Sugammadex Reduces PACU Recovery Time after Abdominal Surgery Compared with Neostigmine.

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.

'Organisation of delivery of care in operating suite recovery rooms within 48 hours postoperatively and patient outcomes after adult non-cardiac surgery: a systematic review'.

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.

The Effects of Music on the Life Signs of Patients in the Reanimation Unit/Recovery Room After Laparoscopic Cholecystectomy.

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).

Time to recovery after general anesthesia at hospitals with and without a phase I post-anesthesia care unit: a historical cohort study.

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.

Quality Improvement Initiative to Improve Postoperative Pain with a Clinical Pathway and Nursing Education Program.

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.

Four-Year Evolution of a Thrombophylaxis Protocol in an Enhanced Recovery After Surgery (ERAS) Program: Recent Results in 485 Patients.

"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.

Nicotine addiction management following surgery: a quality improvement approach in the post anesthesia care unit.

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%.

Improving flow in the OR.

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.

A Comparison of the Incidence of Post-Dural Puncture Headache and Backache After Spinal Anesthesia: A Pragmatic Randomized Controlled Trial.

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.

Tracheal extubation practices following adenotonsillectomy in children: effects on operating room efficiency between two institutions.

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.

Scheduling elective surgeries: the tradeoff among bed capacity, waiting patients and operating room utilization using goal programming.

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.

Example of cost calculations for an operating room and a post-anaesthesia care unit.

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.

Coming to a theatre near you soon a witnessed CPR event'.

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.

Quality of post-operative patient handover in the post-anaesthesia care unit: a prospective analysis.

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.

Chinese whispers in the post anaesthesia care unit (PACU).

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.

Lack of utility of a decision support system to mitigate delays in admission from the operating room to the postanesthesia care unit.

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).

Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project.

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.

Acute pain management in the postanesthesia care unit.

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.

Interdisciplinary rounds in the postanesthesia care unit: a new perioperative paradigm.

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.