NO LOITERING Our reader survey uncovered many ways to fast track patients in PACU.

Can recovery rooms learn a lesson from the ER's philosophy of "treat 'em and street 'em?" In the harsh reality of the ER, it's get the patients in, stabilize them, treat them and send them back out the door. In a kinder, gentler way, "treat 'em and street 'em" can also apply to the PACU. As Debbie Perdue, CST, manager at the First Hill Surgery Center in Seattle, Wash., puts it, "We like to remind patients how much more comfortable they'll be at home in their own bed."

Pre-op is perhaps the best place to start greasing the skids for a short stay in PACU. For it's there where you can prevent post-op pain and avoid PONV, the 2 most frequently cited causes of prolonged recovery in our nationwide survey of 190 surgical facility managers. Pain (68.0%) and PONV (55.2%) topped the list (survey respondents could indicate all that applied), followed by extended observation (23.2%), patient hasn't voided (22.7%), hemodynamic instability (16.0%) and hypothermia (4.4%). Other less-obvious reasons cited for prolonged recovery included anesthesia (oversedation and duration of the neuraxial block), paperwork delays to logistics (no bed available in PACU, and no ride available in the parking lot), to physicians who visit the bedside to speak with the patient and family.

Read on to see how your PACU compares to our survey-takers in key areas.

Preventing delayed discharge
So many variables spanning patients' entire stays with you affect how long it takes to discharge them. Did you administer pre-emptive analgesia and antiemetic agents? What about aggressive post-op pain management? Is your discharge process streamlined? Did you pre-schedule the post-op appointment and ensure that the patient's ride home is ready and waiting? Here's what our survey respondents rated as the biggest positive influencers of fast discharge:

Yes, teamwork is No. 1. "Our nursing assistants help with cleaning beds, helping patients dress and wheeling patients out to vehicles," says Christina Williams RN, BSN, of the Tracy (Calif.) Surgery Center. "It must be a team approach that starts pre-operatively in the surgeon's office once surgery is scheduled and continues until the patient is discharged," adds BJ O'Connor, RN, nurse manager of the Palmetto Surgery Center in Columbia, S.C. "Being able to see the big picture is a must for all involved in the patient's care."

Cooley Dickinson Hospital in Northampton, Mass., has a length-of-stay team. "We spend a lot to time trying to enhance our process of getting patients discharged in a safe and efficient manner," says Nurse Manager Shonda Huggins, BSN. "There are many challenges from staff perception, patient perception to actual workflow and case types coming to my PACU and discharge unit. The work is worthwhile, but can be challenging."

It's not uncommon for the same perioperative nurse to follow the patient from pre-op preparation to post-op recovery. "Our circulators will follow patients from beginning to end," says Jeanette Sartain, ADN, surgery coordinator at Box Butte General Hospital in Alliance, Neb. "We've found that will sometimes speed up our whole day."

Nurse-to-patient staffing ratio
What is your nurse-to-patient staffing ratio for Phase I and II recovery? Here's what our survey respondents said:

Not all surgical facilities separate PACU into Phase I and II. "We only have Phase II recovery, as all our patients receive conscious sedation," says Tammy White, RN, BSN, MHA, executive director of the Indianapolis Endoscopy Center.

Average length of PACU stay
With the exception of cataract cases or local anesthesia cases, we asked survey respondents to tell us their average length of PACU stay. For most (58.1%), it's somewhere between 30 minutes to 1 hour. For one-fourth of respondents (25.8%), patients are discharged in 1 to 2 hours, and for 1.6%, it's more than 2 hours. The Albany (Ga.) Surgery Center is among the 14.5% of facilities that can boast a mean PACU stay of 30 minutes or less.

"We do only IV sedation with nerve blocks, so our recovery and turnover are rapid," says OR Supervisor Sherry Butts, RN, BSN. "PACU is only 30 minutes unless the patient has post-op nausea, has breakthrough pain requiring another nerve block or needs a dressing change due to bleeding."

Albany specializes in podiatric surgery. All patients get a post-op nerve block for pain control. "It's great for the patients to get home with little to no pain initially post-op," says Ms. Butts.

The Pontchartrain Surgery Center in Covington, La., offers peripheral nerve blocks to its orthopedic and podiatric patients for post-op pain control. "Patients recover virtually pain- and nausea-free when anesthesia administers these blocks timely in recovery or during pre-op," says Dana Galivan, BSN, the director of nursing. Ms. Galivan adds that procedures that are delayed and performed in the late afternoon frequently result in extended recovery times due to fluid deficits, nausea and fatigue.

"We have an exceptional anesthesia staff that proactively works to prevent PONV or uncontrolled pain," says Brenda Vahle, RN, CAPA, clinical director of the Beaver Sports Medicine Surgery Center in Corvallis, Ore. "We are lucky that extended recoveries are kept to a minimum."

Only 7.4% of our survey respondents assign an additional nurse to give discharge instructions. "It lets the PACU nurse concentrate on the patient and a discharge nurse to assist the family," says Ms. Butts. At the Beaver Sports Medicine Surgery Center, a certified athletic trainer gives exercise instructions to the patient and their family. These include a personal sign-on to a web page where exercises are patient-specific," says Ms. Vahle.

"The same nurse prepares the patient for surgery and cares for the patient through recovery also gives all discharge instruction and routinely makes follow-up calls to the same patient," says anesthesiologist W. Bradley Worthington, MD, of the Hospital for Spinal Surgery in Nashville, Tenn.

ON THE MENU
What Snacks Do You Offer Patients?

What snacks do you serve your patients in post-op? Here's a rundown, based on our survey of nearly 200 surgical facilities. Respondents could check all that applied.

• Juice	81.3%	• Coffee or tea	50.3%
• Crackers	78.1%	• ?Popsicles	40.6%
• Water	77.0%	• ?Muffins	9.1%
• Soda	63.6%

"If they are coffee drinkers, give them coffee," says a facility manager.

FUEL UP Juice and crackers are the most popular post-op snacks, according to our reader survey.

A hospital administrator reports that she offers patients lunch trays "if they're here over the noon hour, along with a tray for a family member." Her patients also have a choice of white or wheat toast, hot or cold cereal, and soups.

Another hospital administrator says a carbonated drink or warm tea helps with laparoscopic surgeries. "For local anesthesia," she says, "we've started giving a small plate of fresh fruits or small bowl of chicken soup."

The Prairie du Chien (Wisc.) Memorial Hospital offers full meals, unless otherwise ordered by surgeon, says Jayne Prew, RN.

Not all surgical facilities offer patients refreshments. "I don't offer water or ice very often. Their stay is so short that it makes them nauseated if they start pounding fluids immediately," says Stormi Frusetta, RN, BS, the nurse administrator of the North Scottsdale (Ariz.) Outpatient Surgery Center. "As soon as the patient is extubated and/or awake and alert, I raise the head of their bed up. This seems to help lessen the shock of getting out of bed and dressed. Patients tend to get nauseated if they remain flat their entire stay in PACU."

— Dan O'Connor

Agents for post-op pain control
We asked respondents which agent they you use primarily for post-op pain control. Nearly two-thirds (63.5%) use fentanyl, about one-fourth (24.5%) use morphine and 11.9% use Demerol. Several respondents use dilaudid and such oral pain medications as Vicodin (acetaminophen and hydrocodone), Nucynta (tapentadol), Toradol (ketorolac) and extra-strength Tylenol.

"It depends on the surgeon and the type of surgery done," says a hospital administrator. "For fast short-term relief, we use fentanyl. For longer relief, we use morphine. The doctors often have Toradol given either intra-operatively or in the recovery room also."

"Multimodal pain therapy with pre-op non-narcotic meds," is how John Hsu, MD, the director of anesthesia at Presbyterian Intercommunity Hospital in Whittier, Calif., describes his pain regimen.

Regional blocks in many cases obviate the need for narcotic pain relief. "Our facility has a great nerve block program," says Dora Rieves, RN, BSN, the block charge nurse at Andrews Institute Surgery Center in Gulf Breeze, Fla. "The majority of the orthopedic surgeries are blocked in pre-op. Less anesthetic agents are used intraoperatively, which helps with post-op pain control and nausea and vomiting."

Family in PACU?
Nearly two-thirds (61.4%) of our survey respondents allow family members at the bedside in PACU. Allowing family members at the bedside in PACU aids in comforting the patient and lets the RN caring for the patient begin discharge instructions quickly, says Ms. Galivan. However, a hospital OR manager notes that "having visitors at bedside may be a patient and family satisfier, but it can also cause delay in the recovery process."

For some facilities, Phase I recovery is for patients and staff only. Family can visit during Phase II recovery when patients are closer to discharge. "Patients seem more relaxed with family at bedside and encouraged for going home," says Jean Atkinson, RN, director of nursing at Specialty Surgery Center in Crossville, Tenn.

"Once the patient is discharged to Phase II recovery, we let 2 family members come back," says Ms. O'Connor. "This helps to alleviate anxiety and concerns from the patient and family. It also lets the nurse focus on areas of concern that my need a little more attention, such as frequency of pain medication, how to administer and with what types of foods."

"Patients and relatives like it, but we only allow it when the PACU is pretty empty late in the day," says anesthesiologist Robert Bullock, MD, medical director of the Grossmont Plaza Surgery Center in La Mesa, Calif.

"Parents of pediatric patients come back early in the recovery process and this helps speed up the discharge. Other family members of adults are not invited back to PACU until the patient is almost ready to be discharged," says Lorraine Gambol, manager of the Surgery Center of Chester County in Exton, Pa.

To keep the PACU flowing, Beaver Sports Medicine Surgery Center makes sure the patient is awake and dressed before family is allowed in. "Seeing their family member dressed and awake helps the family member see the patient as ready to go home," says Ms. Vahle. "If they were in a hospital gown, some family members see the patient as sick and feel their recovery should be longer."