Question for PACU Nurses

carcha · Oct 1, 2003

sounds like a mixture of poor management, inexperience, poor communication and panic. This patient should never have left the or room, let alone be rushed further away from the one area he needed to be in the or. I would certaintly write up a "near miss" form and recommend in it that the medical and nursing staff who dealt with this patient, reflect on their actions and decisions and without blaming anyone, come to an agreement on what course of action should have been taken and should be taken in the future.

mattsmom81 · Oct 2, 2003

I'm an ICU nurse considering a move to PACU, and the OP's post caught my eye as I've been in this situation several times too.

It's been a combination problem...inexperienced PACU nurse, reluctant surgeon, etc... agree it is also wanting to find more warm bodies to help out ...so let's go to ICU now and sort this out later....

I agree with those who said look at this as a patient advocate to try to problem solve the situation. Sadly it is the surgeon who says 'no' to returning to the OR who endangers the bleeding patient; the anesthesiologist can also worm out of responsibility, and both can disappear...leaving the problem square on the nurses . That's when the documentation and notification of superiors must start. We have to be patient advocates along with covering our backsides...the life of a nurse, eh? .

Sometimes we DO feel dumped on and we just do the best we can....and let our managers try to fix problems that originate in other departments.

As an ICU nurse, sometimes I feel iritated that surgery looks at me as an extension of their department...when I am already overworked and understaffed trying to manage my OWN dept. That is where some of the antagonism can come into play in our relationships.

I don't mind being a team player til I notice it's not reciprocated.

squeek · Oct 14, 2003

i cant believe this patient ever left the OR!! I am an anaesthetic nurse ( and an old PACU nurse ) our patients will bypass PACU if they are to be ventilated in ICU ... however they do not leave the OR until they are stable ...... they certainly dont leave if they are haemorrhaging ...

wildwood · Oct 14, 2003

I'm an OR nurse, not PACU, but I can certainly understand why you are concerned! We are a small rural hospital, but we would never think of asking an ICU nurse to manage our patients. Our anesthesiologists and nurses make sure patients are ready to go to the floor, or if the patient is on the vent, go with us to transport to ICU. I can't understand why the patient wasn't taken right back to OR from PACU when the drain was filling up with blood so fast. Thank God we have competent surgeons here! This was definitely an indication for a risk management review!

ckalston · Nov 24, 2003

At our facility we usually don't even know for sure a patient is going to ICU because most of the time they go straight from OR to ICU. Our PACU is capable of recovering critical patients and on occasion we do when ICU is to busy. As someone else mentioned, if this JP was filling up that fast, someone should have noticed before even sending up to ICU.

Originally posted by Zee_RN
He never made it into PACU; they rushed him right up to ICU, the PACU nurse in attendance along with anesthesiologist. Both of whom piddled around while the pulmonologist and two ICU nurses managed the care of the patient (which meant four other ICU patients were not seen by their nurses--the nurse assigned to the patient had TWO other patients and the nurse who helped her had two ICU patients of her own). The surgeon is one who rarely operates at our facility (and will certainly never touch a member of MY family!) and I was unfamiliar with the anesthesiologist too. Maybe because it was Saturday? The surgeon, as I said in the first post, truly just walked around--with his hands clasped behind his back--while the pulmonologist managed the case.

So the general rule is--patients leave PACU when stable? Even when it is an ICU patient (although the patient was not in any way in a critical state when LEFT ICU to go to the O.R.).? Thanks for helping me understand this issue.

seeley · Feb 7, 2004

I agree that it is obvious that the patient should never have left the OR in the first place. The surgeon and the anesthesiologist were wrong to end the case like that...also, I've never heard of the OR calling for an ICU nurse to come to the OR...that indicates the lack of competence going on in that OR at that time... that said... it should depend on who has the most available resources at the moment the OR wants to bring the case to a unit, i.e.staff. I have worked in a University setting for a long time and now work in a large community hospital. Policy should be in place for what works best for your institution. Policy can be broken however if one staff is more able to handle the crisis at that time...this requires quick and trusting communication between charge nurses of the ICU and and PACU. I have worked both...I know both can be busy...sometimes at the same time. That is when you must default to hospital policy as to where the patient goes.

Where I am currently; a community hospital, the policy is that the PACU accepts all ICU patients until 7pm and then all ICU patients must go direct to ICU. This is based on staffing levels that drop severely in the PACU after 7 pm.

In your posting you mention that there was no intensivist readily available to manage this patient. Most PACUs don't employ intensivists either...that is rare!

Good luck with your nursing career:)

pacu nurse 2216 · Feb 15, 2004

I'm newly appointed Charge Nurse in ICU, having work there as a staff nurse for >3 years. Had an event yesterday that I need input on.
We sent a patient to the OR for a lap chole. He was in a SR and on room air (88-years-old). The PACU nurse called me and said they were sending him straight up to ICU post-op because he was ventilated, on dopamine, neo and epi. OK, fine (? happened?!) but fine. Nearly immediately she called back and said "you need to send a nurse to the OR; he's crashing." Ummm...never heard of that! ICU send a nurse to the OR?! We couldn't do that and she said "OK, he's coming up right now." So this patient comes into the ICU with an ABP systolic of 50. Never got it any higher. We poured blood products and fluids and added levophed to the routine and desparately tried to get a central line in him (they sent him up with a 22g in his left hand and a 14 gauge angio cath in his neck!). After about 90 minutes of this (ABP never higher than 50) with blood pouring out of his JP drain requiring constant (every minute) emptying, we took him back to the OR where they found a bleeder (big surprise) and fixed it. He came back and we were able to wean some of the pressors off (down to dopamine 6 and levophed 16).
My question: doesn't PACU handle these types of crises? I thought that was the purpose of PACU--so they could send them back to the OR urgently if needed, under the supervision of the anesthesiologist. We DO NOT have an intensivist in our unit. We have family practice residents--on call. We just happened to have the pulmonologist there on the unit yesterday and HE managed the case while the patient was crashing in ICU and inserted the triple lumen. The surgeon paced uselessly back & forth.
I'm honestly looking for advice; I'm new to charge (only 6 shifts under my belt!) and I'm not sure what to expect from ancillary departments. The charge nurse who followed me said "did you write it up?!" Ummm, well, no. Didn't realize it was "write-up-able." What do you think?

i think that pacu should have taken care of the problem. this sounds like a case of " i don't know what to do so i will dump patient on them" that pacu is liable for that patient and should have contacted the anesthesiologist. i would certainly write it up and let them know that you do mean business!

pacu nurse 2216 · Feb 15, 2004

i think that pacu should have taken care of the problem. this sounds like a case of " i don't know what to do so i will dump patient on them" that pacu nurse is liable for that patient and should have contacted the anesthesiologist. i would certainly write it up and let them know that you do mean business! i can't believe that a pacu would do something like that. you should talk to the nurse in charge of the unit and asked the reasoning behind their choices.