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The PACU as Critical Care Unit

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IT’S NOT DIFFICULT to imagine the PACU as acritical care unit. As a matter of fact, ICUs cameinto existence as an extension of PACUs.1 PA-CUs had been developed to care for patientswho needed intensive monitoring until theyrecovered from anesthesia. With the technolog-ical explosion, critical care units were devel-oped to group the sickest patients with nurseswho knew the technology and wanted to carefor them. With the development of more tech-nology (mechanical ventilators, cardiac moni-toring, intra-aortic balloon pumps, pulmonaryartery lines, etc), critical care units have be-come more and more in demand.

In the past few years, hospitals have actuallybegun to develop into centers made up of emer-gency departments, surgical services, and criti-cal care units (including telemetry units) with adecrease in the numbers of patients on themedical-surgical units. Those patients are nowtreated as outpatients or sent home as soon aspossible. Critical care units in 1998 already ac-counted for about one third of total hospitalcosts.2

Dynamic Boundaries

The 2002 Standards of Perianesthesia Nurs-ing Practice3 speak to the environment whereperianesthesia nursing is performed. The prac-tice of perianesthesia nursing is referred to asphases of care on a continuum, not as thefunctions performed in a specific “room” orunit. This is because the boundaries of perian-esthesia nursing practice are dynamic. The peri-anesthesia patient may be found in ambulatorysurgery settings, PACUs, Phase III settings, labor

Journal of PeriAnesthesia Nursing, Vol 18, No 6 (December), 2003: p 431-433

nd delivery, pain management services, physi-ian and dental offices, and other special proce-ural areas, such as radiology and endoscopy.he importance of the ASPAN Standards is that

hey apply to the care of the perianesthesiaatient regardless of the setting in which thatare is delivered.

hat same phenomenon has occurred in theeld of critical care nursing. Critical care nurs-

ng is no longer defined as care of the criticalare patient in the ICU or coronary care unitCCU). For years, those of us who worked inhase I PACU have cared for patients whoseltimate destination was ICU or CCU. We recov-red these patients from their anesthesia and, inany instances, stabilized them before dis-

harge to ICU where they could receive inten-ive monitoring for a longer stay.

ospitals admit patients now who are muchicker. The patient that used to be on the med-cal surgical unit for 5 days recovering from anppendectomy is now treated as an outpatient.he patient who has a procedure such as ca-otid endarterectomy or femoral-popliteal by-ass now goes to the medical surgical floor

nstead of ICU. This in itself creates more de-and for critical care services in the PACU

The ideas and opinions expressed in this editorial are thoseolely of the author and do not necessarily reflect the opin-ons of ASPAN, the Journal, or the Publisher.

Jan Odom-Forren, MS, RN, CPAN, FAAN, is a perianesthesiaursing consultant.Address correspondence to Jan Odom-Forren, MS, RN,

PAN, FAAN, 800 Edenwood Circle, Louisville, KY 40243;-mail address: jodom29373@aol.com.© 2003 by American Society of PeriAnesthesia Nurses.1089-9472/03/1806-0012$35.00/0

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because, in many cases, the patient spendsmore time in PACU to assure stability beforetransfer to the floor.

The ICU is made up of the sickest, oldest, andmost complex patients. This shift in intensity ofhospitalized patients has created an increaseddemand for critical care beds and telemetrybeds. Many hospitals have not had the re-sources to build new units to meet those de-mands. Enter the PACU—a monitored areastaffed by nurses knowledgeable about patientcare from outpatient herniorraphy to cranioto-mies. Administrators who were dealing with abackup of critical care patients in the Emer-gency Department (ED) saw empty space, avail-able monitors, and competent staff.

The Overflow Patient

Many PACUs now find themselves facing thelong-term care of patients when ICU, CCU, ortelemetry beds are not available. From my per-spective, the overflow patient is here to stay—for the immediate future, anyway.

What are some of the concerns that have beenidentified?

● How do we staff for overflow patients?● How can we assure the PACU nurse

taking care of the overflow patient is anurse competent in critical care skills?

● How can we continue to care for surgi-cal patients when the staff is tied up withcare of overflow patients?

● How can the PACU nurses remain com-petent in skills that are not needed on adaily basis because overflow may notoccur on a regular basis?

ASPAN, in conjunction with the American As-sociation of Critical Care Nurses (AACN) andthe American Society of Anesthesiologists’ An-esthesia Care Team Committee and Committeeon Critical Care Medicine and Trauma Medicinedeveloped a joint position statement that wasapproved by ASPAN in 2000.4 The recommen-

dations from that joint position statement in-clude the following4:

1. Recognition of the primary function ofPhase I PACU—to provide care to post-anesthesia patients and maintain flow ofsurgery schedule.

2. Appropriate staffing requirements tomaintain safe and competent nursingcare of both the ICU and PACU patient.

3. Staff in PACU competent to care for thecritically ill.

4. A comprehensive plan to manage over-flow and provision of resources by man-agement.

5. Development of multidisciplinary planto address appropriate use of ICU beds.

The issue should be handled on a proactivebasis and not as the crisis is occurring. Nursingadministration, PACU nurses, ICU nurses, sur-geons, anesthesia providers, and intensivistsneed to come together to develop a usable,comprehensive plan that covers appropriatecare for all patients and adequate resources tomeet those needs. Some hospitals provide ICUnurses to the PACU for care. Other hospitalsprovide additional staffing for the PACU tocover those overflow patients. Many hospitalsinclude postanesthesia nurses in the criticalcare courses that ICU nurses attend, as theyshould.

It is a complex problem, but one that can besolved. It requires flexibility on the part of thenurses and a positive attitude that keeps thepatient at the front and center of the discussion.A positive attitude can go a long way in provid-ing reassurance for the family that is concernedabout the family member receiving care some-where other than the ICU. As one author stated,“The bottom line is: nurses with critical careskills, including ethical decision making, willcontinue to be a valued, sought out resource.”2

Those of us who work with the Journal ofPeriAnesthesia Nursing have tried to meet

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some of the ongoing educational needs of thepostanesthesia nurse caring for the critically illpatient by providing this focus issue on thecritical care patient. Our guest editor, SueFetzer, has much experience and knowledge onthe care of the critically ill patient and hasbrought that knowledge to this issue. She also isan educator, and as such has made all the arti-cles in the issue available for contact hours.Good luck as you become that “valued, andsought-out resource.”

References

1. Odom J: Evolution of postanesthesia nursing. In LitwackK, (ed): Core Curriculum for Postanesthesia Nursing. Philadel-phia, PA, Saunders, 2001

2. Rivers R: Critical care nursing: The hospital perspective.Curr Rev PeriAnesth Nurs 19:226-232, 1998

3. ASPAN: Standards of Perianesthesia Nursing Practice.Cherry Hill, NJ, ASPAN, 2002

4. ASPAN: A joint position statement on ICU overflow pa-tients developed by ASPAN, AACN, and ASA’s anesthesia careteam committee and committee on critical care medicine andtrauma medicine. In ASPAN: 2002 Standards of PerianethesiaNursing. Cherry Hill, NJ, ASPAN, 2002, pp 78-79

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