Aim
To ensure clinical staff understand their institution’s established Post Anaesthesia Care Units (PACU) guidelines and broader guidelines, in particular, Australian and New Zealand College of Anaesthesia (ANZCA) PS04 (A) Position statement on the post-anaesthesia care unit.
To ensure the PACU ‘escalation of care’ process is visible to, and understood by all clinical staff, facilitating timely and effective responses to a patient’s changing clinical needs.
Background
The Anaesthetic Subcommittee (ASC) of the Victorian Perioperative Consultative Council (VPCC) has recently reviewed a series of deaths and significant adverse events occurring in PACU and/or in the early stages of post operative ward care. These cases have highlighted the importance of considering the potential for adverse outcomes by identifying patients at risk of anaesthesia and/or surgical post-procedural complications by:
- Ensuring that patients are physiologically stable before leaving the operating room and on admission to the PACU,
- Early consideration of the potential for adverse outcomes that may occur in the post-operative period (such as respiratory or cardiac events), related to patient physiology or the surgical procedure undertaken,
- Establishing a clear plan for timely escalation of care in the event of such adverse outcomes or in response to changes in a patient’s recovery trajectory,
- Ensuring on discharge from PACU, that the patient will be discharged to the receiving clinical area, where the care will be appropriate for the level of acuity the patient requires (Intensive Care Unit, High Dependency Unit, surgical ward).
The Anaesthetic Subcommittee acknowledges the differences between private and public hospital practices and recognises that some limitations seen in private hospitals, in particular availability of “supernumerary” medical staff, may also apply to regional facilities.
Recommendations
The Anaesthetic Subcommittee recommends that:
- Clinical staff (nursing and medical) must be familiar with the policies describing escalation of care for post-operative patients in each facility they work in.
- Pre-operative assessment should address risk factors for early post-operative decline such as obesity, sleep-disordered breathing, high opioid requirements, unstable physiology or limited physiological reserve.
- During handover to the PACU nursing staff by an anaesthetist, beyond the standard handover described in ANZCA PS04, the following factors should be communicated:
- Issues or complications that may arise during PACU stay, related to the patient’s physiology or the surgical procedure.
- Guidelines for when PACU staff should seek urgent medical (or surgical) review,
- Specific instructions on how to seek timely medical assistance.
- In facilities with a Medical Emergency Team (MET) call system, all medical and nursing staff should be empowered to activate this process to ensure prompt medical assistance, especially when the treating anaesthesia team is not immediately available.
- When the anaesthetist is the only available medical professional, they should not proceed with the care of their next patient where they would not be immediately available to attend until the patient’s current clinical trajectory is predictable and stable.
References
ANZCA PS04 (A) Position statement on the post-anaesthesia care unit