PS04 2018: Post-anaesthesia care unit

 

List:

·         General requirements

·         Patient care

o   Written protocols

o   Staffing

o    

o   Handover

o   Observations

o   Discharge criteria

·         Equipment and design

o   Design of entire unit

o   Equipment for entire unit

o   Design of each bay

o   Equipment for each bay

·         Second stage recovery

 

General requirements:

·         Patients are directly supervised

·         Design should reflect the patients, anaesthetics and operations

·         Safety trumps privacy/dignity; patients must not be alone behind curtains

·         Education, training are provided to staff

 

Patient Care

 

Written protocols: (by anaesthetists)

·         Checking equipment and drugs

·         Pain relief

·         Managing unconscious patients

·         Managing common complications

·         Managing agitated or violent patients (medication, restraint, security guards)

·         Discharge criteria (may be bent by the anaesthetist)

 

Staffing:

·         Nurse in charge

·         All staff trained or directly supervised

·         If paed patients: at least one nurse able to manage paed complications

·         2:1 ratio if complex e.g. airway support, unwell (especially upon arrival)

·         1:1 ratio standard

·         1:2 ratio if a) simple patients b) voluntary control of airway c) stable vital signs d) awake e) communicating purposefully

 

Hand-over: (see PS53)

(note oxygen en route!)

·         Must not start until ABCs stable

·         Must not leave until recipient explicitly says that is ok

·         Patient ID confirmed

·         Pre-op: HOPC, PMHx

·         Intra-op: surgery, anaesthesia incl airway, drugs, fluids, major events

·         Post-op: disposition, instructions (written and verbal), concerns

·         If ETT (see PS18): monitored with capno, pulse ox, ECG. Extubation by the anaesthetist or a trained delegate.

·         If LMA: must be spont venting and taker must be competent

·         Giver: must remain contactable and able to attend unless delegating

·         Taker: must have appropriate skills

·         Transferring patients: at least 4 people, with anaesthetist at the head

 

Observations:

·         Conscious state

·         RR / HR / BP / SpO2 / Temp

·         Urine output

·         Dressings and drains
Sensory and motor blockade if neuraxial or regional block

·         Neuro obs if neuro patient

·         Vascular obs if limb surgery

 

Discharge criteria:

First stage

·      Conscious

·      ABC stable

·      Pain under control

·      Nausea under control

·      Normothermia

·      No active bleeding

·      No surgical complications

Second stage

·      Pain and nausea controlled with oral medications

·      Brain working normally

·      Walking safely

·      (not listed: somebody to take the patient home?)

 

Equipment and design

 

Design of entire unit:

·         Area is for recovering patients and nothing else

·         Close to operating rooms

·         Easy entry (for help) and exit (for evacuation)

·         Free internal passage (for help)

·         Line of sight for every bay (for safety)

·         Enough bays for peak load

·         If paeds: separate area, paeds equipment, somewhere to breastfeed

·         If obs: equipment for neonates

·         Emergency call system (for help from OR and elsewhere)

·         Consider separate area for contact precautions

·         Consider separate area for end-of-life care

 

Equipment for entire unit:

Airway

·      Bag-mask 1:2 ratio or a minimum of 2 in total

·      Guedel airway, LMA, ETT, laryngoscope

·      Difficult airway equipment available

·      Nebulisers

·      High flow nasal prongs*

·      Mechanical ventilator*

Monitoring

·      Stethoscope

·      Capnography*

·      ECG: 3 lead, 12* lead

·      ABP and CVP monitoring*

·      Thermometers

·      Neuromuscular monitoring*

Diagnostics

·      Glucose and ketone tests

·      Blood gas, haemoglobin, electrolytes*

·      Diagnostic imaging available*

Drugs and fluids

·      Intubation drugs

·      Emergency drugs

·      Analgesics and antiemetics

·      Cannulae, syringes, needles

·      IV fluid

Emergency

·      Defibrillator easily accessible

·      Ideally disaster-specific kits with cognitive aids: e.g. MH, anaphylaxis, LAST

Other

·      Handwashing basin

·      Warming cupboard*

·      Forced air warmers and fluid warmers*

·      Refrigerator for drugs and blood*

·      Procedure light*

·      Basic surgical tray*

·      Urinary catheter equipment*

*Required if general anaesthesia or major neuraxial anaesthesia

 

Design of each bay:

The bay

·      Easy access to patient’s head

·      Minimum area per bay: 9m2 standard, 20m2 higher acuity

·      (room for relatives, helpers, crash trolley)

·      Lighting and wall colour allows skin colour assessment (no dimming)

·      Emergency lighting

The bed

·      Firm base and mattress (for CPR)

·      Can tilt whole bed ≥15° Trendelenburg and reverse Trend

·      Can place head right up

·      Wheels

·      Brakes

·      Rails go up and down

·      IV fluid poles

 

Equipment for each bay:

·         Wall oxygen, delivery system, flow meter

·         Wall suction, yankeur and catheters

·         4 power outlets

·         Emergency lighting

·         Place for patient record / computer if electronic charting

·         “Facilities for mounting necessary equipment”

·         NIBP both manual and auto, range of cuff sizes

·         Pulse oximetry

 

Second Stage Recovery

·         Reclining chairs

·         Adequate staffing for patient numbers

·         Privacy for discussion of procedural outcomes

·         Discharge instructions given

·         Food and drink

·         Toilet

 

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