PS1070 SARASOTA MEMORIAL HOSPITAL PERIOPERATIVE DEPARTMENT POLICY TITLE: ADMISSION/DISCHARGE CRITERIA: POST ANESTHESIA CARE UNITS (PACU) EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: Job Title of Responsible Owner: Director of Perioperative Services PACU 126.802 Maternal 1/88 10/16 DEPARTMENTAL NTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 7 PURPOSE: POLICY STATEMENT: To establish admission and discharge criteria for the post-anesthesia patients as set forth by the Department of Anesthesia. 1. Patients requiring intensive nursing care during the immediate post-anesthetic phase will be admitted to the post anesthesia care units according to the criteria established in this department policy. Patients who have received anesthesia will be assessed on admission and monitored by the PACU RN. Based on this data, the RN will transfer the patient from the PACU when the established discharge criteria are met. The patient will be reassessed prior to the transfer. 2. All patients having vaginal deliveries in the Delivery room, uncomplicated Cesarean deliveries or tubal sterilization will be observed in the Obstetrical/Post Anesthesia Care Unit (OB/PACU) or Labor & Delivery Unit. EXCEPTIONS: The following postoperative patients will not be admitted unless Cardiovascular ICU RN s are present. 1. Patients admitted to the Cardiovascular ICU for recovery. 2. Patients with intra-aortic balloon pumps will be cared for in collaboration with the Director or designee of the appropriate unit. 3. Surgical patients from ICU, receiving sedation. Cape Surgery will follow policy.cape, Admission/Discharge Criteria: Cape Surgery Post Anesthesia Care Unit DEFINITIONS: Obstetrical/nursing unit located within the Obstetrical Labor & Delivery Unit, which provides recovery and observation of patients. 4 th Floor Surgery Center (4SC) also provides Phase 1 and Phase 2 nursing care.
2 of 7 PROCEDURE: 1. Admission Criteria: A. Surgical patients who have undergone the following types of anesthesia will be admitted for nursing care: 1) General Anesthesia 2) Spinal/Regional Anesthesia 3) Sedation-by Anesthesia 4) Local /Stand-by anesthesia at discretion of the anesthesiologist. B. Perioperative patients requiring intensive nursing who have had their surgical procedure cancelled can be admitted at the discretion of the anesthesiologist and/or surgeon. 1) Patients receiving general anesthesia in other sections of the hospital at the discretion of the anesthesiologist. 2) Procedures requiring an anesthesia provider, such as, but not limited to: a) Joint manipulations, electro-convulsive therapy, line insertions. b) Procedures done by the anesthesiologist such as epidural blood patch. C. Nursing personnel will follow established policies, procedures and standards of care pertaining to the immediate postoperative care of the patient. 2. Discharge Criteria: A. The patient will have a discharge order from the anesthesiologist. B. The following criteria will be met (see attached PACU Discharge Assessment Standards): 1) Level of consciousness/sedation: a) Behavior appropriate to situation. b) Level of sedation 1, 2, or 3 and arouses readily to verbal stimulus. 2) Psychosocial: The patient s expressed concerns and fears are addressed. 3) Respiratory: a) The patient maintains airway. b) Respirations are of good quality. c) Rate 10 or greater. d) Respiratory rate is counted when the patient is not stimulated. e) Respiratory rate is stable. f) Unless supplemental oxygen is ordered post-op, oxygen is discontinued 10 minutes prior to discharge. g) If the 02 sat is less than 92%, 02 will be restarted at 2 Lpm cannula per anesthesia order. If O2 sat is less than 92% on 2Lpm, consult with the anesthesiologist about a higher flow rate unless the patient was on a
3 of 7 higher flow preoperatively. The PACU RN can leave the oxygen on at their discretion. h) If there is an order for extubation, the patient is extubated and observed for 30 minutes prior to discharge. 4) Vital signs stability: a) Systolic blood pressure is not greater than 20% of preoperative blood pressure unless approved by anesthesiologist. b) Cardiac: The patient s rhythm and rate are within the pre-op range. If any changes noted, anesthesia will be notified. c) Temperature: The patient s temperature will be between 96.8º and 100ºF unless patient was febrile prior to surgery. The patient may be transferred to ICU with warming device if needed. 5) Musculoskeletal: The patient s movement and strength are at a level equal to pre-op, unless pt has spinal, epidural or extremity block. Spinal patients will be able to move lower extremities or remain in PACU for one hour, whichever occurs first. 6) Patients receiving spinal anesthesia will meet the previous criteria with the possible exception of #5. In addition, orders are written specific to the level of sensation/motor activity and/or time required. 7) Pain: a) The patient is experiencing an optimal comfort level within safe physiological parameters and level of sedation. b) The patient is encouraged to self-report pain using the Visual/Verbal Analogue Scale 0-10. The nurse may document descriptors regarding objective observations of patient (ability to deep breath, cough, move effectively). If the patient is unable to give a self-report of pain, the hierarchy of pain will be used (extent of surgery, pain behaviors, proxy report, and lastly, physiological signs). c) The patient will be observed 20 minutes past the last dose of opioid or sedating drug. d) If ordered by the surgeon, the Patient Controlled Analgesia pump is initiated and the patient may use the PCA button if within the parameters of the policy (policy # 139.1615). The PCA button will be tested in PACU. e) If Narcan is given in PACU or OR, the patient must remain in the PACU for at least 1 hour after the drug is given. 8) Patients receiving vasoactive drugs must be observed in PACU at least 30 minutes unless patient is being
4 of 7 transferred to ICU. 9) IV site: The IV site is patent, without redness and swelling. 10) The PACU RN will document on the PACU record that discharge criteria are met prior to transfer. If the patient does not meet criteria, an explanation will be documented in the PACU record and anesthesia is consulted for a discharge order. 11) All post-op orders will be reviewed. STAT orders will be completed and documented. 3. Preparation for Transport and Transfer: A. Inform patient of transfer. B. Provide emotional support in an attempt to reassure the patient and allay fears. C. Document the following information in the appropriate electronic record: 1) Discharge criteria met. 2) Last vital signs within 15 minutes of discharge time. 3) Transfer data. 4) Electronic signature and status. D. Check and complete postoperative orders (pertaining to the recovery phase). Discontinue to pre-op and PACU Anesthesia orders. E. The anesthesiologist will enter an order for transfer of the patient from the PACU. F. A report will be given to the nurse assigned to the patient including the following information (Handoff communication policy 01.PAT.25): 1) Patient s name/admission number, date of birth, physician. 2) Type of anesthetic and procedure. 3) Medication and intravenous fluids given and IV credit. 4) PCA drug and settings and if patient has button. 5) Vital signs and level of consciousness/sedation as well as LOC prior to surgery. 6) Status of dressings, drain tubes and drainage if an obstetrical patient. 7) Intake and output to include time patient voided. 8) Immediate postoperative surgical or medical complications, if any, during the recovery period. 9) Review of pending orders or labs. 10) Pertinent history/allergies. G. All patients will be transported from the PACU by either a registered nurse, licensed practical nurse, clinical technician,
5 of 7 multi-skilled tech, or hospital transporter. See Transportation and Monitoring of Patients policy # 01.PAT.23. NOTE: All OB patients will be transported to the PACU by an OB registered nurse or LPN. RESPONSIBILITY: REFERENCE(S): It is the responsibility of the department directors to assure that medical and nursing staff is familiar with and adhere to this department policy. Standards of Post Anesthesia Nursing Practice, American Society of PeriAnesthesia Nurses Standards, Current Edition. ASA Standards for Post-anesthesia Care (Approved by the ASA House of Delegates on October 27, 2004, and last amended on October 15, 2014 American Society of Anesthesiologists. Retrieved from: http://www.asahq.org/~/media/sites/asahq/files/public/resou rces/standards-guidelines/standards-for-postanesthesiacare.pdf Comprehensive Accreditation Manual for Hospitals, Joint Commission, Current Edition. SMH Policies. Handoff Communication Guidelines, Policy # 01.Pat.25, Transportation and Monitoring of Patients, Policy #01.PAT.23, REVIEWING AUTHOR(S): Christina Henry, Manager, PeriAnesthesia Patricia O Donnell, BSN, RN, CPS, PACU Dr. Jeffrey Torine, Chief, Anesthesia Debbie Dietz, MSN, RNC-OB, C-EFM, APN, Women s Services Lindsay Tinker, BSN, RN, PACU ATTACHMENT(S): a. PACU Discharge Assessment Standards
6 of 7 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy Date Committee/Sections (if applicable): Clinical Practice Council 10/6/16 10/11/16 Director of Perioperative Services 10/10/16 Director Women s and Children s Services Vice President/Administrative Director (if applicable): 10/12/16 Connie Andersen, Vice President, Chief Nursing Officer
7 of 7 PACU DISCHARGE ASSESSMENT STANDARDS Level of Behavior appropriate to situation. Consciousness/Sedation Level of sedation will be 1, 2, 3 and arouses to verbal stimulus readily. Psychosocial Respiratory Integumentary Pain IV Sites Safety Vital Sign Stability Musculoskeletal Incision and/or Dressing Sites Significant other interactions Expressed concerns and fears are addressed. The patient maintains airway. Respirations are of good quality. Rate 10 or greater per minute. Respiratory rate is counted when the patient is not stimulated. Respiratory rate is stable. Unless supplemental oxygen is ordered post-op, oxygen is discontinued 10 minutes prior to discharge. If the O2 sat is less than 92%, O2 will be restarted at 2 Lpm cannula per anesthesia order. Consult with the anesthesiologist about a higher flow rates unless the patient was on a higher flow preoperatively. The PACU RN can leave the oxygen on at their discretion. The RN If there is an order for extubation, the patient is extubated and observed for 30 minutes prior to discharge. If the patient is to remain intubated and/or ventilated after transfer from the PACU an ICU admission order will be written. Unchanged from operative assessment. Patient experiencing maximal comfort level within safe physiological parameters and level of sedation. Patient self-pain assessment utilizing Verbal Analogue Scale will be encouraged. No pain=0 -----10=Worst Imaginable Pain. Patient will be observed 20 minutes past last dose of opioid and/or sedation (unless patient is ventilated). Patient may be using PCA button if criteria are met. IV site(s) are without redness, swelling. Patient transport to room via surgi-lift, bed, stretcher, or wheelchair. Soft upper extremity restraints may be used on intubated patients to prevent self-extubation. Systolic blood pressure is not greater or less than 20% of pre-op normal BP. Cardiac: The patient s rhythm and rate are within the pre-op range. If any changes noted, anesthesia will be notified. Temperature: The patient s temperature will be between 96.8º and 100ºF unless patient was febrile prior to surgery. The patient may be transferred to ICU with warming device if needed. Movement and strength as it was preoperatively except possibly spinal/epidural anesthesia. Dressing, if present or surgical site with an acceptable amount of drainage. Drains patent, connected as ordered. Family waiting will be notified of patient s discharge to nursing unit and if patient is delayed in the PACU.