Do You Hold Discharges for Change of Shift?

Specialties PACU

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Specializes in PACU,Trauma ICU,CVICU,Med-Surg,EENT.

Hi,

We're trying to improve our flow of patients through PACU -apparently the average case is in and out of PACU in one hour -don't quite know how they compute this,keeping in mind the mixture of everything between sedation + nerve block outpatients to general anesthetic spine,etc cases. In any case,I hear that we are keeping pts longer and need to tighten things up.

One question we have is whether your PACU holds on to ready-for-discharge cases who are ready for discharge between 18:30 and 19:30 while the oncoming floor nurses get their report,like my unit does. They started this as a courtesy,now it is expected by the floors. We'd like to know how your unit deals with discharges this time of the evening.

While patient safety is paramount,we are told to keep in mind that PACU is like "fast food service and not fine dining" - which makes perfect sense to me.

What steps has your PACU put in place to improve the flow through the unit? Could you please indicate the size of your hospital and whether it is a Trauma 1 centre. Thanks!

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Specializes in PACU, OR.

I presume by trauma 1 you mean major trauma? The classification works differently in my country.

From your description it sounds like you have a large PACU, with presumably heavy patient flows moving in and out. The primary function of the PACU is to ensure that the patient is haemodynamically stable, maintaining adequate unassisted ventilation and reasonably oriented-I suppose you use the Aldrete principles when determining criteria for discharge.

Our PACU is, by contrast, extremely small, only 4 bays, one for each theater (too small actually, best practice indicates there should be at least 6 bays) and we only take minor trauma and medical emergencies. However, the basic principle remains the same; your patient is only ready for discharge once he or she meets the criteria, and the length of time varies from patient to patient. You can have one individual post haemorrhoidectomy who takes an hour or more to wake up properly, while the spinal fusion who came out at the same time is wide awake and ready to go in 30 minutes. If the patient is not ready for discharge, nothing you can do will speed up the process. I always tell my nurses not to rush their patients awake-their own bodies will dictate when it's time.

As for your problem with discharging patients at handover time, I fail to understand why this should be a problem; even if handover is in progress; surely there are still day staff on duty who can receive the patient? Obviously, if the ward is very busy, it's a matter of courtesy to keep the patient until after change of shift, but if it's not too hectic, I think it's unreasonable of them to expect you to hold the patient there.

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No, we don't hold patients because of shift change. That would result in us not having space for cases coming out of the OR and backing up the OR scheduled. Once you meet discharge criteria we send them out.

Academic university hospital. 1,000+ beds. 24 recovery room bays staffed 24/7

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Specializes in PACU,Trauma ICU,CVICU,Med-Surg,EENT.

GHGoonette said:

"As for your problem with discharging patients at handover time, I fail to understand why this should be a problem; even if handover is in progress; surely there are still day staff on duty who can receive the patient? Obviously, if the ward is very busy, it's a matter of courtesy to keep the patient until after change of shift, but if it's not too hectic, I think it's unreasonable of them to expect you to hold the patient there."

Yes,I agree GHGoonette - that's my point, too.One of the difficulties is getting a truthful answer as to how busy they are in that hour. Sometimes I know the floor nurses are run off their feet,but many other times are at the main desk chatting during hand over (which on the floors is listening to a taped report,not a 1-on-1.

I'm going to email my manager to look at this again.

:) Thanks for your help!

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Specializes in Medsurg/ICU, Mental Health, Home Health.

I can't speak for my current hospital (which is a level I trauma center) as I've never been in the PACU there except as a patient.

However, I worked in my old hospital's PACU as a tech/clerk...and YES, the patients were held until change of shift. I never knew that this could be an issue until I found myself a new grad RN on the surgical floor, receiving all the post-ops at once...at the end of the 7A-7P shift!

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Specializes in PACU,Trauma ICU,CVICU,Med-Surg,EENT.
No, we don't hold patients because of shift change. That would result in us not having space for cases coming out of the OR and backing up the OR scheduled. Once you meet discharge criteria we send them out.

Academic university hospital. 1,000+ beds. 24 recovery room bays staffed 24/7

This problem,thankfully,only crops up in the evening.50% of the time,like last evening, we were almost fully cleared out by 18:30, though a few cases were still in the OR. The other 50% we are extremely busy and we tell the floor the pt has to come now. The only time we have to put the ORs on hold in the evening is when there is a staffing issue within PACU (eg someone crashing,ICU hold absorbing a nurse,etc)-we would never put the OR on hold because of shift changeover. This issue needs to be revisited.

As an aside,

When you say staffed 24/7, I take it you are staffed every night (2300-0700) and not on call as we are during that time? If so,are these cases emergencies only and very long day cases, or do they do elective surgery through the night too?!

Thanks for your reply.

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Specializes in PACU, OR.
I can't speak for my current hospital (which is a level I trauma center) as I've never been in the PACU there except as a patient.

However, I worked in my old hospital's PACU as a tech/clerk...and YES, the patients were held until change of shift. I never knew that this could be an issue until I found myself a new grad RN on the surgical floor, receiving all the post-ops at once...at the end of the 7A-7P shift!

Yes, this can be a problem in the larger hospitals. A lot depends on what kind of ops were performed, and the resulting acuity of the patient.

Minor surgical cases, you receive the patient, do initial observations and then can safely hand the patient over to a junior staff member for further monitoring; chances are the patient will be going home in a couple of hours anyway. But when you've got two or three bigger cases coming out one after the other, one must consider patient safety. In such situations it might be better to wait 15 minutes or so between transfers, depending on ward staffing.

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Specializes in PACU, OR.

Yes,I agree GHGoonette - that's my point, too.One of the difficulties is getting a truthful answer as to how busy they are in that hour. Sometimes I know the floor nurses are run off their feet,but many other times are at the main desk chatting during hand over (which on the floors is listening to a taped report,not a 1-on-1.

I'm going to email my manager to look at this again.

:) Thanks for your help!

If it's my last patient, and the ward "can't" come immediately to fetch the patient, I pull on "outside" shoes and gown and take the patient to the ward myself. If I see they're really too busy to take the patient, no problem. I put the BP cuff on and do a set of observations while I'm waiting. On the other hand, if the nurses are standing around yakking, it's a laugh to see them scatter when the old dragon from Recovery Room lands in their midst...:D

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Specializes in PACU, OR.

By the way, someone mentioned ICU patients; we have to keep ours until ICU is ready to receive them. This is a real nuisance when ICU is full, it entails them having to open a private room on Surgical or Medical and placing a staff member there to "special" the patient. We have no choice but to wait until they're ready.

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Specializes in ICU, Research, Corrections.
No, we don't hold patients because of shift change. That would result in us not having space for cases coming out of the OR and backing up the OR scheduled. Once you meet discharge criteria we send them out.

Academic university hospital. 1,000+ beds. 24 recovery room bays staffed 24/7

My PACU and hospital is very similar. We do hold patient's between 19:00 and

19:30 while the shift is changing and report is going on. If the floor is still refusing

patients at 19:45, then a supervisor is going to become involved. This situation has

the potential to shut down the OR because PACU will shut down.

We are still doing electives in addition to emergency surgeries at this time. Level

1 trauma center.

More problematic at my hospital, is getting a room for our PACU pt. We hold for hours

due to this. :crying2:

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As an aside,

When you say staffed 24/7, I take it you are staffed every night (2300-0700) and not on call as we are during that time? If so,are these cases emergencies only and very long day cases, or do they do elective surgery through the night too?!

Thanks for your reply.

Yes, we are staffed 24/7. At night we staff with 2 RNs and two techs. No first call, only back up call if there are too many cases coming out for the two RNs to handle. These are long cases, elective cases, and trauma. Our OR is staffed 24/7 as well.

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We have had similar issues along these lines in the past. Policy here is that when a patient is ready to go, they can't refuse report on grounds of shift change. BUT at some point we did the same and gave the floor a few courtesies they took advantage of. As our hospital got recently absorbed by a major network, the throughput of OR is being heavily scrutinized and the floors are starting to position someone to take report even in cases where the receiving nurse may be tied up. This at lease moderately helps us get over bottlenecks involving communication.

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