Going from OR to Floor bed (inpatients)

[anbuitachi]

Anyone know if any guidelines regarding this from societies? This is for inpatients who come to the OR and instead of going to PACU, go back to the patient's room.
Im asking because due to nursing shortages, the PACU is often backed up, and we are facing PACU holds, sometimes up to TWO HOURS. By then the patient is awake alert, meeting aldretes and we want to send them back to the patients bed instead of to the PACU. However this isnt in the hospital policy and Floor nurses are pushing back. We need guidelines about this from societies.. does anyone know any?
Thanks

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[Urzuz]

We used to send Covid patients straight back to their rooms from the OR after meeting PACU discharge criteria. Not sure why you wouldn’t be able to do the same with regular patients.

Luckily our PACU nursing shortage hasn’t been so terrible that we have needed to institute a policy with regular patients. That being said, I have discharged non-Covid patients straight back to their rooms without the floor RNs caring at all.

 

[DrZzZz]

Anyone know if any guidelines regarding this from societies? This is for inpatients who come to the OR and instead of going to PACU, go back to the patient's room.
Im asking because due to nursing shortages, the PACU is often backed up, and we are facing PACU holds, sometimes up to TWO HOURS. By then the patient is awake alert, meeting aldretes and we want to send them back to the patients bed instead of to the PACU. However this isnt in the hospital policy and Floor nurses are pushing back. We need guidelines about this from societies.. does anyone know any?
Thanks

If the patient meets criteria for discharge from pacu, there is no reason the floor should be refusing the patient (other than pure laziness). Doesn't matter whether the patient was recovered in pacu or in the OR due to pacu hold. If they're ready, they're ready.

 

[Justice4all]

Maintain the current flow. OR to PACU to floor. I do not see the role of the society for accomodating this change in practice. Let the hospital come up with locums nurses or book appropriate OR cases for their current staffing.

 

[Ronin786]

You're the physician discharging the patient. Floor nurses shouldn't have a say where they come from as long as they look the same.

 

[IlDestriero]

We have had to do this once to my knowledge, because of a number of factors all lining up that day. RN Shortage, back up, pacu holds, and call outs.
Several patients were recovered in the OR, documentation was done in the nursing notes section documenting recovery time, vitals, discharge criteria, etc. It was very disruptive, crushed the late team, many complaints, a few cases moved to Saturday, etc. If we had an evening trauma and/or transplant it would have gotten very ugly. It got the highest level attention, and hasn’t repeated.
If the patient meets discharge criteria and it is properly charted, they have nothing to push back on. Though people may have said patients were ready for d/c when they clearly weren’t. If this happens with any regularity, you should have a policy and clear guidelines, and a go by on how to properly document the recovery.

 

[coffeebythelake]

Patient had a PACU recovery in the OR.

 

[anbuitachi]

You're the physician discharging the patient. Floor nurses shouldn't have a say where they come from as long as they look the same.

well thats exactly the issue. im a physician. i cant tell nurses what to do, and they are saying it needs to be nurse to nurse hand off. physician cant replace a nurse!

also as physicians we are not familiar with documenting nursing stuff in epic. not sure if we even have access to all that stuff

 

[MirrorTodd]

well thats exactly the issue. im a physician. i cant tell nurses what to do, and they are saying it needs to be nurse to nurse hand off. physician cant replace a nurse!

also as physicians we are not familiar with documenting nursing stuff in epic. not sure if we even have access to all that stuff

That's weird. I'm willing to bet if you pressed the nurses to show proof of that policy, they'd give you diddly squat. This sounds like a hospital leadership problem. I would just keep the anesthetic record going while the pt recovers q15min vitals. Once they meet aldrete score, call up yourself or if it is easier have the OR circulating nurse call report. Ultimately, the anes department needs to give a VERY strong pushback on any BS the floor nurses throw your way. Like most things in the hospital, this boils down to poor leadership.

FWIW, our current policy is for covid+ pt's to recover in OR under anesthesia care, then send directly to floor. If there is a lot of covid+ pt's to get through, then we send the patient to the one isolation room we have in PACU where they recover. It's been a little bit of ****show, cause despite repeated highlighting the current policy, ignoramus anesthetists will drop the covid+ pt directly to PACU.

 

[IMGASMD]

We’ve had a few PACU holds just got out of hand….
Solution 1: anesthesiologist recover the patient, but still charging anesthesia time, because they still under anesthesia care. Would love to see hospital’s response when the patient/insurance call back.
Solution 2: as soon as the tube is pulled, the patient is “good”. Hand off to the OR circulator. They’re nurses right?!

My current work place is a little enigma. When I take a patient to ICU, I don’t ever talk to the physician, not even the resident. I give report to a the ICU nurse. There had been times that I actually have to track down the resident to tell them what’s up…..

 

[pgg]

well thats exactly the issue. im a physician. i cant tell nurses what to do, and they are saying it needs to be nurse to nurse hand off. physician cant replace a nurse!

also as physicians we are not familiar with documenting nursing stuff in epic. not sure if we even have access to all that stuff

My god every time you post something, we learn something new and horrible about your job.

If I get PACU gridlocked and have to do phase I recover in the OR ... when it's done, I tell the OR nurse (who's stuck there with me) that the patient can go to phase II recovery on the floor. And the OR RN calls the floor nurse and gives report, same as they do when they call the PACU at the end of a case.

 

[Hoya11]

You're the physician discharging the patient. Floor nurses shouldn't have a say where they come from as long as they look the same.

"oh my god they sent me this patient who was sooooo sleepy after surgery, can you believe it? I just didnt feel comfortable!!"

Charge nurse initiates meetings with clip board suits and thats the end of that.

 

[DocVapor]

"oh my god they sent me this patient who was sooooo sleepy after surgery, can you believe it? I just didnt feel comfortable!!"

Charge nurse initiates meetings with clip board suits and thats the end of that.

That's when you send the OR manager to explain to them how much money the hospital is losing by keeping patients in the OR unnecessarily. Let the clipboard nurses fight the clipboard nurses.

 

[deleted875186]

I had the same happen to me in residency. PACU hold for one hour. Patient was wide awake in the OR, drinking juice, I called and told my attending and we bypassed PACU to floor, I called and gave signout, when I showed up it was the end of the world …. Tough to change the hosptial culture unfortunately.

 

[Ronin786]

I had the same happen to me in residency. PACU hold for one hour. Patient was wide awake in the OR, drinking juice, I called and told my attending and we bypassed PACU to floor, I called and gave signout, when I showed up it was the end of the world …. Tough to change the hosptial culture unfortunately.

It's only getting worse. With all the nurse shortages they're a much hotter commodity than physicians. Administrators are bending over backwards to make sure nurses get whatever they want.

 

[anbuitachi]

It's only getting worse. With all the nurse shortages they're a much hotter commodity than physicians. Administrators are bending over backwards to make sure nurses get whatever they want.

Because they work shifts. While MD cover calls and cases to whenever. We put ourselves in this position

 

[anbuitachi]

I had the same happen to me in residency. PACU hold for one hour. Patient was wide awake in the OR, drinking juice, I called and told my attending and we bypassed PACU to floor, I called and gave signout, when I showed up it was the end of the world …. Tough to change the hosptial culture unfortunately.

Nice you got juice in the OR. They won't let us bring in juice

 

[nimbus]

Nice you got juice in the OR. They won't let us bring in juice

Then how do you stay hydrated?

 

[Volatile]

As a locums I did this all the time at night or on weekends. I was the only one there with the OR nurse. I’d sit the case then recover the patient myself, I’d recover in the OR or in a pacu bay but it was just me and the OR nurse. It’s great when youre payed hourly to babysit a “pacu” patient yourself! There is nothing wrong with it as long as they are meeting pacu discharge criteria, the floor nurses at your hospital are incorrect.

 

[anbuitachi]

Then how do you stay hydrated?

drink irrigation fluid

 

[anbuitachi]

As a locums I did this all the time at night or on weekends. I was the only one there with the OR nurse. I’d sit the case then recover the patient myself, I’d recover in the OR or in a pacu bay but it was just me and the OR nurse. It’s great when youre payed hourly to babysit a “pacu” patient yourself! There is nothing wrong with it as long as they are meeting pacu discharge criteria, the floor nurses at your hospital are incorrect.

we anesthesiologists def believe they are incorrect but so far its just our 'belief' so we need something more than that preferably from society of somewhere. otherwise i guess hospital will need to sit down and write a policy. probably the direction we are going, but will probably take ages

 

[IlDestriero]

Nice you got juice in the OR. They won't let us bring in juice

Sometimes I give minimal MAC/spinal/local patients a couple ice chips. Don’t tell the JC. We also have Sweer-Ease for the baby spinals. The ASC is the Wild West. I could probably eat a sandwich in there.

 

[IlDestriero]

we anesthesiologists def believe they are incorrect but so far its just our 'belief' so we need something more than that preferably from society of somewhere. otherwise i guess hospital will need to sit down and write a policy. probably the direction we are going, but will probably take ages

They need to produce a policy that says what they are demanding. It may not exist. I doubt any society has guidelines about this at that level of detail because it’s ridiculous, and would be institution dependent.
As an alternative you could get a pacu nurse to come into your OR, confirm that they meet your institution’s discharge criteria and sign out to the RN on the floor. It’s far cheaper to have an extra PACU nurse walking around than hours of OR delays. I can’t understand how the OR administration and surgeons haven’t gone nuclear already with these delays.

 

[nimbus]

Sometimes I give minimal MAC/spinal/local patients a couple ice chips. Don’t tell the JC. We also have Sweer-Ease for the baby spinals. The ASC is the Wild West. I could probably eat a sandwich in there.

How about pizza?

 

[Mman]

Anyone know if any guidelines regarding this from societies? This is for inpatients who come to the OR and instead of going to PACU, go back to the patient's room.
Im asking because due to nursing shortages, the PACU is often backed up, and we are facing PACU holds, sometimes up to TWO HOURS. By then the patient is awake alert, meeting aldretes and we want to send them back to the patients bed instead of to the PACU. However this isnt in the hospital policy and Floor nurses are pushing back. We need guidelines about this from societies.. does anyone know any?
Thanks

I do not know of any society guidelines because it is an issue that is so stupid a society shouldn't have to come up with a guideline for it. The guidelines are all criteria based for discharge from PACU to a lower level of nursing care. If you can document that you have met all those criteria, they are clearly safe by guidelines to go to a lower level of nursing care than PACU.

If the floor nurses have a problem, it sounds like the OR leadership needs to tell their boss that's how it is going to be because slowing down the ORs for hours is flushing money down the toilet.

 

[Urzuz]

we anesthesiologists def believe they are incorrect but so far its just our 'belief' so we need something more than that preferably from society of somewhere. otherwise i guess hospital will need to sit down and write a policy. probably the direction we are going, but will probably take ages

Please. The ASA is useless enough as is. Please don’t give them more useless ideas to waste their time on.

Why would any society have to create a policy that says it’s ok to bypass PACU if the patient meets all PACU discharge criteria?!

 

[Status Sciaticus]

Please. The ASA is useless enough as is. Please don’t give them more useless ideas to waste their time on.

Why would any society have to create a policy that says it’s ok to bypass PACU if the patient meets all PACU discharge criteria?!

so administrators and clip board nurses get off your back about sending them to the floor directly