Is My Patient Safe for Is My Patient Safe for Discharge?Discharge?

Myrna Mamaril, MS, RN, CPAN,CAPA, FAANMyrna Mamaril, MS, RN, CPAN,CAPA, FAAN

Essential Components of Essential Components of Discharging Patients from PACUDischarging Patients from PACU

I. Define ASPAN’s PACU Phase I Discharge I. Define ASPAN’s PACU Phase I Discharge Assessment Criteria. Assessment Criteria.

II. Identify the elements of negligence. II. Identify the elements of negligence.

III. Describe the standard of care for PACU nurses III. Describe the standard of care for PACU nurses related to discharging patients in the PACU.  related to discharging patients in the PACU.  

IV. Discuss the PACU nurse’s duty with activating IV. Discuss the PACU nurse’s duty with activating the “Chain of Command” in life threatening the “Chain of Command” in life threatening emergencies.emergencies.

  

  

100,000 Lives Campaign100,000 Lives Campaign Preventing harm to patientsPreventing harm to patients Majority of PACU emergencies are preceded Majority of PACU emergencies are preceded

by observable indicators or subtle “cues” by observable indicators or subtle “cues” before event occursbefore event occurs

Evidence supports:Evidence supports: Early recognition of deteriorating signs & Early recognition of deteriorating signs &

symptomssymptoms Activating the “Chain of Command”Activating the “Chain of Command” Effective communicationEffective communication Ensuring experts are at patient’s bedsideEnsuring experts are at patient’s bedside

Malpractice RiskMalpractice Risk PACU nurses are at higher risk for PACU nurses are at higher risk for

malpractice suits than other nursing malpractice suits than other nursing specialtiesspecialties

Provide specialized nursing care to diverse Provide specialized nursing care to diverse patient populations in an environment of patient populations in an environment of constant activity, high volume, rapid turnover, constant activity, high volume, rapid turnover, and intense pressureand intense pressure

Nursing practice requires quick, effective life-Nursing practice requires quick, effective life-saving interventions when emergencies occursaving interventions when emergencies occur

Mitigating Malpractice RiskMitigating Malpractice Risk Knowing and practicing ASPAN’s Standards & Knowing and practicing ASPAN’s Standards &

Recommended GuidelinesRecommended Guidelines Ensuring effective “Hand-Off” ReportsEnsuring effective “Hand-Off” Reports Recognition of deteriorating physiologic conditionsRecognition of deteriorating physiologic conditions

• Documenting factual assessments, interventions, and Documenting factual assessments, interventions, and outcomes to interventionsoutcomes to interventions

Adoption of well-designed policies for opioid Adoption of well-designed policies for opioid administration (knowing peak action of medications)administration (knowing peak action of medications)

Advocating the use of the chain of commandAdvocating the use of the chain of command Objective and comprehensive documentationObjective and comprehensive documentation

Mitigating Malpractice RiskMitigating Malpractice Risk

Knowing and practicing ASPAN’s Knowing and practicing ASPAN’s Standards & Recommended Standards & Recommended

GuidelinesGuidelines

Mitigating Malpractice RiskMitigating Malpractice Risk

Ensuring Effective “Hand-Off” Ensuring Effective “Hand-Off” ReportsReports

Mitigating Malpractice RiskMitigating Malpractice Risk

Recognition of deteriorating physiologic Recognition of deteriorating physiologic conditionsconditions

• Documenting factual assessments, Documenting factual assessments, interventions, and outcomes to interventions, and outcomes to

interventionsinterventions

Mitigating Malpractice RiskMitigating Malpractice Risk

Adoption of well-designed policies for Adoption of well-designed policies for opioid administration (knowing peak opioid administration (knowing peak

action of medications)action of medications)

Fentanyl Citrate (Sublimaze)Fentanyl Citrate (Sublimaze)

Short acting effectsShort acting effects Stored in fat and Stored in fat and

muscle tissuemuscle tissue

Onset: 1 to 3 Onset: 1 to 3 minutesminutes

Duration: 30 to 60 Duration: 30 to 60 minutesminutes

Dose: Adult: 0.05 Dose: Adult: 0.05 to 2to 2g/kg, titratedg/kg, titrated

Morphine Sulfate Morphine Sulfate

End MetabolitesEnd Metabolites

Second PassSecond Pass

Onset: 1 to 3 Onset: 1 to 3 minutesminutes

Duration 1 to 2 Duration 1 to 2 hourshours

Dose 2 to 10 mg Dose 2 to 10 mg titratedtitrated

Hydromorphone (Dilaudid)Hydromorphone (Dilaudid)

Short half-lifeShort half-life No metabolitesNo metabolites

Onset: 3 to 5 minutesOnset: 3 to 5 minutes Duration: 3 to 4 hoursDuration: 3 to 4 hours More potent than More potent than

morphine: 5-7 to 1morphine: 5-7 to 1 Morphine 10 = Morphine 10 =

hydromorphone hydromorphone 1.5mg1.5mg

Naloxone the Opioid ReversalNaloxone the Opioid Reversal

Rapid reversal of opioids only!Rapid reversal of opioids only! Dilute 0.4mg with 9ml of NS (0.04mg per Dilute 0.4mg with 9ml of NS (0.04mg per

ml): 1/2cc @ time – titrate slowly for effectml): 1/2cc @ time – titrate slowly for effect Onset 1 to 2 minutesOnset 1 to 2 minutes Duration: dependent on dose and routeDuration: dependent on dose and route

How long must I keep my How long must I keep my patient after narcotic?patient after narcotic?

High variability among hospitalsHigh variability among hospitals Is it dose dependent? Is it dose dependent? Related to length of stay:Related to length of stay:

5 minutes5 minutes 10 minutes10 minutes 15 minutes15 minutes 20 minutes20 minutes 30 minuted30 minuted

Knowing and Practicing ASPAN’sKnowing and Practicing ASPAN’sStandards & GuidelinesStandards & Guidelines

PACU Phase I Discharge Assessment CriteriaPACU Phase I Discharge Assessment Criteria Respiratory (Bstability) - SnoringRespiratory (Bstability) - Snoring Circulatory (stability) - Blood pressureCirculatory (stability) - Blood pressure Neurological (LOC, Pupils, Sensory/Motor)Neurological (LOC, Pupils, Sensory/Motor) Pain and ComfortPain and Comfort Emotional comfortEmotional comfort *Surgical/Procedural site and continued procedural *Surgical/Procedural site and continued procedural

sitesite End Organ Perfusion – transport/perfusion End Organ Perfusion – transport/perfusion

Nsg Documentation: Action/Intervention / OutcomeNsg Documentation: Action/Intervention / Outcome

Standard of Care in Standard of Care in EmergenciesEmergencies

The PACU nurse is held to the same The PACU nurse is held to the same standard of care as any reasonably standard of care as any reasonably prudent PACU nurse would act in similar prudent PACU nurse would act in similar situations when discharging patients to situations when discharging patients to home or transferring patients to an home or transferring patients to an inpatient unit.inpatient unit.

Legal ImplicationsLegal Implications

Important for the PACU Nurse to know:Important for the PACU Nurse to know: Standards of CareStandards of Care

Hospital & PACU Policies, Procedures, Hospital & PACU Policies, Procedures, ProtocolsProtocols

ASPAN Standards & Recommended GuidelinesASPAN Standards & Recommended Guidelines Regulatory StandardsRegulatory Standards

Basic “Elements of Negligence”Basic “Elements of Negligence” Legal implications of practiceLegal implications of practice

Elements of NegligenceElements of Negligence

DutyDuty Breach of DutyBreach of Duty CausationCausation HarmHarm

Examples of NegligenceExamples of Negligence

Anterior CorpectomyAnterior Corpectomy T&A T&A Not recognizing respiratory distressNot recognizing respiratory distress Overdose of opioidsOverdose of opioids Premature transfer of patients to the Premature transfer of patients to the

inpatient unitinpatient unit Premature discharge of patients to homePremature discharge of patients to home

Airway/Respiratory ChangesAirway/Respiratory Changes

Stridor/LaryngospamsStridor/Laryngospams Wheezing with low oxygen saturationWheezing with low oxygen saturation Noncardiac pulmonary edemaNoncardiac pulmonary edema Respiratory DistressRespiratory Distress Change in voice – coarseChange in voice – coarse Drooling – unable to control secretionsDrooling – unable to control secretions

Cardiovascular Cardiovascular

Poor perfusion in ChildrenPoor perfusion in Children Insertions of Central LinesInsertions of Central Lines Perfusion ComplicationsPerfusion Complications

Orthopaedic, Orthospine, Vascular Orthopaedic, Orthospine, Vascular Procedures Procedures

Cardiac Cath/Interventional Radiology Cardiac Cath/Interventional Radiology ProceduresProcedures Bleeding from groin siteBleeding from groin site

Neurological ChangesNeurological Changes Assessing level of consciousness is imperative! Assessing level of consciousness is imperative! Most sensitive indicator always compare Most sensitive indicator always compare

baselinebaseline Assessing pupilsAssessing pupils Assessing sensor/motorAssessing sensor/motor Neuro surgery specific assessments and timely Neuro surgery specific assessments and timely

documentationdocumentation Neurovascular surgery specific assessments and Neurovascular surgery specific assessments and

timely documentation – grade pulsestimely documentation – grade pulses

Improving Perioperative HandoffsImproving Perioperative Handoffs

Inside:Inside:- Why improve hand offs?Why improve hand offs?- Video clip of a poor hand offVideo clip of a poor hand off- Highlights of baseline studyHighlights of baseline study- New hand off protocolNew hand off protocol- New hand off content checklistsNew hand off content checklists

Why Improve Handoffs?Why Improve Handoffs?

High risk periods for miscommunicationHigh risk periods for miscommunication Associated with increased risk for patient Associated with increased risk for patient

adverse events. adverse events. In a recent analysis of 240 malpractice cases In a recent analysis of 240 malpractice cases

involving medical errors, >66% involved involving medical errors, >66% involved teamwork breakdownsteamwork breakdowns errors due to hand offs were twice as errors due to hand offs were twice as

prevalent among physician trainees. prevalent among physician trainees.

Weinberger,S.E. 2006; Laine,C. 1993; Petersen,L.A. 1994; Sinha,M., 2007; Orwitz,L.I. 2006

Why improve postoperative hand Why improve postoperative hand offs?offs?

Few examples from PACU events:Few examples from PACU events:

Isolation status not reported to PACU so isolation Isolation status not reported to PACU so isolation precautions were not observed and other PACU precautions were not observed and other PACU patients were put at risk (multiple instances)patients were put at risk (multiple instances)

Multiple reports of missing information issues prior Multiple reports of missing information issues prior to patient arrival, and after admission to unit. to patient arrival, and after admission to unit.

Missing information issues regarding future care Missing information issues regarding future care plan plan

Need to use Peds examples

Improving Perioperative Hand offsImproving Perioperative Hand offs

Inside:Inside:- Why improve hand offs?Why improve hand offs?- Video clip of a poor hand offVideo clip of a poor hand off- Highlights of baseline studyHighlights of baseline study- New hand off protocolNew hand off protocol- New hand off content checklistsNew hand off content checklists

What did you observe?What did you observe?

NoisyNoisy Overlapping conversationsOverlapping conversations Side conversationsSide conversations Completely unstructuredCompletely unstructured Silos of careSilos of care Lack of TeamworkLack of Teamwork

Improving Perioperative Hand Offs:Improving Perioperative Hand Offs:Johns Hopkins Baseline Study Johns Hopkins Baseline Study

JHH Descriptive Study

Surveyed 82 nurses & physicians

Studied hand off problems

Conducted a series of focus groups to discuss potential interventions

Top 5 issues:Top 5 issues: Different communication Different communication

stylesstyles Providers not at bedsideProviders not at bedside Simultaneous tasks of Simultaneous tasks of

technology and technology and information transferinformation transfer

Reduced opportunity to Reduced opportunity to ask questionsask questions

Handoff Content Checklist: SurgeryHandoff Content Checklist: Surgery

□ Actual Surgery Performed

□ Surgical findings (anticipated & unanticipated)

□ Surgical complications

□ Drains/tubes — location, number, and type

□ Special instructions

e.g. “chest tubes to suction for 12 hrs”

“remove NGT in 6 hours”

“nasal cannula sutured in naris” etc.

2011 JHH PACU Studies

Handoff Content Checklist: SurgeryHandoff Content Checklist: Surgery

□ Actual Surgery Performed

□ Patient Disposition (home, floor, IMC/ICU) and if to be discharged provide discharge instructions

□ Responsible 1° service (medicine, ortho etc.)

□ Who to Page

Conclusion: “The thing that I am most concerned about in this patient is __________.”

2011 JHH PACU Studies

Handoff Content Checklist: NursingHandoff Content Checklist: Nursing

□ Actual surgery performed

□ Isolation Type (if applicable): Contact, Airborne …

□ Lines - IV , CVP, Art line , PiC Line ...

□ Drains - Foley, JP, Davol, Neprostomy tube …

□ Skin Inspection e.g. alteration of skin integrity, pressure points, location,…

□ Packing: rectal, vaginal, nasal...

□ Special Equipment/ Others: Iceman, Vac machine, SCD Sleeves /TED …

2011 JHH PACU Studies

Handoff Content Checklist: NursingHandoff Content Checklist: Nursing

□ Actual Surgery Performed

□ Special needs: Wheelchair, chemo, pacemaker/shunt re-program necessary

□ Psychosocial / behavioral issues

□ Family Information: Spouse, children …

□ Belongings and Valuables

□ Events / Concerns

Conclusion: “The thing that I am most concerned about in this patient is __________.”

2011 JHH PACU Studies

Handoff Content Checklist: AnesthesiaHandoff Content Checklist: Anesthesia

Preop:□ History of Present Illness

□ Allergies and CODE status

□ Meds- specify which taken prior to surgery (esp. beta blockers, sedatives, antibiotics)

□ Baseline vital signs; height; weight

□ Baseline physical exam – neurologic, demeanor etc.

□ Baseline labs

2011 JHH PACU Studies

Handoff Content Checklist: AnesthesiaHandoff Content Checklist: Anesthesia

Intraop:

□ Airway – intubation technique, abnormalities etc.

□ Lines – size, location etc.

□ Procedures – blocks, spinal etc.

□ Fluid totals

□ Paralytic status - relaxed, reversed

□ Labs

□ Meds: Narcotic totals, antibiotics, anticoagulant, anticonvulsant , reversal agents etc.

□ Key events - e.g. unexpected episode of SVT/hypotension/hypoxia etc.

Conclusion: “The thing that I am most concerned about in this patient is __________.” 2011 JHH PACU Studies

Handoff of CareHandoff of Care

“The thing that I am most concerned about in this patient is: this patient received 500 mcg and 40mg Morphine in the OR. Please note the patient needed to be reversed twice – one in the OR and 1 hour ago in the PACU.

The patient had an anterior cervical fusion Be sure to watch for snoring as that is a sign of

partial airway obstruction”.

Activating PACU Activating PACU Chain of CommandChain of Command

Hospital/Facility Organizational ChartHospital/Facility Organizational Chart Hierarchical Reporting for Nursing Hierarchical Reporting for Nursing

Leadership and Medical LeadershipLeadership and Medical Leadership Defining Roles and ResponsibilitiesDefining Roles and Responsibilities Identify respective nursing and physician Identify respective nursing and physician

pager numbers/ telephone numberspager numbers/ telephone numbers

Activating PACU Activating PACU Chain of CommandChain of Command

Negotiating reasonable communication Negotiating reasonable communication time-limits for responsetime-limits for response Urgent (Deteriorating Conditions)Urgent (Deteriorating Conditions) Emergent (Life-threatening Emergencies)Emergent (Life-threatening Emergencies)

Reviewing importance of the Activation of Reviewing importance of the Activation of the Chain of Command with all the Chain of Command with all stakeholders stakeholders

Critical Thinking SkillsCritical Thinking Skills

PeriAnesthesia Core Clinical PeriAnesthesia Core Clinical KnowledgeKnowledge Understanding the anesthesia agents Understanding the anesthesia agents

and neurophysiologyand neurophysiology Understanding the total surgical Understanding the total surgical

procedureprocedure Understanding estimate blood loss, Understanding estimate blood loss,

especially when irrigating surgical site.especially when irrigating surgical site. Understanding patient’s chief complainsUnderstanding patient’s chief complains

Case StudiesCase Studies Deteriorating respiratory conditionsDeteriorating respiratory conditions

Patients with low oxygenationPatients with low oxygenation Patients with stridorPatients with stridor Patients with apneaPatients with apnea

Deteriorating cardiac conditionsDeteriorating cardiac conditions HypotensionHypotension Signs and Symptoms of ShockSigns and Symptoms of Shock Symptomatic dysrhythmiasSymptomatic dysrhythmias Life Threatening EmergenciesLife Threatening Emergencies

Deteriorating neurologic conditionsDeteriorating neurologic conditions

Case StudiesCase Studies Deteriorating circulatory conditionsDeteriorating circulatory conditions

Patients with fast heart ratePatients with fast heart rate Patients with considerable bleedingPatients with considerable bleeding Patients with no palpable pulsesPatients with no palpable pulses Patients with obstructive shockPatients with obstructive shock Patients with developing hematomasPatients with developing hematomas

Deteriorating neurologic conditionsDeteriorating neurologic conditions Change in Level of ConsciousnessChange in Level of Consciousness Change in motor or sensory conditionsChange in motor or sensory conditions Change in pupil size or responsesChange in pupil size or responses

Case StudiesCase Studies Patients who have been administered Patients who have been administered

frequent multiple doses of different opioidsfrequent multiple doses of different opioids Patients who have downward trending Patients who have downward trending

oxygen saturations and hypotensive oxygen saturations and hypotensive eventsevents

Patients with low urinary outputPatients with low urinary output Patients who are discharged from the Patients who are discharged from the

PACU with or without an anesthesia PACU with or without an anesthesia provider evaluation.provider evaluation.

Importance of DocumentationImportance of Documentation

Understand the importance of Understand the importance of documentation:documentation: Descriptive wordsDescriptive words Objective factsObjective facts Electronic documentationElectronic documentation Timing of eventsTiming of events Late PACU nursing entriesLate PACU nursing entries Experts at the bedsideExperts at the bedside

Importance of DocumentationImportance of Documentation

Understand the importance of the timing of Understand the importance of the timing of documentation:documentation: Chronologic flow chartsChronologic flow charts Chronologic narrativesChronologic narratives Emergency situations…. No time to document ?Emergency situations…. No time to document ? Reconstructing time intervals Reconstructing time intervals Be Ware of conflicting documentationBe Ware of conflicting documentation, e.g. Flow , e.g. Flow

charts/automatic self-populating data versus charts/automatic self-populating data versus NarrativesNarratives

Failure to RescueFailure to Rescue

Lack of PACU nurse’s ability to Lack of PACU nurse’s ability to recognize early signs and symptoms recognize early signs and symptoms of deterioration in the patient’s of deterioration in the patient’s condition.condition.

Failure to monitor – MN CaseFailure to monitor – MN Case Failure of the PACU nurse to do Failure of the PACU nurse to do

timely assessments/interventions.timely assessments/interventions.

Failure to RescueFailure to Rescue

Failure of the PACU nurse to activate Failure of the PACU nurse to activate the PACU Chain of Command.the PACU Chain of Command.

Acting to late to prevent harm or Acting to late to prevent harm or injuryinjury Acting too late to prevent:Acting too late to prevent: Respiratory Arrest Respiratory Arrest Cardiac ArrestCardiac Arrest Neuro – Hypoxic Encephalopathy.Neuro – Hypoxic Encephalopathy.

Legal ImplicationsLegal Implications

Important for the PACU Nurse to know:Important for the PACU Nurse to know: Standards of CareStandards of Care

Hospital & PACU Policies, Procedures, Hospital & PACU Policies, Procedures, ProtocolsProtocols

ASPAN Standards & Recommended GuidelinesASPAN Standards & Recommended Guidelines Regulatory StandardsRegulatory Standards

Basic “Elements of Negligence”Basic “Elements of Negligence” Legal implications of practiceLegal implications of practice

Case StudyCase Study Priority of nursing interventions A –B – C -DPriority of nursing interventions A –B – C -D

Airway -Airway - Breathing – Breathing – Circulation – Circulation – Disability/NeuroDisability/Neuro Request physician to stay and evaluate patient at Request physician to stay and evaluate patient at

bed bedside until critical elements are stablebed bedside until critical elements are stable Activate the Nursing and Medical Chain of Activate the Nursing and Medical Chain of

CommandCommand Document comprehensive assessments, Document comprehensive assessments,

interventions, responses, and outcomesinterventions, responses, and outcomes

Case StudiesCase Studies

Orthospine procedures Orthospine procedures Mastectomy proceduresMastectomy procedures Thyroid proceduresThyroid procedures T&A ProceduresT&A Procedures Esophageal Dilatation ProceduresEsophageal Dilatation Procedures Nephrectomy ProceduresNephrectomy Procedures

SummarySummary Discharging Patients according to:Discharging Patients according to:

ASPAN Standards and Recommended GuidelinesASPAN Standards and Recommended Guidelines Hospital/Unit Policies/Regulatory Standards*Hospital/Unit Policies/Regulatory Standards*

Advocate for effective communication during Advocate for effective communication during handoffs communicationhandoffs communication

Remember not to be afraid to activate your nursing Remember not to be afraid to activate your nursing and medical chain of commandand medical chain of command

Discharge documentation should be factual, Discharge documentation should be factual, timely, and thorough according to ASPAN and timely, and thorough according to ASPAN and Hospital StandardsHospital Standards