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PACU Bottlenecks- A Shared Responsibility

PACU Bottlenecks- A Shared Responsibility. Pam Bush Clinical Director of Perioperative Services, The Ottawa Hospital MOHLTC Perioperative Coaching Team member NAPAN May 23 rd , 2009. Overview. Perioperative Coaching teams in Ontario Their purpose-The process-The findings

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PACU Bottlenecks- A Shared Responsibility

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  1. PACU Bottlenecks- A Shared Responsibility Pam Bush Clinical Director of Perioperative Services, The Ottawa Hospital MOHLTC Perioperative Coaching Team member NAPAN May 23rd, 2009

  2. 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

  3. Perioperative Coaching teams Recommended by Report of the Surgical Process Analysis and Improvement Expert Panel June 2005 www.health.gov.on.ca

  4. 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

  5. Site Visits • 58 hospitals in Ontario have had Perioperative coaching visits • 45 Hospitals have had follow up visits • Fall 2005-May 2009

  6. 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

  7. 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

  8. 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

  9. 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

  10. Findings

  11. Findings

  12. Findings

  13. 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

  14. 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

  15. 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

  16. 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

  17. Nursing Units that Affect PACU Efficiency • PAU • SDCU/SDA • OR • PACU • ER • ICU • Stepdown • Psychiatry • Surgical inpatient • DI- Everyone

  18. 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

  19. 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

  20. 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

  21. Strategies to Optimize PACU Efficiency • Optimize nursing staff to meet patient demand • Separate inpatients from outpatients in PACU

  22. 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

  23. 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

  24. 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

  25. 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?

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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?

  31. 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

  32. 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

  33. ICU/ Stepdown impact to PACU efficiency • Review of ICU admission criteria • Review of ICU discharge criteria • Review of Stepdown admission and discharge criteria

  34. 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

  35. Questions?

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

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