OR patients bypass PACU for ICU

[fedupnurse]

Just wondering if anyone else out there is seeing a trend toward patients who should go to the PACU being sent to general ICU's directly from the OR instead? This is a common practice for our open heart ICU and the staff of that unit receives extensive training to safely provide this type of care. They also have 1:1 staffing. Our general Medical and Cardiac ICU's generally have 2 to 3 patients per nurse and we are not trained to care for surgical ICU patients (but often get their overflow). We are also not trained in anesthesia reversal. Any thoughts or input would be greatly appreciated!!

[fedupnurse]

Thanks for the feedback. One of the units effected doesn't have a dedicated full time intensivist and it seems this practice is being pushed because the anesthesiologists want to sign off and be gone. We only have residents *medical and surgical-no anesthesia residents) available at night which is usually when this issue arises. It is rare that we staff patients 1:1 (only IABP and CRRT are currently "permitted" to be 1:1) and with no attending doc in house and physically present on the unit, for the unit where I work, safety is a huge concern. There is a lot to know about the anesthetic agents if you are receiving patients who have just received them so you can watch for potentially serious and life threatening complications.

Thanks again for the input!

[lpnstudentin2010, LPN]

this summer after my surgery i went strait to icu..this was becasue they had to leave the tube in my throat

[charles-thor]

How to give anestheisa. You ready???

Induction - Give a syring of anestheisa. Give just enough, but certainly not too much!

Maintance - Cuddle up to a good book, and try to stay warm.

Emergence - Turn anestheisa off.

PACU - Pretend to finish your charting while you snicker and discretly watch the PACU RN hook-up to monitors and deal with the patient who got just a wee too much ketamine.

So what do you mean you're not trained in anesthesia reversal???

:chuckle :roll :chuckle

Sorry folks, I just couldn't help myself.

In all honesty, inadaquate training only leads down one road - the bad one. Insist that you are propertly trained how to recover post-op pts.

And now, back to the books and only one more study day until the "big quiz"...

[gentle_ben_RN, ASN]

So it's funny to let the PACU RN deal with the patient who has a little too much ketamine huh? It's no big deal. You just leave the patient in our hands and go on to your next case, we'll take care of the rest like we always do.

[cardiacRN2006, ADN, RN]

In general, most of our surgical pts come back to the ICU unless we are full or short of nurses. We don't have them as 1:1 just because they are fresh post-op either. I've had some pts come back with open bellies (for more surgery tomorrow or not enough fascia/skin to close), and still not be 1:1.

[Marie_LPN, RN, LPN, RN]

Also forgot to add that our AAA cases go to CCU post op as well.

[Nursonegreat]

when i worked PACU, all vented cases went str8 to ICU unless they were full or it was the crazy anesthesiolgist going thru her crazy phase (came and went with irreularity). then we had to bring a pt to PACU check their vitals, hook up all the monitors, turn on vent, chart, hook up to transport monitor, call respiratory to accompany and bag and give report to ICU before sending pt. ridiculous if can be avoided. biggest thing when coming out of anesthesia is airway. well if u have an ET tube, u r covered! oh ya, and our anesthesiologists would cange clothes, make sure the pt was still alive and go home, while pt is still in PACU (i didnt agree with).

[gentle_ben_RN, ASN]

Our patients only go straight back to ICU if they 1:were already in ICU on a vent prior to surgery and will go back to the same room or 2: are not extubated and don't plan to be extubated and have a ready ICU bed to go to. Otherwise, they will come to PACU.

[subee, MSN, CRNA]

Think Narcan; reversal-bringing pt. out of the anesthesia necessary for surgery, something usually done in PACU. In my ACCU, we see extremely critical patients, and sometimes overflow come directly to the ACCU. Usually they are patients that can not be immediately extubated.

Narcan is used only rarely in my community hospital anesthesia practice. We don't "reverse" the anesthesia. Its all a matter if timing. The only patients that we send directly to the ICU are patients that are intubated because our PACU nurses are not ICU nurses. If we didn't sedate the patient for the transfer from the OR to the ICU they would be talking to you by the time they got off the elevator. By the time the intubated patient arrived to ICU we're already talking about what we're going to use for sedation because the drugs we use in the OR are so short acting. We're a 150 bed community hospital.

[nowplayingEDRN]

At the trauma center the liver transplants go to TICU and sometimes the CABG patients will go straight to CTICU. Any other vented patient comes to PACU and is monitored for a short time. At the trauma center, sometimes the vent patients are held in PACU because of lack of ICU/CCU beds. At my previous facility the vent patients came to PACU and usually stayed for about one[1] hour, primarily because the SCU nurses were too spoiled (I know it isn't nice but in this instance it was true) and the fellow didn't want to be bothered. However, if the patient had not come out of the OR before PACU closed (they did not run a 24/7 PACU. Closing was at 12 midnite, so anything from 1130 on was pushing the envelope) they went to SCU to be recovered, vented or not. Of course it was always a fight to get the patient there. On rare ocassion, a vented patient went straight to SCU but that was if the patient was having tremendous problems intraop. I do, however, agree that if a nurse is going to be recoving a patient, no matter where they are going, the staff on that floor should have some sort of PACU training. If staff are having to recover fresh post-op patients and they are not comfortable, they should be contacting their nurse manager, the nursing supervisor and if they are unionized, file an unsafe staffing report to protect themselves and then request training from Staff Developement. There is no replacement for proper training and education to maintain safe patient care and nursing practice.

[amnesia]

Our burn patients all go straight back. Also any stable unit pt that came to OR already intubated can return straight back as well. Obviously any pts. that require stabilization post-op do come to us at the discresion of Anethesia.

[meandragonbrett]

None of our ICU patients go to PACU, there's really no need for it. The unit has all of the equipment that the PACU has and is equipped to deal with any emergencies that may arise.