all PACU RNs Wrote up!

db pacu policy queen · Oct 16, 2008

I'm not sure where you are or what your liscening board would say, but our facility has a policy that states that discharge can be done form Phase I pacu by the alderete scoring, and our anesthesia dept is on board with it. we switched anesthesia groups about 1 year ago and there have been some discussions on all of our policies, and Aspan's standards state that discharges need to be based on several data collections and assessments ( I think they list about 12 criteria) and the discharge criteria should be in consultation with anesthesia and medical staff. It sounds like you need to open up the communication with your new doc, bring in some literature, evidence based practice and work together. i do think a warning like that sounds a bit over the top

fins · Oct 17, 2008

Just wait until the new policy causes some OR backup because anesthesia hasn't written the d/c orders yet and PACU is full - I'm sure they'll make that your fault, too somehow.

loricatus · Oct 17, 2008

Can't you ask for standing orders?

We have preprinted order sheets with fill in the blanks for meds. Part of the standard preprinting says: "Discharge when PACU criteria met." All the doc or CRNA has to do is sign it & when they forget, we just write it as a verbal order.

This gives a lot of leeway to the nurses to use their judgement, but still technically be forllowing orders.

jrgrad1912 · Oct 17, 2008

can't you ask for standing orders?
we have preprinted order sheets with fill in the blanks for meds. part of the standard preprinting says: "discharge when pacu criteria met." all the doc or crna has to do is sign it & when they forget, we just write it as a verbal order.
this gives a lot of leeway to the nurses to use their judgement, but still technically be forllowing orders.

the surgeon still writes a discharge order. this hospital does not have standing orders.

we have been doing this for a week now and we have no stress! we call the crna and they come and look at the pt. and writes the order.

now if a patient crashes on the floor or in acu it is the anesthesia's fault. not the pacu rn. i am upset how they handled it. just come and tell us they are changing the way we discharge pts. just a note. they still have not changed the policy!

jrgrad1912 · Oct 17, 2008

Just wait until the new policy causes some OR backup because anesthesia hasn't written the d/c orders yet and PACU is full - I'm sure they'll make that your fault, too somehow.

Thanks for your reply.

I asked about that. the ACNO said "It does not matter". We have lost so many surgeons on some days we only have 4-5cases!

All4Seasons · Nov 16, 2008

OP, Do you mean that in order to discharge a pt from PACU, to either a postop hospital bed,phase 2 recovery or to home,you are required now to have an MD personally write an order for discharge? I wonder what the reason is for what seems,on the surface,to be a power issue? Perhaps he has had some negative pt outcomes somewhere else, or is not cognizant of modern,accepted national standards of post anesthetic nursing care.

Here we must follow strict guidelines which have been developed,criteria which the pt must meet before we can discharge from PACU to anywhere. That being said, we are also treated as the professionals we are, and are credited for using common sense and sound judgement in assessing patients for suitability for discharge,and trusted to follow the procedures which have been established to maximize pt safety. Of course,there are always those cases that we consult with the anesthetist for if the case isn't clear cut - but those are the exception and not the rule.

I was very surprised that you all were approached by HR for practise-based criticism - this seems authoritarian and ill-informed ("working outside your scope of practise"?)....what has your Unit Manager's role been in all of this?! Usually she/he is the direct supervisor of nursing staff,is this not the case where you work?

You would have thought that the MD,as a professional,would have directly approached his fellow professionals - the bedside RNs and the unit manager - and arranged a meeting to explain his thoughts and concerns,and to be open at least to discussion. Sounds to me his thinking is antiquated and/or territorial...or,horrors, both! :icon_roll

I can appreciate that, there being such a small number of you,it might be easier for the MD and HR to intimidate you. Prior to requesting a meeting,it might be a good idea to have in hand the widely accepted ANSPAN Standards of Practise for discharge,as well as,if you can find them,statistics (or opinion articles) supporting the fact that these standards are well thought out and time tested.

Good luck with this and please let us know what develops!

jen :)

jrgrad1912 · Nov 17, 2008

one pacu rn took it to the ceo and it is going to be reversed(i am not holding my breath). i do not know whose idea it was, the crnas hate it. they have to sit in pacu with us after hours.

the rn who took it to the ceo said the complaints were like, pt with a small bloody spot on gown. my favorite was the pt was nauseated. the pts do better becauce the crnas give higher and better pain meds. that was another complaint the pts had pain. we told our manager our hand were tied we could only give what the surgeon orders, and if we give a pain med we have to hold the pt for 30 minutes. she is from a big or and did not have to do any thing with pacu.

it is interesting how little people understand anesthesia.

i would like to thank all the nurse who replie!d to this. jr

anne74 · May 30, 2009

Where is your manager in all of this? How was this allowed to happen? How about having a meeting and making a new policy to start requiring DC orders, instead of sending you straight to HR and punishing you for something you were never told to do in the first place? Shame on whoever "reported" you, and shame on HR for allowing that to happen. That's totally unprofessional and I'd be weary of working for an organization that handles these issues so poorly. That's essentially harassment.

gambutrol · May 30, 2009

in our institution we have to inform the anesthesiologist that the patient is for discharge.. he/she would look into the discharge orders of the surgeon and assess if the patient is ready for discharge.. he/she then orders the discharge

debthern · May 30, 2009

We have to have an anesthesia note signed before our patients can be discharged but it has nothing to do with our practice it is because if it is not signed medicare will not pay

shellabelle · Mar 24, 2010

Our MDs write in their orders, To PACU, then admit to floor/day surgery or write a D/C order when we discharge from PACU. We also have a PACU Protocol that has orders for pain meds, nausea meds, oxygen, and says at the bottom DISCHARGE FROM PACU WHEN CRITERIA MET. We have the anesthesiologists sign packets of them at a time and keep them in folders so they don't have to write/sign individual orders. We also go by the Aldrete system. These have worked well for us and we have never had any problem.