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Pre-op nurse alone

Posted
by RN_1978 RN_1978 (New) New

Hello all

Im an R.N & work at an outpatient surgery center. I usually work in pre-op and on occasion I work pacu. My question is on days that I work pre-op my manager insists on always scheduling me to be alone in preop. For example there will be slow days where only 8-10 cases are scheduled that day and I'm put alone. There are times where it's a mix of peds and adults scheduled for surgery. 

I've voiced my concerns about how it's not safe but they don't seem to get it.

My question is....is it the norm for an R.N to be in pre-op alone?

Thanks

EDNURSE20, BSN

Specializes in ED, med-surg, peri op. Has 4 years experience.

For the whole day? Seems off. what if something goes wrong? Who covers your break? 

when I worked in pre op, from 1500-1930 there was only one nurse. But pacu was always next door, and I could ask for help when needed. 

Closed Account 12345

Has 14 years experience.

I don't think that sounds bad or abnormal.  Outpatient/elective pre-op patients don't require ongoing nursing care and supervision after you've gone through the initial paperwork and completed whatever procedures need doing.  As long as you aren't expected to prep more than about 3 adult or 2 pedi patients an hour, it sounds pretty reasonable to staff one nurse... It actually sounds like a cush gig! Paying two nurses for 10 (or even 15) pre-op patients throughout the day would be a poor use of funds. I would expect that surgeons and anesthesia are regularly popping in throughout the day, too, for their pre-op roles, so if you can't get an IV as the lone nurse, you could just ask anesthesia for help.

On 9/11/2020 at 8:53 PM, RN_1978 said:

Hello all

Im an R.N & work at an outpatient surgery center. I usually work in pre-op and on occasion I work pacu. My question is on days that I work pre-op my manager insists on always scheduling me to be alone in preop. For example there will be slow days where only 8-10 cases are scheduled that day and I'm put alone. There are times where it's a mix of peds and adults scheduled for surgery. 

I've voiced my concerns about how it's not safe but they don't seem to get it.

My question is....is it the norm for an R.N to be in pre-op alone?

Thanks

I realize that generally pre-op patients for elective surgery don't need constant supervision. However at the end of the day I am still responsible for them. My concern comes when I have patients in pre-op, waiting to go in for their surgery and I have to assist a wheelchair bound patient or a fall risk patient to the bathroom or when I have to go get the the next patient from the waiting room. Since I'm alone, those patients are alone for a brief moment as well. 

Anything can happen...a patient can suddenly feel dizzy etc...

 

Closed Account 12345

Has 14 years experience.

7 hours ago, RN_1978 said:

I realize that generally pre-op patients for elective surgery don't need constant supervision. However at the end of the day I am still responsible for them. My concern comes when I have patients in pre-op, waiting to go in for their surgery and I have to assist a wheelchair bound patient or a fall risk patient to the bathroom or when I have to go get the the next patient from the waiting room. Since I'm alone, those patients are alone for a brief moment as well. 

Anything can happen...a patient can suddenly feel dizzy etc...

 

Think of it this way.  If your ambulatory, stable, elective patient was at a busy family practice clinic, they may sit without any degree of supervision for 40 minutes.

If your ambulatory, stable, elective patient was on a Med-Surg unit, they might spend 11 hours out of a 12 hour shift without any clinical supervision.

If your ambulatory, stable, elective patient was in a facility that pre-ops patients in individual rooms instead of a large bay area, those patients wouldn't be under your watchful eye once you finished the initial process. 

There's no standard of care requiring 1:1/1:2 continuous nursing care and supervision for ambulatory, stable, elective Pre-Op patients.  Reasonably prudent nurses leave the bedside of healthy patients who just came from home for a scheduled elective procedure every day- and typically for longer periods of time than assisting another patient to the restroom or pulling the next patient from the waiting room. I think you're imposing a standard of care on yourself that simply doesn't exist for this work environment.

Freak accidents can happen in any nursing environment any day.  We can't always predict them, and when patients are stable and well, no one would expect you to remain immediately available at the bedside.  If this was the expectation, Med Surg nurses, who are dealing with sick patients, could only accept 1 patient per shift, not 6, to avoid the what ifs.  

There's no reason to expect a stable, ambulatory, elective surgery patient to crump on you. Sure, they might start feeling dizzy, anxious, or develop a headache in the 3-8 minutes you're away from the bedside. None of those requires immediate nursing care. Just make sure their beds are low and side rails are up. Let them know you're about to briefly step away to assist another patient but will return to check on them afterwards. If you return and find that your seemingly-healthy and stable patient has randomly coded while you were away for 5 minutes, respond appropriately; there's no nursing negligence there. 

Now, if this was about PACU, I'd agree 100% that you need eyes physically on your patients at all times and at least one other nurse available to help in emergencies, but that's a totally different specialty, and the elective patient's condition has changed by that point.

I'm not trying to downplay your concerns... Just trying to help you realize that you can probably let go of this worry! 

-Your fellow Pre-Op/PACU nurse 🙂

Edited by FacultyRN

londonflo

Specializes in oncology. Has 44 years experience.

Do you ever have to run blood pre-op? Do you draw labs or is all that done before they arrive at the hospital? 

EDNURSE20, BSN

Specializes in ED, med-surg, peri op. Has 4 years experience.

14 hours ago, FacultyRN said:

I don't think that sounds bad or abnormal.  Outpatient/elective pre-op patients don't require ongoing nursing care and supervision after you've gone through the initial paperwork and completed whatever procedures need doing. 

Pt can wait a long time for there surgery, and  they not all stable/easy Pt you can leave. What if you have to start a infusion on you diabetic pt Whose been NBM for 12 hours and is having a hypo? What if your pt has Autism and Can’t handle being there, waiting? What if your pt is from a rest home and is 2xa and needs to be changed? Or if your pt is freaking out and needs a pre med to calm down, now needs monitoring because youve just given Midaz? 

these were pretty routine things we dealt with in pre op on a daily bases. It’s not just a matter of paper work and starting IVs!

Closed Account 12345

Has 14 years experience.

7 hours ago, EDNURSE20 said:

Pt can wait a long time for there surgery, and  they not all stable/easy Pt you can leave. What if you have to start a infusion on you diabetic pt Whose been NBM for 12 hours and is having a hypo? What if your pt has Autism and Can’t handle being there, waiting? What if your pt is from a rest home and is 2xa and needs to be changed? Or if your pt is freaking out and needs a pre med to calm down, now needs monitoring because youve just given Midaz? 

these were pretty routine things we dealt with in pre op on a daily bases. It’s not just a matter of paper work and starting IVs!

These are outpatient elective surgery patients in a surgery center. They don't arrive 8 hours prior to a schedulee procedure and require a day of acute nursing care; they're not getting bumped for emergent cases all day like a hospital setting. They are coming from home where they woke up that morning, got themselves ready, and managed to get to a scheduled appointment in stable condition.

I don't feel that a fully dependent double amputee from a nursing home is a common patient for an outpatient elective procedure at a surgery center.  In fact, I've never encountered a single one. Patients requiring ongoing acute nursing care before/after a procedure should be more appropriately scheduled for surgery a hospital - not a business that closes the doors at 5 pm. What would I do if the hypothetical double amputee from a nursing home became soiled in the 5 minutes I was away from the bedside pulling another patient from the waiting room? I'd clean them up as soon as I became available, which would be a reasonable and appropriate time frame- likely quicker than they'd be cleaned and changed in a hospital or nursing home setting. 

As for the hypothetical autistic patient who can't be left alone, I would assume that the surgeon was aware of the patient's condition prior to scheduling their outpatient elective surgery and, knowing only 1 pre-op nurse is routinely staffed, still felt the outpatient surgery center was an appropriate care environment. All patients at outpatient surgical centers should have another adult with them who will accept responsibility for the patient post-operatively and provide the ride home. At my place of employment, no verifiable ride present at the time of checking in means the patient doesn't even make it as far as pre-op. If the patient was a minor, they would be accompanied by a parent or guardian.  If the person was an adult, they would be accompanied by the person providing their ride home. I would have that person, who'd be more familiar and comforting to the patient than a random nurse, remain at the bedside. I'd also argue that someone who is, behaviorally or mentally, outside of appropriate limits, unable to communicate, or unable to cope and calm oneself down (beyond typical pre-op anxiety) is not competent to consent to an elective surgery at that time.

If I had a hypoglycemic diabetic in need of acute nursing care, I'd remain at the bedside, treat the patient, and let my nursing supervisor know the situation. I wouldn't beebop out to a waiting room to get the next pre-op patient until things were settled. At that point, the nursing supervisor could come assist me to keep things moving, send over a helper nurse from PACU, or accept that the next patient might not be ready on time.

To summarize this long response: In the given rare and uncommon hypothetical outpatient elective surgery situations you described, I'd use my critical thinking, prioritization, and nursing judgment skills.  

 

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

10 hours ago, londonflo said:

Do you ever have to run blood pre-op? Do you draw labs or is all that done before they arrive at the hospital? 

Since this is a day surgery center, it is extremely unlikely that needing to run blood will be an issue- they usually don’t even have access to a blood bank. For those patients needing emergency transfusion (more likely in intraop or postop phase), the standard of care is to call 911 and initiate transfer to a hospital. 

As for lab work, pretty much the only thing being done day of surgery even for those being admitted to inpatient is finger stick glucose and for some renal patients a potassium. We have a workflow that says what tests are required and they are completed well before patient shows up. 

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

8 hours ago, EDNURSE20 said:

they not all stable/easy Pt you can leave. 

There is actually a standard of care for patients that are eligible for surgery in an outpatient facility and who should not be a patient in an outpatient facility. Those that are not stable (pretty much anything above ASA 2) will require a hospital setting. There are also many other factors that determine appropriateness for an outpatient setting, some addressing the cognitive disabilities that may make a patient more difficult. 

My facility consists of 2 hospital and 1 outpatient settings where surgery takes place. They are all coordinated by a surgical home that does a lot of work in getting these patients to the right setting with the right pre work. Does that mean there will never be an emergent scenario at the outpatient facility? No, and in fact we had one last week- MH crisis in a patient with no risk factors, no prior anesthesia, and zero family history. But the run of the mill things like suspected difficult airway, combativeness, etc can be planned for and placed in the appropriate setting. 

MLTBB20

Has 7 years experience.

Because it’s a probably a for profit facility I’m assuming and they trust you at your job.

Mini2544, ASN, RN

Has 1 years experience.

Do you ever have more than 2 patients at 1 time? Also does your facility use ASPAN guidelines? Do you medicate patients with versed and fentanyl before the procedure? Also I assume there is a post op nurse somewhere in the near area? 

LibraNurse27, BSN, RN

Specializes in Community Health, Med/Surg, ICU Stepdown. Has 8 years experience.

@Rose_Queen by MH crisis did you mean mental health crisis or malignant hypothermia? Just curious! I know malignant hyperthermia is rare but I was thinking it's more related to an outpatient surgery center emergency than a mental health crisis... but you never know. 

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

@LibraNurse27, malignant hyperthermia. Sorry, so used to what it means in my little corner of the world that I didn’t think about others not being sure what it stood for 🤣

LibraNurse27, BSN, RN

Specializes in Community Health, Med/Surg, ICU Stepdown. Has 8 years experience.

4 hours ago, Rose_Queen said:

@LibraNurse27, malignant hyperthermia. Sorry, so used to what it means in my little corner of the world that I didn’t think about others not being sure what it stood for 🤣

Thanks for clarifying! And wow, that is scary! I hope the patient was OK

michaelb, BSN, RN

Specializes in ICU. Has 22 years experience.

I worked a very similar situation, the only issue that arouse was signing narcotic wastes after the fact....