How many patients

[sameasalways, ASN, RN]

Hi, we are a small Pacu and so when we do phase 1 patients we do phase 2 for them as well. Sometimes (like for GI) we only do phase 2.

How many patients do you typically have in a situation like this? I am a little concerned because management recently sent out an email stating we would be expected to have 2 and up to 3 patients at a time.

We have 4 Pacu bays, seperated by curtains.

There are 2 rooms right next to Pacu that we often use for pre-op and then phase 2 recovery of the same GI pt. My concern is having 2 or more patients and one or 2 are in seperate rooms so you don't know what is happenning to 1 or more patients being recovered.

The GI pts come out every 15-20 min, so when you have 2, it's okay except that you frequently have one pt ready to leave in a wheelchair but you can't take them down because the next GI is coming down the hall for recovery.

We don't have a set person to take the patient out to the car, and recently they sent a email stating that due to increased patient loads/cases, nurses were not to help other nurses (so that we can "get our work finished in time")...and that they appreciate how teamwork oriented we are and that in order to be and team we need to only ask the charge nurse for help if help is needed , rather than jumping in and helping other nurses.

I have never worked Pacu anywhere but here...it's a small place and the vast majority of our patients are outpatients. We do get TURPS, and some bowel resections, total knees/hips etc. The inpatients are generally easiest because you can bring them to the floor in 30 min, whereas the outpatients we have to get them dressed, do DC instructions, etc. and they are there for an hour.

I can handle 2 pts at a time, I just have some concerns about the pts being in different rooms and until now most of the nurses have really worked together, and we ALWAYS get everything done. ..Maybe I am being negative about the email and upcoming changes?

[azhiker96, BSN, RN]

I'd suggest writing to ASPAN for their advice. The separate area for GI raises a red flag for me. My understanding is that each area would need two nurses at all times. That means a nurse ( could be the manager or from the OR) needs to cover when one leaves to transport a patient. ASPAN has a published set of minimum standards. Those are what a lawyer will use in comparison to your practice.

The current ASPAN standards and perhaps a reply on your situation will carry more weight with management than my random online opinion. If needed, include risk management in the discussion but keep a couple of things in mind. You put your license at risk if you accept an unsafe case load. Also, sometimes the squeaky wheel gets fired.

[sameasalways, ASN, RN]

I tread very very lightly, I am actually afraid to say very much at work because management has been so poor. The manager of surgical services who oversees Pre and Post-op has worked in the OR pretty much her whole life and she has no idea what we do in recovery. I am seriously considering looking for a different job but they just hired a new manager and I am hoping things get better. The job itself has been awesome except for their lack of policy and concerns of safety. They just opened as a new hospital 2 years ago so I think a lot of stuff was just kind of thrown together and see what happens type situation.

[sameasalways, ASN, RN]

Oh I forgot to say that the regular pacu bays (4) are on one wall, and the 2 GI rooms are right next to them, but they are actually rooms with doors, so if you are in one room you don't know what's happenning in the other room. If you have a pt in a bay, and a pt in the GI room, you can kind of see their monitor or and hear it if you turn and walk over by the door to the GI room , but if you are in the GI room you won't see or hear the monitor on the pt in the Bay. The manager and charge nurse act like you are being ridiculous to bring up such a concern...hence why I am careful to voice concerns.

[RainMom]

Oh my.

When you say "GI rooms" do you mean these are pts recovered after endoscopy, ie IV sedation?

I agree, trying to take care of both phase I & phase II pts (in different rooms) is not safe. How many nurses do you typically have working? Is it possible to assign a nurse to the GI rooms only? That would seem doable. Where I work, IV/local sedation cases are taken directly back to the pre-op area (which is our phase II) & a nurse often takes care of 2-3 pts until discharge.

What about pts with airways? They should always be 1:1. Our nurses won't take more than 2 steps from the bed & only take 2 pts as a last resort (the first pt is usually within minutes of dc to phase II when taking the second one).

Hope you are able to find a better solution.

[sameasalways, ASN, RN]

According to Aspan standards, or my interpretation of them, what you are saying about a max of 2 pts if one is a phase 1, seems accurate. The email sent out last week states that the expectation will be to take 2-3 pts at a time, but doesn't specify circumstances. Typically we only have 1 phase 1 pt, sometimes 2 phase 2 patients. Sometimes a phase 1 pt and a phase 2 pt that is stable. My concern is, are they saying we will be doing a phase 1 and 2 phase 2? Is that still ok? I am not sure, it doesn't feel right...

The vast majority don't come out with an airway at all. But they are still phase one and drowsy or unresponsive to voice or light sternal rub at the worst.

We do inpatient and outpatient and don't have transport. I guess management didn't specify the way these extra patients will be managed...I am concerned because of light corner cutting going on and perhaps getting worse, but maybe getting better (hopefully since we have new management starting soon).

I think other facilities are busier than we are, but also more organized than we are? if that makes sense...I don't feel our nurse manager looks out for safety. Mainly, she just doesnt understand what PACU does. She has often come out in to the Pacu asking "how long has that patient been here", or "why is that pt still here?", when the patient is always there for either unstable vitals or problems with pain/nausea... (if they are in Pacu longer than the 1 hour they are supposed to be). She doesn't understand how to look in to the documentation to check, and will interrupt you while on the phone waiting to give the floor nurse report with these sorts of questions.

Most pts are there for their alotted time, but if there is an issue with O2, BP, Pain, or Nausea or sedation level then we have to keep them until they are an aldrete 8. Even if their Aldrete is 8, we can't discharge them if they require NC O2, and we can't get phase 2 sign outs on a pt still on O2. (phase 1 patients to the floor obviously we can as long as aldrete 8).

I am not sure if the place is just teetering on unsafe, or if I am just not a good fit for either PACU , or just this specific PACU. I would like to be in an environment more focused on safety and a positive learning environment. An example of that is when I received a pt that was on neosynephrine and needed 2 U PRBC. I had never given either product in Pacu because we very rarely get a pt that unstable. The problem was 2 fold, I didn't know the rate to hang the neosynephrine (pt brought out by CRNA, not anestesiologist), and his BP was stable running at the drip the CRNA had him at. 2ndly, I had never hung blood using their tubing without an IV (I had worked at a different facility and it was a busy MedSurg floor, so we had to use IV pumps for all blood products, not just run it open in to the pt), and our blood tubing utilized a Pall filter, which this facilities blood tubing doesn't use).

Suffice it to say, when I got the patient, the charge nurse said to another nurse that she wasn't going to help "because they need to learn how to manage complex patients". Then, after all this was sorted out and I was started on the 2nd unit PRBC, the manager asked why I hadn't brought the pt to the floor yet....

I hadn't brought the pt to the floor yet because you can't transport a pt who is receiving blood. That was my understanding but at the time I wasn't confident in my answer because I didn't have the confidence to say that. I was pretty unfamiliar at the time with hanging blood in the PACU (this was about 6 months ago).

I have had a lot of complex situations and patients before, on the MedSurg floor...but I was not familiar with the med Neosynephrine or hanging blood products in this facility. I felt very unhappy with the response of the charge nurse and the manager in that situation. I will say that the charge nurse spoke up to the manager when she had asked why the pt had not been transported to the floor yet ("because he was getting blood").

I had not been in a work environment with that level of negativity. Please bear in mind I am the kind of person who gets along with virtually anyone, but I am not very aggressive. I especially try not to say a lot at this specific facility, due to concerns of being the squeaky wheel. I have been a nurse for 7 years, so I am not brand new, but I certainly have lots I can learn too.

Sorry about the rambling...I really like the majority of people I work with, and I know it's a great job, but I keep feeling like it is unsafe every day in the PACU if something goes wonky in an unusual way/unexpected way.

[twozer0, NP]

phase 1 = 2 patients max (or 1 if critical). Phase 2 = 3 patients max, you should not have any critical patients in phase 2 (they should all be awake, talking, with minimal need for intervention). These are ASPAN standards and we follow them.

[sameasalways, ASN, RN]

Our GI patients are phase 2 ut not always awake and talking etc. Some of them are super sleepy for up to 10 minutes then start snapping out of it but they are wide awake once they are awake and we an get them out the door close to their 30 minute time limit. I definitly wouldn't want 2 phase 2 pts like that or 3 we. you ha e them in seperate rooms. I guess I will just have to wait and see how things go down...

[twozer0, NP]

Our GI patients are phase 2 ut not always awake and talking etc. Some of them are super sleepy for up to 10 minutes then start snapping out of it but they are wide awake once they are awake and we an get them out the door close to their 30 minute time limit. I definitly wouldn't want 2 phase 2 pts like that or 3 we. you ha e them in seperate rooms. I guess I will just have to wait and see how things go down...

By awake and talking this can also be with arousal. So long as youre not getting pts pulled deep, smoking plastic, oral/nasal airways (though this might still be present), or pts that usually have neuromuscular blockade reversal (ga). Gi pts are fine if they are sleepy, typically they are only mac cases which is appropriate for phase 2 most of the time.