Hybrid Room: PACU Staff Working in the OR
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Implications for Practice: Nurses have an awareness of current manufacturers’ recom- mendations regarding new catheter testing and outcomes Involving nurses in surveys determines their rationale for cur- rent trends and practices Awareness of nursing practices regarding pre-inflation of current types of catheters that may cause greater discomfort to patients when removed promotes positive out- comes Encouraging protocol awareness related to manufacturer recommendations improves patient outcomes Recommendations for Further Research: Is there a potential for increased CAUTI due to failure to follow manufacturer recommendations and guidelines regarding pre- inflation? If nurses follow the current guidelines to pre-inflate, is there a potential for urethra irritation or trauma due to pos- sible balloon-surface irregularity as a result of pre-inflation testing? Program: 5 PACU Critical Care Area Elizabeth Cox, RN, MSN, CMSRN, Gail Davis, RN, CNS-BC, CCRN Barnes-Jewish Hospital, St. Louis, Missouri The Perianesthesia Care Unit (PACU) sees 100 surgeries a day. The patient population varies. As surgical volume has increased, the PACU has had increases in delays of patient transition to the next level of care. The average number of PACU-transition delays is 200 per month. With such delays. there are many nights when ICU patients are boarded in the recovery room. As boarder volume has increased, the Perioperative Services leadership team instituted placing a 10-bed critical- care area in the PACU. Methods: The PACU leadership team rearranged the flow of patients in the recovery room to accommodate the space for a 10-bed area. Three committees were formed to begin to work on items that were needed to implement changes to this area. The committees addressed ancillary support, physician coverage and computerized documentation. A workplan of items was created for each committee. Weekly meetings were scheduled for each committee to address case management, re- spiratory, dietary, housekeeping, pharmacy, patient placement and guest services. Staff for the area has been put through addi- tional training. Evaluation: The 10-bed critical care section has opened and is operating smoothly. The area has physician and nurse practi- tioner coverage. The area has alleviated the stress on the recov- ery-room flow with boarders. The critical-care area has offered patients the level of care that they require in an environment with appropriate support and staff. Program: 6 Lean Processes in the PACU Elizabeth Cox, RN, MSN, CMSRN, Gail Davis, RN, CNS-BC, CCRN Barnes-Jewish Hospital, St. Louis, Missouri The Perianesthesia Care Unit (PACU) consists of 91 bays and 80-100 surgeries. Ensuring supplies and processes in place are ef- ficient, safe and high are essential. The PACU performed 5S, pull system and managed for daily improvement (MDI) process events. These events were performed to capture supply process, restocking and daily data management for process improvement. Description: Lean is a discipline that empowers frontline em- ployees to make decisions about how to improve their environ- ment and the processes in the unit. In addition, 5S is a part of Lean. Sort, straighten, shine, standardize and sustain are the five S’s ^ aVœSs^ aV that make up the process. The supply rooms in the PACU, nurse’s stations and bays were all 5S’d. Then to take the lean concept a step forward, the bays were rearranged to implement a new stocking system. The staff would pull cards from each supply bin to allow for a visual cue to when the bay needed to be stocked. In addition, a MDI board was created to capture the daily 5S score, the IV starts and safe transport. Evaluation and Outcomes: The PACU has sustained the im- provements. The supply rooms are organized and supplies are easy to find. Overstock and supply cost have decreased. The staff involved in restocking found it easier to know when to re- stock the bays. The MDI boards have motivated staff to deal with issues daily and to improve on those issues immediately. The percentage of compliance with IV starts and safe transport has increased by 20%. Program: 7 Hybrid Room: PACU Staff Working in the OR Elizabeth Cox, RN, MSN, CMSRN, Gail Davis, RN, CNS-BC, CCRN Barnes-Jewish Hospital, St. Louis, Missouri Purpose: The Hybrid Room is the size of two regular operat- ing rooms in Barnes-Jewish’s Cardiothoracic Operating Room (OR) Suite. Cases previously performed in the cardiac catheteri- zation lab that may be better suited to an OR setting are in the Hybrid OR. The room has fixed fluoroscopy and imaging, which enables physicians to get a clearer definitive image. Therefore they can diagnose and perform the procedure for treatment all in one setting. The room allows for angiography vascular proce- dures with moderate sedation and percutaneous valve replace- ments with general anesthesia. Previously these cases were done in the cardiac procedure center (CPC). The cases with mod- erate sedation needed to be done by a nurse with critical care experience. The PACU was tasked with providing procedural sedation in the OR setting. Description: A multidisciplinary team was formed consisting of PACU staff, CPC staff, Vascular Surgeons and OR staff. PAGE 92 JOURNAL OF VASCULAR NURSING JUNE 2011 www.jvascnurs.net
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Transcript of Hybrid Room: PACU Staff Working in the OR
PAGE 92 JOURNAL OF VASCULAR NURSING JUNE 2011www.jvascnurs.net
Implications for Practice:
� Nurses have an awareness of current manufacturers’ recom-mendations regarding new catheter testing and outcomes
� Involving nurses in surveys determines their rationale for cur-rent trends and practices
� Awareness of nursing practices regarding pre-inflationof current types of catheters that may cause greaterdiscomfort to patients when removed promotes positive out-comes
� Encouraging protocol awareness related to manufacturerrecommendations improves patient outcomes
Recommendations for Further Research:
� Is there a potential for increased CAUTI due to failure to followmanufacturer recommendations and guidelines regarding pre-inflation?
� If nurses follow the current guidelines to pre-inflate, isthere a potential for urethra irritation or trauma due to pos-sible balloon-surface irregularity as a result of pre-inflationtesting?
Program: 5
PACU Critical Care Area
Elizabeth Cox, RN, MSN, CMSRN, Gail Davis, RN, CNS-BC,CCRNBarnes-Jewish Hospital, St. Louis, Missouri
The Perianesthesia Care Unit (PACU) sees 100 surgeriesa day. The patient population varies. As surgical volume hasincreased, the PACU has had increases in delays of patienttransition to the next level of care. The average number ofPACU-transition delays is 200 per month. With such delays. thereare many nights when ICU patients are boarded in the recoveryroom. As boarder volume has increased, the PerioperativeServices leadership team instituted placing a 10-bed critical-care area in the PACU.
Methods: The PACU leadership team rearranged the flowof patients in the recovery room to accommodate the spacefor a 10-bed area. Three committees were formed to begin towork on items that were needed to implement changes to thisarea. The committees addressed ancillary support, physiciancoverage and computerized documentation. A workplan ofitems was created for each committee. Weekly meetings werescheduled for each committee to address case management, re-spiratory, dietary, housekeeping, pharmacy, patient placementand guest services. Staff for the area has been put through addi-tional training.
Evaluation: The 10-bed critical care section has opened andis operating smoothly. The area has physician and nurse practi-tioner coverage. The area has alleviated the stress on the recov-ery-room flow with boarders. The critical-care area has offeredpatients the level of care that they require in an environmentwith appropriate support and staff.
Program: 6
Lean Processes in the PACU
Elizabeth Cox, RN, MSN, CMSRN, Gail Davis, RN, CNS-BC,CCRNBarnes-Jewish Hospital, St. Louis, Missouri
The Perianesthesia Care Unit (PACU) consists of 91 bays and80-100 surgeries. Ensuring supplies and processes in place are ef-ficient, safe and high are essential. The PACU performed 5S, pullsystem and managed for daily improvement (MDI) processevents. These events were performed to capture supply process,restocking and daily data management for process improvement.
Description: Lean is a discipline that empowers frontline em-ployees to make decisions about how to improve their environ-ment and the processes in the unit. In addition, 5S is a part ofLean. Sort, straighten, shine, standardize and sustain are thefive S’s aVœSsaV that make up the process. The supply roomsin the PACU, nurse’s stations and bays were all 5S’d. Then totake the lean concept a step forward, the bays were rearrangedto implement a new stocking system. The staff would pull cardsfrom each supply bin to allow for a visual cue to when the bayneeded to be stocked. In addition, a MDI board was created tocapture the daily 5S score, the IV starts and safe transport.
Evaluation and Outcomes: The PACU has sustained the im-provements. The supply rooms are organized and supplies areeasy to find. Overstock and supply cost have decreased. Thestaff involved in restocking found it easier to know when to re-stock the bays. The MDI boards have motivated staff to dealwith issues daily and to improve on those issues immediately.The percentage of compliance with IV starts and safe transporthas increased by 20%.
Program: 7
Hybrid Room: PACU Staff Working in the OR
Elizabeth Cox, RN, MSN, CMSRN, Gail Davis, RN, CNS-BC,CCRNBarnes-Jewish Hospital, St. Louis, Missouri
Purpose: The Hybrid Room is the size of two regular operat-ing rooms in Barnes-Jewish’s Cardiothoracic Operating Room(OR) Suite. Cases previously performed in the cardiac catheteri-zation lab that may be better suited to an OR setting are in theHybrid OR. The room has fixed fluoroscopy and imaging, whichenables physicians to get a clearer definitive image. Thereforethey can diagnose and perform the procedure for treatment allin one setting. The room allows for angiography vascular proce-dures with moderate sedation and percutaneous valve replace-ments with general anesthesia. Previously these cases weredone in the cardiac procedure center (CPC). The cases with mod-erate sedation needed to be done by a nurse with critical careexperience. The PACU was tasked with providing proceduralsedation in the OR setting.
Description:Amultidisciplinary teamwas formed consistingof PACU staff, CPC staff, Vascular Surgeons and OR staff.
Vol. XXIX No. 2 JOURNAL OF VASCULAR NURSING PAGE 93www.jvascnurs.net
The team met for one 6-hour day and one 3-hour day. The teamdeveloped a workplan andmet each month until the room opened.A core group of nurses from the PACU volunteered and were cho-sen to learn how to provide the care needed for pre-, intra- andpost-care. The PACU staff went to the CPC to learn how to pullsheaths and to learn about the supplies, process and monitoring.The core group of nurses also attended additional training to learnthe new computerized documentation system. Standard opera-tional procedures were developed. When the room constructionwas completed, the PACU and OR staff did rehearsals of the pro-cess. They walked through each step to ensure that when the firstpatient was scheduled for a procedure, the process would besmooth and safe.
Evaluation and Outcomes: The first day and first patient’sprocedure went safely and effectively. The OR and PACU stafftruly worked as a team to provide excellent care. The vascularphysicians were pleased with how smooth and on time the processwas and continues to be.
Program: 8
Cutaneous Capnography in the PACU: ImmediateAssessment of Respiratory Status Emerging FromAnesthesia
GailDavis,MSN,CNS-BC,CCRN,ElizabethCox,MSN,CMSRN,Rachel Stratman Wolfe, PharmD, BCPS, Colleen Becker, MSN,CCRNBarnes-Jewish Hospital, St. Louis, Missouri
Purpose: Transcutaneous measurement of carbon dioxide(TrCO2) is a noninvasive method of estimating arterial pressureof carbon dioxide (PaCO2). Side-stream capnography is commonin assessing ventilation but its ability to estimate hypoventilationis affected by patient factors. Measurement of oxygen saturationis a standard of care but is a poor indicator of early hypoventila-tion. Our PACU recovers over 100 surgeries daily. We wanted toassess the use of TrCO2’s ability to provide early recognition andtreatment of airway compromise to increase patient safety.
Discussion: Transcutaneous capnography was used andtrends recorded on 50 patients admitted to the PACU. Documen-tation of concurrent use of side stream CO2 monitoring was ob-tained. Arterial blood gases were not routinely performed. Ifordered, results were included in the data. Comparisons weremade between all results available. It was noted that for 12 pa-tients management of care was altered due to the TrCO2 measure-ment. One patient arrived with a SpO2 saturation of 98%, 40%FM, drowsy but arousable and a capnography level of 99. Arterialblood gas measurement confirmed the results. BIPAP was initi-ated and successfully thwarted intubation. Staff caring for knownobstructive sleep apnea patients were diligent at stimulatingpatients if TrCO2 levels increased.
Results: Noninvasive cutaneous CO2 monitoring is more ac-curate in detecting hypercarbia in patients who were hypoventi-lated than nasal EtCO2 patients. Using TcCO2 monitoringprovides PACU nurses with the ability to achieve early recogni-tion and treatment of airway compromise in patients recoveringfrom anesthesia. TcCO2 provides a quick, reliable method forassessment.
Program: 9
Left Ventricular Assist Device Support in PACU
Gail Davis, MSN, CNS-BC, CCRN, Elizabeth Cox, MSN,CMS-RNBarnes-Jewish Hospital, St. Louis, Missouri
Purpose: Patients with left ventricular assist devices (LVAD)present with special requirements to post-anesthesia nurses in thePACU. The hospital LVAD program has experienced significantgrowth over four years. In 2008, we performed more LVAD im-plants than heart transplants. Previously, patients with this devicewere monitored by a certified technician during transport.Patients receive extensive discharge instructions enabling themto care for their device at home with phone support only. There-fore, technician support was removed from patients who wereindependent before hospitalization. However, in the operatingroom and PACU, patients are often not capable of managing theirdevice due to sedation or anesthesia. To develop a process totransport safely and to care for stable LVAD patients who are ad-mitted for procedures, a PACU LVAD committee was formed toincrease knowledge and safety.
Description: Educational needs for PACU staff prompted theformation of a core group to become LVAD certified. Our cardio-thoracic intensive care unit (CTICU) provides education andyearly certification regarding LVAD patients. PACU and CTICUclinical nurse specialists collaborated to organize certification of6 PACU nurses. PACU nurses were selected based on the criteriaof previous ICU experience and years of employment.
Results: All 6 nurses received certification. Written commit-tee expectations and LVAD information were placed in the unitnewsletter and on the Web site for reference. Future plans includeinservices to staff regarding LVAD function, capabilities andmanagement, utilizing staff committee members as content ex-perts to answer questions, to maintain certification of the corecommittee and to send additional staff for certification.
Program: 10
Boarding In the PACU:What DoWe DoWhen the PatientStays Past Sign-Out of Anesthesia?
Gail Davis, MSN, CNS-BC, CCRN, Elizabeth Cox, MSN, CMS-RN, Rachel Stratman-Wolf, PharmD, BCPSBarnes-Jewish Hospital, St. Louis, Missouri
Purpose:Our Perianesthesia Care Unit (PACU) recovers over100 surgery patients per day. Length of stay in PACU is approx-imately 2 hours and is determined by many factors, such as typeand length of surgery. As hospital census and patient acuity in-creased, it was noted that several patients would remain in thePAC for an extended period of time after anesthesia personneltransitioned care to the primary service. A process was neededto identify and to optimally care for patients who remained inthe PACU after anesthesia discharge.
Implementation: The PAC clinical nurse specialist, managerand clinical pharmacist met to discuss current state; concerns andpotential solutions were identified. Plans were developed to initi-ate a formal rounding process on patient ‘boarding overnight.’Daily rounds by the clinical nurse specialist and pharmacist
