Or CHAPTER 14 Postanesthesia Care Units
Or CHAPTER 14 Postanesthesia Care Units
Or CHAPTER 14 Postanesthesia Care Units
CHAPTER 14
Lead Authors: Denisa Haret, MD, Clinical Assistant Professor of Anesthesiology, University of
Iowa; Misty Kneeland, Resident, University of Arkansas for Medical Sciences; Edmund Ho, MD,
Resident, University of Arkansas for Medical Sciences
Checklist
PACU Location
Ideally, the PACU should be directly contiguous to the OR area from which the greatest number
of patients come. While this is certainly preferable, it may not always be possible due to
constraints of preexisting architecture or construction imperatives in a new facility. Then the
question arises: How far away is too far? There are no published standards on this, leaving the
issue to the so-called rule of reason. One key point is to avoid elevator trips as a routine part
of a transfer from the OR to the PACU if at all possible. Elevator transport simply introduces
both a delay and a potential for great vulnerability if the patient were to experience an
untoward development while in the elevator. Assuming that the PACU is relatively nearby and
on the same floor as the OR, the ease of negotiating the hallways (e.g., straight path versus
multiple turns) is just as important as the actual distance. The time it would take to travel from
the most distant OR to the PACU door while pushing a stretcher and several intravenous (IV)
poles with infusion pumps should be estimated through actual time trials before construction
plans are finalized. The responsible anesthesiologists should determine if this time is
reasonable, or alternatively, should strongly lobby for a closer PACU location.
Independent of its location, it is very important that the orientation of the PACU facilitate the
flow of patients. There should be a direct entrance to the PACU from an OR corridor and a
separate exit, preferably to a main hospital corridor. This places the PACU between the OR and
the ultimate destination of the routine patient, whether that is a hospital bed or a Stage II
recovery area for outpatients. Constructing the PACU so that the same door is used for both
entrance and exit will inevitably lead to traffic jams and potentially dangerous situations. For
example, a patient leaving the PACU may prevent the rapid entrance of a new patient who is
having a problem (e.g., airway obstruction) during transport. Both the entrance and exit doors
must be extra wide to guarantee the smooth and safe passage of the widest equipment. A fullsized hospital bed with an intra-aortic balloon pump console and people pushing IV poles on
both sides should serve as the standard. It is remarkable to witness the irritation and expense
associated with knocking out parts of walls to replace doors that were installed with only a
standard-sized hospital stretcher in mind. Automatic opening of the doors operated by a push
button on the wall or by motion sensors is a modern convenience added in newer facilities.
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PACU Traffic
The PACU should be constructed so that patients directly enter from the OR and then exit from
the other end into a corridor on the way to their next destination. All of the patient portals
should be standard automatic double doors that are activated by push buttons on the wall,
pressure-sensitive floor mats, or electric eyes above the door. Very important and often
overlooked is the need for enough open space and wide aisles to allow movement of stretchers
and beds without disruption of care to the other patients in bed slots. Optimally, there should
be enough room around to each bed slot for a regular hospital bed with a full set of suspension
traction to make a 360 turn.
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Staff
The PACU is a division of the anesthesiology department, and there is always an
anesthesiologist assigned to be responsible for final medical decisions in the PACU. Usually,
however, a charge nurse, who also acts as a backup care nurse when the PACU gets busy,
supervises the minute-to-minute operation. In at least one hospital with a large PACU, an
advanced practice nurse with advanced cardiac life-support expertise has been specifically
trained to direct the PACU, under the supervision of the anesthesiology department.2 Each
patients postoperative care remains under the direction of the operating anesthesiologist, who
makes decisions related to the patients vital functions (i.e., respiration, circulation, fluid, and
metabolic balance) and analgesia. The operating surgeon is responsible for decisions about the
results of the operation.
PACU Nurses
Skilled nurses provide the direct postoperative patient care in a PACU. PACU nurses should be
trained in airway management, basic life support, and the special needs of postoperative
patients emerging from anesthesia. They should also be adept at caring for acute surgical
wounds and a variety of drainage catheters. For each PACU, a health care professional trained
in advanced cardiac life support should always be available.
Patients are more likely to have medical difficulties as they begin to emerge from anesthesia
than later in their recovery; therefore, for the initial 15 minutes in the PACU, it is necessary to
have one nurse caring exclusively for that patient. After about 15 minutes, patients who are
conscious and stable can usually be monitored by a nurse who is simultaneously watching one
or even two other similar patients.
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PACU Communications
A common problem of many PACUs is an inadequate number of telephones. The best
suggestion is to seek advice from a consultant as to how many telephones would be
appropriate and then install double that number. Cordless telephones can be quite useful, since
they allow the nurse to talk on the telephone without leaving the bedside. Obviously, the main
telephone at the unit secretary or coordinators desk needs to be as free as possible for
incoming calls. It is advisable to have a telephone number that is different from the main
number and used only by OR circulating nurses (and posted on the wall in each OR as its only
listing) to call the PACU to advise of impending patient transfers from the OR to the PACU. A
potential redundancy for this function arises when the utility of an intercom system is
considered. Some PACU staff find that, no matter how good the intentions, the regular facility
telephone system is not reliable enough for necessary incoming information and, more
importantly, outgoing calls for help. Therefore, a dedicated intercom system exclusive to the
surgical suite area is a viable alternative.
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Patient Monitoring
Beyond the requirement that a quantitative method of assessing oxygenation, such as pulse
oximetry, be employed in the initial phase of recovery4 , there are no specific promulgated
standards for patient monitoring in the PACU that would be analogous to American Society of
Anesthesiologists Standards for Basic Anesthetic Monitoring. A pulse oximeter must be
available for all newly admitted PACU patients. Many units have simply installed a pulse
oximeter at each bed slot, and it is often left on and functioning throughout the patients stay.
Alternatively, if the plan is to have pulse oximeters on rolling stands that are moved from
patient to patient, there must be enough of them so that one is not removed and shifted to a
new patient when it is still needed on the original patient.
It has become a de facto standard of care that there be a physiologic monitor for each PACU
patient. At a minimum, this includes an electrocardiogram monitor. Most of these monitors will
also have noninvasive blood pressure modules. Whether some or all of these monitors should
have invasive pressure channels will depend on the patients and procedures in that facility.
Most acute care hospitals in which major surgery is done will have pressure measurement
capabilities at most, if not all, PACU bed spaces. These devices can be freestanding so that they
can be moved to the patients who need them most. The availability and use of noninvasive
blood pressure devices does not eliminate the need for a standard, classic sphygmomanometer
and stethoscope in each bed space. There needs to be a way to accurately measure
temperature. There are a variety of rapid-acting electronic thermometers, but old-style
mercury thermometers should be available, too. The question of capnography as a patient
monitor has been repeatedly raised with regard to the PACU. It certainly seems wise to have at
least one capnograph immediately available to monitor ventilation in a seriously ill patient or
verify correct intubation and adequacy of ventilation. If there is the likelihood of many
ventilated or severely ill patients, it may be reasonable to have a capnograph in the physiologic
monitor at many or even all bed spaces.
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Step-Down Recovery
The step-down recovery area or predischarge area (synonyms are phase II recovery, short-stay
recovery unit, and secondary recovery area) may share a space with the preoperative area for
ambulatory surgical patients or may be a separate area. Here, patients are physiologically
stable, awake, and oriented, with a postoperative pain control plan already implemented. They
are tolerating oral intake yet still have the IV catheter in place upon arrival. Nurse-to-patient
ratio is much lower in this area, and family is often allowed to participate in the recovery
process. The patient may be in a semirecumbent position or sitting position in a lounge-type
chair, and activities such as nutrition, voiding, ambulation, dressing, and predischarge
instruction are carried out at this time. Staff must be prepared to treat pain, nausea, and
emesis and continue to evaluate patients for late development of postoperative complications.5
Cross-Training of Staff
Efforts are being made to better utilize recovery room staff and appropriately match staffing to
actual patient care needs. These include frequently updated staffing analyses based on patient
numbers and acuity, as well as cross-training staff to handle other groups of patients, such as
patients recovering from radiology, catheterization laboratory, or gastrointestinal procedures.
Criteria-Based Recovery
The concept of criteria-based recovery has emerged along with the availability of short-acting
anesthetic drugs. As compared to arbitrary time-based recovery, in which patients stay in each
phase of the recovery process a minimum amount of time, criteria-based recovery allows
patients to move through the recovery process at their own speed, determined by their
meeting specified criteria for each transition. Patients who have received short-acting
anesthetics; are awake, alert and responsive; have stable vital signs; are able to ambulate with
minimal assistance; and have manageable pain and nausea may pass to step-down recovery
after a very short stay in the phase I recovery area or move directly from the OR to phase II
recovery (fast tracking).5
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