine.

That just burns me......

Not only is discharging a patient from PACU at 10:30 pm completely insane, how is it that you are the only RN on duty at that time?

Even when our PACU is completely empty, two RN's must be on duty at all times 24 hours.

gentle_ben_RN, ASN · Dec 30, 2006

During regular hours there are always 2 or more RN's in the PACU. I work 12 hours, 11AM to 11PM, and so does one other nurse. He and I usually work opposite days, but some overlap. Another RN works 10AM to 10PM. It has only happened one time that a patient (the hip reduction) needed to be discharged. I was the 11PM nurse that day, and the other nurse left at 10PM. I was able to get a transporter to take the patient and family to their car so I didn't have to leave the PACU. I would like it if our hospital always had 2 RN's all the time. I'm not sure why we don't. For instance, our on-call time starts at 11PM after I leave. There is 1 RN on-call and a back-up RN on-call if the 1st nurse needs them. But it sometimes occurs that I am the only RN for that 1 hour window between 10 and 11PM. But, if I needed help, the 10PM nurse would not have left me. I work with a very good group of people. I wonder what most hospital policies are about PACU staffing? I work in a large level 2 trauma center.

RN34TX · Dec 30, 2006

I don't know what the standards are off the top of my head, but at some point, I think that you and I need to look up what ASPAN standards are with regard to minimum number of nurses in PACU.

My facility is level one trauma and that means PACU is open 24/7 with minimum 2 PACU RN's physically staffed on the unit (not on call) at all times, even if the PACU is completely empty.

I just don't think the scenerios you present are meeting ASPAN standards but I'd have to look to be sure.

In any case, the scenerios are highly inappropriate on so many levels regardless.

starae · Dec 30, 2006

I agree that the standards need to be addressed for those of you who work one nurse in PACU. Our rules are if there is a patient in the unit, there must be 2 RNs.

We are expected to discharge patients if our admission/discharge area is closed. Sometimes we run into problems where they are "full" and cannot accept anymore patient before their closing cutoff. That means we have to do it in addition to recovering the endless flow of patients out of the OR. None of us like to do it, but fortunately it doesn't happen on a regular basis.

gentle_ben_RN, ASN · Dec 30, 2006

I went to the ASPAN homepage to research the 24 hour staff issue. If you look under clinical practice and then go to patient classification from the home page, staffing is addressed. According to ASPAN for phase 1 PACU, only the nurse to patient ratio is mentioned. The ratio depends on LOC, stable vs unstable, age, mechanical ventilation, ect. I could not find where it was required that 2 RN be present 24 hours. It probably is not policy because my facility is not a level 1 tauma center where trauma patients are needing surgery all hours into the night and morning. If there is and emergent case after hours (11PM) or several late cases are running over, our on-call staff is called in before the case is started and are required to be able to be in the PACU within 20 Minutes of being called. The 2nd RN is called in also depending on level of acuity. So there are always to RN's if needed, they just need to be called. It would be nice if we were already there though.

Because I don't usually see major trauma (MVA, gun shot, stabbing) I was wondering if you could tell me about some interesting cases you've had. Have a great day.

RNPamP · Jan 3, 2007

Here is a direct copy of the ASPAN position on RN staffing in Phase I PACU; this info came from the website:

Position

It is, therefore, the position of ASPAN that two licensed nurses, one of whom is a Registered Nurse competent in postanesthesia nursing, will be present in the Phase I Postanesthesia Care Unit whenever a patient is recovering from anesthesia.

There is also further description of this postion (which is in the ASPAN "Standards of Perianesthesia Nursing Practice" book but not on the website), which further clarifies that "present" means in the PACU and NOT nearby in the OR or in pre-op, for instance. I did some research on this topic when I recently changed hospitals and found out that my new PACU was only using one RN and a tech on the weekends. We are also a Level One Trauma, so of course this situation was unsafe. I brought the standards to the attention of my NM, and now we are requiring 2 RNs at all times for Phase I!

By the way, if you would like to see other perspectives on this issues, there are a few threads on the chat boards on the ASPAN website. The overwhelming majority feel that it is incredibly important to abide by this staffing standard.

As for the discharge question, we do discharge outpatient surgical patients from our PACU as a rule. There is an outpatient surgery center, but if the surgeon wants to do the case in the main OR anyway, we get the patient in our PACU. The previous hospital I worked at had a short-stay discharge area, so I have worked both ways. In my opinion, it is much better to be able to send a patient to another area to do the discharge work. However, we do make our situation work, and have policies in place regarding d/c'ing pt's from PACU. Basically, we are required to have kept the pt one hour, they must meet a PAR score of 9, be taking PO without N/V, and have appropriate pain control. Then we send them home with a responsible adult. This also includes peds. For the record, I felt really uncomfortable doing this at first, but like anything, it becomes easier with experience. Just make sure you are following your hospital and units policies, and it should be possible to do a PACU d/c.

Hope this helps!

DUECSON · Feb 19, 2007

Most if not all military hospitals d/c pts from PACU. Peds with BMT's, most breast bx, and others are d/c'd from Pacu. We have no problems with these pts returning to ER. Most of the surgeries are anest. with local mac. If a pt have gen. anesthesia they must come to SDS.

healingtouchRN · Apr 1, 2007

Since I work 3rd shift I often discharge patients from PACU since OPS closes at 9pm. They must meet the criteria mentioned above in the ASPAN guidelines. The patient must Void, be taking po, have adequate pain management, verbalize understanding to information & have someone to care for them, & drive them home before discharge can take place. I've only rarely gotten someone out to the carport & they felt woozy or vomited, then I turn them around & take them back to PACU for further monitoring until they feel ready for discharge & assess ready as well. Safety first!

BigDog · Apr 11, 2007

Nobody is dischargesd from PACU to home from a hospital.If the pt needs monitoring for X number of hours at 0900 they need the same at 2300.I go round and round with a surgeon who wants to send kids home from PACU post closed reduction and I refuse to do it.The wqrtite ups are almost comical anymore all I say is What do you want to tell mom when jr wakes up dead or aspirated cause we skipped seending them to trhe floor