Peri-Anesthesia Care Unit

The Peri-Anesthesia Care Units in Shands Hospital (North), Cancer Hospital (South) and the Heart Vascular and Neuromedicine Hospital (HVN/East) are located on the second floor, of each respective tower adjacent to the Operating Rooms.  The PACU is organized into three different phases of care to facilitate the perianesthesia/periprocedural continuum of care – Preanesthesia (Preoperative holding), Postanesthesia Phase I (Main Recovery), Phase II (Ambulatory Surgery/Discharge Area) may be utilized for extended care when indicated.  Bays within the PACU can flex to accommodate preoperative/postoperative overflow patients. Care is provided 24 hours a day, 7 days a week.

North Tower Pre-Operative Holding: Pre-op holding has ten bed spaces that are capable of complex hemodynamic monitoring (ECG, IBP, NIBP and oxygen saturations). Patients are admitted either preoperatively from the Ambulatory Surgical Waiting Room or from the surgical floors.  Hours of operations are 0600-1830, Monday through Friday. Pre-op patient accommodations are evaluated by the PACU Charge Nurse during off hours.

South Tower Pre-Operative Holding: Pre-op holding has ten bed spaces, one interventional room, and six block spaces.  All beds are capable of complex hemodynamic monitoring.  Patients are admitted either preoperatively from the Ambulatory Surgical Waiting Room or from the surgical floors.  Hours of operation are 0600 – 1830, Monday through Friday. Pre-op patients are accommodated in PACU off hours.

HVN Tower Pre-Operative Holding: Pre-op holding has 20 Pre-op/Phase II bed spaces that will serve the Operating Room, Cath Lab and Interventional Radiology. All beds are capable of complex hemodynamic monitoring.  Patients are admitted either preoperatively from the Ambulatory Surgical Waiting Room, from the surgical floors or select IMC units.  Hours of operation are 0600 – 1830, Monday through Friday. Pre-op patients are accommodated in PACU off hours.

North Tower Phase I Post Anesthesia Care Unit (Main Recovery): Main Recovery consists of 17 recovery spaces and a block room that is capable of holding two patients. Bay 19 is a negative pressure isolation room that is utilized as a main recovery slot pending the need for negative pressure isolation.  Each bay in PACU has the capability of ECG, NIBP, capnography, CVP, and arterial monitoring. PACU bays can accommodate mechanically ventilated patients. All PACU bays are equipped with a direct emergency alarm system to the operating room and the anesthesia attending office.  A center wall allows the division of the pediatric and adult patients from each other.  Phase I Main recovery focuses on providing post anesthesia nursing in a safe transition from the immediate post anesthesia period to Phase II, the inpatient setting or to an intensive care setting for continued care. Hours of operation are 24 hours a day seven days a week.

South Tower Phase I Post Anesthesia Care Unit (Main Recovery): Main recovery consists of 14 bed spaces plus 2 isolation rooms.  Each slot in PACU has the capability of ECG, NIBP, capnography, CVP, and arterial monitoring.  PACU slots are able to handle mechanically ventilated patients.  All bed spaces are equipped with a direct emergency alarm system to the operating room and the anesthesia attending office. Phase I recovery focuses on providing a safe transition from the immediate post anesthesia period to Phase II, the inpatient setting, or to an intensive care setting for continued care.  Hours of operation are 24 hours a day seven days per week.

HVN Phase I Post Anesthesia Care Unit (Main Recovery): Main recovery consists of 16 bed spaces, 3 private rooms and 1 negative airflow isolation rooms.  Each slot in PACU has the capability of ECG, NIBP, capnography, CVP, and arterial monitoring.  PACU slots are able to handle mechanically ventilated patients.  All bed spaces are equipped with a direct emergency alarm system to the operating room and the anesthesia attending office. Phase I recovery focuses on providing a safe transition from the immediate post anesthesia period to Phase II, the inpatient setting, or to an intensive care setting for continued care.  Hours of operation are 24 hours a day seven days per week.

North Tower Phase II Ambulatory Surgery Discharge Area: The Ambulatory Surgery/Discharge Area consists of five bays.  NIBP and oxygen saturation monitoring are available at each bay.  Postoperative outpatients are admitted to the Phase II area after an initial postoperative period in Phase I.  Patients may be admitted to the Phase II area if they meet the appropriate admission criteria and their recovery can be completed in Phase II prior to their transfer back to the floor.  Fast tracking in PACU involves admitting patients from the operating room directly to Phase II and bypassing Phase I.  This practice occurs based on established admission criteria.  Patient care in Phase II is directed at preparations for discharge home or to an extended care environment.  Hours of operations are 1000-2030, Monday through Friday.  Ambulatory surgery patients are cared for in the main recovery after hours and on weekends.

The Phase II Ambulatory Surgery Discharge Area bays and Phase I Main Recovery bays   often serve a dual role at the beginning of the surgical day and may be utilized to accommodate overflow from Pre-op Holding. Patients are assigned to bays which serve in a pre-operative holding capacity. After the initial cases are started, the Phase I Main Recovery and the Phase II Ambulatory Surgery Discharge Area revert back to their roles.

South Tower Phase II Ambulatory Surgery Discharge Area: The Ambulatory Surgery Unit consists of eight bed spaces.  All spaces are capable of complex hemodynamic monitoring ECG, NIBP, capnography, CVP, and arterial monitoring.  Generally, postoperative outpatients are admitted to Phase II after an initial post-operative period in Phase I.  Inpatients can be admitted to the Phase II area if they meet the appropriate admission criteria.  Their recovery can be completed in Phase II prior to their transfer back to the floor.  Fast tracking involves admitting patients from the operating room directly to Phase II bypassing Phase I.  This practice occurs based on established admission criteria.

HVN Tower Phase II Ambulatory Surgery Discharge Area: The Ambulatory Surgery Unit consists of 18 spaces.  All spaces are capable of complex hemodynamic monitoring ECG, NIBP, CVP, and arterial monitoring.  Generally, postoperative outpatients are admitted to Phase II after an initial post-operative period in Phase I.  Inpatients can be admitted to the Phase II area if they meet the appropriate admission criteria.  Their recovery can be completed in Phase II prior to their transfer back to the floor.

The ambulatory surgery unit bed spaces often serve a dual role at the beginning of the OR schedule.  Outpatients are often admitted to those bed spaces which serve in a pre-operative holding capacity.  After the initial cases are started, they revert to a Phase II role.

The PACU is a patient care area, which provides acute care to adults and pediatric patients who undergo anesthesia-related procedures including general and regional anesthesia. This includes the immediate preoperative and postoperative phases of surgical care and nonsurgical post anesthesia care.  Typically, we find the optimal length of stay for the post-anesthesia care unit is 90 minutes.

The exceptions to this are those patients who require the technology available in the intensive care units.  The Recovery Room can accommodate a limited number of patients staying overnight as Floor/IMC/SICU.  The most common surgical procedures include exploratory laparoscopies, total hip arthroplasties, hysterectomies, cystoscopies, angioplasties and angiograms.  Various Neurosurgery procedures are recovered in the PACU also i.e., craniotomies, cervical fusions, neck dissections, endarterectomies, and stenting procedures.

The Nursing staff in the PACU strives to achieve excellence in quality patient care through the utilization of the nursing process.  The job description identifies specific patient populations served, the equipment utilized, the skills performed, the clinical parameters monitored, the safety precautions, and the emergency events encountered. The PACU nursing staff is committed to patient advocacy and innovative patient care through the assessment, diagnosis, evaluation and treatment of: pain and nausea, respiratory compromise, fluid and electrolyte abnormalities, neurological changes, and hemodynamic instability.  They assess the patient’s needs preoperatively both physically and psychologically.  The patient’s Peri-operative process is coordinated using the Perioperative standard.  The PACU nurse works hard to minimize family anxiety by providing updates and visitation while the patient is in PACU.  The outpatient discharge needs are assessed by the ambulatory nurse to make sure the patient receives optimal care at home after discharge.  Feedback is solicited regarding patient satisfaction through third party solicitation.  Patients are called randomly after discharge from the hospital and they are asked to evaluate their experience while they are at our facility.  Changes are made to our processes if possible based on the feedback received.

The Medical Director of the PACU is an attending anesthesiologist appointed by the Department of Anesthesiology.  The medical director assists with policy and procedure development, and assists the educator with continuing education activities.  Medical staff coverage is coordinated by the Department of Anesthesiology.  An anesthesia resident is assigned to the PACU for a period of one month.  A CRNA may also be assigned to provide coverage in the PACU.  He/she assists with all pain management issues, hemodynamic issues and signs the patients out from the Phase I and II areas if all discharge criteria have been met.  Off shift coverage is provided by the anesthesia resident and or attending on call.

The nursing management structure of the PACU consists of a Director of Perioperative Services, a Clinical Coordinator and a Clinical Leader.  The Director of Perioperative Services has the responsibility of assisting the Associate Vice President of Surgical Services with program development, marketing activities, financial and productivity goals. The Clinical Coordinator serves as a clinical and administrative support to the Director of Perioperative Services to ensure the delivery of professional and outcomes-focused care. The Clinical Coordinator is accountable for daily staffing and unit-based follow-up of issues that assist in the assessment, planning, implementation and evaluation of patient care needs based on quality benchmarking, patient acuity/care trends, staff clinical education needs and patient satisfaction.  In the absence of the Clinical Coordinator, another RN will be designated as the charge nurse for the day. The Clinical Leader (CL) serves as a clinical expert for patient care and services on the unit by providing clinical leadership support.  The Clinical Leader provides clinical and analytical support to the perioperative leadership to plan and predict patient care needs based on quality benchmarking, patient acuity/care trends, staff clinical education needs and patient satisfaction.  The Clinical Leader focuses on education, program development and quality measures within Perioperative Services. The unit practice council fosters autonomous, accountable nursing practice by supporting staff involvement in unit practice decision making.  Collaboration on the unit among nurses is fostered by precepting, mentoring, and encouraging the team approach to holistic care.

Patient assignments are made by the charge nurse based on the identification of patient care needs, acuity and competency levels of the practitioner.  Professional behaviors inherent in perianesthesia practice are the acquisition and application of a specialized body of knowledge and skills, accountability and responsibility, communication, autonomy and collaborative relationships with others.  Those others include but are not limited to patients, family members, Surgeons, Anesthesiologists, Lab/blood bank staff, Social Workers, Respiratory and Physical Therapists and Pharmacists.

Staffing patterns are based on patient acuity, census, patient flow process, physical facility and competency level of staff members.  Staffing for Preoperative holding is dependent on patient volume, patient health status, and required services for preanesthesia interventions.  Two registered nurses must be present in Phase I Main recovery at all times as patients are receiving Phase I level of care, one being competent in Phase I postanesthesia care nursing (ASPAN Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements (2019-2020, p. 26)).  In Phase II Ambulatory Surgery/Discharge Unit, staffing is dependent on patient acuity, volume, and competent personnel.  Two registered nurses must be present in the unit, one of whom is an RN competent in Phase II postanesthesia nursing.  The need for additional RNs and support staff is dependent on the patient acuity, and patient census.

References:

American Society of Perianesthesia Nurses (2018). Perianesthesia nursing standards, practice recommendations and interpretive statements 2019-2020. Cherry Hill, NJ. ASPAN 

Reviewed and Revised: 1/2021