OR Manager - March 2020 - 16

Back to basics: How collaboration can improve PACU patient flow
Performance improvement
ealthcare technology can be a
great thing, but nurses at Abington-Jefferson
Health, in Abington,
Pennsylvania, have discovered that
sometimes stepping back from it is the
best way to make progress. Going lowtech
was the key that unlocked patient
flow gridlock that had plagued the postanesthesia
care unit (PACU).
H
Jennifer
Prater,
BSN, RN,
CCRN, CPAN
Before 2017, PACU
staff had experienced
long holding times, and
some patients never received
bed assignments.
" We were discharging
some patients
directly home after a
day or two in the PACU, "
says Jennifer Prater,
BSN, RN, CCRN, CPAN,
nurse manager, PACU and Same Day
Post Op. " We felt that was a disservice
to the patients because they might have
missed some services they would have
gotten on an inpatient unit, such as
case management and other resources
that are not in the PACU's usual scope
of practice. "
The situation reached a tipping point
when some critical-care patients were
held and cared for in the PACU until
discharge. Patients received the standard
of care, but it wasn't through the
normal pathway. " They never got an
ICU bed, and they did not get care in
the step-down unit, either. They missed
two steps of their care, " says Katie
Domrzalski, BSN, RN, team coordinator,
PACU and Same Day Post Op.
Despite the fact that all PACU nurses
are qualified to provide ICU care, patients
and staff alike were frustrated by
the situation. " The nurses felt like they
couldn't give the most optimal care, "
says Prater. " PACU is designed to be a
transitional unit, and as the manager, I
was holding my breath because boarding
patients put us at a high risk to
make errors. We had to figure out a better
way. "
In 2017, the PACU nurses decided
it was time to take back surgical flow.
16
OR Manager | March 2020
Taking seven steps out of the bed
assignment process has cut time in half.
After 2 years of data collection on patient
flow and hold times, Prater and
Domrzalski developed a simplified bed
assignment plan, which was approved
for a trial by the director of the Patient
Flow Center (PFC) in spring 2017. The
PFC is kept very busy controlling all bed
assignments and patient flow throughout
the organization, so the director
and staff were receptive to an idea that
might streamline their processes. " They
decided to give it a try and see how it
worked, " says Prater.
The preliminary plan was launched in
July 2017 along with the Surgical Flow
Collaborative. The collaborative included
management, and PACU and postoperative
surgical nurses met biweekly to
monitor and fine-tune the plan. Their
process included assessing the new
plan and barriers to efficiency, developing
strategies to overcome obstacles,
and creating metrics to measure progress.
All decisions were made by group
consensus. By January 2018, the process
had been streamlined enough to
reduce meetings to a monthly schedule.
Eliminating time-consuming steps
The old process included a total of 14
steps to getting a bed assignment,
many of which were done electronically.
" There were a lot of barriers in the process, "
says Prater. " First, we would
send a message to the PFC and assume
it had been received. Then the
PFC would call the floor and wait for the
charge nurse to call back with a bed
assignment. Because the PFC is busy
managing multiple, complex processes,
there were times when a bed was ready
for quite a while before they had a
chance to enter it into the system. Each
of these steps took more time, which
all added up. "
In the new plan, a PACU nurse calls
the floor charge nurse directly when a
patient has met PACU discharge criteria
and is ready for a bed. This eliminates
seven time-consuming steps, cutting
the process in half and saving significant
time.
" The goal now is to receive a bed assignment
on the first call to the charge
nurse, " says Domrzalski. " If there are
no empty beds, a time is discussed and
set to get one. " For example, the PACU
and unit charge nurses will discuss the
times of imminent discharges and the
patients who may be ready to be moved
to another level of care, which will open
beds. This tactic is especially helpful
in getting critical-care surgical patients
to the ICU as quickly as possible. They
also agree on the time the primary
nurse will take report and what to do if
that nurse in not available at that time.
" We set time goals for each step of the
way, " says Domrzalski.
The data speaks for itself, and staff
continue to collect and monitor the
times from when patients meet PACU
discharge criteria to when they are transported
out. The findings are startling:
* flow times dropped from an average
PACU wait time of 59.6 minutes in
April 2017 to a wait time of 33.7
minutes in August 2019
* OR/PACU holds decreased from 42
holds/month (552 minutes) in April
2017 to zero OR/PACU holds in August
2019.
Taking a step back
Despite the success of the new patient
flow model, there were concerns
about the plan initially, says Prater. " I
did not know how the process would
be received because it felt like we were
taking a step backward. The centralized
PFC was a new concept at the time, and
our plan was eliminating the electronic
technology piece of it, " she says.
The primary role of the centralized
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OR Manager - March 2020

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