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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 23 rd , 2009. Overview. Perioperative Coaching teams in Ontario Their purpose-The process-The findings

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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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  • 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

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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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  • 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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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


  • 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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  • 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 bottlenecks

  • 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 bottlenecks

  • 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 bottlenecks

  • 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 bottlenecks 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 bottlenecks

  • Review of ICU admission criteria

  • Review of ICU discharge criteria

  • Review of Stepdown admission and discharge criteria

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Corporate Policy bottlenecks

  • 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? bottlenecks

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Contact Info bottlenecks

  • Pam Bush

  • Clinical Director Perioperative Services,

  • The Ottawa Hospital

  • 613-737-8719

  • [email protected]