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

  1. Why would an ICU pt go to PACU? Unless obviously there is no bed/staff and PACU is holding until a bed/nurse opens. But what if there IS a bed? My question is why would an intubated, sedated ICU pt make a pit-stop in the PACU to be recovered when there is nothing to recover? Why not go straight to the ICU when the plan is for them to go there anyway and the ICU has known about the admission for hours? I can understand if there is no nurse or bed at that time, but someone please help me understand why ICU nurses dont want to take a pt directly from the OR? I would think that an ICU trained nurse would be more competent to deal with issues such as hemodynamic instability, resp. compromise and fluid status. I worked SICU for 5 years and we took pt's straight back if they were scheduled to come to ICU intubated or not. Now I work in a 5-bed PACU and the 20-bed ICU is refusing to take pt's back until they spend "some time" in the PACU- how can they do that? We use the Aldrette scoring and can discharge a pt with a score of 9. An ICU pt would never attain that score! Many ICU's admit pt's straight from the ER- why is the OR any different? Is the PACU better equipped to take fresh post-op ICU pt's? I know ASPAN doesn't really take a stand on this issue- every hospital is different. I would really be interested in hearing other nurses comments on this issue. Please help! Thanks!
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    About Cschroy1

    Joined: Jun '09; Posts: 5; Likes: 3

    16 Comments

  3. by   nannymcpheeRN
    We rarely see our ICU patients go direct. When we do, we are thrilled....those nurses are certainly well-prepared to recover. The issue for us (PACU 25 bays, ICU 50 beds) seems to be timing. The ICU nurse is not ready to receive the patient and the OR team whips them around the corner to us in PACU. The Anes MD's are stretched and it's easier for them to care for pt's in closer proximity. All ICU pts must be signed out by an Anes. MD prior to ICU transfer.
  4. by   Southern Fried RN
    Quote from Cschroy1
    I would think that an ICU trained nurse would be more competent to deal with issues such as hemodynamic instability, resp. compromise and fluid status.
    Not necessarily. I have transported ICU pts straight from the OR with an anesthesiologist and when we arrive to the ICU they run around like chickens. I've brought pts to ICU without a vent being in the room, or an a-line cable, or worse people just staying at the desk when we roll in. It's not like they aren't told in advance about these things. Some of these people just don't have their priorities in order when accepting a patient from PACU--why is a nasal MRSA swab being done when the patient isn't even hooked up to the monitor?

    BTW PACU nurses are MORE than capable of handing hemodynamic instability or respiratory compromise.
    Are you saying ICU nurses are more competent that PACU nurses?

    In my facility, pts can go directly to ICU from OR if they are to remain intubated/sedated post-op. However, each anesthesiologist is different and lately they tend to want to stop in PACU because of bad experiences in ICU. It really makes them mad when the above-named events occur. Sometimes if the patient is really unstable or has coded in the OR they want them in PACU because we have emergency drugs at the bedside and an MD right there if something happens. They don't want to take the chance on the patient going bad in an elevator or in ICU where they aren't right around the corner.

    Yes, in a perfect world it is much better for all parties involved for a vented ICU pt to go straight up from OR.
  5. by   PostOpPrincess
    I am "over" ICU patients. Literally, I would love NOTHING more than for them to go straight to ICU. But sometimes there is no nurse, no bed.

    I always get stuck with the ones upside down, on 15 drips, with PA lines and high frequency ventilation with metabolic acidosis incompatible with life. I am worn out!

    I left the ICU for this very reason. Give me a lap appy or lap choley ANYTIME.
  6. by   PostOpPrincess
    Oh, and it is a myth that the PACU nurse is not capable. PACU is generally where nurses with umpteenth years of ICU experience "graze" or ahem, "retire."

    Most of us have 15 to 20 years of ICU, including Open Hearts on a BIVAD--and everything in between. Those used to be my favorite oh, and Trauma to boot. I know our Anesthesia docs prefer us to the ICU because we have years of experience--sometimes they don't want to transfer. But our ICU nurses, albeit they are quite young, can handle it as well.

    Us oldies-we no longer feel the need for the adrenaline rush.

    I LOVE my laparascopic appendectomies, and outpatients.

    Nice and calm. =)
  7. by   Cschroy1
    Thanks guys for resonding! I enjoyed reading your comments. To clarify for Southern Fried RN: 1) I def think PACU nurses are competent. I would say that it depends on the individual nurse! I've worked with some not-so-smart ICU nurses and then some outstanding PACU nurses... the whole gambit. It depends on the unit, the pt population and the experience level of the nurse. 2) The reason I said they would be more competent is b/c they probably see those issues more. Our pt's in PACU are in and out. ICU pt's LOS is longer, hence the ICU nurse may see those issues arise more, plus ICU pt's are usually sicker. 3) I am really talking specifically about our hospital, but was curious if you all felt the same way about your hospitals. Hope this helps with the clarification! If not, let me know!
    Okay so I got to thinking.... What if PACU just took every post-op pt no matter where the destination(including ICU). What, if any disadvantages would there be to the pt and unit? I thought of 3 so far.... 1) extra cost? 2) need to repeat tests- ABG/CXR (r/t bumpy elevator ride). 3) Pt is usually sedated pretty well when they first arrive(good for PACU) and start to wake up more when they reach the ICU 30 min later(bad for them) and leaves nurses scrambling for medication/orders. Oh, and 1 more question- what is the average time you all keep your ICU's pt's in PACU? Tell me what you think! Thanks!
  8. by   swolfe_2
    All of our ICU pts who are still intubated come directly to ICU. Something else to consider for some facilities is cost-sharing between departments, dont forget to think about the $$.
  9. by   PostOpPrincess
    When there are no ICU beds, we have been known to turn our unit into mini-ICUs--unfortunately, utilizing the services of the PACU. Just imagine how terrible that is when the surgical schedule has a TREMENDOUS amount of cases and you have your nurses tied up with ICU cases.

    More than anything, holding the OR causes all sorts of problems.
  10. by   antonia_lois
    i dont think there is a need to compare between ICU and PACU nurses.. like who's better and who's not.. we come to work as a TEAM. that's all i know of.
  11. by   sjaneo
    the problems that have occured in my hospital is that pt transfer from OR to ICU is not happening due to shift change..due to the MD not telling OR where the pt should go.. if they came straight from ICU to OR .. yes in a perfect world they will go straight back to their room in ICU.. in our world we live in the 9 times out of 10 come to PACU.
    we have fast tracked pts before and had them back up to their ICU room in 30 min.. but it takes a lot of work to quickly get them there.
    $$ plays a big issue here b/c PACU has to obsorb so much of the cost with the pt staying in our dept for so long..
    the worst cases are when our hospital has no ICU beds available and PACU is the hold over .. this happens quite often

    i wish nursing would all work as a team ..but it doesnt happen ICU nurses get upset when we bring a pt up and things arent perfect with the pt.. PACU gets upset when we get all the ICU pts instead of going straigh up to their previously assigned room.. its a horrible cycle we go through..
  12. by   NurseKitten
    Two thoughts that come to mind immediately: they can bill for a PACU stay and PACU nurses are more attuned to surgery-specific complications such as MH. Unless a diagnosis specifically called for it, we wouldn't insert a rectal probe for temp monitoring in the ICU, and only check every hour or so.
  13. by   rstrainRN
    In my facility our ICU patients typically go straight to the ICU MOST of the time. There are situations where they're unable to take a patient and they're diverted to PACU. We're certainly equipped to take care of them, but it isn't an ideal situation. Lately the ICU has been really good and we haven't held many of their patients in PACU.
  14. by   All4Seasons
    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.

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