Using Discharge Criteria to Improve Patient Flow in
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Using Discharge Criteria to Improve Patient Flow in the Recovery Room Team Membership: Irwin Brown, D. O. Elaine Fluder, RN, MSN Kris Sawicki, RN, BSN Bruce Kleinman, M. D. W. Scott Jellish, M. D. , Ph. D Jeri Katsaros, RN Loyola University Dept. of Anesthesiology Post Anesthesia Recovery Room Nursing
Opportunity Statement and Desired Outcome Currently, patient stay in the post anesthesia recovery unit (PACU) room is often prolonged. This results in unnecessary use of expensive PACU resources and reduces the ability to move patients from the operating room to PACU in a timely manner. The goal of this project is to achieve significant reductions in the length of patient stay in the PACU
Likely Causes for Delay of Discharge from PACU Lack of timely physician order High variability in decision making about discharge readiness Multiple clinicians involved in discharge decision Lack of explicit discharge criteria Lack of bed availability PACU nursing and/or transportation personnel unavailable for transfer Complications (i. e. , hemodynamic instability, bleeding, cardiac, neurologic event) Pain management Uncontrolled nausea and vomiting
Solutions Implemented Ø Criteria were developed to allow nurses to discharge selected patients from PACU without evaluation by a physician Ø Patient population included: • All adult non-emergent surgical cases • General anesthesia with or without regional block • Discharge to floor bed anticipated at time of PACU admit (pts needing ICU were excluded) Ø A policy for discharge per criteria was implemented Ø Education for both physicians and nursing
Criteria Used for Assessment of Discharge Readiness 1 Moves all extremities as per pre-op status 2 Able to deep breathe/cough freely, Resp. 12 -25/min. +/-20% of baseline, 02 saturation of 97% or greater RA_ or supplemental 02 3 Hemodynamic stability: HR 60 -100 +/-10% of baseline – SR or same as pre-op and B/P +/-20% of pre-op baseline – 2 consecutive readings 15 min. apart at discharge 4 Orientated to person – Obeys simple commands 5. Temp. 36 C = 37. 8 C 6 VAS pain score of 4 or less 7 Urine output (. 5 -1 cc/kg/hr) if Foley present 8 No intractable nausea/vomiting 9 No undue anxiety or agitation 10 No excess surgical bleeding 11 An anesthesiologist has reviewed all lab/tests obtained by anesthesiologist order
Results PACU mean discharge time in the physician group was 133 minutes vs. 102 minutes for nurse implementation of discharge criteria. This clearly demonstrates that utilization of discharge per criteria substantially reduces length of PACU stay – see chart.
8/ 200 12 2 /2 8/ 00 19 2 / 8/ 200 26 2 /2 0 9/ 02 2/ 20 9/ 02 9/ 9/ 200 16 2 /2 9/ 00 23 2 /2 9/ 00 30 2 / 10 200 /7 2 10 /20 /1 02 4 10 /2 02 1 10 /2 02 8/ 2 3/ 00 10 2 / 3/ 200 17 3 /2 3/ 00 24 3 / 3/ 200 31 3 /2 0 4/ 03 7/ 4/ 200 14 3 /2 4/ 00 21 3 / 4/ 200 28 3 /2 0 5/ 03 5/ 2 5/ 00 12 3 /2 5/ 00 19 3 /2 5/ 00 26 3 /2 0 6/ 03 2/ 20 6/ 03 9/ 20 03 5/ 8/ Average PACU Time (min) PACU LENGTH OF STAY PHYSICIAN VS. NURSE DISCHARGE PER CRITERIA 180 160 140 Mean = 130. 6 120 100 80 60 Mean = 101. 9 Discharge per physician Nurse discharge per criteria
Conclusion Ø Implementation of uniform discharge criteria has significantly shortened patient stay in PACU. Next Steps Ø Implementation of PACU discharge criteria for all patient populations. Ø Address other causes of patient delay in discharge from PACU.
