Unsafe anesthesia practices in phase 2

[Pacurn]

I need some advice from my fellow nurses in surgical services in particular pacu and phase 2 nurses.

I work in an ambulatory care unit doing phase 2 recovery (though the majority of my experience is in phase 1) my fellow coworkers and myself are constantly receiving patients in phase 2 that are not appropriate. We are regularly receiving patients coming straight from the OR (bypassing phase 1) who have undergone general anesthesia, who are requiring oxygen, far too sedated, the crnas are pushing neo on the way out of the OR then walking away; patients straight out with spinal anesthesia, uncontrolled pain and nausea, ASA 3 and 4 patients and are even getting patients with chest tubes and on those who require telemetry on the floor.

To be clear we are a DISCHARGE unit. The patients coming to us are NOT on monitors. We have a 3:1 ratio with only 9 bays available and 3 nurses who discharge up to 40+ patients per day. This is a major red flag and a huge no no to any nurse with phase 1 experience. We have ALL complained to management and expressed our concerns about the safety of our patients and these assignments being inappropriate especially as we don't have the capability to monitor these patients closely (patients are in a room by themselves until family arrives) and we are very busy constantly discharging patients back to back and physically can't be there to give those patients the close observation that is necessary.

I've quoted ASPAN standards to my managers but apparently ASPAN relaxed standards significantly during COVID and they haven't issued new standards since which I'm sure they will do in the near future. But in the meantime it appears managers are using this COVID loophole to justify sending unsafe patients to our unit on a daily basis. BOTH of my managers have 20+ years of experience and much of that experience was in phase 1 nursing so I know that they know this is unsafe.

I had a patient today who was far too sedated to come straight from the OR and complained of 8/10 pain on arrival to myself and the CRNA (did nothing to rectify the situation even after my request for her to do so and just left) when the patients family arrived they were reasonably upset to see their loved one this way and when I mentioned (innocently) that the patient came straight out of the OR and that explained her excessive sedation and pain they demanded to speak with my nurse manager. My nurse manager later told me "to be careful what I say to families" and went on to justify why the patient was appropriate to come straight to phase 2. But if the patient was truly appropriate to come to phase 2 in the first place then why would I need to "be careful" what I said to the family? She basically told me to lie/omit what I told the family to avoid upsetting them. If she truly felt the assignment was appropriate to begin with then there would be no need to watch what I say to them, this is unethical and not the way I believe in practicing, patients have the right to know and to make informed decisions about their care.

My nurse manager even tried to justify the situation by saying "bypassing the phase 1 unit saves the patient money" and asked me if I were the patient would I want to be charged thousands of extra dollars to go to pacu? To which I replied "absolutely" and said " I could also save tens of thousands of dollars by having my surgery in South America or a third world country but I wouldn't do it because I would want it to be done safely and that that's why our patients come to us and trust us, so that it is done right".

I'm at my wits end and so are my coworkers. And I'm not sure which steps I should take at this point. I've done countless incident reports and had private meetings with management about the situation (as have many of my coworkers) and it just continues to happen. How exactly should I escalate this situation? Who do I report these unsafe practices to? Joint commission, the BON, the medical board? I don't necessarily dislike my job and I love my coworkers so I don't want to leave but more importantly if I left I could save myself the trouble but these things would still be occurring and it's unsafe and unethical for me to not intervene because these things will continue to happen with or without me there. There needs to be a change for the safety of the public who trust us, and btw this isn't some small hospital in the middle of nowhere, I work for a very large hospital downtown in one of the major cities in the southeast.

Any advice would be appreciated by myself and my coworkers who only want to do the right thing 

[offlabel]

I had a patient today who was far too sedated to come straight from the OR and complained of 8/10 pain on arrival to myself

Honest question...how does a 'far too sedated' patient complain of 8/10 pain? And I've never heard of a phase II recovery unit without monitors. Not even a pulse ox?

 

[Ms. Angela]

Hello there,

Sorry you and your coworkers are placed in this horrible situation,and I can feel your frustrations through your words. I would suggest you reach out to your hospitals Ethics and Compliance Officer and have these unsafe practices addressed. Incidents such as these cost hospitals more than money, but can give the hospital a very bad reputation, and word of mouth and social media, can be the worst kick anyone can receive, especially hospitals. People who not feeling well and need surgery, already arrive with some anxiety but also hope of becoming better so that they can move on with life, and for a nurse manager to speak as if she's a patient who may not want to pay more money for the services they need for their health, is asinine and irresponsible. Please speak up for your patients and your conscience. We have enough people in management positions, who's focus is on how good the numbers look on paper, saving the hospital money, which then becomes their annual bonus. 

 

[azhiker96, BSN, RN]

Highly recommend you purchase your own copy of the ASPAN standards. It is too easy for managers to try to bend the standards when they are being pressured by OR to just take a patient. The standards are the minimum safe standards, not a target or average of care. Excerpt from the ASPAN 2023-2024 Standards

Study the standards and when you are ready, put in a Midas report when you or another nurse is given an unsafe assignment. Be sure to quote the ASPAN standard as well as the page, paragraph, date, etc. Be sure the tone is a desire to provide safe care within the recommended guidelines of our National organization.

It can also help if you prepare and give an inservice to your department so that everyone is aware of the safe standards of care. 

Be aware that you may not change anything and only end up getting a target on your back. Some managers hate it when staff nurses push back. Be ready to find a better, safer PACU if needed.  

[Spiker, ASN, RN, EMT-P]

Well, you've tried talking to your department managers to no avail,  Maybe it's time to move up the chain of command and voice your concerns to your DON, patient safety advocate/ethics department.  Your patients aren't only compromised, but your license could be on the line.  Good luck, be strong!

[brandy1017, ASN, RN]

I would file a complaint with CMS Medicare.  They are the only ones that will take this seriously!  Joint commission is a waste of space!  They will just give them a slap on the wrist.

[C.Love, MSN, NP]

This is bad medical care, unsafe. I would look for another place to work that shares your desire for honest quality care. 

[kp2016]

This is so unsafe. Given your managers who based on their backgrounds should 100% know better than this, continuing to write incident reports is unlikely to have much impact and will result in you being "the bad guy". I would discretely encourage the families complain. Poor ratings, reviews and complaints even when wildly unfair seem to get attention.

I would likely start getting family back as quickly as I could. When they ask for pain relief...

- "I'm really sorry, because this is phase 2 I can't give IV analgesia" 

- I can give something oral. Oh, gosh, they are nauseated and threw up when we tried to get them up (which is why I normally ensure the pain is treated IV in phase 1 to avoid oral in phase 2)... best get an order for an antiemetic, I'm assuming the orders for that were only phase 1, so probably a delay, oh well. 

- whoops, phase 2 is now back up so you physically have no where to put the patients coming from phase 1 or the direct admits from the OR, oh well. Never mind I'm sure the CRNA's or Doctors will call a manager to yell about it and demand they find a solution. 

In my experience the Doctors want to do what ever they perceive to be the quickest so they can get as many surgeries done as possible. The simplest fix is to stop trying to make it work and let it take as long as it takes, the real trick is too let the families do the complaining for you. And work on your innocent face and tone, you will need it.