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Duke University Medical Center

The PACU team implemented phased postoperative care in the OR platform

Duke University Medical Center, Durham, N.C.

TEAM: PeriAnesthesisa Care Unit

CATEGORY: Best Initiative


In September 2014, the Duke University Hospital PeriAnesthesia Care Unit (PACU) Team partnered with our anesthesia colleagues to implement phased postoperative care in our operating room (OR) platform. In doing so, our 120+ member team overcame challenges to achieve a significant reduction in the average recovery care time for patients in the Duke University Hospital PACU, while improving their overall experience.

Prior to September 2014, the Duke University Hospital PACU was a single-phase, mixed care area that safely cared for more than 25,000 patients each year. Before that date, our average length of stay for ambulatory patients exceeded national benchmarks at 120 minutes. When looking at national benchmarks, we learned that top-performing facilities safely recover and discharge ambulatory surgery patients in less than 60 minutes. We identified phased PACU care as our best opportunity to reduce discharge delays for our inpatient population of intermediate care postsurgical patients. In a phased PACU, we would fast-track specific patients to a defined care area designed to support safe recovery. It was staffed with nurses who specialize in the needs of a target population. The phased approach would also be supported by multidisciplinary colleagues, including anesthesia providers, physical therapists, social workers, pharmacists and surgeons.

We implemented an evidence-based scoring system for patients waking from anesthesia in the OR to help discern proper postsurgical PACU placement (Phase I or Phase II care). We adopted the American Society of PeriAnesthesia Nurses (ASPAN) guidelines for recommended staffing ratios and care focuses. We reviewed and modified nurse staffing and scheduling to meet the operational need s of the unit. Education was rolled out to the surgeons, anesthesia providers and OR staff highlighting the goals for both the Phase II implementation and evidence-based scoring application. Our PACU Phase II Team also identified and purchased the equipment and supplies necessary for a dedicated Phase II area in the PACU.

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The Duke University Hospital PACU Team collaborated with numerous interprofessional colleagues for support of the initiative. Most importantly, with support from their peers, a core group of Phase II PACU nurses partnered with two anesthesia providers to lead the initiative from inception to implementation. Our multidisciplinary team helped the Duke University Hospital PACU achieve significant improvements in distinct areas over the course of one fiscal year, based upon our preliminary review. First, regarding length of stay, we reduced the average recovery time for both ambulatory surgery patients and intermediate inpatients by 54%, to 65 minutes. Furthermore, our Phase II area now cares for more than one-third of our total postoperative volume. Finally, the projected cost savings since implementation of Phase II PACU secondary to decreased length of stay are significant. Conservative average costs of PACU care per minute estimate that the Phase II PACU initiative has saved our patients (or their insurers/payors) more than $1 million. Even better, our patient satisfaction scores have not been affected.

Our PACU Team continues to demonstrate its initiative by pursuing opportunities for further improvement, including the expansion of phased care and the refinement of processes. The nursing members of the Phase II Team developed discharge instructions for patients receiving intraoperative chemotherapy instillations. We continuously review patient satisfaction feedback and average length of stay by surgical service, then identify areas of focus for improvement initiatives.

From the onset of the Phase II PACU plan, our multidisciplinary team has been inspiring to watch. We have demonstrated not only initiative, but also teamwork and interprofessional collaboration. The Duke University Hospital PACU Phase II implementation has helped our service line improve patient throughput, but our greatest accomplishment, by far, is our PACU's renewed drive for continuous improvement.


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