Recovery in the OR, PACU backed up

[sensoricaine]

More and more frequently we are up against the situation whereby PACU becomes backed up with overflow ICU patients and inability to move recovered patients to the floor because hospital is full and no beds available for hours on end. We then end up having to recover patients in the OR for some period of time.

Have any of you run into this situation at your program? Do you recover the patient in the OR? Do you have a policy in place? How frequently does it happen?
Who stays in the OR? Anesthesia only, circulator, scrub, surgery resident, everyone or some combination of the above???
Is the patient billed for OR time or recovery time?
If fully recovered in the OR does the patient go to the floor directly from the OR? Who transports patient to the floor? Who gives report to the floor nurse?
Are OR cases put on hold if no beds are available in the hospital or if the PACU is full?

Comments are greatly appreciated.

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[Noyac]

It happened on rare occasions in my training. It sucks and it is obviously the most inefficient use of manpower. I made sure I was going to be the next one admitted to the pacu every time, however. I would make sure my pt woke up fast and I would grab a transport monitor and push the pt to the entrance of the pacu and sit there instead of in the OR. They had to take me next.

 

[zippy2u]

I loved it when this happened in residency. I'd always wait and be the last one to the PACU. Why? Less cases to do. You were goin' home at 3-5PM regardless each day when you weren't on call. Work the system to your advantage Pops, don't fight it. Regards, ----Zip

 

[Noyac]

I loved it when this happened in residency. I'd always wait and be the last one to the PACU. Why? Less cases to do. You were goin' home at 3-5PM regardless each day when you weren't on call. Work the system to your advantage Pops, don't fight it. Regards, ----Zip

Wouldn't rather do a case or two then sit and recover a pt?😕

 

[zippy2u]

Really now, let me give ya the big picture perspective. This happened to me less than 10 times during a 3 year residency. Is he goin' to miss out on a landmark case of separating conjoined twins with film crews and the whole shebang or working with a world famous surgeon attempting a new surgical technique? Nah dude, prolly some mindless, monotonous washout or lap chole or knee scope. Same mindset applies to pullin' your kids out of school to go on vacation. What are they goin' to discover, a new geometrical theorem or postulate and name it after themselves in a week's time? Bah, just hang out in the OR for as long as ya can, it's all good... Regards, ----Zippy

 

[Noyac]

Really now, let me give ya the big picture perspective. This happened to me less than 10 times during a 3 year residency. Is he goin' to miss out on a landmark case of separating conjoined twins with film crews and the whole shebang or working with a world famous surgeon attempting a new surgical technique? Nah dude, prolly some mindless, monotonous washout or lap chole or knee scope. Same mindset applies to pullin' your kids out of school to go on vacation. What are they goin' to discover, a new geometrical theorem or postulate and name it after themselves in a week's time? Bah, just hang out in the OR for as long as ya can, it's all good... Regards, ----Zippy

No No No!

Thats not at all what I'm saying. All I am saying is that I would rather be doing something/anything than recovering a pt. Thats for the nurses to do. If you would rather sit there making small talk with your pt while he recovers from his knee scope b/c the powers that be can't get their **** together then thats your perogative.

This is like the partner that shuffles his feet to start the next case in hopes that you will finish yours so that he can dump it on you and go home. No thanks man.

 

[jwk]

Have any of you run into this situation at your program? Do you recover the patient in the OR? Do you have a policy in place? How frequently does it happen?
Who stays in the OR? Anesthesia only, circulator, scrub, surgery resident, everyone or some combination of the above???
Is the patient billed for OR time or recovery time?
If fully recovered in the OR does the patient go to the floor directly from the OR? Who transports patient to the floor? Who gives report to the floor nurse?
Are OR cases put on hold if no beds are available in the hospital or if the PACU is full?

I'm in private practice. This happens in our hospital from time to time - when it starts happening routinely, we start complaining up the nursing chain of command, particularly if it's a staffing issue. Hey, even the VP of nursing services can come push a stretcher to help clear out the PACU.

ANY TIME that you are involved with the patient is perfectly legitimate BILLABLE TIME. BTW, that includes the time in the OR you've been waiting for the surgeon who's "pulling in the parking lot". All that time is expensive and I never miss the chance to point that out to the OR administration. 😉

If the circulator happens to be ACLS certified and cross-trained in PACU, you can sign off to that RN just like you would in the PACU. Just leave the patient on the monitors, give a report, and off you go. Then it's their problem.

 

[Monty Python]

....... If the circulator happens to be ACLS certified and cross-trained in PACU, you can sign off to that RN just like you would in the PACU. Just leave the patient on the monitors, give a report, and off you go. Then it's their problem.

Same way at my place.

On a tangent: what if they're "out" of gurneys? Can't find a single one to transport the pt from OR to PACU? I'm not talking about an ICU bed ... just a basic gurney. Happened to me at a teaching hospital. After waiting 15 minutes, my chief came to the conclusion that it was near shift change and all the civil-service people (orderly, PACU RN, who knows who?) simply didn't want to be bothered this close to getting off-shift. So, my chief comes into my OR and gives me straight forward instructions.

I unlock the OR table, and with my chief's assistance we push the pt/OR table down the hall to PACU. I seem to recall it making more noise than a gurney would.

 

[coprolalia]

I unlock the OR table, and with my chief's assistance we push the pt/OR table down the hall to PACU. I seem to recall it making more noise than a gurney would.

HAHA! That is AWESOME! Nice work!

-copro

 

[jetproppilot]

I unlock the OR table, and with my chief's assistance we push the pt/OR table down the hall to PACU. I seem to recall it making more noise than a gurney would.

Way to go, Trin. Way to go.

 

[jwk]

I unlock the OR table, and with my chief's assistance we push the pt/OR table down the hall to PACU. I seem to recall it making more noise than a gurney would.

HAHAHAHA - been there done that - makes a sh*tload of noise going down the hall. I only had to do it once to make my point!

 

[VentdependenT]

I put the patient on a garbage bag and slide him/her to the PACU.

 

[sensoricaine]

It happened on rare occasions in my training. It sucks and it is obviously the most inefficient use of manpower. I made sure I was going to be the next one admitted to the pacu every time, however. I would make sure my pt woke up fast and I would grab a transport monitor and push the pt to the entrance of the pacu and sit there instead of in the OR. They had to take me next.

see thats not an option really..
frequently we recover in excess of 45 mins, over an hour...
and its occuring more and more often😱

 

[Noyac]

see thats not an option really..
frequently we recover in excess of 45 mins, over an hour...
and its occuring more and more often😱

I seem to remember it only happening on a rare occasion and we didn't have to recover them for long.

 

[swpm]

Some programs will pay a resident extra money to recover patients in the OR.

I know UVA does ... can't remember, but I think they said it was something like $35/hour every time you got put on PACU hold.

 

[kraphtymac]

I put the patient on a garbage bag and slide him/her to the PACU.

Ha! Awesome. I'll have to remember this one.

On a more serious note, I recall at my MGH interview that they are trialling an OR setup they call a POD. They take 4 OR rooms, let 3 of them run cases, and then make the 4th a PACU. Sounds pretty sweet in theory, it SHOULD help with congestion of main PACU, but I don't know how it works in the real world.

 

[Laurel123]

It happens in the private practice world occasionally when the PACU gets filled up. Usually it is not longer than 15 minutes. So, I just keep the patient on moniters, and keep making my ticks on the chart. It's all billable time anyways. I get them on the gurney, tuck them snuggly in with some warm blankets and they snooze quietly while I relax and 'watch the vitals' and wait for PACU to open up.

 

[jwk]

Ha! Awesome. I'll have to remember this one.

On a more serious note, I recall at my MGH interview that they are trialling an OR setup they call a POD. They take 4 OR rooms, let 3 of them run cases, and then make the 4th a PACU. Sounds pretty sweet in theory, it SHOULD help with congestion of main PACU, but I don't know how it works in the real world.

That makes no sense from an economic standpoint. OR's make money by doing surgery in them, not recovering patients. Sounds like a horribly inefficient PACU is more of an issue.

 

[Volatile Agent]

I'm an anesthesia resident at UVa and PACU hold happens here A LOT! Not everyday but certainly several days each week.
This is how it goes: When we can't get to the PACU it is either because there aren't enough beds in the hospital to get patients out of the PACU, or there aren't enough nurses in the PACU to recover them. Its usually a lack of bed space in the hospital. Our Administration has figured out that the ORs make the money so they run them like crazy, even if there is no room in the hospital for the patients who are coming out of the ORs. So if the PACU can't take us we (the Anesthesia residents) become the PACU nurses. We get paid $30 for every 1/2hr we're on hold. Of course we get a lot of 25min holds because they don't want to pay us and if its less than 30min we get nothing.
The circulating nurse stays in the room but the surgery residents are free to leave. We always end up going to the PACU eventually, we don't call report or transport patients to the floor directly. We also get ICU holds, but we just call report ourselves and take them to the ICU when they have space (no different than if we didn't have a hold).
Cases get delayed because of the holds but they NEVER get canceled. Our surgeons are happy to operate all night if thats what it takes to get their cases done. And like I said the Administration wants the income so the surgeries go on no matter what.
Overall PACU hold Sucks! The only thing that makes it tolerable is getting paid for it. If we weren't getting paid we'd be furious and I might just park the patient outside the PACU or take them to the floor and wait in the hallway.
That's the UVa way. Any questions?

 

[DuckhuntingDoc]

Happened all the time where I trained. Even if we made it to PACU there wasn't always a nurse there to take the patients...

 

[Volatile Agent]

Duck Hunter, where did you train?

 

[DuckhuntingDoc]

University of Rochester

 

[caligas]

Im trying to bump this really old thread.

is it true that pacu hold time is billable? Can anybody confirm?

 

[deleted9493]

It absolutely is billable as anesthesia time.

 

[risnwb]

Im trying to bump this really old thread.

is it true that pacu hold time is billable? Can anybody confirm?

In residency we had huge problems with pacu hold when I was a ca1. We would often sit for 20-30 minutes and occasionally up to 2 hours in the or. We had electronic records and would just let it run and record vitals for as long as we sat there, so we were absolutely billing for the time. We were told specifically NOT to write comments about pacu hold in the record as the higher ups said "that's not part of the MEDICAL record". So often there would be long periods following extubation with train track vitals with no explanation...

 

[caligas]

In residency we had huge problems with pacu hold when I was a ca1. We would often sit for 20-30 minutes and occasionally up to 2 hours in the or. We had electronic records and would just let it run and record vitals for as long as we sat there, so we were absolutely billing for the time. We were told specifically NOT to write comments about pacu hold in the record as the higher ups said "that's not part of the MEDICAL record". So often there would be long periods following extubation with train track vitals with no explanation...

Yeah, which seems sketchy

 

[jwk]

In residency we had huge problems with pacu hold when I was a ca1. We would often sit for 20-30 minutes and occasionally up to 2 hours in the or. We had electronic records and would just let it run and record vitals for as long as we sat there, so we were absolutely billing for the time. We were told specifically NOT to write comments about pacu hold in the record as the higher ups said "that's not part of the MEDICAL record". So often there would be long periods following extubation with train track vitals with no explanation...

Not sure why it makes a difference - I document "delay for surgeon" when the patient is asleep and the surgeon disappears. Why wouldn't you document "delay for PACU" after you've extubated your patient?

 

[Random Anesthesiologist]

We are experiencing consistent pacu holds in the evening a few days a week. Couple weeks ago I sat with my pt on hold in OR for I hour, I kid you not. We brought the issue up to our staff but ultimately it's a nursing staffing issue. Maybe when people see the exorbitant bills from anesthesia and complaint they will do something, because the answer we got was pretty much "sorry, not sorry".

 

[kazuma]

I wonder how common this occurs, I've had a number of applicants ask if this happens at our program. I've never had to recover anyone in the OR, we've had PACU tell us that they are full, but we bring them out anyway and overflow into pre-op. If it's an ICU bed problem, we call respiratory to bring down a vent and they hang out in PACU until an ICU bed is available. I've see up to 4 or 5 vented patients in the PACU but I've never heard of anyone having to recover a patient in the OR.

 

[jwk]

I wonder how common this occurs, I've had a number of applicants ask if this happens at our program. I've never had to recover anyone in the OR, we've had PACU tell us that they are full, but we bring them out anyway and overflow into pre-op. If it's an ICU bed problem, we call respiratory to bring down a vent and they hang out in PACU until an ICU bed is available. I've see up to 4 or 5 vented patients in the PACU but I've never heard of anyone having to recover a patient in the OR.

We wouldn't be able to use pre-op - it's full of pre-op patients.

This is rarely a space problem in our place - it's a nursing shortage i.e. management problem. Nursing management sees the exact same schedule we do - in fact, they look at these things constantly every day. There's always enough staff for the OR's during the day, but amazingly, that same staffing push doesn't carry through to PACU, which is why it's a management problem, or lack thereof.

 

[Psai]

Same way at my place.

On a tangent: what if they're "out" of gurneys? Can't find a single one to transport the pt from OR to PACU? I'm not talking about an ICU bed ... just a basic gurney. Happened to me at a teaching hospital. After waiting 15 minutes, my chief came to the conclusion that it was near shift change and all the civil-service people (orderly, PACU RN, who knows who?) simply didn't want to be bothered this close to getting off-shift. So, my chief comes into my OR and gives me straight forward instructions.

I unlock the OR table, and with my chief's assistance we push the pt/OR table down the hall to PACU. I seem to recall it making more noise than a gurney would.

this is amazing

 

[kidthor]

When I was on my cardiac rotation this would happen just about every day... the longest hold I heard about was 5 hours (this happened to a co-resident). The norm was about 1-2 hours.

 

[deleted171991]

Im trying to bump this really old thread.

is it true that pacu hold time is billable? Can anybody confirm?

You are there taking care of the patient. Clearly billable. Also clearly contestable by the patient, not to you but to the hospital, whose fault it is.

However, the right thing to do is to document the cause of the delay.

 

[Orin]

Our practice is to not bill for the time as our rate is so much higher than the PACU time and it doesn't seem fair to the patient. We document anesthesia end and free the attendings to take more rooms. We document that we are on PACU hold to allow for finding out how often this happens in our EMR for when the $$$ folk meet to talk about staffing. We are asked to put them on monitors and get a temp of some sort in that hold time for SCIP guidelines.

Personally, as a resident, I generally recover the patient in the PACU if there is space and no PACU nurse so my OR staff/surgery folks can get freed up if it isn't an ICU patient. I have no problem taking the patient to their room directly if they've got one assigned and someone to help transport. It also gets our PACU to find nurses way faster. I'd much rather be doing cases, but at that level it is fun and educational to see the results of your anesthetic plan.

 

[urge]

Hospitals are constantly lobbying to decrease original fees and increase facility fees, yet you find this going on nationwide.

Dint be ok with this. This is unacceptable.

 

[jwk]

Our practice is to not bill for the time as our rate is so much higher than the PACU time and it doesn't seem fair to the patient. We document anesthesia end and free the attendings to take more rooms. We document that we are on PACU hold to allow for finding out how often this happens in our EMR for when the $$$ folk meet to talk about staffing. We are asked to put them on monitors and get a temp of some sort in that hold time for SCIP guidelines.

Personally, as a resident, I generally recover the patient in the PACU if there is space and no PACU nurse so my OR staff/surgery folks can get freed up if it isn't an ICU patient. I have no problem taking the patient to their room directly if they've got one assigned and someone to help transport. It also gets our PACU to find nurses way faster. I'd much rather be doing cases, but at that level it is fun and educational to see the results of your anesthetic plan.

Time is money - it's that simple - always.

Every billable minute spent taking care of the patient while waiting for PACU or in PACU is a minute that can't be charged to anyone else. Now - if you can charge the hospital for that time (and collect), more power to you. As a resident, you don't really see the effect this has on your bottom line. If you're out in private practice, it's glaringly obvious. What's not "fair" is for a group to be losing money - literally - due to the hospital's inefficiencies or mismanagement. What's also not fair is to see what the hospital charges for various items - then an extra $20-100 on an extra RVU or two becomes a drop in the bucket - that might change your perspective as well.

When do you end your anesthesia time on a case that you're not delayed? At the moment you walk through the PACU doors, or is it the time when you complete your "hand-off" to the PACU nurse and walk away from the patient? It should be the latter - anything earlier and you're leaving money on the table.

 

[Orin]

When do you end your anesthesia time on a case that you're not delayed? At the moment you walk through the PACU doors, or is it the time when you complete your "hand-off" to the PACU nurse and walk away from the patient? It should be the latter - anything earlier and you're leaving money on the table.

Agree the incentives are different. End time is when you walk away. I think our policy is a passive way to exert financial pressure on the system to improve PACU patient flow. I would prefer a more direct approach.

 

[Random Anesthesiologist]

I look at it this way... If there's a chance something could go wrong under my care, the record is running. If it's not documented, it didn't happen.