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PACU Bottlenecks A Shared Responsibility

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Title: PACU Bottlenecks A Shared Responsibility


1
PACU Bottlenecks- A Shared Responsibility
  • Pam Bush
  • Clinical Director of Perioperative Services,
  • The Ottawa Hospital
  • MOHLTC Perioperative Coaching Team member
  • NAPAN May 23rd, 2009

2
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

3
Perioperative Coaching teams
  • Recommended by Report of the Surgical
  • Process Analysis and Improvement
  • Expert Panel June 2005
  • www.health.gov.on.ca

4
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

5
Site Visits
  • 58 hospitals in Ontario have had Perioperative
    coaching visits
  • 45 Hospitals have had follow up visits
  • Fall 2005-May 2009

6
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

7
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

8
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

9
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

10
Findings
11
Findings
12
Findings
13
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

14
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

15
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

16
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

17
Nursing Units that Affect PACU Efficiency
  • PAU
  • SDCU/SDA
  • OR
  • PACU
  • ER
  • ICU
  • Stepdown
  • Psychiatry
  • Surgical inpatient
  • DI- Everyone

18
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

19
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

20
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

21
Strategies to Optimize PACU Efficiency
  • Optimize nursing staff to meet patient demand
  • Separate inpatients from outpatients in PACU

22
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

23
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

24
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

25
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?

26
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

27
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

28
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

29
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

30
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?

31
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

32
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

33
ICU/ Stepdown impact to PACU efficiency
  • Review of ICU admission criteria
  • Review of ICU discharge criteria
  • Review of Stepdown admission and discharge
    criteria

34
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

35
  • Questions?

36
Contact Info
  • Pam Bush
  • Clinical Director Perioperative Services,
  • The Ottawa Hospital
  • 613-737-8719
  • pbush_at_toh.on.ca
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