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The intensive care unit (ICU) was born from the postanesthesia care unit (PACU). In today's hospital systems, there remains a lot of overlap in the care missions of each location. The patient populations share many similarities and many of the same care, technology, and care protocols apply to patients in both units. As shown by the COVID-19 pandemic, there is immense value in maintaining protocols, processes, and staffing models for the safe care of ICU patients in the PACU when ICU demands exceed capacity., Competing Interests: Disclosures Drs M.R. Gaylor and K. Tyson have no disclosures. Dr D.N. Hager is funded by the CDC (IVY Network) and NIH (ACTIV-4d) via subcontracts with Vanderbilt University Medical Center., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Handoffs between the operating room (OR) and post-anesthesia care unit (PACU) require a high volume and quality of information to be transferred. This study aimed to improve perioperative communication with a handoff tool., Methods: Perioperative staff at a quaternary care center was surveyed regarding perception of handoff quality, and OR to PACU handoffs were observed for structured criteria. A 25-item tool was implemented, and handoffs were similarly observed. Staff was then again surveyed. A multidisciplinary team led this initiative as a collaboration., Results: After implementation, nursing reported improved perception of time spent (2.63-3.68, p = .02) and amount of information discussed (2.85-3.73, p = .05). Anesthesia also reported improved personal communication (3.69-4.43, p = .004), effectiveness of handoffs (3.43-3.82, p = .02), and amount of information discussed (4.26-4.76, p = .05). After implementation, observed patient information discussed during handoffs increased for both surgical and anesthesia team members. The frequency of complete and near-complete handoffs increased (40%-74%, p < .001)., Conclusions: A structured handoff tool increased the amount of essential information reported during handoffs between the OR and PACU and increased team members' perception of handoffs., Competing Interests: Conflicts of Interest and Source of Funding: This work was supported by the Cleveland Medical Center Graduate Medical Education Innovation Award grant. An internal grant that is established for quality improvement projects was utilized for the funding of this study. The authors declare no conflicts of interest., (Copyright © 2024 National Association for Healthcare Quality.)

Objective: This study blindly evaluated sugammadex compared with neostigmine on length of stay in the postanesthesia care unit (PACU)., Methods: Fifty patients undergoing elective laparoscopic cholecystectomy or abdominal wall hernia repair consented to receive either sugammadex (2 mg/kg) or neostigmine (0.07 mg/kg) for the reversal of rocuronium neuromuscular blockade. Reversal agents were administered during surgical closing, and the train of four was measured until a twitch ratio of T4:T1 ≥ 0.9 was obtained to signify a robust reversal. Postreversal outcomes also were measured during PACU stay. Aldrete scores, pain visual analog scale score, and nausea were measured during the PACU stay., Results: Patients receiving sugammadex experienced a shorter PACU stay at the time of discharge than patients receiving neostigmine, by an average of 12 minutes ( P < 0.05)., Conclusions: Sugammadex patients had a significantly shorter PACU stay.

With regard to the hospital drug supply chain, the safest system is the individual automated drug dispensing one provided by the pharmacy. For several years we have been trying to convince hospital decision-makers to set it up. In the meantime, to mitigate the risks of medication errors incurred by patients and caregivers, we have set up several work teams within the care units. These teams, made up of one pharmacist and one or two hospital pharmacy technicians, who notably manage the medicine cabinets in care units. The close collaboration with doctors and nurses developed over the years was a determining factor when it became necessary to provide the newly created additional intensive care units with drugs and medical devices (MDs) in order to cope with the crisis triggered by the SARS-CoV-2 epidemic. Daily monitoring of the drugs consumed by each patient, particularly neuromuscular blocking agents and MDs was a key element in managing stocks and anticipating changes of drugs, packaging and/or devices references. These facts give weight to the Claris report published in France which recognizes that the interactions of pharmacy technicians and pharmacists in the care units have positive effects in terms of quality and safety of patient care. They highlight the dangers to which patients and caregivers are exposed on Saturdays, Sundays and holidays when the pharmacy is closed. They legitimize the question of extending the opening of the pharmacy with a full team 365 days a year., (Copyright © 2021 Académie Nationale de Pharmacie. Published by Elsevier Masson SAS. All rights reserved.)

Background: In the post-anesthesia care unit in our hospital, selected postoperative patients receive care from anesthesiologists and nursing staff if these patients require intensive hemodynamic monitoring or treatment to stabilize vital functions (e.g., vasopressor use and mechanical ventilation support) during a one-night admission. We investigated the agreement between elective preoperative planning for post-anesthesia care unit admission and the postoperative reality, along with the consequences of planning failures., Methods: Data from records for 479 consecutive patients from June 1 to November 30, 2014, in a tertiary referral hospital were reviewed and analyzed. All patients admitted to PACU were included, along with patients scheduled to be referred to PACU but ultimately transferred to another ward. The primary outcome was the efficiency of planning PACU admission for elective patients. Secondary outcomes included secondary admissions to PACU or the intensive care unit (ICU) and 30-day morbidity and mortality., Results: Of the 479 included patients, 342 (71%) were admitted per preoperative planning. Five patients (1%) needed cardiopulmonary resuscitation, and six (1%) did not survive the follow-up period. Patients admitted to PACU because of a shortage of beds in the ICU had the highest readmission (20%) and mortality rates (20%) (P = 0.01)., Conclusions: Preoperative planning for PACU admission was off-target for 29%. However, efficient care always takes precedence over efficient planning. In particular, downgrading patients to PACU because of a shortage of beds in the ICU was associated with a mortality increase.

Context: Postoperative recovery rooms have existed since 1847, however, there is sparse literature investigating interventions undertaken in recovery, and their impact on patients after recovery room discharge., Objective: This review aimed to investigate the organisation of care delivery in postoperative recovery rooms; and its effect on patient outcomes; including mortality, morbidity, unplanned intensive care unit (ICU) admission and length of hospital stay., Data Sources: NCBI PubMed, EMBASE and Cumulative Index to Nursing and Allied Health Literature., Study Selection: Studies published since 1990, investigating health system initiatives undertaken in postoperative recovery rooms. One author screened titles and abstracts, with two authors completing full-text reviews to determine inclusion based on predetermined criteria. A total of 3288 unique studies were identified, with 14 selected for full-text reviews, and 8 included in the review., Data Extraction: EndNote V.8 (Clarivate Analytics) was used to manage references. One author extracted data from each study using a data extraction form adapted from the Cochrane Data Extraction Template, with all data checked by a second author., Data Synthesis: Narrative synthesis of data was the primary outcome measure, with all data of individual studies also presented in the summary results table., Results: Four studies investigated the use of the postanaesthesia care unit (PACU) as a non-ICU pathway for postoperative patients. Two investigated the implementation of physiotherapy in PACU, one evaluated the use of a new nursing scoring tool for detecting patient deterioration, and one evaluated the implementation of a two-track clinical pathway in PACU., Conclusions: Managing selected postoperative patients in a PACU, instead of ICU, does not appear to be associated with worse patient outcomes, however, due to the high risk of bias within studies, the strength of evidence is only moderate. Four of eight studies also examined hospital length of stay; two found the intervention was associated with decreased length of stay and two found no association., Prospero Registration Number: This protocol is registered on the International Prospective Register of Systematic Reviews (PROSPERO) database, registration number CRD42018106093., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The operating room is a major cost and revenue center for most hospitals. Thus, more effective operating room management and scheduling can provide significant benefits. In many hospitals, the post-anesthesia care unit (PACU), where patients recover after their surgical procedures, is a bottleneck. If the PACU reaches capacity, patients must wait in the operating room until the PACU has available space, leading to delays and possible cancellations for subsequent operating room procedures. We develop a generalizable optimization and machine learning approach to sequence operating room procedures to minimize delays caused by PACU unavailability. Specifically, we use machine learning to estimate the required PACU time for each type of surgical procedure, we develop and solve two integer programming models to schedule procedures in the operating rooms to minimize maximum PACU occupancy, and we use discrete event simulation to compare our optimized schedule to the existing schedule. Using data from Lucile Packard Children's Hospital Stanford, we show that the scheduling system can significantly reduce operating room delays caused by PACU congestion while still keeping operating room utilization high: simulation of the second half of 2016 shows that our model could have reduced total PACU holds by 76% without decreasing operating room utilization. We are currently working on implementing the scheduling system at the hospital.

The purpose of the study is to determine the effects of music on the life signs of patients in the postanesthesia care unit after laparoscopic surgery. The study was carried out as a quasi-experimental model with pretest-posttest and control group in the postanesthesia care unit of a training and education hospital from March 2017 to May 2018. The sample consisted of 148 patients (74 experiment and 74 control) who were selected by the method of nonprobability sampling determined on the basis of power analysis who met the inclusion criteria. When the change in the life signs between the groups was examined, after music treatment (second measurement), there was a significant difference only in the respiratory rates (P < .05). There was a significant difference in terms of diastolic blood pressures and respiratory rates in the first admission to the clinic from the postanesthesia care unit (third measurement) (P < .05).

Purpose: This quality improvement project aimed to evaluate the benefits of implementing a checklist in the postanesthesia care unit (PACU) setting to decrease the omission of health information during the handoff from anesthesia to PACU nurses., Design: Patient handoffs from anesthesia providers were anonymously assessed by PACU nurses before and after the implementation of a handoff checklist with the Situation, Background, Assessment, Recommendation format., Methods: PACU nurses recorded use of the handoff checklist and if five items of health information were included in the handoff during the preintervention and postintervention phase., Findings: Checklist use increased from 0% to 73% with omitted information decreasing with checklist use: procedure from 19% to 2%, allergies 23% to 4%, input and output 16% to 0%, antiemetic used 21% to 4%, and lines 19% to 11%. Completed handoffs increased from 13% to 82% whereas checklist use remained high, at over 79%, for the 12 weeks after implementation., Conclusions: The project was successful in implementing a standardized checklist and echoed the success of the articles reviewed. The use of a PACU handoff checklist can improve transfer of care by ensuring the provider receives more pertinent medical information during these transfers., (Published by Elsevier Inc.)

Purpose: There is little knowledge about how hospitals can best handle disruptions that reduce post-anesthesia care unit (PACU) capacity. Few hospitals in Japan have any PACU beds and instead have the anesthesiologists recover their patients in the operating room. We compared postoperative recovery times between a hospital with (University of Iowa) and without (Shin-yurigaoka General Hospital) a PACU., Methods: This historical cohort study included 16 successive patients undergoing laparoscopic gynecologic surgery with endotracheal intubation for general anesthesia, at each of the hospitals, and with the hours from OR entrance until the last surgical dressing applied ≥ two hours. Postoperative recovery times, defined as the end of surgery until leaving for the surgical ward, were compared between the hospitals., Results: The median [interquartile range] of recovery times was 112 [94-140] min at the University of Iowa and 22 [18-29] min at the Shin-yurigaoka General Hospital. Every studied patient at the University of Iowa had a longer recovery time than every such patient at Shin-yurigaoka General Hospital (Wilcoxon-Mann-Whitney, P < 0.001). The ratio of the mean recovery times was 4.90 (95% confidence interval [CI], 4.05 to 5.91; P < 0.001) and remained comparable after controlling for surgical duration (5.33; 95% CI, 3.66 to 7.76; P < 0.001). The anesthetics used in the Iowa hospital were a volatile agent, hydromorphone, ketorolac, and neostigmine compared with the Japanese hospital where bispectral index monitoring and target-controlled infusions of propofol, remifentanil, acetaminophen, and sugammadex were used., Conclusions: This knowledge can be generally applied in situations at hospitals with regular PACU use when there are such large disruptions to PACU capacity that it is known before a case begins that the anesthesiologist likely will need to recover the patient (i.e., when there will not be an available PACU bed and/or nurse). The Japanese anesthesiologists have no PACU labour costs but likely greater anesthesia drug/monitor costs.

Weaning of mechanical ventilation occurs in intensive care units by nurses, which stimulates the prospect of nurse-led extubation extending into the PACU environment for improved patient outcomes and reduced demand of hospital resources. Nurse-led patient extubation in the PACU, would involve specially trained nurses weaning mechanical ventilation via an established protocol for a specific patient group, prior to the patient being extubated by an anaesthetist or intensivist.

Background and Aims: We created a multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery., Design: A multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery., Settings: Pain management education of postanesthesia recovery room nurses through a practical intervention has the potential to improve patient pain experience, especially in those with a history of opioid tolerance., Participants/subjects: Postanesthesia recovery nurses/postanesthesia patients., Methods: The intervention included two components: a clinical pain pathway on multimodal analgesia for both opioid-naïve and opioid-tolerant patients undergoing surgery and an educational program on pain management for frontline clinical nurses in the postanesthesia care unit (PACU). We measured the intervention's impact on time to pain relief, PACU length of stay, and patient satisfaction with pain management, as measured by self-report., Results: Patient PACU surveys indicated a decrease in the percent of patients with opioid tolerance who required more than 60 minutes to achieve adequate pain relief (from 32.7% preintervention to 21.3% postintervention). Additionally, after the intervention, the average time from a patient's PACU arrival to his or her discharge criteria being met decreased by 53 minutes and PACU stay prolongation as a result of uncontrolled pain for opioid-tolerant patients decreased from 45.2% to 25.7%. The sample size was underpowered to perform statistical analysis of this improvement., Conclusions: After the combined intervention of a clinical pain pathway and interactive teaching workshop, we noted shortened PACU length of stay, reduced time to reach pain control, and improved overall patient satisfaction. Although we could not determine statistical significance, our findings suggest improved management of acute postoperative pain, especially for patients who are opioid tolerant. Because of the paucity of data, we were not able to conduct the analysis needed to evaluate quality improvement projects, as per SQUIRE 2.0. could be adopted by any institution., (Copyright © 2018 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

"Enhanced recovery after surgery" (ERAS) protocols may reduce morbidity, length of hospital stay (LOS), and costs. During the 4-year evolution of a bariatric ERAS protocol, we found that administration of thrombophylaxis selectively to high-risk morbidly obese patients (assessed postoperatively by Caprini score ≥ 3) undergoing omega loop gastric bypass ("mini" gastric bypass) or sleeve gastrectomy resulted in safe outcomes. Both procedures proved equally effective with this protocol. The vast majority of rapidly mobilized, low-risk patients did not appear to require antithrombotic heparin. Similar to other reported ERAS outcomes, our recent year's results in 485 patients included a mean LOS of 1.08 ± 0.64 days (range 1-14), with 460 (95.0%) discharged on day 1 and 99.6% by day 2. There were 13 30-day complications (2.7%), two reinterventions (0.4%), and no hemorrhages.

Quality Problem: For smokers, hospital admission is accompanied by forced involuntary nicotine abstinence due to smoke-free site/grounds policies. An audit of patients admitted to our surgical wards revealed that identification of smoking status was inadequate and that nicotine addiction management (NAM) was infrequently offered. The project aimed to enhance both these metrics by initiating NAM in the post anesthesia care unit (PACU)., Initial Assessment: Out of 744 patients admitted to our PACU in August 2015, 54% had their smoking status documented. The 200 patients (27%) out of the 744 were smokers and only 50% were offered NAM before discharge., Choice of Solution: PACU unit staff to determine the smoking status of every patient before discharge from the PACU (later changed to OR nursing staff) and, if a patient was identified as a smoker, to offer NRT (patch and mouth spray only) and initiate therapy prior to transfer of the patient to the ward., Implementation: Data about number of patients admitted, presence of documented smoking status, number of identified smokers, and number offered/accepted nicotine replacement therapy (NRT) were collected at baseline and thereafter quarterly. Engaging video education sessions addressed the education gaps highlighted in a needs assessment. Identification of smoking status was made part of preoperative checklist and NRT was made available in post-operative recovery room., Results: These interventions resulted in an increase in screening for tobacco use from 54% at baseline to 95% and the offer of NRT to smokers from 50 to 89%.

Purpose The purpose of this paper is to increase efficiency in ORs without affecting quality of care by improving the workflow processes. Administrative processes independent of the surgical act can be challenging and may lead to clinical impacts such as increasing delays. The authors hypothesized that a Lean project could improve efficiency of surgical processes by reducing the length of stays in the recovery ward. Design/methodology/approach Two similar Lean projects were performed in the surgery departments of two hospitals of the Centre Hospitalier Universitaire de Québec: Hôtel Dieu de Quebec (HDQ) and Hôpital de l'Enfant Jesus (HEJ). The HDQ project designed around a Define, Measure, Analyse, Improve and Control process revision and a Kaizen workshop focused on patients who were hospitalized in a specific care unit after surgery and the HEJ project targeted patients in a post-operative ambulatory context. The recovery ward output delay was measured retrospectively before and after project. Findings For the HDQ Lean project, wasted time in the recovery ward was reduced by 62 minutes (68 percent reduction) between the two groups. The authors also observed an increase of about 25 percent of all admissions made in the daytime after the project compared to the time period before the project. For the HEJ Lean project, time passed in the recovery ward was reduced by 6 min (29 percent reduction). Originality/value These projects produced an improvement in the flow of the OR without targeting clinical practices in the OR itself. They demonstrated that change in administrative processes can have a great impact on the flow of clinical pathways and highlight the need for comprehensive and precise monitoring of every step of the elective surgery patient trajectory.

Background: Although bed rest is recommended after spinal anesthesia to prevent the occurrence of post-dural puncture headache, current literature suggests that periods of bed rest did not prevent headache as well as increase the risk of other complications such as backache. However, information is scarce regarding an appropriate period of bed rest following a dural puncture., Aim: The aim of this study was to compare the incidence of post-dural puncture headache and backache after different periods of bed rest following spinal anesthesia., Methods: This study was a pragmatic, parallel-group, blinded, and randomized controlled trial (trial registration number KCT0001797). A total of 119 patients who underwent surgery under spinal anesthesia participated in this study from December 2013 to June 2014. The participants were randomly allocated to three groups: the immediate mobilization group (n = 45), 4-hour bed rest group (n = 40), and 6-hour bed rest group (n = 34). The severity of headache and backache was measured using the Dittmann scale and a visual analogue scale, respectively. Data were collected for 5 consecutive days postoperatively by one researcher blind to the group allocation., Results: No significant difference in the incidence of headache among the three groups was detected. However, the incidence of backache in the 6-hour bed rest group was higher and was significantly more severe than the other groups., Linking Evidence to Action: Bed rest after spinal anesthesia did not prevent the occurrence of headache and increased the incidence of patients experiencing a backache and, therefore, is not recommended. The findings provide information for establishing evidence-based nursing practices for patients after a dural puncture., (© 2017 Sigma Theta Tau International.)

Purpose: This article describes the development and psychometric testing of a new Postanesthesia Care Unit (PACU) Readiness for Discharge Assessment Tool (RDAT) that can be used in assessing patients' readiness for discharge from a phase 1 PACU., Design: This study used an instrument development methodology described by Waltz and Strickland that included item development and testing for content and convergent validity and interrater reliability., Methods: Items were developed from a review the literature, best practice exemplars, and input from an expert panel. Ten items were identified for patient assessment using a dichotomous response set (yes/no). Two nurses independently assessed the patients using the RDAT and Respiration, Energy, Alertness, Circulation, and Temperature, and comparing independent assessments using the RDAT., Finding: The content validity index was determined to be a = .80, and interrater reliability index was a = 1.0., Conclusions: The RDAT is a useful, safe tool to assess patients' readiness for discharge from the PACU., (Copyright © 2016 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Background: Adenotonsillectomy is one of the most commonly performed operative procedures in children. It is imperative to find the most efficient and cost-effective methods of practice to facilitate operating room management while maintaining patient safety. We investigated the efficiency of two different approaches of tracheal extubation in pediatric patients following adenotonsillectomy at two tertiary care pediatric hospitals with large surgical volumes. The primary aim of the study was to determine the difference in the operating room time according to the institutional practice of tracheal extubation in the postanesthesia care unit (PACU) as compared to the operating room., Methods: After obtaining IRB approval, a retrospective chart review was performed over a 12-month period at two large, tertiary care children's hospitals including the first hospital, where patients undergo tracheal extubation in the operating room after completion of the surgical procedure and a second hospital, where patients are brought directly to the PACU and undergo tracheal extubation in the PACU by nurses, with immediate availability of the pediatric anesthesiology faculty. Patients ≤12 years of age undergoing adenotonsillectomy were eligible for inclusion in the study. Patients with significant cardiopulmonary disease or scheduled for recovery in the critical care unit were excluded. Patient demographics, total time in the operating room, surgical time, total time in the PACU, and, when applicable, time until tracheal extubation, were noted., Results: The study cohort included 672 patients from the first hospital and 700 patients from the second hospital. Average operating room time was 17 min shorter at the first hospital than at the other, with most of the difference due to a reduction in the time between surgery end and transport from the operating room. PACU times were also 26 min shorter at the first hospital than at the second children's hospital., Conclusion: Tracheal extubation in the PACU is an efficient use of operating room time and resources., (© 2017 John Wiley & Sons Ltd.)

Scheduling of surgeries in the operating rooms under limited competing resources such as surgical and nursing staff, anesthesiologist, medical equipment, and recovery beds in surgical wards is a complicated process. A well-designed schedule should be concerned with the welfare of the entire system by allocating the available resources in an efficient and effective manner. In this paper, we develop an integer linear programming model in a manner useful for multiple goals for optimally scheduling elective surgeries based on the availability of surgeons and operating rooms over a time horizon. In particular, the model is concerned with the minimization of the following important goals: (1) the anticipated number of patients waiting for service; (2) the underutilization of operating room time; (3) the maximum expected number of patients in the recovery unit; and (4) the expected range (the difference between maximum and minimum expected number) of patients in the recovery unit. We develop two goal programming (GP) models: lexicographic GP model and weighted GP model. The lexicographic GP model schedules operating rooms when various preemptive priority levels are given to these four goals. A numerical study is conducted to illustrate the optimal master-surgery schedule obtained from the models. The numerical results demonstrate that when the available number of surgeons and operating rooms is known without error over the planning horizon, the proposed models can produce good schedules and priority levels and preference weights of four goals affect the resulting schedules. The results quantify the tradeoffs that must take place as the preemptive-weights of the four goals are changed.

The post-anesthesia care unit (PACU) is a major contributor to the operating room (OR) process flow and efficiency. A sudden failure of hospital facility infrastructure due to a burst pipe resulted in the complete loss of a 66-bed combined preoperative and PACU facility of a major academic medical center. The OR suites were undamaged. The clinical and administrative challenges of caring for surgical patients without the usual preoperative and postoperative care areas are discussed. Our strategy for maintaining OR functions and management of patient flow, OR personnel, case prioritization, and equipment needs are detailed from the time of initial crisis until restoration of these clinical care areas. Utilization of the hospital disaster Incident Command Structure and the activation and decision support provided by the hospital Emergency Operations Center (EOC) for the week immediately following the crisis, helped maintain OR functionality.

This article reviews the management of an operating room (OR) schedule and use of the schedule to add value to an organization. We review the methodology of an OR block schedule, daily OR schedule management, and post anesthesia care unit patient flow. We discuss the importance of a well-managed OR schedule to ensure smooth patient care, not only in the OR, but throughout the entire hospital., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate the cost of an operating room using data from our hospital. Using an accounting-based method helped us., Methods: Over the year 2012, the sum of direct and indirect expenses with cost sharing expenses allowed us to calculate the cost of the operating room (OR) and of the post-anaesthesia care unit (PACU)., Results: The cost of the OR and PACU was €10.8 per minute of time offered. Two thirds of the direct expenses were allocated to surgery and one third to anaesthesia. Indirect expenses were 25% of the direct expenses. The cost of medications and single use medical devises was €111.45 per anaesthesia. The total cost of anaesthesia (taking into account wages and indirect expenses) was €753.14 per anaesthesia as compared to the total cost of the anaesthesia. The part of medications and single use devices for anaesthesia was 14.8% of the total cost., Conclusion: Despite the difficulties facing cost evaluation, this model of calculation, assisted by the cost accounting controller, helped us to have a concrete financial vision. It also shows that a global reflexion is necessary during financial decision-making., (Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Information loss can occur during all phases of care. The transfer of care (handoff) from the operating room to the postoperative anesthesia care unit (PACU) is an especially susceptible time. Information loss can lead to an increase in medication errors, sentinel events, and poor patient outcomes. High-reliability organizations, such as the aviation industry, use checklists to decrease errors and improve safety. As the healthcare industry becomes more complex, it is in the interest of patient safety to develop, validate, and use similar objective procedures as those used in high-reliability organizations. The purpose of this research was to determine if the utilization of a formulated checklist with objective measures during the handoff from the operating room to the PACU decreased information loss, the need for information clarification, and anesthesia providers' time spent in transfer of care, with improved adequacy of the handoff. Specific metrics were monitored before and after implementation to assess for information loss, information clarification, anesthesia providers' time, and to rate the adequacy of the report.

A current review of the last thirty years is indicative of improvement in outcome across surgical specialities with the implementation of safer working practices and initiatives in enhanced recovery, preparing patients to be 'fit' for surgery. The focus of training for nurses and operating department practitioners lies with assuring technical competence and the drive is to establish best practice based on evidence. Once qualified, training for professionals within the perioperative environment is developed to enable participation in areas of anaesthesia, surgery and recovery roles. Advanced, intermediate and basic life support as well as advanced scrub practitioner courses are available, further aspects for patient safety have been implemented and pathways developed.

Background: Anaesthesiology plays a key role in promoting safe perioperative care. This includes the perioperative phase in the post-anaesthesia care unit (PACU) where problems with incomplete information transfer may have a negative impact on patient safety and can lead to patient harm. The objective of this study was to analyse information transfer during post-operative handovers in the PACU., Methods: With a self-developed checklist including 59 items the information transfer during post-operative handovers was documented and subsequently compared with patient information in anaesthesia records during a 2-month period., Results: A total number of 790 handovers with duration of 73 ± 49 s was analysed. Few items were transferred in most of the cases such as type of surgery (97% of the cases), regional anaesthesia (94% of the cases) and cardiac instability (93% of the cases). However, some items were rarely transferred, such as American Society of Anesthesiologists physical status (7% of the cases), initiation of post-operative pain management (12% of the cases), antibiotic therapy (14% of the cases) and fluid management (15% of the cases). There was a slight correlation between amount of information transferred and duration of post-operative handovers (r = 0.5)., Conclusion: The study shows that post-operative handovers in the PACU are in most cases incomplete. It appears useful to optimise the post-operative handover process, for example by implementing a standardised handover checklist., (© 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: When the phase I postanesthesia care unit (PACU) is at capacity, completed cases need to be held in the operating room (OR), causing a "PACU delay." Statistical methods based on historical data can optimize PACU staffing to achieve the least possible labor cost at a given service level. A decision support process to alert PACU charge nurses that the PACU is at or near maximum census might be effective in lessening the incidence of delays and reducing over-utilized OR time, but only if alerts are timely (i.e., neither too late nor too early to act upon) and the PACU slot can be cleared quickly. We evaluated the maximum potential benefit of such a system, using assumptions deliberately biased toward showing utility., Methods: We extracted 3 years of electronic PACU data from a tertiary care medical center. At this hospital, PACU admissions were limited by neither inadequate PACU staffing nor insufficient PACU beds. We developed a model decision support system that simulated alerts to the PACU charge nurse. PACU census levels were reconstructed from the data at a 1-minute level of resolution and used to evaluate if subsequent delays would have been prevented by such alerts. The model assumed there was always a patient ready for discharge and an available hospital bed. The time from each alert until the maximum census was exceeded ("alert lead time") was determined. Alerts were judged to have utility if the alert lead time fell between various intervals from 15 or 30 minutes to 60, 75, or 90 minutes after triggering. In addition, utility for reducing over-utilized OR time was assessed using the model by determining if 2 patients arrived from 5 to 15 minutes of each other when the PACU census was at 1 patient less than the maximum census., Results: At most, 23% of alerts arrived 30 to 60 minutes prior to the admission that resulted in the PACU exceeding the specified maximum capacity. When the notification window was extended to 15 to 90 minutes, the maximum utility was <50%. At most, 45% of alerts potentially would have resulted in reassigning the last available PACU slot to 1 OR versus another within 15 minutes of the original assignment., Conclusions: Despite multiple biases that favored effectiveness, the maximum potential benefit of a decision support system to mitigate PACU delays on the day on the surgery was below the 70% minimum threshold for utility of automated decision support messages, previously established via meta-analysis. Neither reduction in PACU delays nor reassigning promised PACU slots based on reducing over-utilized OR time were realized sufficiently to warrant further development of the system. Based on these results, the only evidence-based method of reducing PACU delays is to adjust PACU staffing and staff scheduling using computational algorithms to match the historical workload (e.g., as developed in 2001).

Background: In the healthcare domain, different analytic tools focused on accidents appeared to be poorly adapted to sub-accidental issues. Improving local management and intra-institutional communication with simpler methods, allowing rapid and uncomplicated meta-reporting, could be an attractive alternative., Methods: A process-centered structure derived from the industrial domain - DEPOSE(E) - was selected and modified for its use in the healthcare domain. The seven exclusive meta-categories defined - Patient, Equipment, Process, Actor, Supplies, work Room and Organization- constitute 7CARECAT™. A collection of 536 "improvement" reports from a tertiary hospital Post anesthesia care unit (PACU) was used and four meta-categorization rules edited prior to the analysis. Both the relevance of the metacategories and of the rules were tested to build a meta-reporting methodology. The distribution of these categories was analyzed with a χ 2 test., Results: Five hundred and ninety independent facts were collected out of the 536 reports. The frequencies of the categories are: Organization 44%, Actor 37%, Patient 11%, Process 3%, work Room 3%, Equipment 1% and Supplies 1%, with a p-value <0.005 (χ 2). During the analysis, three more rules were edited. The reproducibility, tested randomly on 200 reports, showed a <2% error rate., Conclusion: This meta-reporting methodology, developed with the 7CARECAT™ structure and using a reduced number of operational rules, has successfully produced a stable and consistent classification of sub-accidental events voluntarily reported. This model represents a relevant tool to exchange meta-informations important for local and transversal communication in healthcare institutions. It could be used as a promising tool to improve quality and risk management., (Copyright © 2013. Published by Elsevier SAS.)

We audited verbal handover of information by anaesthetists to recovery room nurses based on Situation, Background, Assessment and Recommendation. In Audit A, 100 handovers for elective procedures were included. For audit B, a second cohort of 100 patients was examined post educational session. There was an improvement in handover of medical background (46.15% Audit A, 77% Audit B, p < 0.001) and allergy status (42% Audit A, 56% Audit B, p = 0.048). Handing over immediate postoperative instructions remained unchanged (58% Audit A, 59% Audit B) and there was a 4% decline in verbal handover of instructions for ward care. Nurse satisfaction with handovers improved by 12%. We conclude that a structured process of information transfer, led to improved handover of immediate care. Further education focussed on the importance of instructions for the ward to maintain continuity of care is recommended.

Postanesthesia care units or PACUs (earlier called recovery rooms) flourished after World War II as social, political, and economic influences advanced enormous changes in health care expectations and delivery in the United States. Innovations in science and technology, facilitated by increased federal funding of scientific research in the years preceding and during the war, heralded a postwar need for greater complexity of hospital care safely delivered by trained personnel. PACUs began to open in new and modernized postwar hospitals as a means to safely provide more complex postoperative care during a time of persistent nursing shortages. PACUs proved to be an effective and cost-efficient means of decreasing the significantly high incidence of contemporary postoperative morbidity and mortality. Continuous and skilled observation by the recovery room nurses was credited with the improved patient outcomes. Once firmly established, PACUs have remained vital to the delivering of safe and cost-effective postoperative and postprocedural care.

Background: Ineffective communications among healthcare providers are common and increases the risk of medical errors. During the perioperative period, multiple handoffs occur within a short period of time, and failure to convey important patient information can compromise safety. We used quality improvement methodology to improve the reliability of our handoffs in the operating room and postanesthesia care unit (PACU)., Methods: Two quality improvement teams were developed to focus on the intraoperative and postanesthesia handoff processes. Key driver diagrams and 'smart aims' were developed for each process based on feedback from anesthesia and nursing staff, and handoff checklists were developed and revised using multiple plan-do-study-act cycles. Data on the reliability of the handoff processes were obtained prior to initiation of the projects and throughout the 6-month project period., Results: The reliability of intraoperative anesthesia handoffs improved from 20% to 100% with use of the intraoperative handoff checklist. Similarly, with the introduction of a standardized PACU checklist, the reliability of PACU handoffs improved from 59% to greater than 90%., Conclusion: We utilized quality improvement methodology to develop and implement standardized checklists for handoffs of care in the operating room and PACU. Acceptance of and adherence to the standardized handoff protocols dramatically increased the quality and reliability of our handoff process., (© 2013 John Wiley & Sons Ltd.)

Aims: We describe our aim to create a zero-error system in our pediatric ambulatory surgery center by employing effective teamwork and aviation-style challenge and response 'flow checklists' at key stages of the patient surgical journey. These are used in addition to the existing World Health Organization Surgical Safety Checklists (Ann Surg, 255, 2012 and 44)., Background: Bellevue Surgery Center is a freestanding ambulatory surgery center affiliated with Seattle Children's Hospital, WA, USA. Approximately three thousand ambulatory surgeries are performed each year across a variety of surgical disciplines., Methods: Key points in the patient surgical journey were identified as high risk (different time points from the WHO safer surgery checklists). These were moments when the team, patient, and equipment have to been reconfigured to maximize patient safety. These points were departure from induction room, arrival in the operating room, departure from operating room, and arrival in the postanesthesia care unit. Traditionally, the anesthesiologist has memorized a list of 'do-not-forget items' for each of these stages. We recognized the potential for error to occur if the process was solely the responsibility of one individual and their memory. So we created 'flow checklists' executed by the team at every one of these high-risk points. We adopted a challenge and response system for these flow checklists as this is a tried and tested system widely used in aviation for critical tasks such as configuring an aircraft pretakeoff and prelanding., Results: A staff survey with a 72% response rate (n = 29) showed that the team valued the checklists and thought they contributed to patient safety. To date, we have had zero incidence of omitting any of the 24 items listed on the four flow checklists., Conclusions: We have created a reproducible model of care involving multiple checklists at high-risk points in the patient surgical journey. The model is reliable and has a high degree of staff engagement. It promotes patient safety by ensuring the patient, team and equipment are correctly configured at every key transition stage in the surgical journey. We have been able to achieve this with no measurable increase in turnover times or reduction in operating room efficiency., (© 2013 John Wiley & Sons Ltd.)

Objective: This study was aimed at examining team communication during postoperative handover and its relationship to clinicians' self-ratings of handover quality., Background: Adverse events can often be traced back to inadequate communication during patient handover. Research and improvement efforts have mostly focused on the information transfer function of patient handover. However, the specific mechanisms between handover communication processes among teams of transferring and receiving clinicians and handover quality are poorly understood., Method: We conducted a prospective, cross-sectional observation study using a taxonomy for handover behaviors developed on the basis of established approaches for analyzing teamwork in health care. Immediately after the observation, transferring and receiving clinicians rated the quality of the handover using a structured tool for handover quality assessment. Handover communication during 117 handovers in three postoperative settings and its relationship to clinicians' self-ratings of handover quality were analyzed with the use of correlation analyses and analyses of variance., Results: We identified significantly different patterns of handover communication between clinical settings and across handover roles. Assessments provided during handover were related to higher ratings of handover quality overall and to all four dimensions of handover quality identified in this study. If assessment was lacking, we observed compensatory information seeking by the receiving team., Conclusion: Handover quality is more than the correct, complete transmission of patient information. Assessments, including predictions or anticipated problems, are critical to the quality of postoperative handover., Application: The identification of communication behaviors related to high-quality handovers is necessary to effectively support the design and evaluation of handover improvement efforts.

Pain management in the postanesthesia care unit (PACU) is continually evolving, with several new nonopioids expanding the list of available agents. Pain in the PACU is not an inevitable outcome of surgery. With careful planning, multimodal analgesic techniques instituted preoperatively will reduce pain in the PACU. Accurate assessment of the characteristics of pain will direct rational drug choices while minimizing side effects. Better management of pain in the PACU setting will likely improve patient satisfaction and facilitate shorter PACU stays.

Patients in the perioperative and postanesthesia care unit (PACU) experience several transitions in patient care at the same time that the majority of major morbidities will arise. The transitions for these patients are at the critical juncture between surgery and a steady sustained recovery. Historically these important medical problems have been addressed as a nonformalized process. The authors have introduced a formalized process, based on interdisciplinary rounding strategies used in intensive care units, to attend patients and address problems., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: To describe a new type of acute inpatient unit, the Acute Recovery Unit, at the Concord Centre for Mental Health, Sydney and to report patient characteristics and outcome data for the first 18 months of operation., Methods: The mission, values, principles of care and operation of the Acute Recovery Unit are presented, including the lessons from a review of the first 18 months of operation. The specialist assessment procedure, academic detailing and range of specialist interventions are described., Results: Clinical outcome measures including the Health of the Nation Outcome Scale, Multidimensional Incomplete Recovery - Clinical Global Index and community tenure time post-discharge are presented., Conclusions: The Acute Recovery Unit is an important component of the range of services required at a regional level to respond to those who will develop treatment refractory mental illness.

This article describes the development of a new service - the post-anaesthesia care unit (PACU) - that provides extended care in a recovery unit for patients who would have formerly been 'fast-tracked' through a high dependency unit (HDU). Patients requiring major surgery who stay in the recovery unit overnight are invasively monitored, have tight fluid management, blood chemistry analysis and frequently have pharmacological support. However, our overnight recovery service is not considered suitable for ventilated patients. Over 90% of patients are able to be discharged to a surgical ward within 24 hours of admission, following medical review.

Purpose of Review: The comparison of inhalational and intravenous anaesthesia has been the subject of many controlled trials and meta-analyses. These reported diverse endpoints typically including measures of the speed and quality of induction of anaesthesia, haemodynamic changes, operating conditions, various measures of awakening, postoperative nausea and vomiting and discharge from the recovery area and from hospital as well as recovery of psychomotor function. In a more patient-focused Health Service, measures with greater credibility are overall patient satisfaction, time to return to work and long-term morbidity and mortality. In practice, studies using easier to measure proxy endpoints dominate - even though the limitations of such research are well known., Recent Findings: Recent study endpoints are more ambitious and include impact on survival from cancer and the possibility of differential neurotoxic impact on the developing brain and implications for neuro-behavioural performance., Summary: Economic analysis of anaesthesia is complex and most published studies are naive, focusing on drug acquisition costs and facility timings, real health economics are much more difficult. Preferred outcome measures would be whole institution costs or the ability to reliably add an extra case to an operating list, close an operating room and reduce the number of operating sessions offered or permanently decrease staffing. Alongside this, however, potential long-term patient outcomes should be considered.

Background: The aim of this article is to propose a new model called Healthcare Lean Six Sigma System that integrates Lean and Six Sigma methodologies to improve workflow in a postanesthesia care unit., Methods: The methodology of the proposed model is fully described. A postanesthesia care unit case study is also used to demonstrate the benefits of using the Healthcare Lean Six Sigma System model by combining Lean and Six Sigma methodologies together., Results: The new model bridges the service gaps between health care providers and patients, balances the requirements of health care managers, and delivers health care services to patients by taking the benefits of the Lean speed and Six Sigma high-quality principles., Conclusions: The full benefits of the new model will be realized when applied at both strategic and operational levels. For further research, we will examine how the proposed model is used in different real-world case studies.

We performed an experimental single-blind crossover design study in a postanaesthesia care unit (PACU): (i) to test the hypothesis that patients will experience a higher degree of wellbeing if they listen to music compared to ordinary PACU sounds during their early postoperative care, (ii) to determine if there is a difference over time, and (iii) to evaluate the importance of the acoustic environment and whether patients prefer listening to music during their stay. Two groups received a three-phase intervention: one group (n=23) experienced music-ordinary sound-music and the second group (n=21) experienced ordinary sound-music-ordinary sound. Each period lasted 30 min, and after each period the patients assessed their experience of the sound. The results demonstrated a significant difference (p<0.001) between groups in the proportions of patients reporting that the acoustic environment was of great importance for their wellbeing during the three-phase intervention, and most participants (n=36 versus n=8) noticed that they were exposed to different sounds during the PACU period. The results also revealed that most participants (n=32) preferred listening to music versus listening to ordinary sound (n=3) while in the PACU (p<0.001). These findings promote use of listening to music to establish a healing environment for patients in a postanaesthesia care unit.

Background: When a recovery room is fully occupied, patients frequently wait in the operating room after emerging from anesthesia. The frequency and duration of such delays depend on operating room case volume, average recovery time, and recovery room capacity., Methods: The authors developed a simple yet nontrivial queueing model to predict the dynamics among the operating and recovery rooms as a function of the number of recovery beds, surgery case volume, recovery time, and other parameters. They hypothesized that the model could predict the observed distribution of patients in recovery and on waitlists, and they used statistical goodness-of-fit methods to test this hypothesis against data from their hospital. Numerical simulations and a survey were used to better understand the applicability of the model assumptions in other hospitals., Results: Statistical tests cannot reject the prediction, and the model assumptions and predictions are in agreement with data. The survey and simulations suggest that the model is likely to be applicable at other hospitals. Small changes in capacity, such as addition of three beds (roughly 10% of capacity) are predicted to reduce waiting for recovery beds by approximately 60%. Conversely, even modest caseload increases could dramatically increase waiting., Conclusions: A key managerial insight is that there is a sensitive relationship among caseload and number of recovery beds and the magnitude of recovery congestion. This is typical in highly utilized systems. The queueing approach is useful because it enables the investigation of future scenarios for which historical data are not directly applicable.

Objective: This study used the discrete-events computer simulation methodology to model a large hospital surgical centre (SC), in order to analyse the impact of increases in the number of post-anaesthetic beds (PABs), of changes in surgical room scheduling strategies and of increases in surgery numbers., Methods: The used inputs were: number of surgeries per day, type of surgical room scheduling, anaesthesia and surgery duration, surgical teams' specialty and number of PABs, and the main outputs were: number of surgeries per day, surgical rooms' use rate and blocking rate, surgical teams' use rate, patients' blocking rate, surgery delays (minutes) and the occurrence of postponed surgeries. Two basic strategies were implemented: in the first strategy, the number of PABs was increased under two assumptions: (a) following the scheduling plan actually used by the hospital (the 'rigid' scheduling - surgical rooms were previously assigned and assignments could not be changed) and (b) following a 'flexible' scheduling (surgical rooms, when available, could be freely used by any surgical team). In the second, the same analysis was performed, increasing the number of patients (up to the system 'feasible maximum') but fixing the number of PABs, in order to evaluate the impact of the number of patients over surgery delays., Conclusion: It was observed that the introduction of a flexible scheduling/increase in PABs would lead to a significant improvement in the SC productivity.