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.