Factors influencing Stay in the PACU
Medical Issues
The type (i.e., patients undergoing ophthalmologic and urologic
procedures stayed 60% and 26% longer, respectively) and length (i.e., for each 30-minute
increase in duration of surgery, the length of PACU stay increased 9%) of the surgical
procedure, general anesthesia versus sedation, and American Society of Anesthesiologists
(ASA) status were predictors of PACU length of stay for 16,411 ambulatory surgical
patients.[49]
Patients with dizziness, postoperative
nausea and vomiting, cardiovascular events, and pain stayed 31%, 25%, 23%, and 22%
longer, respectively, than did patients without these adverse events. The hypothetic
elimination of all adverse events resulted in a 9.6% decrease in mean length of stay
in patients receiving general anesthesia but only a 3.8% decrease in patients receiving
monitored anesthesia care.
A separate study (1067 adults scheduled for surgery with general
anesthesia) found that 11% of the variation in prolonged PACU length of stay could
be predicted by age, pain medication at the time of PACU admission, and postoperative
cardiovascular, pulmonary, and pain symptoms.[50]
A history of smoking also results in longer stays in the PACU.[51]
TABLE 71-4 -- Two examples of discharge criteria systems
|
Postanesthesia Recovery Score (Modified Aldrete
Score) |
Postanesthesia Discharge Scoring System |
|
Activity |
Vital signs (BP and Pulse) |
|
2 = Moves all extremities voluntarily/on command |
2 = Within 20% of preoperative baseline |
|
1 = Moves two extremities |
1 = 20%–40% of preoperative baseline |
|
0 = Unable to move extremities |
0 = >40% of preoperative baseline |
|
Respiration |
Activity |
|
2 = Breathes deeply and coughs freely |
2 = Steady gait, no dizziness |
|
1 = Dyspneic, shallow or limited breathing |
1 = Requires assistance |
|
0 = Apneic |
0 = Unable to ambulate |
|
Circulation |
Nausea and Vomiting |
|
2 = BP + 20 mm of preanesthetic level |
2 = Minimal: treat with PO medications |
|
1 = BP + 20–50 mm of preanesthetic level |
1 = Moderate: treat with IM medications |
|
0 = BP + 50 mm of preanesthetic level |
0 = Continues: repeated treatment |
|
Consciousness |
Pain |
|
2 = Fully awake |
Acceptable to patient; control with PO medications |
|
1 = Arousable on calling |
2 = Yes |
|
0 = Not responding |
1 = No |
|
Oxygen Saturation |
Surgical Bleeding |
|
2 = SpO2
>92% on
room air |
2 = Minimal: no dressing change required |
|
1 = Supplemental O2
req. to maintain SpO2
>90% |
1 = Moderate: up to 2 dressing changes |
|
0 = SpO2
<92% with
O2
supplementation |
0 = Severe: more than 3 dressing changes |
|
10 = Total score |
10 = Maximum score |
|
Score >9 required for discharge |
Score >9 required for discharge |
Interestingly, many patients are not discharged at the moment
that the medical criteria have been met. For example, actual stay averaged 95 minutes
(standard deviation [SD], 43 minutes) for 340 PACU patients, whereas the time required
to achieve a medically stable condition for safe PACU discharge averaged 71 minutes
(SD of 37 minutes).[52]
Actual length of stay was
over 30 minutes longer than the medically appropriate PACU stay for 20% of the patients.
Organizational Factors
A variety of nonmedical factors are important predictors of prolonged
PACU stay. No available ward bed, waiting for test results, transport delay, or
lack of physician release accounts for many delayed discharges from the PACU. In
the ambulatory setting, even after discharge criteria are met, delays of longer than
30 minutes because of nonmedical reasons occur in 54% of outpatients, with the most
common reason being the unavailability of escorts to take them home or lack of their
discharge medications.[53]
Another study found that 76% of patients were delayed in transport
from the PACU, with 26% waiting 30 minutes.[54]
The average delay in discharge for patients increased during the day. Five causes
or "system errors" were identified as being responsible for the unnecessary delay:
orderly too busy (41%), awaiting anesthesia assessment (36%), PACU nurse too busy
(15%), receiving floor not ready (6%), and patient awaiting radiographic interpretation
(2%). Nearly complete removal of causes of delays in discharge from the PACU may
not substantively reduce PACU staffing or delays in admission. Staffing is affected
predominantly by the average PACU stay, not the outliers.[55]
