PACU Bypass

     I have recently been inspired by one of my fantastic CRNA’s, Ashley Hayes,  to begin bypassing the PACU, and it is kind of addicting, I have to say. I’ll go on record as saying that I know I broke one of my own rules of building up and  preparing infrastructure in doing this, but (so far) there has not been a negative fall out. It is like when you are playing spades, and someone ‘goes low’ for the first time in the game; next thing you know, everybody has the itch.

     I believe the first case  was [nonmember]…

 

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an 18 or 20 year old guy with a sports injury for an ORIF of the thumb. He had been hurting pre-op, so I offered him a single injection supraclavicular block ahead of time. We ended up sedating a little for the case with propofol, and he was wide awake and already met PACU discharge criteria in the O.R. I got word that Same Day Services was ready for him ‘as is’, and my CRNA told me that she was just going to skip through PACU. Well, you don’t have to push me too much to take another step toward super-efficiency. I have been teaching (preaching, it feels like) to students regularly, ending with “and if we do these things, this kind of patient ought to be able to go right back to Same Day….when we get things ironed out a little better.” Finally, someone else’s bravado breaks the seal. It was awesome to walk in on the surgeon in Same Day Services with the patient just as he was just beginning to explain things to the parent…and the patient looked as if nothing had happened to him at all. He required no nursing interventions, and they were out of the hospital in less than 30 minutes. No PACU and an EASY Same Day stay!!

     OK, I broke my own rule, but it was a minor break. I could even call it a ‘reasonable step’ toward bigger cases and more complex patients -which is my ultimate goal. We’ve watched plenty of patients after a variety of cases sit in the PACU fully awake and completely asymptomatically for quite a while because “that’s the way we’ve always done it.” These simple cases (Carpal Tunnels and Finger Pinnings) are giving us a ‘feel’ for it as we iron out minor issues. Our patients have also been either been ASA I or II patients, and I work with experienced CRNA’s that know how ‘block patients’ should be managed optimally intraoperatively and evaluated immediately post-operatively. Well, come to think of it, this wasn’t really out of the blue at all. OK, maybe I didn’t (hardly) break my own rule at all…I just needed inspiration to ‘break the ice’. Thanks again Ashley!!

     So, am I pushing too much? Have I inappropriately put too much on the Same Day RN’s?? Did I prepare them adequately for this?? Here’s MY answer. They are picking out patients and cases FOR me (“They said they would be ‘up’ for one of those blocks so they would get to skip PACU….if you wanted to talk to them about it, Dr Jones” or “This is the bomb!” or “Why don’t we ALWAYS do this, Dr Jones?”).  I haven’t been yelled at in PACU for depriving those RN’s of patients either. When RN’s stop me to tell me how wonderful this or that intervention was, that’s when I know things are going right! It’s better for the patient, and it’s easier on them, too. And, yes, we are tracking our times and nursing interventions in case administration is curious about how our changes are affecting things in the hospital. I’ll post our stats against historical averages as we build enough to show a difference.

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