Curious... Why would an ICU pt go to PACU?

All4Seasons · Dec 13, 2009

The way it works in our hospital is that the surgical ICUs (in this facility that means Med/Surg/Neuro ICU and CVICU) receive their admissions straight from the OR with no stop in PACU; that being said,we have, on occasion, taken an ICU-bound case because of some temporary calamity, or whatever, in the unit - but that is the exception,not the rule.However,the most frustrating cases are those which have to come to us so that ICU can come in and assess them for fitting ICU admission criteria....why in the name of time that can't be done between anesthetist and intensivist while the pt is in the OR,is beyond me! - PACU seems to be a convenience.

I worked in CVICU before PACU - and not once in 10 years was I ever aware of one of our cases going to PACU first - for any reason, and rightly so. An advanced ICU should be more than capable of caring for critically ill patients who are also recovering from anesthesia. As we all know,caring for an ICU case in PACU significantly impacts how the flow of patients, through the bottle neck that a PACU is, is managed. At least one,if not two or three nurses are required for a fresh ICU admission. In our unit that immediately translates into theatres on hold and cases (possibly) canceled.

If the reason is no ICU bed or nurse, then our PACU will take one of their (MedSurgNeuro's) more stable cases, and they'll take the fresh case. Although PACU is considered a critical care unit, with critical care experience and/or a critical care course required to work here,and despite the fact that a number of us are former ICU nurses, the very best place for these pts is in a unit which solely cares for the critically ill. That ensures that the advanced skills needed - intimate knowledge of ventilatory support,inotropic drips,hemodynamic instability,etc are practiced on a daily basis.

The only ICU whose patients come to us first - and none of us understand it - is the Coronary Care ICU. Some anesthetists have successfully been able to take their cases directly to CCU,but there are some nurses up there who fight it (and we're not even talking general anesthetic - but a mg of Midazolam!). 100% of our cardiac cases are post PM, AICD, or loop recorders -all their field, and they (often,I'm assuming) have ventilated,critically ill,unstable patients...so I don't know on what basis they make their protest. But we also have an (older) anesthetist who insists that his pacemakers/AICDs recover in PACU first.I've never asked him why,perhaps he's had a bad experience.

Direct-to-ICU in all cases provides better continuity of care, with fewer chances for potentially serious errors to occur.

suanna · Dec 13, 2009

Aside from the sniping back and forth over who is better PACU nurse or ICU nurses. A patient may be better off in PACU for a while post OR for a number of reasons- 1) it is usually attached to the OR- any urgent complications that arise that would require a return to OR and they are right there-ie: bleeding, wound dehiscence... 2) The patient is not "sedated", they are under anesthesia- different drugs, different problems. Not every patient in ICU is knocked out for the count and full vent supported. If the patient is to be breathing on thier own, with or without vent support, the PACU- near the anesthesiologist is where they need to be monitored until the OR meds wear off a bit. 3) Is the surgeon managing the patient or the ICU medical staff? Many surgeons want to be in control of the patients total care for at least 24hrs post op. The surgeon may be more comfortable with the PACU staff, and likewise the PACU staff may be more familiar with the expectations of that surgeon. I'm sure there are more reasons, but those are a few I can think of off hand.

PostOpPrincess, BSN, RN · Dec 15, 2009

The way it works in our hospital is that the surgical ICUs (in this facility that means Med/Surg/Neuro ICU and CVICU) receive their admissions straight from the OR with no stop in PACU; that being said,we have, on occasion, taken an ICU-bound case because of some temporary calamity, or whatever, in the unit - but that is the exception,not the rule.However,the most frustrating cases are those which have to come to us so that ICU can come in and assess them for fitting ICU admission criteria....why in the name of time that can't be done between anesthetist and intensivist while the pt is in the OR,is beyond me! - PACU seems to be a convenience.
I worked in CVICU before PACU - and not once in 10 years was I ever aware of one of our cases going to PACU first - for any reason, and rightly so. An advanced ICU should be more than capable of caring for critically ill patients who are also recovering from anesthesia. As we all know,caring for an ICU case in PACU significantly impacts how the flow of patients, through the bottle neck that a PACU is, is managed. At least one,if not two or three nurses are required for a fresh ICU admission. In our unit that immediately translates into theatres on hold and cases (possibly) canceled.
If the reason is no ICU bed or nurse, then our PACU will take one of their (MedSurgNeuro's) more stable cases, and they'll take the fresh case. Although PACU is considered a critical care unit, with critical care experience and/or a critical care course required to work here,and despite the fact that a number of us are former ICU nurses, the very best place for these pts is in a unit which solely cares for the critically ill. That ensures that the advanced skills needed - intimate knowledge of ventilatory support,inotropic drips,hemodynamic instability,etc are practiced on a daily basis.
The only ICU whose patients come to us first - and none of us understand it - is the Coronary Care ICU. Some anesthetists have successfully been able to take their cases directly to CCU,but there are some nurses up there who fight it (and we're not even talking general anesthetic - but a mg of Midazolam!). 100% of our cardiac cases are post PM, AICD, or loop recorders -all their field, and they (often,I'm assuming) have ventilated,critically ill,unstable patients...so I don't know on what basis they make their protest. But we also have an (older) anesthetist who insists that his pacemakers/AICDs recover in PACU first.I've never asked him why,perhaps he's had a bad experience.
Direct-to-ICU in all cases provides better continuity of care, with fewer chances for potentially serious errors to occur.

I would love nothing better than to transfer all ICU cases immediately. It doesn't happen all the time, and on a daily basis we get some very, very sick ICUs. We "practice" everyday (I would prefer not, I'm over the ICU experience), but I am often "stuck" with them. The same with the newborns (MY FAVORITES)--those I never complain about..hehe..

We are well versed in inotropic support, can do indexes, and pulmonary support/vents and sometimes will wean them off the vents when the etomidate or zem hasn't worn off. We tube, we do everything. I get more practice now with emergency cases in the PACU then I did in ICU as often times they come out sick as a dog...have to stabilize and then BAM the next one comes out...it is TIRING sometimes.

I have often asked why, if there is a bed, they cannot go directly to icu. They only go when vented. It seems there are parameters in our ICU that anesthesia covers, and parameters they don't. The bottom line is who is in charge of what and when.

Territory, territory, territory.

It does get old, let me tell you....

PacuRN1 · Jan 8, 2010

Nice to hear our pacu is not the only one dealing with overcrowding issues. My hospital just added a new tower with tons of icu space. We still get ICU pts. Our problem is not only lack of space but sometimes Anesthesia does not want to travel with the pts. We are right next door. Much quicker for them. Big hastle for us. We are already sooo overcrowded!!!! 21 slots, 56 cases and no beds coming from bed management. Then the OR is having a fit because they are on hold. Millions of dollars spent and still no one can do simple math!!!!!

WoosahRN, MSN, RN · Apr 21, 2010

I am in PICU and we do take admits right from OR. Usually with the surgeon accompanying them. We are alerted before we get a kid and we always know if they are coming back vented (even if its a maybe) so we have a vent ready (we have awesome RTs). If they are vented obviously true 'recovery' is not the goal since they are on drips anyway, but we still do post op vitals (Q15min, Q30min, etc) to ensure VS are stable. I will say that I work nights so the situation might be diff. Surgeries we get are emergencies (most common is ruptured anything, usually appy) so I imagine during the day with scheduled surgeries the surgeon wouldn't make the special trip. I guess I am on the same train of thought as the OP. I would think that most PACU/ICU patients would go to the ICU right after. We aren't a trauma hospital and most of our surgeries are ones that are scheduled in advance or we are at least notified that a kid went from ER to OR and will be admitted to our unit.

On a somewhat similar note, I had a co-worker that used to work in a PICU in a trauma hospital. I guess they would have to keep their numbers in check and couldn't have too many patients die in the OR or they would lose their trauma status. She said it was common to get an 'admit' being wheeled in, bleeding from wounds and still open from OR (or very rapidly closed), CPR being done on them so that the patient could code and/or die in the PICU. That way the death is recorded as not happening in the OR. So basically I am ok with just about any admit compared to that.