Refining nursing assessment and management in the Post-Anaesthetic Care Unit: a new discharge criteria tool to minimise surgical patient risk

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1 Refining nursing assessment and management in the Post-Anaesthetic Care Unit: a new discharge criteria tool to minimise surgical patient risk Dr Maryann Street Professor Nicole M Phillips Dr Emily Haesler Professor Bridie Kent

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3 Background Nurses in the Post Anaesthetic Care Unit (PACU) have responsibility for assessment, ongoing monitoring and management of patients, and for making clinical decisions on readiness for discharge from the unit. Approximately 15% of surgical patients will experience an adverse event Nurses play an important role in identifying patients at risk of an adverse event, such as clinical deterioration

4 Setting Eastern Health Melbourne, Australia 7 acute and sub-acute care hospitals 5 Surgical Units (day procedure and inpatient) Approximately 13,000 elective surgical admissions / year

5 Aims To evaluate whether use of a newly designed discharge assessment tool - the Post-Anaesthetic Care Tool (PACT) would: a) enhance the recognition and response to patients at risk of deterioration b) improve nursing handover c) result in improved patient outcomes

6 Study Design Design Prospective, non-randomised, pre- and post-implementation study Phase 1 patients who had surgery prior to the introduction of PACT Phase 2 patients who had surgery after the introduction of PACT Inclusion criteria: Patients aged 18 years or older Elective surgery before PACT and using PACT PACU admission Street M, Phillips NM, Kent B, Colgan S. Minimising post-operative risk using a Post-Anaesthetic Care Tool (PACT): protocol for a prospective observational study and cost-effectiveness analysis. BMJ Open (2015).

7 Research program Systematic review- identified evidence-based criteria and the gaps in knowledge Incidence and nature of adverse events relating to PACU at a large health organisation in Australia (PRiSM) Delphi study- to achieve expert consensus on the essential components of an effective discharge scoring tool, leading to the development of a Post-Anaesthetic Care Tool (PACT) Pilot study to evaluate the PACT Proposed: Randomised control trial to evaluate the effectiveness and impact of the PACT

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9 Development of the PACT Developed by subcommittee of clinicians in consultation with Deakin University Researchers in 2011 and 2012 Submitted to various EH committees for approval in 2012 Revised and redesigned to include criteria for recognition and response to clinical deterioration in 2013 Implemented all sites 17 th March 2014

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11 Methods Observation of nursing assessment in PACU Observation of nursing handover Patient data collected from medical record Audit of PACT completion both time taken and comprehensiveness

12 Results 1417 eligible patients included; 723 before PACT (Phase 1) and 694 after PACT (Phase 2) No significant difference between Phase 1 and Phase 2 for Age or Gender Patient acuity or Comorbidities Proportion of patients having day procedures or overnight admissions

13 % 100 Nursing management Analgesia administered Pain score recorded on discharge PONV Antiemetic Assessed and administered recorded Use of warming blankets Recording temperature Medical consultation requested All discharge criteria met Phase 1 Phase 2 All p<0.01

14 Most common adverse events Phase 1 and Phase 2 % P1 P2 P2 P2 P1 P1 P2 P1 0 Clinical Deterioration Cardiovascular Uncontrolled pain Respiratory event

15 Length of Stay in PACU survival curves All patients (n=1417) Patients with AE in PACU (n=174) Median difference + 7 minutes Median difference -16 minutes

16 % 100 All ISOBAR elements All sites PACU 1 PACU 2 PACU 3 Phase 1 Phase 2 Significant changes: Situation (94.5 vs 91.6) Observations (90.5 vs 87.2) Background (72.6 vs 82.0)

17 Key findings Conscious state, oxygen saturation and the vital signs of respiratory rate, heart rate and blood pressure were recorded for almost 100% in both Phases. From Phase 1 to Phase 2, there was a significant increase in nursing assessment of pain, PONV and temperature with increased administration of analgesia, anti-emetics and use of warming blankets Nurses recognised clinical deterioration requiring a medical consultation more often using the PACT There was a significant decrease in notification that all discharge criteria had been met prior to PACU discharge: 73.6% vs 66.5% (p=0.004) Time spent on documentation remained the same: 14.6 min vs 13.9 min per hour of PACU stay, (p=0.857) with a high level of completion in both phases Handover from PACU nurse to Ward nurse improved significantly

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19 Conclusions This study found that when using an evidencebased discharge tool, the PACT: Nurses were prompted to assess and identify emerging clinical issues, leading to improved patient care Nurses recognition and response to patients who experienced clinical deterioration was enhanced Assessing discharge criteria and delivering a comprehensive clinical handover from PACU to the ward was improved Patients who experienced an adverse event in PACU had reduced length of stay in PACU and hospital

20 Acknowledgements This project was funded by the HCF Health and Medical Research Foundation We acknowledge and thank all the nursing managers and staff who contributed to this @easternhealthau