PACU recovering patients in the ICU?

MunoRN, RN · Apr 6, 2021

Generally speaking the 1:2 ratio of an ICU should be sufficient for a 'stable' phase I PACU patient.

In my experience these sorts of rules (requiring a PACU nurse to initially recover or help recover a patient), comes from poorly handled situations prior that.

A common pet peeve is the patient who goes to the OR due to a perf'd bowel for instance, and is then sent to the ICU directly from the OR with no central line, pressors ordered, etc, and with the Intensivist not even yet consulted by the surgeon or anesthesiologist. Post perf'd bowel clean-out the patient will inevitably crump, so the ICU nurse now has a patient under their care without even so much as an "admit to ICU" order yet to at least be able to override meds, and that's in addition to their other critically ill patient. In those situations the patient should really continue to 'belong' to the OR and PACU until they've safely handed off the patient.

JadedCPN, BSN, RN · Apr 6, 2021

It’s been years since I worked PICU, but the PACU RN would come with the patient to the ICU but then we would immediately take over care of the patient.

0.9%NormalSarah, BSN, RN · Apr 6, 2021

Our PACU recoveries done in the ICU are done by us, the ICU nurses, 1:1 for at least the first hour. If we have another patient, they go under the care of the resource nurse for that hour so that we can properly care for and document on the recovery. Not sure if this is always necessary, but it sure does help so you don’t miss anything important happening in the recovery phase.

LovingLife123 · Apr 6, 2021

Patients that stay intubated do not need to be recovered, therefore, no pacu nurse is needed. My unit has our own nurses that recover non intubated patients if there is a bed available.

RNperdiem, RN · Apr 6, 2021

No PACU nurse needed here either. In SICU, anesthesia and the surgical team transport the patient to the unit an do a bedside handoff with the ICU docs and the ICU nurse. PACU nurses are not involved

JBMmom, MSN, NP · Apr 7, 2021

23 hours ago, MunoRN said:

A common pet peeve is the patient who goes to the OR due to a perf'd bowel for instance, and is then sent to the ICU directly from the OR with no central line, pressors ordered, etc, and with the Intensivist not even yet consulted by the surgeon or anesthesiologist. Post perf'd bowel clean-out the patient will inevitably crump, so the ICU nurse now has a patient under their care without even so much as an "admit to ICU" order yet to at least be able to override meds, and that's in addition to their other critically ill patient.

Were you in my unit this weekend?! I got a 15-30 minute heads up that the patient would be coming to the unit after surgery for ... you guessed it- perf'd bowel. I quickly found that this patient with a known IVDA history had a 22# in the AC and a EJ so I gave the PACU nurse a called and asked if they could request a central line before he comes to ICU. Since sedation *might* be a challenge when the heroin, cocaine and marijuana wear off on top of the roc and prop. Next thing I know a patient is rolling through the unit and all I have are "admit to ICU" and "Q3 hr dilaudid" for orders. We've had a number of dumps in the past so I admit my hackles were up a bit. I told them the patient was not going to be wheeled into the room and I would not accept care of the patient until I had the appropriate orders. Fortunately, the new surgeon had accompanied the CRNA and circulator nurse and he got right to work. And when I mentioned the central line they all said it was unfortunate that no one thought to have it placed in the OR, now we would have to wait for the surgical PA to get there. I was fit to be tied and told them that, in fact, someone HAD thought of it and I even called over to the PACU to have the nurse request one!!

Well, that was a bit of a tangent, sorry, but thanks for listening. As others have said, if intubated patients come over there isn't really a recovery since they're staying intubated. As long as we do have the correct orders and consults, it's not an issue and a PACU nurse isn't needed.

gizmopacurn · Apr 19, 2021

our ICU pt's that are intubated go directly to ICU. We do not send a PACU nurse there, we don't even have enough nurses for our unit let alone sending one to ICU to watch over and intubated pt that an ICU can do themselves.

I agree though, they need to have orders in place for the ICU RN if this is a planned direct admit.

kp2016 · Apr 19, 2021

I've done this before, it was a nightmare. Part of the problem with it is that the PACU nurse is now recovering the patient in a completely unfamiliar environment which makes if hard to function safely. The other factor is you are often alone in an ICU room instead of in the main PACU where you have other staff you can pull to give you a quick hand.

Other problems I ran into was the ICU nurse took their break as soon as I started the recovery as "it's a PACU patient and I won't be able to take my break once I take the patient". Thanks, now I'm recovering alone in an ICU room. To be clear this wasn't exactly the ICU nurses choice, they had been assigned to cover everyone else's breaks while waiting for their patient.

Anesthesia provider refused to write any additional orders that were needed as it was an ICU patient, the intensivist refused to write orders as it was a still a PACU patient.

This is one of those idea's managers love as they can use staff across two units in the same shift. The reality from the perspective of the PACU and ICU nurse is that it forces us into unsafe working conditions, reduces our ability to swiftly get orders from over covering doctors for a critical patient and just basically puts the onus for shorting out the fighting between Anesthesia / ICU providers onto the shoulders on the nurses.

In general just a horrible idea. It should be either a PACU patient and comes to the PACU and is recovered by a PACU nurse or it's a direct admit to ICU and is taken directly from OR to ICU.