Pediatric PACU Decreases Patient LOS

In 2015, the average patient length of stay (LOS) in the pediatric post-anesthesia care unit (PACU) at Cleveland Clinic’s main campus was two hours, 53 minutes. Today, the LOS is two hours, 13 minutes. The pediatric PACU shaved 40 minutes off its LOS time after implementing a process improvement project to improve workflow related to postoperative pain orders.

“To decrease average length of stay to that degree is almost unheard of in a PACU,” says Kristen Vargo, MSN, RN, NE-BC, Nurse Manager on the 10-bed unit. “The clear outcome is that we are able to provide safe, effective, exemplary care to our patients.”

Taking a multidisciplinary approach

The pediatric PACU initiated the multidisciplinary process improvement project in the fall of 2015 after Vargo and Assistant Nurse Manager Michelle Levay, MSN, RN, CPN, conducted an audit of patient charts. The audit confirmed their belief that patients recovering in the PACU were not receiving pain medication in a timely fashion, which led to increased time to meet discharge criteria and increased time spent in the PACU.

“We had a lot of issues with patients coming out of the operating rooms without postoperative orders being written,” says Vargo. “So we had delays in patient care because we didn’t have the order and resources we needed to provide effective care.”

The audit revealed that the average time between when the patient entered the PACU and when the nurses received medication orders was 17 minutes. “That’s a significant amount of time when you have a child coming out of the operating room in pain,” says Vargo.

In addition, Vargo and Levay surveyed the 12 nurses on their unit about their perceptions of pediatric pain management practices. Some of the questions included the following:

• How often do you have pain medication orders that encompass all pain levels on the 1-10 pain scale?
• How often do you have to obtain further postoperative pain medication orders from anesthesia?
• How often do you have a patient requiring pain medication and you need to wait for pharmacy verification?

“The survey highlighted that our nurses didn’t have the required resources to provide optimal patient care and a positive patient experience,” says Vargo. “Our nurses were in distress: They knew the importance of being able to medicate patients and make sure they are comfortable, but they had to follow procedures.”

Next, Vargo and Levay created a process map to chart all the steps nurses take related to postoperative medication. The map detailed about 30 steps, from receiving medication orders to loading medications in the Pyxis MedStation™ automated medication dispensing system, and finally medicating the patient. “Creating the process map made us realize we needed all the disciplines involved to help with the project,” says Vargo.

The process improvement project included nurses from the pediatric PACU, as well as staff from the pediatric anesthesia department, the pediatric pharmacy and surgical operations. “We learned about the issues that everyone had, worked through the barriers and ended up with a much better process,” says Levay.

Implementing problem-solving interventions

The interdisciplinary team devised three main solutions to help decrease average LOS on the pediatric PACU:

1. Patient handoff changes – PACU nurses can now delay accepting handoff if the patient doesn’t have postoperative medication orders on admission to the unit. “We won’t refuse the patient a bed, but we can postpone taking handoff at the bedside,” says Levay. “The anesthesia team and staff who bring the patient out of the OR must stay at the bedside until we have postoperative orders. This empowers PACU nurses to say, ‘I don’t have what I need to take care of the patient. Can you write orders right now?’ This handoff change made a huge shift in the right direction.”
2. Pediatric postoperative order set changes – Prior order sets didn’t cover the full pain scale with appropriate dosing because most anesthesia providers expressed concern with opioid doses listed for higher pain scores (7-10). The order set was adjusted to expand first-line treatment dosages to encompass broader pain score ranges and delineate higher opioid dosages for breakthrough pain only. “The new order set helped our nurses receive orders for the full 1-10 pain scale,” says Vargo. “We saw drastic improvements in the quality of our pain medication orders when the new order set was implemented.”
3. Pyxis override policy – Previously, staff in the Pediatric PACU waited for pain medication orders to be approved from pharmacy, which often further delayed the ability to medicate patients. As part of the project, the pediatric pharmacy reviewed the Pyxis override policy and identified medications that didn’t require prior pharmacist approval, including ones that are immediately necessary, require minimum preparation and would compromise the clinical status of the patient by a delay resulting from a pharmacist review. The override policy also includes medications used in situations when the physician controls the ordering, dispensing and administering, such as in the Emergency Department or the OR suite.

Reducing LOS and improving nurse engagement

The interventions were a success. In addition to reduced patient LOS, the pediatric PACU decreased the average time to meet discharge criteria from three hours, 20 minutes to two hours, 6 minutes. It also reduced annualized patient care by more than 3,400 hours and annualized RN hours (assuming a one RN to two patient ratio) by more than 1,700 hours.

Just as important as the numbers, are the benefits related to employee morale. “The changes have helped with collaboration with our anesthesia team,” says Vargo. “We can go to them when we foresee a problem and talk through it. This has truly impacted the care provided by both anesthesia and the PACU.”

In addition, the PACU’s Press Ganey nurse engagement scores have risen from a lower Tier 2 to a Tier 1. “The nurses have the resources to do their jobs and know that we are going to listen to them, understand any issues they have on the unit and work to make them better,” says Vargo.

Last year, the pediatric PACU was awarded nursing unit of the year on Cleveland Clinic’s main campus. “That’s another huge win that speaks to the mindset of our nurses and their dedication to our patients,” says Levay. “We are always looking for better ways to provide care.”