Streamlining the PACU Experience for Total Joints Patients

Standardized pain management, surgical approach and clear communication help ensure a seamless transition from recovery bays to home.

Achieving optimal and timely recoveries for total joints patients isn’t easy. Before someone with a new hip, knee, shoulder or ankle can be discharged, they must be infection-free, in only a small or moderate amount of pain and have successfully stood up and walked around.

UCHealth Yampa Valley Medical Center and Steamboat Surgery Center, both in Steamboat Springs, Colo., are home to many snow sport Olympians and other competitive athletes. That has also made it an orthopedic surgical hub with a sharp focus on getting active patients back to the activities they love as soon as possible.

The PACU experience

There are five requirements for discharge at UCHealth Yampa Valley Medical Center:

• Controlled and manageable pain levels.
• No significant postoperative nausea or vomiting.
• Safe and successful ambulation with assistive devices under the direction of a physiotherapist.
• Patients and members of their support network understand the signs of infection and complications such as deep vein thrombosis.
• Patients have prescriptions for postoperative medications in hand and understand how to use them.

Before patients arrive in the PACU, a member of the surgical team reviews their historical medical records, the medications they’re taking and any concerns noted by the pre-op nurses. “This allows me to have a view of the patient’s health status prior to their arrival to PACU so I can focus on the intraoperative report from anesthesia and the OR nurse,” says UCHealth Yampa Valley Medical Center Staff Nurse Sarah Smith, RN, BSN.

Ms. Smith also employs a structured approach in her conversation for the OR-to-PACU handoff that covers medications given during the surgery, the procedure performed and any modifications to the original surgical plan.

Alexander Meininger, MD, FAAOS, a surgeon at UCHealth Yampa Valley Medical Center and Steamboat Surgery Center, a partnership between Steamboat Orthopaedic & Spine Institute and UCHealth, and a physician for the U.S. Ski Team, informs the anesthesia team about the patient’s pain thresholds and anesthetic preferences to better tailor the care the patient will receive in the PACU.

There are several additional components that occur during the PACU experience, says Ms. Smith:

• Wound watch. The OR nurse and others assess the surgical wound to establish a baseline. Estimated blood loss reported during surgery, as well as any unique wound attributes the patient might have, are factored into this monitoring process.

• Pain management. The plan made in concert with the anesthesia team is monitored and the level of pain the patient is experiencing is compared to the level the anesthesia team had anticipated.

• Vital signs. Patients receive a complete physical assessment on arrival at PACU. Particular attention is paid to sounds in the lung, along with the color, temperature and pulses of the affected limb. “These assessments are done very frequently in the PACU phase to ensure progression of recovery and to monitor for any issues,” notes Ms. Smith. “Also, knowing the patient’s baseline blood pressure and collaborating with anesthesia on its acceptable parameters are key in the recovery phase of care.”

• Family communication. Including family in the discussion about discharge care is essential because patients might not remember the instructions. Enough time is always allotted for this process to ensure family members can think through the instructions and ask follow-up questions.

• Encouraging early, but safe, mobility. A physiotherapist (PT) and occupational therapist (OT) visit the patient in the PACU once an RN determines the patient is ready to move. Patients must be able to walk and meet certain criteria set by the PT/OT team. If there are steps in the patient’s home, the patient must be able to walk steps with PT prior to discharge. Assistive devices help support this early mobility.

Patients are also provided written instructions on the progression of their mobility and their post-op PT plan, which she says is critical to meeting their recovery goals. “I stress that managing mobility is a delicate balance once the patient gets home,” says Ms. Smith. “Rest is important, but so is being mobile to ensure complications do not develop.”

Start at the beginning

IN CONCERT OR Nurse Sarah Vreeman (in scrub cap) gives a report to Primary PACU Nurse Hestia Chase as Secondary PACU Nurse Carri Rochon checks a patient’s vitals following an orthopedic procedure at UCHealth Yampa Valley Medical Center.   |  Photo courtesy of UCHealth

Dr. Meininger collaborates with primary care physicians prior to surgery to ensure comorbidities such as diabetes or hypertension are well-managed preoperatively. Once surgery is a go, his preoperative regimen focuses on four key areas he says help to optimize patients postoperatively.

• Patient education. Patients and their support network learn about all aspects of pain management and goals for their post-op mobility are set. They also learn about the discharge process at this time, which Dr. Meininger says reduces their anxiety.

• Prehabilitation. Pre-op exercises are encouraged to increase the patient’s strength and mobility, which improves surgical outcomes. Some patients receive home exercise packets, while others are referred to physical therapists.

• Multimodal pain management. The doctor uses acetaminophen, COX-2 inhibitors and neuromodulators as preemptive analgesics. Alpha-1 blockers are sometimes used with male patients to reduce urinary retention and expedite mobilization.

• Regional anesthesia. Nerve blocks using long-acting, slow-release liposomal bupivacaine provide 72 hours of postoperative relief. To a lesser extent, they also help intraoperatively.

"Managing mobility is a delicate balance once the patient gets home."
Sarah Smith, RN, BSN

Days before surgery, the preadmission nurse calls the patient to review preoperative skin preparation that the patient must complete at home. “The nurse often takes this opportunity to review other aspects of infection prevention and recovery that are then reiterated once the patient is in preoperative care,” says Ms. Smith.

Surgical steps for healing

Dr. Meininger employs a standardized set of intraoperative practices to optimize recovery for discharge and promote postoperative healing and mobility. This starts with minimally invasive surgical techniques that reduce soft-tissue trauma. “Quadriceps-sparing approaches to knee replacement and a muscle-sparing anterior approach for hip replacements reduce blood loss and operative time, while facilitating quicker recovery and shorter PACU stays,” he says.

Dr. Meininger uses short-acting anesthetics and avoids narcotics when possible in an effort to reduce postoperative nausea and vomiting. Hemostasis and fluid balance are achieved by using bipolar electrocautery knives and wands. Fluid overload is avoided to minimize swelling and postoperative complications. To close wounds, Dr. Meininger prefers a zipline adhesive system he says is comfortable for the patient, doesn’t limit their mobility and promotes cosmetic healing. He also uses occlusive wound dressings that reduce infections and promote healing.

Within 48 hours of discharge, Ms. Smith calls the patient at home to check in and answer any questions or, if necessary, routes the patient to the correct level of care for treatment, such as the surgeon’s office, primary care provider, urgent care or the emergency department. “Getting the patient connected with their physician is a priority so the patient has continuity of care, which sometimes means I contact the surgeon directly on the patient’s behalf,” she says.

While surgical teams do everything possible to ensure optimal outcomes, they also must be prepared for anything. OSM