Longer PACU stay helps some patients skip the ICU

Boon for aneurysm, carotid artery patients
December 16th, 2015

Like many good ideas, its seed came from simple observation. University of Colorado School of Medicine vascular surgeon Omid Jazaeri, MD, had placed a stent during a minimally invasive surgery. That same day, he saw the patient sitting up and having dinner in a University of Colorado Hospital intensive care unit. It struck Jazaeri that this helped neither the patient nor the hospital.

The seed germinated into an “Extended Stay Program” in UCH’s Post-Anesthesia Care Unit (PACU). The program, launched earlier this year after extensive preparation, was designed for patients who undergo some endovascular procedures, such as uncomplicated repairs of aortic aneurysms and removal of plaque that blocks carotid arteries to prevent stroke. Patients identified for the program spend six hours in the PACU for close monitoring – several hours longer than is customary. If they meet criteria such as minimal bleeding and controlled blood pressure, they are transferred to the Medical Surgical Progressive Care Unit (MSPCU), skipping the ICU. That frees up beds and improves the patient’s hospital experience.

PACU charge nurse Krista Hall (left) led the Extended Stay Program for endovascular procedures at UCH. Hall’s colleague, Emily McCollum, RN, is helping to roll out a similar program for thyroidectomies.

If all goes well, patients spend one night in the MSPCU and are discharged the next day, said Krista Hall, RN, CPAN, charge nurse for the Inpatient PACU at UCH and team leader for the Extended Stay Program. Thus far, 22 patients have been part of the program, with 21 successfully transferring to the MSPCU, she said. With the per-day cost of an ICU admission without a ventilator nearly double the cost of a stay in a progressive care unit, Hall estimates the program saved the hospital tens of thousands of dollars on those patients.

The program is now set to expand in January to patients who undergo thyroidectomies, said Emily McCollum, RN, a staff nurse in the Inpatient PACU. McCollum is working with endocrine surgeon Maria Albjua-Cruz, MD, on an extended-stay protocol for these patients, with the aim of discharging them home on the same day as the surgery.

Simplifying the complex

Admission to the ICU might seem mandatory for patients who have had dangerous bulges in their arteries fixed with painstakingly placed stents or had the artery feeding blood to their brain exposed for cleaning – and that is often the case. But it’s not always necessary, Jazaeri said.

“There are some things that are straightforward even if the procedure itself is very complicated,” Jazaeri said. For example, the minimally invasive endovascular aneurysm repairs require only two tiny punctures in the groin to create entryways for stent-bearing catheters, he said. If there are no immediate complications, requiring those patients to take up an ICU bed “doesn’t make sense,”  he maintained.

“Some patients do well after surgery and want to go home, but they can’t because we’ve admitted them to the ICU,” he said.

Jazaeri noted that avoiding unnecessary ICU admissions not only saves money and keep beds open for more seriously ill patients; it’s also a boon for patients undergoing procedures, he said.

“We more quickly get them mobilized and back to recovering in their home environment, as opposed to staying in a hospital bed,” he said. A quicker discharge, in turn, decreases patients’ risk of falling because of unfamiliar environments and acquiring infections, Jazaeri added.

Plenty of prep

Vascular surgeon Omid Jazaeri, MD, suggested extended stays in the PACU after seeing some patients sent to the ICU despite making quick post-surgical recoveries.

If Jazaeri’s initial insight was inspiration, making the Extended Stay Program happen was about perspiration. Hall said preparations required a multidisciplinary effort of physicians, nurses, and pharmacists.

“It was a new concept that involved lots of education for nurses in the PACU and on the [med/surg] floors,” she said. Many MSPCU nurses, she explained, were not used to seeing patients who had previously gone to the ICUs. Guidelines and order sets were developed for PACU staff so they could properly care for these patients for an extended period of time. Arterial lines and Foley catheters are removed before patients are transferred from the PACU prior to the MSPCU, where they can begin moving, a key to decreasing length of stay, Hall said.

The Extended Stay Program also meant a “culture change” for PACU nurses used to caring for patients for a shorter period of time and helping to manage capacity and OR efficiency by expediting their transfer to another unit rather than keeping them longer.

“There was a concern that extended stay would affect the flow of the PACU and put the ORs on hold,” Hall said. Nurses also worried about keeping patients comfortable for a longer period of time in the sometimes hectic and noisy PACU.

In response, program leaders (see box) focused on communication and education. Kristen Alix, RN, ACNP-BC, an adult nurse practitioner in vascular surgery, presented an in-service training for both PACU and progressive care nurses, explaining the guidelines and order sets for extended-stay patients and outlining the rationale for the change.

“We explained to nurses that we started the program to reduce the number of unnecessary ICU admissions,” Hall said.

Surgeons also helped to smooth the way by carefully selecting the patients eligible for the program and explaining to them in advance what they should expect, Jazaeri said.

He emphasized that the program is not for all patients. Exclusions include age, comorbidities, complications that may occur during surgery, uncontrolled blood pressure, and complex procedures, such as those that involve the renal artery or arteries of the intestines.

Meanwhile, McCollum said she is applying the same educational approach in preparing nurses for extended-stay thyroidectomy patients. She created a presentation that defines inclusion and exclusion criteria for the program and the process for implementing it. Among other information, the presentation also explains the pre-op visit to determine the patient’s eligibility; outlines a brochure for patients that tests their understanding of the process; and presents the order set for extended-stay thyroidectomy patients and the labs that determine their risk.

“We will also follow up with a post-op phone call to check patients for symptoms, as well as their satisfaction and how comfortable they were with going home,” McCollum said.

The Extended Stay Program is an example of positive change that results from close attention to the day-to-day flow of life in a hospital, Jazaeri concluded.

“You never know where you will find areas to improve processes,” he said. “We’re trained to think of things as they happen in the OR. But by thinking about how things happen in pre- and post-op we can also save days of hospital stays for patients.”


Stay just a little bit longer
Members of the team that developed the Extended Stay Program for vascular surgery patients:

  • Kristen Alix, RN, ACNP-BC
  • Nicole Babu, RN, CPAN
  • Michelle Ballou, RN, MSN, CPAN
  • Monica Brock, RN, MSN
  • Omid Jazaeri, MD, FACS
  • Justin Oeth, RN
  • Amanda Swedhin, RN, CMSRN

About the author

Tyler Smith is a freelance writer based in metro Denver.