Thinking about PACU

Editorial Team / Admin · Sep 1, 2015

A lot of your questions are going to depend on the facility. In mine, the PACU ratio is 1 nurse : 2 patients. Exception is 1:1 if the patient is awaiting critical care or is a peds patient. As a level 2 trauma facility, we have both an anesthesiologist and a CRNA in house at all times, although not necessarily in the unit- they may also be responding to codes, doing cases in endo, responding to traumas in the ER, etc. If there is a patient in the unit at all, they aren't supposed to be sleeping in the call rooms. We have all sorts of cases ranging from quick little cases where the patient will be going home to major traumas, cardiac, and thoracic patients. When possible, any patient remaining intubated for more than 2 hours postop will go directly to the ICU or trauma ICU. The only time these patients will go to PACU is if there is hopes to get them off the vent (a "wake up" vent because they just aren't metabolizing the anesthetic drugs fast enough to be extubated in the OR) or if ICU truly doesn't have an available bed and has to get another patient transferred out first. We don't do holds in PACU; if there are patients who can't get rooms upstairs, they go to our overnight surgical observation unit until a bed opens up. Very rarely happens as PACU keeps in contact with the facility's nursing supervisor, anesthesia, and the charge nurse so that if PACU starts backing up, we put ORs on hold.

turnforthenurse, MSN, NP · Sep 2, 2015

Thank you! What do you like the most about working in the PACU? What do you like the least? What are the most challenging aspects of your job?

Editorial Team / Admin · Sep 2, 2015

I don't actually work in PACU- I'm an OR kind of girl. I do know that one of the frustrations of the PACU nurses is when there are schedule changes (cases flip order/something cancels but another case is booked in its place), add-ons, surgeons running ahead/behind and they aren't notified.

RainMom · Sep 6, 2015

I don't actually work in PACU- I'm an OR kind of girl. I do know that one of the frustrations of the PACU nurses is when there are schedule changes (cases flip order/something cancels but another case is booked in its place), add-ons, surgeons running ahead/behind and they aren't notified.

Yes, the add-ons that are allowed to run everybody late into the evening! I work in a small hospital (no trauma). If the surgery schedule is light for the following day, we give an LCD, sometimes 2; then, of course the following day, there are surgeons who want to add on cases but they can't be scheduled in thru the middle of the day because of light staffing. So, we end up with cases added at 1600 & later, (not too bad if a simple case, but sometimes they sched cases that last 3-4 hrs) keeping the anesthesia & pacu staff much later in the day. This issue is supposed to be worked on...

Some days, the pts just sort of trickle in making for a long day & of course, this is when mgmt decides to walk thru to see us twiddling our thumbs, "ladies in waiting". They rarely come thru when every bay is full & a couple of us have 2 pts.

When I started, I was told that pacu is the bastard child of the surgical dept & nobody thought we did anything most of the day. Similar to when I first started on the floor: it was considered the "penthouse" because it was the newest & had all private rooms.

turnforthenurse, MSN, NP · Sep 7, 2015

Yes, the add-ons that are allowed to run everybody late into the evening! I work in a small hospital (no trauma). If the surgery schedule is light for the following day, we give an LCD, sometimes 2; then, of course the following day, there are surgeons who want to add on cases but they can't be scheduled in thru the middle of the day because of light staffing. So, we end up with cases added at 1600 & later, (not too bad if a simple case, but sometimes they sched cases that last 3-4 hrs) keeping the anesthesia & pacu staff much later in the day. This issue is supposed to be worked on...
Some days, the pts just sort of trickle in making for a long day & of course, this is when mgmt decides to walk thru to see us twiddling our thumbs, "ladies in waiting". They rarely come thru when every bay is full & a couple of us have 2 pts.
When I started, I was told that pacu is the bastard child of the surgical dept & nobody thought we did anything most of the day. Similar to when I first started on the floor: it was considered the "penthouse" because it was the newest & had all private rooms.

So would you say that there are some shifts that go past 12 hours?

RainMom · Sep 9, 2015

So would you say that there are some shifts that go past 12 hours?

Occasionally. Our call person comes in at 11:00 & stays until all cases are done. Most of the time things wrap up by 1900 (sometimes earlier & that person doesn't even get 8 hrs) but it's not unusual for the call RN & the "late" RN (comes in at 0900-1000) to both be there past 2200. That usually happens when we have a couple particular surgeons with multiple long cases or if the ER has been busy.

Our management is rather kind about giving call time (1.5xpay) to those nurses who end up staying significantly longer than 8 hrs, even though they are not technically on call. I had a shift recently where I started at 0800 but didn't leave until almost 1900; I was given call pay for my extra hrs past 1630.

twozer0, NP · Sep 12, 2015

I was an ER nurse, like yourself for 4 years prior to coming to the PACU. I've now been in PACU for 4 years as well. Our backgrounds are almost identical except I work at a local community hospital that isnt a trauma center (but we still got them!).

I found the transition easy and to be honest I love the PACU job much more than I ever loved the ER job. What I miss the most from the ER is the comraderie between staff and docs. I get that to an extent here in PACU but not nearly as much as in the ER. At any rate. ASPAN national standards dictate a nurse to patient ratio of 1:2 or 1:1 for critical/pediatric patients. It is up for your facility to actually inact these as they are not company policy but more of a guideline for entities to follow. We do at our facility. I do not mind caring for children at all, in some instances they are vastly superior to adults once they are oriented. You will do a lot of airway management and making sure your patient is breathing adequately. As far as not having any trauma experience, this is really not a big deal. Really trauma is its own separate thing, set this thought aside, trauma experience doesnt dictate your ability to learn or put you any lower than someone who has experience.

Yes we do call.. A lot of it. I'm actually here on call now as I type this. I would say we average around 300 hours a year of additional time. We are compensated for it but those weekends you are on call, dont plan on doing anything (we do not run scheduled weekends at our facility). The schedule in PACU was much better for my family. It started with every 11th weekend doing call but it got changed to every 5th. meaning I have 4 weekends off in between, something you will never find in any other department!! YOu will have holds.. we have them all the time but it has never kept me here on overtime all but a handful of times and generally they try to get someone in to take the patients from you, even without a room to go to.

My advice on going to PACU is a solid career move. I love it over here. At times I hate the call but the money is great. Its allowed me to continue school and pursue career goals into the graduate level. Best of luck on your decision!

azhiker96, BSN, RN · Sep 12, 2015

Details will vary from facility to facility. At my first PACU they took all patients included vented ICU players. We drew a lot of labs, setup a ton of drips, and administered blood products, electrolytes, and abx. My current PACU is usually bypassed by vented patients but we still get all the non-vented ICU patients along with outpatients and other inpatients.

When you interview or check out your PACU, see if they've heard of ASPAN (American Society of PeriAnesthesia Nurses). ASPAN publishes best practices guidelines which help you stay out of unsafe situations. For example, if you have a patient with an airway they cannot give you a second patient. That would be unsafe. If you go to PACU, consider joining ASPAN as soon as you are able and read their standards.

I love PACU because it has the right mix of autonomy and teamwork. I have lots of help readily available from nearby nurses if a patient turns sour. I also have a variety of PRN orders that I can use to control symptoms. As you gain experience and develop working relationships with the providers, you'll find they generally give you what you ask. BTW, I still learn new things every week. Patients respond differently than I expected or a provider comes up with a different way to treat a symptom.

What I don't like is some days you may have a low census and be flexed home early. Some people like that for the extra time with family. Some don't like it due to lower paychecks or having to use PTO to stay whole.

One other thing I like. Every day I get a great feeling of accomplishment knowing I made a difference in people's lives. I have been allowed to help someone during a difficult time of their life. It may be pain management, treating nausea, or recognizing a stemi and providing the proper meds and notifying providers so that we avoid a code and minimize damage.

Airway management is huge. There are many outpatients who need just a touch of chin lift at the right time so that they can later go home.

turnforthenurse, MSN, NP · Sep 22, 2015

twozer and azhiker, thank you so much for your insight!

twozer, did you gradually make the change to PACU by doing PRN/part time or did you jump in all at once? There are some PRN opportunities available in my area that I am considering. I'm afraid to go all in right away in case I do not like it.

I think I need a change, though. As much as I love the ER, I'm sick of the crappy staffing and getting dumped on all of time (getting 2-3 very sick patients at the very same time with no help and a CN nowhere in sight). I feel like this isn't safe at all. Every day I go to work I dread it...I can't even relax on my days off because I know I have to go back to work in a few days.

twozer0, NP · Sep 28, 2015

twozer and azhiker, thank you so much for your insight!
twozer, did you gradually make the change to PACU by doing PRN/part time or did you jump in all at once? There are some PRN opportunities available in my area that I am considering. I'm afraid to go all in right away in case I do not like it.
I think I need a change, though. As much as I love the ER, I'm sick of the crappy staffing and getting dumped on all of time (getting 2-3 very sick patients at the very same time with no help and a CN nowhere in sight). I feel like this isn't safe at all. Every day I go to work I dread it...I can't even relax on my days off because I know I have to go back to work in a few days.

Sorry for the late follow-up. When I made my career change I just went, no shadowing, not knowing the job at all. The skillset of the ER blends well with that of PACU. You dont do as much general things in PACU but your airway management will be the best of any nurse in the hospital aside from anesthesia. Don't be afraid to take a risk if its what you want. Like you, I was in an ER and experienced much of the same so I was ready for a change. The change will only make you more well rounded and more marketable for the future. You might even decide to do anesthesia! Good luck!