PACU Bottlenecks- A Shared ResponsibilityPam Bush

Clinical Director of Perioperative Services, The Ottawa HospitalMOHLTC Perioperative Coaching Team memberNAPAN May 23rd, 2009

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Overview

• Perioperative Coaching teams in Ontario• Their purpose-The process-The findings• Best Practice Targets for Perioperative Units• Identify Factors in Perioperative units that impact

PACU efficiency • Present strategies to optimize PACU efficiency

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Perioperative Coaching teams

Recommended by Report of the Surgical

Process Analysis and Improvement

Expert Panel June 2005

www.health.gov.on.ca

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Key Recommendation

• To help hospitals to continuously improve OR efficiency, access and quality of service

• Develop Perioperative Improvement coaching teams to help government understand perioperative issues

• To help hospitals improve perioperative efficiency and performance

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Site Visits

• 58 hospitals in Ontario have had Perioperative coaching visits

• 45 Hospitals have had follow up visits• Fall 2005-May 2009

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The Perioperative Coaching Visit

• The coaches: composition, training

• Preparation: Hospital expression of interest, SPAI self assessments, Hospital profile, Wait time data, LHIN information, data

• Pre visit teleconference

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The Site Visit

• Duration• Day 1: CEO, Senior team• Perioperative executive and leaders• Tours of Perioperative units• CPD, Central Process, SPD• Day 1 and 2• Private meetings with Perioperative nursing

leaders, Physician leaders, Support service leaders• Focus groups with Perioperative nursing,

anesthesia, surgeons, support teams

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Site Visit

• Day 2 Identification and review of Issues• Day 2-3 Prioritization of Issues

Action Plan development• Day 3 Debrief with CEO and Senior team

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Deliverables

• Site Visit Summary• SPAI Report Assessment- recommended best

practices rating and timelines• Action Plan- Opportunities, barriers,

Strategies, most responsible person and timeline

• Appendices-OR manager/director qualitative assessment- coaches private comments

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Findings

Leadership and Accountability

• Challenges with OR leadership committees and/or lack of clear leadership for OR • OR governance has continued to challenge many physicians to become partners with their administrative counterparts. The need for physician engagement is critical• Lack of physician understanding of the complexity of the perioperative infrastructure

Allocation of OR resources

• Allocation of OR resources based on historical allocations • Lack of formalized scheduling policies• Urgent/emergent scheduling

Flow and Space Issues

• Surgical bed access (ICU, ward)• Resource intense pre-op programs• Lack of early identification of discharge needs• Matching workflow to resources• Analyze demand and capacity to maximize patient flow

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Findings

Equipment and Supplies

• Few hospitals bundling equipment purchases• High inventory levels

Human Resource Issues

• Lack of interdisciplinary approach to managing OR resources• Recognized need for new roles (i.e. Anesthesia Assistants, RNFAs, etc)• Lack of solid HR strategies to replace retiring surgeons, anesthetists and clinical staff

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Findings

Data Collection • No select group of key indicators• Capacity but no clear understanding of how to use data collected

Education • No regular education sessions for periops staff• Lack of dedicated time and/or funds to support education for staff

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Perioperative Best Practice Targets PAU

SPAI Report appendix D• All elective scheduled patients will be screened either by

phone or in person to ensure they are ready for surgery• All patients and their families will be educated to ensure

that they understand the procedure and participate in their care

• Discharge planning will begin before surgery

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Perioperative Best Practice Targets SDCU/SDA

• Surgery will be conducted on an outpatient basis in a separate location wherever possible

• Surgical patients will be admitted on the same day as the surgery, wherever possible

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Perioperative Best Practice Targets Operating Rooms

• The time the patient goes into the OR to the time the patient leaves the OR will be equal to the time that was booked for the case

• The amount of time scheduled for surgery will be as close to the expected time that the surgery should take

• Surgeries will begin at the scheduled start time

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Perioperative Best Practice Targets Operating Rooms

• The “emergency surgeries” that are conducted will reflect true emergencies

• Surgical cases that have similar procedures will be grouped as a block, where possible

• Surgeons will work in consolidated blocks of time, where possible

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Nursing Units that Affect PACU Efficiency

• PAU• SDCU/SDA• OR• PACU• ER• ICU• Stepdown• Psychiatry• Surgical inpatient• DI- Everyone

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PACUFactors impacting Efficiency

Examine the clinical practice-nursing and anesthesia

Clinical assessments:• Temperatures- ?, preventative, reactive• Pain control- ?, standard protocols, patterns of

pain, PCA , anesthesia , impacting los • Control of nausea/v ? Patterns, protocols,

induction, SDCU/SDA, PAU consults

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PACUFactors impacting Efficiency

• Discharge Criteria-evidence based/ based on clinical condition of patient

• Do RNs discharge patients based on discharge criteria- must anesthesia sign out patients

• Staffing – mapped out patient activity / nursing hours• Days/ Evenings/ Nights- Day of week variation• Data: patient activity, los, beyond meeting discharge

criteria• Clinical indicator tracking-uncontrolled n/v, pain,

reintubation, respiratory arrests

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Strategies to Optimize PACU Efficiency

• Review clinical assessment content• Identify patterns causing delays• Address causes of delays• Standardize pain, antiemetics, sleep apnea

management etc• Determine who needs to remain ON based on

evidence• Review discharge criteria-evidence based

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Strategies to Optimize PACU Efficiency

• Optimize nursing staff to meet patient demand

• Separate inpatients from outpatients in PACU

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Largest Controllable factor impacting PACU efficiency

• Elective OR Schedule

variation in # of ORs running daily

variation in # of service Ors running daily

variation in inpatient bed demands daily

variation in SDCU bed demand daily

variation in stepdown

variation in Critical Care-PACU/ICU overnight

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The BIGGEST JOB

• Revise the Elective OR schedule• Revise the Elective OR schedule to meet

the needs of the patients and the community• Evenly distribute the resource demands

over the week• Stakeholder commitment• Entire organization benefits-reduced

cancellations

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Elective OR Schedule Revision

• Review utilization data• Review surgeons running late• Review activity patterns of surgeons ie medium and long

cases• Limit SDAs/ ICU/PACU/Stepdown per day• Schedule inpatient and outpatients before SDA• Reallocate late rooms to those with long cases• Create scheduling policies to support efficiency-use of

Ors, cutoff for scheduling

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Emergency OR activity

• Does an emergency OR list exist?• Is it communicated in real time to PACU?• Are there policies related to emergency

activity and access times-A,B,C,D?• Are the policies adhered to and activity

reviewed?

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Strategies to address emergency OR activity

• Policies to define emergency cases• Review of emergency activity (after hours)• Consequences to non adherence to policy• Add or convert elective time to emergency day

time• Regularly review volume of activity• Review need to revise PACU nursing hours to

support activity

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SDCU factors affecting PACU Efficiency

• Variation in volume of activity• Scheduling time of day• Nursing staffing / patient activity• SDCU discharge criteria• Lack of rides, or accompaniment

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Strategies to Optimize SDCU Efficiency-prevent PACU

bottlenecks

• Smoothing of Elective OR schedule• Scheduling outpatients first• Review revise discharge criteria• Setting expectations during Pre assessment

appointment• Confirming ride preoperatively

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PAU factors affecting PACU Efficiency

• Inappropriate Route of admission• Lack of communication regarding alerts-

latex allergy, isolation needs, difficult intubation, critical care bed requirements

• Lack of patient/family preparation regarding discharge/expectations

• Lack of discharge planning

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PAU Strategies to optimize PACU Efficiency

• PAU screening of all elective surgical patients

• ROA based on surgical procedure and co morbidities

• Develop communication process between PAU and OR (electronic)

• Develop policies regarding discharge planning- cancel if no arrangements made?

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Who is in your PACU

• Admitted patients waiting for beds• ECT• Critical care overflow• ICU-enroute• Stepdown• Post Arrests?• PACU patients who meet dc criteria on arrival• Interventional radiology

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Strategies to take back your PACU

• Develop a process to determine bed requirements- cancellation process based on clinical priority of hospital

• ECT- develop expertise in MH units• Critical care triage policies- RACE team creation• ICU booking policies-which includes process for cancellation if no

bed• ICU patients directly to ICU• Safety risk adding transition point for ICU direct patients• PACU bypass policies-anesthesia, Perioperative nursing leaders• PACU bypass policy when PACU full

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ICU/ Stepdown impact to PACU efficiency

• Review of ICU admission criteria• Review of ICU discharge criteria• Review of Stepdown admission and

discharge criteria

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Corporate Policy

• Planned closures-summer, Christmas• Bed management• Creation of Short stay unit• Discharge policy• Cancellation policy based on organizational

priority• Perioperative team, patient and family

education

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Questions?

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Contact Info

• Pam Bush• Clinical Director Perioperative Services,• The Ottawa Hospital• 613-737-8719• pbush@toh.on.ca