Minimum staffing in recovery

[JUDY RN CPAN]

I would like to open discussion on ASPAN'S statement on minimum staffing. I am trying to find out how many PACU's do not follow the statement due to the interpretation that recommended means not mandatory. What have you done to encourage management to abide by the recommendation.

[Charity, RN, APRN]

Want to hear of a hospital that actually follow staffing guidelines? Mine does. Usually.

Our OR operates 24/7 and therefore so does the PACU. There is no call. We have a huge full-time day crew and a full-time night crew. Minimum of 2 RN's and a NA during the week and just 2 RN's on the weekend.

Some nights are so busy we can't even take time to call for help. Some nights we are nicely steady. Some nights we are ICU overflow. Some nights we don't see a single patient.

Our hospital is extremely short-staffed. We are getting pulled more often to one of our ICU's. If we are alone, they try to provide another nurse (one who couldn't go to ICU) or at least an aide. If all else fails, a nurse in another unit is put "on alert" to come immediately if I call. If it really comes down to one nurse present, the OR is notified so that they can try to close a room. (usually run 2-3/night). Of course, the nurse can always refuse to accept another patient until she feels it is safe to do so. Anesthesia must stay until then. And they do. We take that very seriously (you would also if you saw our anesthesia residents. Scary bunch). The OR nurses themselves are very nice, but mostly useless.

Our unit's biggest stress is not staffing, but the ICU overflow business. Our night crew are all ICU veterans, but our day people are quite a mix. Lots of whom don't want anything to do with a very ill person.

My hospital is a complete mess. But somehow they stumbled into a safe standard for our PACU, and we are holding them to it with a vengence. --C

[not you again]

We only have RN's on staff in our PACU and there are always 2 present when there are patients during the hours of 7A-11P. From 11P-7A there is one RN, but she does the recoveries up in an ICU or CCU room, where there are other nurses present in case of an emergency. She is able to take 2 patients at a time in those rooms. Any other cases have to wait in the OR for her to get a spot available.

On occasion our PACU stays open to accomodate ICU overflow pts. If there is not an RN to come work with the PACU RN, on occasion they will send 1 or 2 LPN's to work 11P-7A with the PACU RN.

When we do weekend call, we do the recoveries up in the ICU or CCU so that there is help if we need it. We never recover in PACU with less than 2 people.

[sharann, BSN, RN]

Gosh, we recover when on-call at night or whenever with only one RN. No aide, no other nurse. OR nurse leaves, anesthesia is out in the parking lot starting their car before you turn around. It makes me sick at times, just to think that if I had a code, I couldn't even ask someone to call it for me. I think it is unsafe and stupid. So who can we report this to? If you report to JAHCO, your name is involved isn't it. Bye bye job. I have called the supervisor in at times to help transport though. Have had some close calls with wild patients trying to kick me (not on purpose, just emergence delerium). It is frightening, truly.

[OC_An Khe]

Shar

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[cathy ann]

We staff fully during the day then 2 till 11p then 1 rn11-7 and have an oncall person for 11-7 but our acuity isn't too high to need that I am curious about regulations though because I work alone at night alot with almost no help but if i needed help it would be there in 2 minutes.. not sure how i feel about this since i read the other submissions.

[stevierae]

Originally posted by jayep99

The circulator must stay in the PACU with us until we transfer the patient out. They didn't like it at first but then we (PACU ) must come in when the OR crew is called out. We can help transport or do anything they need us to do. So it works both ways. We are all pretty close too so that helps!

Man, I KNEW there was a reason I stopped taking call in the operating room once I turned 30 (I am now 48.) Once you are 30, your free time (and your sleep time!!!!) becomes more and more valuable. They couldn't PAY me enough to stick around in PACU until a patient is discharged.

Uh, EXCUSE me, but I am an operating room nurse for a reason--if they need another PACU nurse, then pay one to take call and come in along with the other one. I really don't want to hang around in PACU for ANY reason, and I don't think the PACU nurse should have to do anything except recover the patient--not come in early to run errands for the OR crew. My job is to circulate or scrub the case.

In the '70s and '80s, there was always only one PACU nurse called in to recover the patient (or patients) and it always worked out fine. PACU nurses are skilled RNs, after all, not rookies; most have worked in ICU or ER and are accustomed to working independently--why do they need, or desire, a back-up?

If ever a problem developed, that nurse could always call or page the nursing supervisor, respiratory therapy, or ER doc, or the anesthesiologist covering OB who, at most facilities, stayed in house. We wouldn't start any subsequent cases, obviously, until anesthesia was assured the patient in recovery was stable, so there were never any "surprises" involving the patient in recovery that could not be handled by phone (that is, by the PACU nurse calling in to the room where we were doing our next case.) This was true even when we were doing trauma.

In the '90s, 2 PACU nurses on call seemed to become the norm. It always seemed like overkill. I never knew if this was a JCAHO recommendation or an actual national standard of care. This new trend (well, since the '90s) of doing elective cases on the weekends may be what prompted most hospitals to put 2 PACU nurses on, since they KNEW the PACU would have multiple patients all day long, back to back. At least with 2, they could get breaks and lunches.

I have, since, worked travel assignments where they have gone back to one PACU RN. I havce NEVER been anywhere where they called in the PACU RN at the same time the OR crew was called. We always just called them in with 30 to 45 minutes notice; let them know what we were doing and maybe we would give them another "heads up" when we started closing, if they wanted us to. Why should they have to come in any earlier than that? If we needed a "runner" for blood, labs, etc. we always called the house nursing supervisor.

I miss the days when doing elective or non-emergent cases on the weekends was strictly forbidden. I can remember being called in, watching the anesthesia provider look at the chart and say, "This is not an emergency. I'm not doing it. You put this case on the schedule" (meaning, during normally scheduled hours of surgery.) Then we would all go home, angry that we had been called in for a non-emergent case, but knowing the doctor would be taken to task by the powers that be later for his abuse of the system. Of course, we still got our guaranteed minimum (usually 3 hours in those days) call in pay. Still, it was an intrusion on our time, and most of us would have preferred the lost time back over the money.

I sometimes feel that the younger generation of OR managers and staff is trying to reinvent the wheel. Why fix something if it ain't broke? Why make such a big production of everything, things that are really quite straightforward and low risk?

Shodobe, are you out there? Don't you agree?

[shodobe]

Where I work PACU takes call with one RN and a CNA. I know this sounds funny and probably not exceptable to others but it has worked out OK for the past 25 years. There is a standard I saw awhile back concerning the number of patients and their condition along with the ages. This is supposed to reflect the number of nurses and how many patients each one can care for. My hospital does not abide by these rules and frustrates the PACU nurses to no end. I help them out when I can by "babysitting" one patient while they transfer another to their room. I WILL NOT take call, come in or personally recover any patient, PERIOD! I am an OR nurse and each department has their own certification so there is very clear distinction between us. Like I said I will help because they are my friends, but no higherups are going to make me do anything I don't want to do. I have refused some jobs in the past because I was told after you do the case, you recover the patient! Just a bunch of cheap SOBs. Mike

[stevierae]

I think Shodobe is my clone. We think so much alike, it's scary.

[jimls2]

Some of you have it lucky. In my facility the OR Nurse recovers the OR patient themselves. The Doc and Anesthesia are gone. The scrub is cleaning the room and instruments and you are by yourself with the patient. The RR is located by itself away from the floors and ER is downstairs. If you have a problem you have to call a code just to get help. Admin won't budget for RR nurse as it's always been this way, know what I mean.

Wish we did have RR nurse and OR nurse to stay with the Patient but Admin won't let that happen, too expensive they say.

Happy nursing.

Jimls2

[Sarah, RNBScN]

OMG

3 PACU nurses

8 - 4 p.m.

9 - 5 p.m.

12 - 8 p.m. on call til midnight only

5 bed unit, sometimes 6 (Keep OR staff to recover pt. if needed)

Vented pt. go directly to ICU.

OR never helps you with transfer(s) or checks in on you BUT they expect you to go next door and assist them with transfer(s) since the surgeon has took off, help them pull cases. I think not, they don't help me get all these PCA's set up or anything. BUT our hospital wants them (OR and PACU) to assist one another etc...Go figure

[clegault]

We would love it if we had to abide by the ASPAN standards. that would mean having an extra hand when were are on-call(not even a person to answer the phone if we are busy, and having an ICU patient and you are all alone) We are following the national senate bill sponsored by Sen Dan Inoye of hawaii--minimum staffing law--in the finance committee now. Write to your senators!! It can be dangerous when you have two busy patients and are given a sick ICU patient on top of it. I hope the Senator's bill passes.

[squeek]

in OZ at all the hospitals that I have worked we have a PACU RN on call, the OR scrub will stay in PACU while the pt is being recovered as a second pair of hands ... if another emerg case is booked, the duty nurse manager has the envious job of finding someone to be the 2nd in PACU .. it is unacceptable for the PACU nurse to be alone with a pt ...we follow the acorn standards ( australian conf. operating room nurses, very similar to your aorn).

prior to entering OR I was a PACU nurse, I refused to recover pts alone (especially unconscious ones) .... not that I wasnt capable but there are just too many things that can go wrong and why risk it?? Now I am an OR RN I happily stay in PACU until the PACU RN is comfortable with the patient. I think it simply a courtesy to my fellow nurses!