Managing PACU Staffing

Staffing in the PACU has to be flexible to provide a ratio of one nurse to one patient for the initial 15 minutes of recovery care, then one nurse to every two patients. Later, a nurse-patient ratio ranging from 1:3 to 1:6 may suffice. If critically ill patients are admitted, the ratio is increased to as high as two nurses to one patient. A charge nurse should oversee the nursing care. Most PACUs are under the medical direction of the anesthesia department; however, a few provide continual physician coverage with a full-time physician in the PACU. In most hospitals, the anesthesiologist responsible for the surgical anesthetic remains responsible for managing the patient in the PACU.

Typically, the PACU has the greatest number of patients in the middle part of the day, with few patients in the early morning. American Society of Post Anesthesia Nurses (ASPAN) standards state that each nurse can simultaneously care for a certain number of patients. Thus, the minimum adequate number of nurses during a shift depends on the peak number of patients during the shift.^[16] Future peak numbers of patients for each daily shift are based on previous daily peak numbers of patients, and staffing requirements can be planned from these predicted peak numbers of patients by using a facility's PACU staffing standards.^[17] PACU nurse managers should use at least 4 months of data when choosing a staffing solution to minimize the chance of patients waiting in operating rooms for PACU admission. ^[18]

As the number of postoperative events increases, so do the associated nursing resources.^[19] The relationship is not linear because resource needs are dependent on the specific type of adverse events. Multiple problems, such as those leading to an unanticipated ICU admission or major respiratory events, contribute disproportionately to staff workload. An efficient recovery room needs staff with multiple skills able to cross-cover various other assignments (e.g., admit patients to the preoperative area) because the type and amount of PACU work fluctuate on any given day.

The two factors that affect the actual number of patients in the PACU are the hourly admission rates and the times to discharge. For example, a prospective observational study of 68 adult inpatients undergoing abdominal procedures found that PACU occupancy was reduced by at least one patient (out of five beds) 26.1% of the time if desflurane was used for the anesthetic instead of isoflurane.^[20]

The challenge of actually reducing peak census is illustrated by the following example. If PACU time averages 120 minutes and 70% of patients in this surgery center receive general anesthesia and 50% of those patients now receive fast-track anesthesia and have their length of stay hypothetically reduced from 120 minutes to 34 minutes, the new mean length of stay in the PACU after the fast-track intervention is 90 minutes [0.7 × 0.5 × 34 minutes] + [1 − (0.7 × 0.5) × 120 minutes]. Thus, decreasing the length of stay with this fast-track intervention from 120 minutes to 34 minutes caused the peak number of patients in the PACU to decrease by only 25% [100 × (1 − 90/120)]. To decrease the peak number of patients in the PACU by 25%, the anesthetic management would have to decrease the average length of PACU stay from 120 minutes to 34 minutes. A PACU stay reduction of this magnitude is probably difficult to achieve.

Theoretically, the single factor most likely to produce PACU cost savings is optimizing the timing of arrival of patients to the PACU to reduce the peak requirements of nursing personnel.^[21] This goal could be achieved by altering the operating room schedule to stagger PACU admissions evenly throughout the day. However, this mathematically proven solution may not be desirable. Surgeons, for example, may not want to lose control over the order of their cases.

PACU nurses consider 60 minutes to be a minimum period of time to check the patient in, process paperwork, and get the patient ready for transfer to the floor.^[22] Because of this timeframe and the high fixed cost structure of the PACU, reasonably achievable decreases in the time to PACU discharge by improvements in anesthesia practice are unlikely to substantially reduce PACU costs.