Division of Phase 1 & 2 PACU need answers

shellabelle · Mar 24, 2010

My unit is a phase I unit with a phase II unit in a separate area of the hospital. We generally recover all surgical patients except for those only requiring sedation analgesia. We also recover non-surgical patients that require general anesthesia, such as an MR patient having an MRI. The surgeons do not separate their outpatient and inpatient surgeries. They do typically try to operate on a patient that will be discharged earlier in the day. We don't generally have problems with the separate units unless there is a heavy surgery schedule and we are bombarding Day Surgery(the phase II units) with patients. We also have problems when we are having to hold patients in PACU because there are no floor beds available.

I have never worked in a combined phase I/phase II unit, but I like the fact that our phase II patients have a separate place to go because it clears a space for other patients. One downside for me is the fact that the day surgery unit closes before surgery and pacu close. We may still have surgeries working "after hours," so we are responsible for recovering and discharging them while caring for patients that are being admitted. Our staff is cut from 8 or 9 nurses to 1-3 at night. Depending on how busy our evening surgery schedule is, this can be very time consuming. The night nurses are responsible for the general hospital and women's hospital recovery rooms, so discharging a patient stretches the nurses and the(one) tech thin.

My hospital's phasing guidelines are pretty straightforward. We are required to keep every patient (pediatric or adult) for at least 30 minutes. The pediatric patient has to be able to maintain an airway and be arousable (our saying is, "see eyes and go.") This is only for pedi patients younger than 4-5 years. Older pedi patients and adults have to be able to maintain an airway and must be awake and/or back to their preop condition. The patients may be sleeping when they are changed to phase II, but they shouldn't be in a sedated sleep. You generally do not want them confused unless that was their preop condition. Their pain should be at a tolerable level or controlled by an epidural or pca(pts going to the floor only). Except for rare circumstances, the patient must be off of oxygen to send them back to Day Surgery. It is ok to sent a patient to the floor with oxygen, but you cannot have any kind of airway in(oral OR nasal). You must feel comfortable with them being in a less monitored environment(nurse is not staying at the bedside). We keep our patients in a phase I status until we feel that they are ready to go to the floor/day surgery.

There is additional criteria for a patient that had a spinal. The spinal must move down 2 levels if above T12 OR move at least one level to reach T12 OR move one level below T12 if that is where the spinal was initially assessed upon arrival. Basically T10 or above, it has to move 2 levels, T11 or below, it has to show progression. If you are unable to assess the spinal(ie alzheimers/dementia) or the spinal is not moving, the patient must stay in recovery for 2 hours with close airway monitoring.

No phase I patient is to be left in a room without the supervision of at least 1 RN. Our Nurse to patient ratio for phase I is 1:2/3 unless there is an ICU patient (1:1). Our nurse can have up to 5 phase II patients(without any phase I patients).

I hope this was helpful.

Yeehah · Mar 24, 2010

Thanks Shellabelle

Appreciate all you can tell me. We have similar practices, we've been practising P1 & P2 since last year and have some issues that will hopefully not reoccur when we move cos its hard to keep it P1 & P2 when the whole recovery room is full and beds are available on P2. So we end of doing both anyway. Love the one about spinal anesthesia - will forward that on with our colleagues.

Our problems are also about waiting for a bed on the floor, so do you have a place where they sit as boarders until the floor is ready?

P2 patients generally have had local, maybe light sedation. Do you have pts bypassing P1 at all? We term it Fast tracking.

Another problem is patients coming out from OR with no O2 on via FM or NProngs. Is this the same experience?

When a pt becomes or is a P2 do they have to get out of the stretcher and sit in a lounger?

shellabelle · Mar 25, 2010

Most of the patients that have light/conscious sedation or just local anesthesia(such as a carpal tunnel release) bypass ph. I. The rest of our Ph. II patients are people who have recovered from "heavier" forms of sedation.

We do not have a separate area to board our patients we hold for rooms. They are just taking up a slot in our recovery room. We do try to move them to the back side of the room so we can pull curtains and let family members back for short visits. We do not let any of our patients get out of the stretcher while in PACU unless we are discharging them ourselves. And that is only to go to the bathroom after they are fully recovered and to get dressed. It is the same in our Day Surgery/phase II area. They are less strict on staying in bed in the Phase II area, but we don't keep recliners in any area but admitted pt rooms. So, the patients are more comfortable staying in the bed than getting into one of the hard chairs. Patients aren't allowed to walk around in the Phase II areas unless going to the bathroom or getting ready to leave. We let them walk enough (with assistance) to assess gait and make sure they are stable enough to go home and get around(or not).

It is very rare for a patient to come to us from the OR with oxygen on at all. The only times they have O2 on are: a) they are still intubated with an ETT, but not with an LMA, b) they have some sort of severe respiratory problem such as SEVERE sleep apnea/COPD, or c) they have had an ERCP and are coming from special procedures, which is a much farther trip than the OR. We do frequently have oral or nasal airways in place, and if they know we will need a face mask instead of a NC the circulator will call into PACU from the OR. There are only a couple of CRNAs that we frequently have problems with patients not wanting to breathe. We OCCASIONALLY have to hold an airway for a short period of time or have to change from NC to face tent b/c a pt can't maintain their sat. We generally don't have problems with our patients' airways, though. Of course, the first thing we do for any patient coming to us is put on O2 at 3-4L NC. That works for us, though. It just depends on the anesthesia styles/practices of each hospital.

swolfe_2 · Apr 28, 2010

Shellabelle,

Do you work in an inpatient hospital setting? We are getting ready to convert to phase I phase II in our inpatient pacu.

shellabelle · Apr 30, 2010

Yes. I work in a hospital that does general, pediatric, and women's surgeries.