atients rarely remember it; adminis- tration seems to have forgotten it; in- P tensive care unit personnel look down

on it; but when things get rough, all rely on the recovery room. In most hospitals, the recovery room staff is called upon to be “jack of all trades” and they respond by becoming master of most. The RR nurse must provide sophisticated care to critically ill major sur- gical patients as well as tender loving care to the little boy whose tonsils are removed. She must be calm enough to comfort an agi- tated patient, yet able to handle the crushing work load.

the high volume of the operating room and a t the same time give high intensity care to

ject to today’s extended major surgical pro- cedures.

provide isolation for contaminated cases and reverse isolation for transplants and yet is staffed for only general observation and care. The RR nurse must cater to the de- mands of an individual patient while also being aware of the overall needs of the re- covery room population. Efficiency demands an established routine but the nurse must be constantly alert for crises. Finally, tradi- tion demands an “open door” admission policy, but the RR nurse often meets a “closed door” when patients are ready for transfer to the units or ICU.

Some of these apparent paradoxes are a result of the recovery room staff’s fine past performances and the willingness of today’s recovery room nurses to deal with problems as they arise. Historically, the specific types of medical problems that developed in the postanesthetic patient could be translated with ease to the types of care required over a long period of time by patients subjected to more complex and lengthier surgical pro- cedures. The rule of thumb was one recovery room bed could service 1.5 operating rooms. In the past 10 to 15 years as the duration of surgery has increased and the complexity

Recovery roo m : pa s t , The recovery room is expected to handle

present, the elderly and sicker patients who are sub-

A recovery room might simultaneously a n d f U t U re

Joseph M Civeffa, MD

806 AORN Journal, April 1975, Vol 21, N o 5

of procedures has magnified, this ratio is clearly out-of-date. At Jack- son Memorial Hospital, Miami, Fla, a 10% increase in the number of cases has been accompanied by a 50% in- crease in OR time. Recovery time rises to an even greater extent since recovery from anesthesia must be supplemented with careful cardio- respiratory monitoring. Monitoring techniques have multiplied, respira- tory support has become com- mon, modalities of anesthesia have changed, and recovery time from anesthesia has changed, each result- ing in increased time for adequate recovery.

Development of open heart sur- gery led to a gradual shift to over- night and then days spent in the recovery room. When patients were being served trays, ambulated, given chairs, and were watching television in the recovery room, i t became ap- parent that an additional facility was necessary.' The recovery room nurses of this era became the first intensive care nurses. In many hospitals today this tradition is maintained in that intensive care units fill up, but the recovery room can always take one more. Thus, the physical separation of intensive care from recovery room patients, though desirable in theory, has not been as workable in fact.

The three major goals of the re- covery room are to provide:

0 satisfactory progression from the anesthetic to the fully re- active state for normal patients

0 early recognition of complica- tions with efficient and rapid routine for treating predictable complications

0 intensive care to patients who undergo complex, major surgi- cal procedures.

In this age of super specialization, some generalists are necessary. This is apparent in large urban hospitals where critically ill patients are pre- sented both day and night. In small hospitals the recovery room often must function as an intensive care unit, trauma unit, recovery room holding area, prolonged observation room, and for outpatient recovery. The recovery room nurse is probably

Joseph M Civetta, MD, is associate pwofcssor, s ioymy, anesthesia, and m c d i c i w , U n i i-c?-sit?j of Micxmi School of nlcdicinc; di)*ecto?*, Intensive Care CcTiter, Jackson Memom1 Hospital, Minnzi; w id co?iszdtnnt, Miami Vet- c)'a??s Adm inisti-ation Hospital. He i s a grmliiate of Boston University School of Medicine.

the only nursing professional capable of providing appropriate care in this multilevel environment.

The complexity of complications possible in the postoperative period and the frequency with which they occur require that the recovery room nurse be capable of dealing with med- ical problems seen and procedures used in intensive care units. In addi- tion, there are certain medical prob- lems indigenous to the recovery

AORN Journal, April 1975, Vol 21, No 5 807

ecovery room nurses R were the first intensive care nurses.

room. These can be divided into three types: pressing, potential, and peculiar.

Pressing problems include: Maintenance of airway. This im-

plies familiarity with oral and naso- pharyngeal airways, endotracheal tubes, tracheostomies, and all the other paraphernalia for delivering oxygen therapy.

Apnea. The postoperative patient who fails to breathe, due to either anesthetic overdose, unreversed mus- cle relaxant, or high-dose morphine, must have respirator support during this period. Familiarity with me- chanical ventilators is an absolute necessity.

Arrhythmias and arrest. Hypoxia, hypovolemia, metabolic abnormali- ties, and the stress of surgery and anesthesia all contribute to a high incidence of arrhythmias and an oc- casional cardiopulmonary arrest in the postoperative patient. Thus, the recovery room nurse must double as a coronary care unit nurse.

Shock and hypotension. Hypovole- mia, cardiac failure, medication overdose, airway obstruction, pump failure, inadequate ventilation, and pneumothorax must be considered in the patient whose blood pressure sud- denly falls. There is no time for delay, even though discerning the

true cause of shock and hypotension may not be easy.

Hypoxia. Inadequate ventilation, secretions, overmedication, inherent pulmonary disease, acute pulmonary insufficiency as well as mechanical problems of airways and airspace, can result in acute hypoxia. This is a pressing emergency since its ef- fects on the cardiovascular system, and ultimately cellular metabolism, are immediate.

Hypertension. It can be related to inadequate ventilation, pain or cate- choI response, changes in peripheral resistance related to body tempera- ture and length of surgery, and is of particular importance in patients undergoing vascular surgery.

Potential problems are those that over a long enough period of time with a large enough volume of pa- tients will be seen. To minimize their harmful effect, a careful watch must be applied to all patients all the time. Potential problems include:

Ventilutory insufficiency may be related to many of the causes pro- ducing apnea. In addition, patients with major intra-abdominal prob- lems, obesity, preexisting chronic pulmonary disease, acute trauma, and disorders of consciousness may become unable to ventilate ade- quately.

808 AORN Journal, April 1975, Vol 21, No 5

Postoperative bleeding due to in- adequate hemostasis or disorders of blood coagulation, or a combination of the two, is frequently seen and must be carefully evaluated. Judg- ment is required to decide if the bleeding will stop or when immediate reexploration is required.

Oliguria. Urinary output is the end result of many factors: anatomic channels (including a kinked Foley catheter), renal function, renal blood flow, cardiac output, blood volume status, and the effect of medications and blood transfusions. All are im- plicated in differential diagnosis of a sudden decrease in urine output.

Hypovolemia can be related to cardiovascular capabilities, renal out- put, bleeding, and even respiratory function. The causes and effects must be simultaneously analyzed and treated.

Hypothermia. Prolonged opera- tions in air-conditioned operating rooms with much of the body ex- posed result in profound hypother- mia. The attendant changes in cardiovascular function, conscious- ness, and general body function are dramatic. Temperatures of 91 to 92 F (33 to 34 C ) are not uncommon after major vascular surgery and contribute to changes in peripheral resistance and hypertension, as well

as directly affecting myocardial function and urine output. In addi- tion, intentional hypothermia may be employed in neurosurgical pa- tients and in septic patients.

Electrolyte imbalance. Hypokale- mia is extremely common in patients subjected to major surgery, and its attendant effects on myocardial per- formance and arrhythmias are of great importance. Diabetes, hyper- alimentation, congestive failure with its fluid and salt problems, and nu- tritional depletion are common in preoperative surgical patients; the addition of some hours of surgery and anesthesia makes these prob- lems acutely worse.

There are certain problems pecu- liar to the recovery room that re- quire tender loving care from the nurse who at the same time must watch for the pressing and potential problems.

Nausea and vomiting, though less frequent with changes in anesthetic techniques, are still seen with reg- ularity. The hazard of aspiration is foremost in the minds of physicians and nurses, but the discomfort in- volved is of primary concern to the patient.

Postoperative pain is common. The patient who desires medication before recovery from general anes-

AORN Journal, April 1975, Vol 21, No 5 809

anagement of potential M problems requires tube technology and ienology.

thesia may be more distressing to the overall milieu in the recovery room than the critically ill post- operative trauma patient.

Disorientation, including noise and thrashing about, is a major person- nel problem since sedation may be unwise, restraints may aggravate the condition, and the care required to deal with such a patient signifi- cantly decreases the total care avail- able to other patients.

The complaining and demanding patient who has recovered from a relatively minor procedure and is well aware of his own discomfort but not the general requirements of the unit uses a disproportionate amount of care compared to the medical necessity of normal recovery from anesthesia.

The lethargic patient who is react- ing to medications, anesthesia, and perhaps the metabolic effects of dis- ease may require prolonged recovery room stay. Subgroups include those whose regional anesthesia lasts long- er than one would like and those who remain under the effects of inhala- tional anesthetic agents for longer than usual.

Pressing problems require knowl- edge of airway management, cardio- pulmonary resuscitation, respirator function, blood gas interpretation,

careful evaluation of neurologic status, and electrocardiogram anal- ysis. Potential problems require “tube technology” including manage- ment of chest and gastrointestinal drainage tubes, wound sumps and drains, knowledge of hemotology and chemistry laboratory values, hypo- thermia machines, pressure trans- ducer monitoring and “veno1ogy”- the ability to draw blood, start infu- sions and give medications intra- venously. Peculiar problems require practical psychology, tender loving care, compassion, and finally, exper- tise in everything else a nurse is ex- pected to know.

There are also significant admin- istrative problems that affect day- to-day living in the recovery room. Efficiency is important. Unfortu- nately, many hospitals have ex- panded their operating room facilities without concomitant expansion of recovery room facilities. Increased duration and complexity of surgery and significant physiologic derange- ments have increased the duration of recovery room stay. Nevertheless, the same amount of space continues to be available for more patients who require more time in the recovery room. As a result, the streamlining of routine recovery care becomes im- portant and staffing patterns must be determined for each individual

810 AORN Journal, April 1975, Vol 21, N o 5

hospital. Transportation of patients requires skilled observation, judg- ment, and person power. Use of a registered nurse to perform such functions may be inefficient but nec- essary.

From careful questioning of most recovery room staffs, it appears there is no “appropriate” time to transfer a patient back to the unit. The possibility of personnel from the unit assisting in transfers and a spe- cific administrative policy governing transfers may be necessary to relieve congestion in the recovery room. In addition, any delay in starting an- other case because of overcrowding in the recovery room is poorly tol- erated by anesthetists and surgeons.

Creation of intensive care units was expected to relieve the recovery room of the burden of caring for critically ill patients for long periods of time. This could be accomplished if there were sufficient ICU person- nel available, but in most hospitals a shortage of critical care personnel has precluded use of the physical space available. It is interesting that rigid patient/nurse ratios in inten- sive care units are the rule, rather than the exception. However, when an additional intensive care patient is created by an automobile accident, major surgical procedure, or a gun- shot wound, there is always room in the recovery room.

Finally, personnel utilization has not been stressed sufficiently. For recovery room personnel to enjoy their work, they must do what they are trained for, they must be trained to do more, and they must be happy in their responsibility. Personnel costs account for nearly 70% of yearly hospital expenditures. Facili- ties and equipment appear to be easier to obtain, yet proper use of

these facilities requires competent, confident, and happy personnel.

What of the future? There will never be adequate in-

tensive care beds (for the critically ill).

There will never be enough in- tensive care nurses (to fulfill the desired 1:l ratio).

There will never be sufficient operating rooms (for the sur- geons).

There will never be a right time to move a patient (for the floor personnel).

There will never be a right time to move a patient (for the operat- ing room staff).

There will never be enough money to build adequate facilities (for the taxpayers).

There will never be enough money to hire more people (for the administration).

But there will always be the re- covery room. cl

HEW publicafion covers hospiful pracfice Basic information about hospital practice for medical and nursing students and others preparing for a health career is given in a new publication, Orientation to Hospital operation-Programmed Instruction for Health Professionals.

Published by the US Department of Health, Education, and Welfare, the text deals with four major hospital areas of particular interest to health professionals: liability, medical staff, patient care and other services, and the physician and standards of quality care.

The publication, No (HRA) 75-4009 may be purchased from the Superintendent of Documents, US Government Printing Office, Washington, DC 20402, for $1.40 per copy.

AORN Journal, April 1975, Vol 21, N o 5 811