Ideas That Work: Clearing the PACU Logjam

ON THE MOVE Improved communication and detective work helped us get patients out of PACU faster.

Clearing the PACU Logjam

Many patients spend more time in PACU than should be necessary, but with improved communication — and a little detective work — you can get the number of lingerers down to a much more manageable level.

That's what we did. A couple of years back, we set a goal of having 80% of our patients discharged within 2 hours after they were admitted to PACU. It was an ambitious goal, considering our success rate at the time was about 13%. And we knew that 2-hour discharge simply isn't a realistic goal for some patients — those who are diabetic or elderly, for example.

But we began to analyze what was causing so many delays for others, and we quickly found some common themes. Most had to do with pain management, sedation, PONV, voiding issues and other miscellaneous communication gaps.

An example of a communication problem: A surgeon would write a prescription for Percocet. But then in PACU, the patient would wake up and tell us Percocet didn't really work for her, and she wanted something else. So we'd have to wait for the surgeon to come back out after his next surgery to get that situation resolved.

Situations like that are relatively easy to prevent. We now have an organized huddle before each patient leaves the pre-op holding area. The goal is to make sure the surgeon, the patient, the anesthesia provider and the nurses are all on the same page. Involving patients is important, incidentally, because it also sets the right expectation for them and puts pressure back on us to deliver. And of course, no patient wants to stay one minute longer than necessary.

We also dug deeper and talked to the different groups at our facility — Ob/Gyn, orthopedics, general surgery, plastics and urology — to try to determine which factors were most likely to be significant for them. In fact, we've made it a point to talk and brainstorm regularly. Every Tuesday we come in a half hour early and we start the OR a half hour later.

It's working. We've managed to find and address a lot of other issues. For example:

• Ease up on the opioids. Excessive opioids were making patients groggy and leading to other unwanted side effects. So we started pre-medicating patients orally and using a multimodal pain-management approach. And we got all of our orthopedic surgeons to agree to use regional blocks whenever possible.
• Mitigate voiding issues. When hysterectomy patients come out of surgery, the sensation to void builds quickly because our surgeons now place 100cc of saline in their bladders. Surgeons were already checking bladders to make sure ureters were intact after surgery, so it was a no-brainer to start placing some fluid.
• Do away with scopolamine patches. We discovered that for hysterectomy patients, our practitioners often used scopolamine patches. But it came to our attention that the patches can cause urinary retention, so we stopped using them.

The effort has paid off. We still hope to do better, but our success rate has gone from 13% to about 65%, and we hit 69% in our best month.

Eswar Sundar, MD
Beth Israel Deaconess Medical Center
Boston, Mass.
[email protected]