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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

PACU Bottlenecks- A Shared Responsibility

Pam Bush

Clinical Director of Perioperative Services,

The Ottawa Hospital

MOHLTC Perioperative Coaching Team member

NAPAN May 23rd, 2009

  • 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
perioperative coaching teams
Perioperative Coaching teams

Recommended by Report of the Surgical

Process Analysis and Improvement

Expert Panel June 2005

key recommendation
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
site visits
Site Visits
  • 58 hospitals in Ontario have had Perioperative coaching visits
  • 45 Hospitals have had follow up visits
  • Fall 2005-May 2009
the perioperative coaching visit
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
the site visit
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
site visit
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
  • 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
perioperative best practice targets pau
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
perioperative best practice targets sdcu sda
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
perioperative best practice targets operating rooms
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
perioperative best practice targets operating rooms16
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
nursing units that affect pacu efficiency
Nursing Units that Affect PACU Efficiency
  • PAU
  • OR
  • PACU
  • ER
  • ICU
  • Stepdown
  • Psychiatry
  • Surgical inpatient
  • DI- Everyone
pacu factors impacting efficiency
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
pacu factors impacting efficiency19
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
strategies to optimize pacu efficiency
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
strategies to optimize pacu efficiency21
Strategies to Optimize PACU Efficiency
  • Optimize nursing staff to meet patient demand
  • Separate inpatients from outpatients in PACU
largest controllable factor impacting pacu efficiency
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

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
elective or schedule revision
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
emergency or activity
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?
strategies to address emergency or activity
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
sdcu factors affecting pacu efficiency
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
strategies to optimize sdcu efficiency prevent pacu bottlenecks
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
pau factors affecting pacu efficiency
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
pau strategies to optimize pacu efficiency
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?
who is in your pacu
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
strategies to take back your pacu
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
icu stepdown impact to pacu efficiency
ICU/ Stepdown impact to PACU efficiency
  • Review of ICU admission criteria
  • Review of ICU discharge criteria
  • Review of Stepdown admission and discharge criteria
corporate policy
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
contact info
Contact Info
  • Pam Bush
  • Clinical Director Perioperative Services,
  • The Ottawa Hospital
  • 613-737-8719