PACU Bottlenecks- A Shared Responsibility

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PACU Bottlenecks- A Shared Responsibility

• Pam Bush
• Clinical Director of Perioperative Services,
• The Ottawa Hospital
• MOHLTC Perioperative Coaching Team member
• NAPAN May 23rd, 2009

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Overview

• Perioperative Coaching teams in Ontario
• Their purpose-The process-The findings
• Best Practice Targets for Perioperative Units
• Identify Factors in Perioperative units that
  impact PACU efficiency
• Present strategies to optimize PACU efficiency

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Perioperative Coaching teams

• Recommended by Report of the Surgical
• Process Analysis and Improvement
• Expert Panel June 2005
• www.health.gov.on.ca

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Key Recommendation

• To help hospitals to continuously improve OR
  efficiency, access and quality of service
• Develop Perioperative Improvement coaching teams
  to help government understand perioperative
  issues
• To help hospitals improve perioperative
  efficiency and performance

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Site Visits

• 58 hospitals in Ontario have had Perioperative
  coaching visits
• 45 Hospitals have had follow up visits
• Fall 2005-May 2009

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The Perioperative Coaching Visit

• The coaches composition, training
• Preparation Hospital expression of interest,
  SPAI self assessments, Hospital profile, Wait
  time data, LHIN information, data
• Pre visit teleconference

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The Site Visit

• Duration
• Day 1 CEO, Senior team
• Perioperative executive and leaders
• Tours of Perioperative units
• CPD, Central Process, SPD
• Day 1 and 2
• Private meetings with Perioperative nursing
  leaders, Physician leaders, Support service
  leaders
• Focus groups with Perioperative nursing,
  anesthesia, surgeons, support teams

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Site Visit

• Day 2 Identification and review of Issues
• Day 2-3 Prioritization of Issues
• Action Plan development
• Day 3 Debrief with CEO and Senior team

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Deliverables

• Site Visit Summary
• SPAI Report Assessment- recommended best
  practices rating and timelines
• Action Plan- Opportunities, barriers, Strategies,
  most responsible person and timeline
• Appendices-OR manager/director qualitative
  assessment- coaches private comments

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Findings
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Findings
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Findings
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Perioperative Best Practice Targets PAU

• SPAI Report appendix D
• All elective scheduled patients will be screened
  either by phone or in person to ensure they are
  ready for surgery
• All patients and their families will be educated
  to ensure that they understand the procedure and
  participate in their care
• Discharge planning will begin before surgery

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Perioperative Best Practice Targets SDCU/SDA

• Surgery will be conducted on an outpatient basis
  in a separate location wherever possible
• Surgical patients will be admitted on the same
  day as the surgery, wherever possible

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Perioperative Best Practice Targets Operating
Rooms

• The time the patient goes into the OR to the time
  the patient leaves the OR will be equal to the
  time that was booked for the case
• The amount of time scheduled for surgery will be
  as close to the expected time that the surgery
  should take
• Surgeries will begin at the scheduled start time

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Perioperative Best Practice Targets Operating
Rooms

• The emergency surgeries that are conducted will
  reflect true emergencies
• Surgical cases that have similar procedures will
  be grouped as a block, where possible
• Surgeons will work in consolidated blocks of
  time, where possible

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Nursing Units that Affect PACU Efficiency

• PAU
• SDCU/SDA
• OR
• PACU
• ER
• ICU
• Stepdown
• Psychiatry
• Surgical inpatient
• DI- Everyone

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PACUFactors impacting Efficiency

• Examine the clinical practice-nursing and
  anesthesia
• Clinical assessments
• Temperatures- ?, preventative, reactive
• Pain control- ?, standard protocols, patterns of
  pain, PCA , anesthesia , impacting los
• Control of nausea/v ? Patterns, protocols,
  induction, SDCU/SDA, PAU consults

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PACUFactors impacting Efficiency

• Discharge Criteria-evidence based/ based on
  clinical condition of patient
• Do RNs discharge patients based on discharge
  criteria- must anesthesia sign out patients
• Staffing mapped out patient activity / nursing
  hours
• Days/ Evenings/ Nights- Day of week variation
• Data patient activity, los, beyond meeting
  discharge criteria
• Clinical indicator tracking-uncontrolled n/v,
  pain, reintubation, respiratory arrests

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Strategies to Optimize PACU Efficiency

• Review clinical assessment content
• Identify patterns causing delays
• Address causes of delays
• Standardize pain, antiemetics, sleep apnea
  management etc
• Determine who needs to remain ON based on
  evidence
• Review discharge criteria-evidence based

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Strategies to Optimize PACU Efficiency

• Optimize nursing staff to meet patient demand
• Separate inpatients from outpatients in PACU

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Largest Controllable factor impacting PACU
efficiency

• Elective OR Schedule
• variation in of ORs running daily
• variation in of service Ors running daily
• variation in inpatient bed demands daily
• variation in SDCU bed demand daily
• variation in stepdown
• variation in Critical Care-PACU/ICU overnight

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The BIGGEST JOB

• Revise the Elective OR schedule
• Revise the Elective OR schedule to meet the needs
  of the patients and the community
• Evenly distribute the resource demands over the
  week
• Stakeholder commitment
• Entire organization benefits-reduced
  cancellations

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Elective OR Schedule Revision

• Review utilization data
• Review surgeons running late
• Review activity patterns of surgeons ie medium
  and long cases
• Limit SDAs/ ICU/PACU/Stepdown per day
• Schedule inpatient and outpatients before SDA
• Reallocate late rooms to those with long cases
• Create scheduling policies to support
  efficiency-use of Ors, cutoff for scheduling

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Emergency OR activity

• Does an emergency OR list exist?
• Is it communicated in real time to PACU?
• Are there policies related to emergency activity
  and access times-A,B,C,D?
• Are the policies adhered to and activity
  reviewed?

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Strategies to address emergency OR activity

• Policies to define emergency cases
• Review of emergency activity (after hours)
• Consequences to non adherence to policy
• Add or convert elective time to emergency day
  time
• Regularly review volume of activity
• Review need to revise PACU nursing hours to
  support activity

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SDCU factors affecting PACU Efficiency

• Variation in volume of activity
• Scheduling time of day
• Nursing staffing / patient activity
• SDCU discharge criteria
• Lack of rides, or accompaniment

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Strategies to Optimize SDCU Efficiency-prevent
PACU bottlenecks

• Smoothing of Elective OR schedule
• Scheduling outpatients first
• Review revise discharge criteria
• Setting expectations during Pre assessment
  appointment
• Confirming ride preoperatively

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PAU factors affecting PACU Efficiency

• Inappropriate Route of admission
• Lack of communication regarding alerts-latex
  allergy, isolation needs, difficult intubation,
  critical care bed requirements
• Lack of patient/family preparation regarding
  discharge/expectations
• Lack of discharge planning

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PAU Strategies to optimize PACU Efficiency

• PAU screening of all elective surgical patients
• ROA based on surgical procedure and co
  morbidities
• Develop communication process between PAU and OR
  (electronic)
• Develop policies regarding discharge planning-
  cancel if no arrangements made?

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Who is in your PACU

• Admitted patients waiting for beds
• ECT
• Critical care overflow
• ICU-enroute
• Stepdown
• Post Arrests?
• PACU patients who meet dc criteria on arrival
• Interventional radiology

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Strategies to take back your PACU

• Develop a process to determine bed requirements-
  cancellation process based on clinical priority
  of hospital
• ECT- develop expertise in MH units
• Critical care triage policies- RACE team creation
• ICU booking policies-which includes process for
  cancellation if no bed
• ICU patients directly to ICU
• Safety risk adding transition point for ICU
  direct patients
• PACU bypass policies-anesthesia, Perioperative
  nursing leaders
• PACU bypass policy when PACU full

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ICU/ Stepdown impact to PACU efficiency

• Review of ICU admission criteria
• Review of ICU discharge criteria
• Review of Stepdown admission and discharge
  criteria

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Corporate Policy

• Planned closures-summer, Christmas
• Bed management
• Creation of Short stay unit
• Discharge policy
• Cancellation policy based on organizational
  priority
• Perioperative team, patient and family education

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• Questions?

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Contact Info

• Pam Bush
• Clinical Director Perioperative Services,
• The Ottawa Hospital
• 613-737-8719
• pbush_at_toh.on.ca