1. PACU Bottlenecks- A Shared Responsibility Pam Bush Clinical Director of Perioperative Services, The Ottawa Hospital MOHLTC Perioperative Coaching Team member NAPAN May 23 rd, 2009

2. 2 Overview Perioperative Coaching teams in Ontario Their purpose-The process-The findings Best Practice Targets for Perioperative Units Identify Factors in Perioperative units that impact PACU efficiency Present strategies to optimize PACU efficiency

3. 3 Perioperative Coaching teams Recommended by Report of the Surgical Process Analysis and Improvement Expert Panel June 2005 www.health.gov.on.ca

4. 4 Key Recommendation To help hospitals to continuously improve OR efficiency, access and quality of service Develop Perioperative Improvement coaching teams to help government understand perioperative issues To help hospitals improve perioperative efficiency and performance

5. 5 Site Visits 58 hospitals in Ontario have had Perioperative coaching visits 45 Hospitals have had follow up visits Fall 2005-May 2009

6. 6 The Perioperative Coaching Visit The coaches: composition, training Preparation: Hospital expression of interest, SPAI self assessments, Hospital profile, Wait time data, LHIN information, data Pre visit teleconference

7. 7 The Site Visit Duration Day 1: CEO, Senior team Perioperative executive and leaders Tours of Perioperative units CPD, Central Process, SPD Day 1 and 2 Private meetings with Perioperative nursing leaders, Physician leaders, Support service leaders Focus groups with Perioperative nursing, anesthesia, surgeons, support teams

8. 8 Site Visit Day 2 Identification and review of Issues Day 2-3 Prioritization of Issues Action Plan development Day 3 Debrief with CEO and Senior team

9. 9 Deliverables Site Visit Summary SPAI Report Assessment- recommended best practices rating and timelines Action Plan- Opportunities, barriers, Strategies, most responsible person and timeline Appendices-OR manager/director qualitative assessment- coaches private comments

10. 10 Findings Leadership and Accountability Challenges with OR leadership committees and/or lack of clear leadership for OR OR governance has continued to challenge many physicians to become partners with their administrative counterparts. The need for physician engagement is critical Lack of physician understanding of the complexity of the perioperative infrastructure Allocation of OR resources Allocation of OR resources based on historical allocations Lack of formalized scheduling policies Urgent/emergent scheduling Flow and Space Issues Surgical bed access (ICU, ward) Resource intense pre-op programs Lack of early identification of discharge needs Matching workflow to resources Analyze demand and capacity to maximize patient flow

11. 11 Findings Equipment and Supplies Few hospitals bundling equipment purchases High inventory levels Human Resource Issues Lack of interdisciplinary approach to managing OR resources Recognized need for new roles (i.e. Anesthesia Assistants, RNFAs, etc) Lack of solid HR strategies to replace retiring surgeons, anesthetists and clinical staff

12. 12 Findings Data Collection No select group of key indicators Capacity but no clear understanding of how to use data collected Education No regular education sessions for periops staff Lack of dedicated time and/or funds to support education for staff

13. 13 Perioperative Best Practice Targets PAU SPAI Report appendix D All elective scheduled patients will be screened either by phone or in person to ensure they are ready for surgery All patients and their families will be educated to ensure that they understand the procedure and participate in their care Discharge planning will begin before surgery

14. 14 Perioperative Best Practice Targets SDCU/SDA Surgery will be conducted on an outpatient basis in a separate location wherever possible Surgical patients will be admitted on the same day as the surgery, wherever possible

15. 15 Perioperative Best Practice Targets Operating Rooms The time the patient goes into the OR to the time the patient leaves the OR will be equal to the time that was booked for the case The amount of time scheduled for surgery will be as close to the expected time that the surgery should take Surgeries will begin at the scheduled start time

16. 16 Perioperative Best Practice Targets Operating Rooms The “emergency surgeries” that are conducted will reflect true emergencies Surgical cases that have similar procedures will be grouped as a block, where possible Surgeons will work in consolidated blocks of time, where possible

17. 17 Nursing Units that Affect PACU Efficiency PAU SDCU/SDA OR PACU ER ICU Stepdown Psychiatry Surgical inpatient DI- Everyone

18. 18 PACU Factors impacting Efficiency Examine the clinical practice-nursing and anesthesia Clinical assessments: Temperatures- ?, preventative, reactive Pain control- ?, standard protocols, patterns of pain, PCA, anesthesia, impacting los Control of nausea/v ? Patterns, protocols, induction, SDCU/SDA, PAU consults

19. 19 PACU Factors impacting Efficiency Discharge Criteria-evidence based/ based on clinical condition of patient Do RNs discharge patients based on discharge criteria- must anesthesia sign out patients Staffing – mapped out patient activity / nursing hours Days/ Evenings/ Nights- Day of week variation Data: patient activity, los, beyond meeting discharge criteria Clinical indicator tracking-uncontrolled n/v, pain, reintubation, respiratory arrests

20. 20 Strategies to Optimize PACU Efficiency Review clinical assessment content Identify patterns causing delays Address causes of delays Standardize pain, antiemetics, sleep apnea management etc Determine who needs to remain ON based on evidence Review discharge criteria-evidence based

21. 21 Strategies to Optimize PACU Efficiency Optimize nursing staff to meet patient demand Separate inpatients from outpatients in PACU

22. 22 Largest Controllable factor impacting PACU efficiency Elective OR Schedule variation in # of ORs running daily variation in # of service Ors running daily variation in inpatient bed demands daily variation in SDCU bed demand daily variation in stepdown variation in Critical Care-PACU/ICU overnight

23. 23 The BIGGEST JOB Revise the Elective OR schedule Revise the Elective OR schedule to meet the needs of the patients and the community Evenly distribute the resource demands over the week Stakeholder commitment Entire organization benefits-reduced cancellations

24. 24 Elective OR Schedule Revision Review utilization data Review surgeons running late Review activity patterns of surgeons ie medium and long cases Limit SDAs/ ICU/PACU/Stepdown per day Schedule inpatient and outpatients before SDA Reallocate late rooms to those with long cases Create scheduling policies to support efficiency-use of Ors, cutoff for scheduling

25. 25 Emergency OR activity Does an emergency OR list exist? Is it communicated in real time to PACU? Are there policies related to emergency activity and access times-A,B,C,D? Are the policies adhered to and activity reviewed?

26. 26 Strategies to address emergency OR activity Policies to define emergency cases Review of emergency activity (after hours) Consequences to non adherence to policy Add or convert elective time to emergency day time Regularly review volume of activity Review need to revise PACU nursing hours to support activity

27. 27 SDCU factors affecting PACU Efficiency Variation in volume of activity Scheduling time of day Nursing staffing / patient activity SDCU discharge criteria Lack of rides, or accompaniment

28. 28 Strategies to Optimize SDCU Efficiency-prevent PACU bottlenecks Smoothing of Elective OR schedule Scheduling outpatients first Review revise discharge criteria Setting expectations during Pre assessment appointment Confirming ride preoperatively

29. 29 PAU factors affecting PACU Efficiency Inappropriate Route of admission Lack of communication regarding alerts- latex allergy, isolation needs, difficult intubation, critical care bed requirements Lack of patient/family preparation regarding discharge/expectations Lack of discharge planning

30. 30 PAU Strategies to optimize PACU Efficiency PAU screening of all elective surgical patients ROA based on surgical procedure and co morbidities Develop communication process between PAU and OR (electronic) Develop policies regarding discharge planning- cancel if no arrangements made?

31. 31 Who is in your PACU Admitted patients waiting for beds ECT Critical care overflow ICU-enroute Stepdown Post Arrests? PACU patients who meet dc criteria on arrival Interventional radiology

32. 32 Strategies to take back your PACU Develop a process to determine bed requirements- cancellation process based on clinical priority of hospital ECT- develop expertise in MH units Critical care triage policies- RACE team creation ICU booking policies-which includes process for cancellation if no bed ICU patients directly to ICU Safety risk adding transition point for ICU direct patients PACU bypass policies-anesthesia, Perioperative nursing leaders PACU bypass policy when PACU full

33. 33 ICU/ Stepdown impact to PACU efficiency Review of ICU admission criteria Review of ICU discharge criteria Review of Stepdown admission and discharge criteria

34. 34 Corporate Policy Planned closures-summer, Christmas Bed management Creation of Short stay unit Discharge policy Cancellation policy based on organizational priority Perioperative team, patient and family education

35. 35 Questions?

36. 36 Contact Info Pam Bush Clinical Director Perioperative Services, The Ottawa Hospital 613-737-8719 pbush@toh.on.ca