- Email: [email protected]
Decreasing the Length of Stay in Phase I Postanesthesia Care Unit: An Evidence-Based Approach
Decreasing the Length of Stay in Phase I Postanesthesia Care Unit: An Evidence-Based Approach Janet M. McLaren, MSN, RN, Joan A. Reynolds, MBA, RN, Margaret M. Cox, DNP, RN, NP-C, Julie S. Lyall, BSN, RN, CAPA, Maureen McCarthy, BSN, RN, Ellen M. McNoble, BSN, RN, CAPA, Veronica R. Petersen, MSN, RN, CNOR, ANE Patient length of stay (LOS) in the postanesthesia care unit (PACU) Phase I and Phase II influences patient throughput, staff nurse satisfaction, and financial expenditure. The purpose of this project was to determine if reeducation of nursing staff would decrease the LOS in Phase I PACU. The goals of the leadership team were to implement a plan that would result in a decreased LOS, decreased financial expenditure, increased patient throughput, and a change in culture of the work environment. Methods included re-education of nursing staff on American Society of Perianesthesia Nursing (ASPAN) Standards for patient care in Phase I and Phase II PACU. In addition, a pre-survey of the nurses was completed to determine their knowledge of the ASPAN Standards and how they perceived their work environment. Data were collected on the LOS in Phase I for two groups of patients who underwent cystoscopy with stent implantation and hernia repair. The LOS data were collected before and after the staff education. Results of this re-education initiative revealed improved patient throughput, decreased operating room hold time, reduced perioperative expenditure, and an increase in staff nurse satisfaction. An unanticipated result was increased scores on patient satisfaction surveys after the educational initiative. Keywords: throughput, nursing staff satisfaction, financial impact, phase I and phase II PACU, culture. Ó 2015 by American Society of PeriAnesthesia Nurses
Janet M. McLaren, MSN, RN, is the Nurse Educator, Department of Perioperative Services, Long Island Jewish Medical Center, New Hyde Park, NY; Joan A. Reynolds, MBA, RN, is a Staff Nurse, Postanesthesia Care Unit, Long Island Jewish Medical Center, New Hyde Park, NY; Margaret M. Cox, DNP, RN, NP-C, is an Assistant Director of Nursing Education, Long Island Jewish Medical Center, New Hyde Park, NY; Julie S. Lyall, BSN, RN, CAPA, is an Assistant Director of Nursing, Department of Perioperative Services, Long Island Jewish Medical Center, New Hyde Park, NY; Maureen McCarthy, BSN, RN, is the Nurse Manager of the Postanesthesia Care Unit, Long Island Jewish Medical Center, New Hyde Park, NY; Ellen M. McNoble, BSN, RN, CAPA, is the Nurse Manager of the Ambulatory Surgery Unit, Long Island Jewish Medical
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Center, New Hyde Park, NY; and Veronica R. Petersen, MSN, RN, CNOR, ANE, is the Associate Executive Director of Perioperative Services, Long Island Jewish Medical Center, New Hyde Park, NY. Conflict of interest: None to report. Address correspondence to Janet M. McLaren, Department of Perioperative Services, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040; e-mail address: [email protected]. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.05.010
Journal of PeriAnesthesia Nursing, Vol 30, No 2 (April), 2015: pp 116-123
DECREASING LOS IN PHASE I PACU
CULTURE IS DESCRIBED AS THE SET OF SHARED ATTITUDES, values, goals, and practices that characterizes an institution or organization.1 The culture that had evolved over time in this particular Phase I and Phase II postanesthesia care unit (PACU) was one of finger pointing and blame, and both units worked in silos. The Phase I PACU receives patients directly from the operating room (OR) with patients requiring constant nursing observation and basic life-sustaining needs for the immediate postoperative period. Patients are stabilized in Phase I PACU and are then moved to Phase II PACU according to criteria set by the American Society of PeriAnesthesia Nurses (ASPAN) Standards. Efficiently moving patients from Phase I to Phase II PACU is termed throughput.2 The concept of throughput was developed in the industrial world and has been adopted in health care to describe effective and efficient patient processes.3 The efficient flow of patients from Phase I to Phase II decreases the length of stay (LOS) in Phase I resulting in decreased holds in the OR, time that patients are held in the OR owing to lack of space in the PACU. Before this educational initiative, evidence-based practice guidelines were not consistently used for patient throughput from Phase I to Phase II. Over time, the nurses who worked in both units developed an attitude of ‘‘us versus them.’’ A sense of teamwork between the staff of the two units was nonexistent and an overwhelming lack of trust between the units prevailed. Inconsistent practice of the ASPAN standards as related to the discharge criteria from Phase I to Phase II created further negativity between staff members of the two units. For example, if the staff members were not familiar with discharge criteria, they sometimes felt the patient was prematurely transferred from Phase I to Phase II. The effect of decreased patient throughput resulted in a negative culture and dissatisfaction among staff nurses and low patient satisfaction scores. A lack of collaboration permeated the interactions of the staff, which led to frustration of the perioperative team. Often times, it created a chaotic atmosphere in both units, resulting in patients not moving appropriately from Phase I to Phase II PACU. The ripple effect was evidenced by the PACU placing the OR on hold, which then required the OR staff to continue to care for the patient in the OR after the completion of the surgical
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procedure. Even in the midst of this negative culture, patient safety was always maintained. The congestion of patient throughput from Phase I to Phase II created delays for the preoperative patients as well. This led to an increase in anxiety among patients when their surgical procedure times were delayed due to a backlog in the OR, and patients verbalized their dissatisfaction to the staff. Increased OR costs were incurred for staffing and operations in addition to the dissatisfaction and frustration of surgeons, anesthesia providers, and OR nurses. A poor work environment led to financial ramifications for the institution. As a result of these long-standing issues, the leadership team was compelled to evaluate the multiple factors affecting perioperative throughput, which led to this project. After extensive analysis of the factors that negatively impacted throughput, the team recognized that addressing re-education of the staff nurses was crucial. A plan was implemented using ASPAN’s evidence-based practice standards to reeducate the staff nurses. In addition, the existing management team was restructured and several current staff nurses, who were considered informal leaders, were promoted to management positions. The new leadership team supported a shadow experience for Phase I and Phase II nurses to assist in transforming the negative culture and improving the work environment. Together the team envisioned a new culture for the future of the perioperative department.4,5
Purpose The main purpose of this project was to improve perioperative throughput from Phase I to Phase II resulting in decreased patient LOS in Phase I PACU. Other goals were to implement a plan that would result in decreased LOS and financial expenditure, an increase in patient throughput, and a change in culture. Literature Review The purpose of the literature review was to ascertain whether other tertiary facilities were experiencing similar challenges and if so, what solutions were implemented. The challenges faced on a daily basis were OR holds, low nurse
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satisfaction scores, and decreased throughput from Phase I to Phase II. Before the start of the project, a comprehensive literature search was conducted using the Cumulative Index to Nursing and Allied Health Literature and Google Scholar search engines with the following keywords: ‘‘PACU,’’ ‘‘throughput,’’ ‘‘operating room traffic patterns,’’ ‘‘Phase I,’’ and ‘‘Phase II.’’ The search yielded limited data in the above areas. The greatest impact on Phase I PACU was inefficient patient flow from Phase I to Phase II PACU and the use of Phase I PACU for in-patient overflow when the hospital had no bed availability. Ziser et al6 identified the use of the PACU for intensive care unit (ICU) patient overflow and the lack of bed availability as a reason for delays. Schweizer et al7 report that PACU beds decrease the need for more ICU beds. Another cause for the retention of patients in PACU was the acuity of the patients. Samad et al8 stated that delays and overstays are caused by factors such as further monitoring, anesthesia sign out, pain management, and surgical complications. The next challenge was related to the lack of adherence to evidence-based guidelines to move patients through the different PACU phases. Studies such as Mamaril’s evaluated fast-tracking patients9 where a patient is transferred directly from the OR to Phase II when meeting PACU discharge criteria. Fairbanks10 implemented a Six Sigma methodology to improve OR throughput. Six Sigma is a methodology that has been adopted by health care systems to improve workflow and streamline a process. Brown et al11 implemented a set of predetermined discharge criteria to reduce PACU LOS. This study attributed some of the delays and inability to obtain physicians order and also supported the nurse determining the patient’s readiness for discharge. White et al12 stated that anesthesiologists play an important role in implementing fast-track programs. Better planning can improve patient care such as premedication, anesthetic choice, and pain management. Staffing is another significant challenge.13 Owing to the increased acuity of patients, there is a greater need for critical care educated nurses, a challenge in an environment of a nursing shortage.14 A change in staffing patterns throughout the day was suggested as a solution. Based on the results
of the literature search, our team decided to create this staff nurse–focused project.
Methods Re-education An anonymous survey was completed by the staff nurses of both units, which identified an educational deficit related to the standards of care in Phase I and Phase II PACU. The survey was designed to identify problems and consisted of questions on the following topics: (1) the discharge criteria, as defined by the hospital policies and procedures and the ASPAN Standards for patients in Phase I and Phase II PACU; (2) the staff nurses’ perception of their colleagues’ responsibilities; and (3) the staff nurses’ perceptions of collaboration among Phase I and Phase II PACU nurses. Analysis of the results identified the need to address the issues through education. The leadership team developed an in-service education for the staff nurses in Phase I and Phase II PACU. Education was developed based on hospital policies and ASPAN Standards for the perianesthesia patient. We focused on the components of ASPAN Phase I and Phase II discharge criteria. An educational tool was created that defined Phase I and Phase II and the level of patient care that should be provided by the Registered Nurse (RN). Components of the tool included assessing the postoperative patient, including the Aldrete score, and the transition process leading to discharge from Phase I and Phase II. The RNs also participated in a shadowing experience where they worked a shift in the opposite unit (eg, Phase I RN shadowed a Phase II RN and vice versa). The goal of the shadow experience was to promote a culture of collegiality and foster teamwork. The education was conducted using mini inservices in small groups, lasting 20 to 30 minutes. Each unit received the same information, which was presented by both a staff nurse and the leadership team. The staff nurses were also given handouts of the ASPAN Standards and hospital policies on caring for patients in Phase I and Phase II PACU, and the educational tool created was placed in a binder that is kept on each unit. Often, the gold standard of PACU throughput is LOS. The leadership group attempted to measure
DECREASING LOS IN PHASE I PACU
the success of the re-education project by measuring the LOS of specifically identified patients. The identified patients were ambulatory surgery cases undergoing either hernia repair or cystoscopy with stent implantation. Culture Change Senior leadership recognized that a need existed to change the culture of the perioperative services and the first step was to change the nursing leadership. The new leadership team began by modeling behaviors that use the theory of transformational leadership to effect change. Transformational leadership is described as ‘‘leader behaviors that transform and inspire followers to perform beyond expectations while transcending self-interest for the good of the organization.’’15,16 The leaders created an atmosphere of trust by respecting the staff and empowering them to be part of the process. Several approaches were used to transform the culture. The shadow experience program began in September 2012 and was conducted over the course of a 7-month period, ending in March 2013. During this time frame, staff nurses from Phase II rotated to Phase I and shadowed the RN through the Phase I PACU process. The Phase II staff nurse was present from the patient’s admission to Phase I from the OR and remained with the patient until the patient met discharge criteria based on ASPAN Standards to move to the Phase II area. The same scenario played out for the Phase I PACU nurse with the shadow experience process in Phase II. The staff nurses were able to see the workflow of the Phase II area once the patient arrived from Phase I and up to the point of discharge to home or other environment of care. Shared governance was employed by conducting daily briefs to allow the staff an opportunity to provide their input related to throughput solutions. A buy-in of the staff was needed for the culture change not only to take place but also to be a success. The Nurse Managers of the Phase I and Phase II PACU wanted the staff to share the same vision and goals as the organization. The negative implications for the institution due to delayed throughput of patients from Phase I to Phase II PACU was discussed with the staff at daily huddles
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and staff meetings. Leadership presented this in a positive manner again ensuring staff that they are part of the process. The nurse managers modeled the desirable behavior that they wanted to create. Change from the top down would send a clear message to all staff that we were a team working toward the same outcomes. The leadership team was frequently in contact to promote the collaboration in each unit, which fostered a sense of teamwork. Rounding in the units by leadership became vital in expediting throughput, and teamwork was essential for the busy units to be successful in achieving their goals.
Results The results of the pre-survey of the RNs revealed that the top three reasons for patient delay in moving from Phase I to Phase II were nausea/vomiting, pain, and voiding. These three variables were the reasons for the delay in patient throughput. After implementation of educational inservices, which included ASPAN Standards and criteria for management of these variables, the time from Phase I to Phase II decreased by 20% for patients who underwent a cystoscopy with stent or hernia repair. Other results from the pre-survey indicated that nurses on both units had a misconception of the other’s roles. For example, there was a resistance from the Phase II RNs regarding the transfer of the patient from Phase I if the patient had not voided or was not tolerating oral intake of fluids. These criteria are not required for the transfer of care from Phase I to Phase II PACU. The shadow experience was instrumental in the staff nurses appreciation of the workflow in both units. It also highlighted some of the challenges in the PACU process that could occur throughout the recovery continuum. The shadowing experience not only brought about appreciation of the workflow, but also more importantly, it brought about camaraderie and respect, something that was lacking before the implementation of this project. Another outcome noted was a significant decrease in OR holds from the first quarter to the second quarter of 2013. In the first quarter of 2013, there were 132 cases placed on hold. These OR holds were directly related to the lack of availability of
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Figure 1. Operating room holds versus expenditures. This figure is available in color online at www.jopan.org.
PACU beds, indicative of poor throughput. The 132 cases placed on hold in the OR translated into 99 hours at a baseline OR cost of $68,805. During the second quarter of 2013, there was a reduction of OR holds to 100 cases. These cases translated into 34 hours of OR time at a cost of $23,630 resulting in a $45,175 reduction in perioperative expenditure (Figure 1). Also noted was that the volume of cases in the first quarter of 2013 was 403 fewer patients than that of the second quarter of 2013 (Figure 2). Further data supporting the implementation of this plan included the National Database of Nursing Quality Indicators (NDNQI) RN Survey related to Practice Environment Scale and Job
Satisfaction from April 2012 through April 2013. The Phase II PACU nursing results showed an increase of 9.77% and the Phase I PACU nursing results showed an increase of 20.15% (Figure 3). Improved patient satisfaction was also noted as a result of this project. The hospital’s Press Ganey results for both the Phase I and Phase II PACU had significant improvements in ‘‘Likelihood to recommend.’’ The Phase II unit increased by 1.40% and Phase I PACU increased by 5.60%.
Discussion During this 1-year period, the elements of this problem were identified and interventions were
Figure 2. Total patient volume in 2013. This figure is available in color online at www.jopan.org.
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Figure 3. 2012-2013 NDNQI Perioperative Practice Environment Scale. NDNQI, National Database of Nursing Quality Indicators. This figure is available in color online at www.jopan.org.
implemented. The goals of the leadership team were to increase the staff nurses knowledge of Phase I and Phase II PACU, decrease OR holds, and ultimately improve perioperative throughput. The most distinguishable outcome was a culture change. As a result of the nursing education and the staff nurse shadow program, not only did the nursing staff gain valuable knowledge and empathy for their colleagues in the respective units but they were also empowered by the leadership team to participate in the changes creating the buy-in atmosphere that was ultimately the teams’ goal. The leadership team also role modeled the behavior of collaboration among themselves. As the new managers’ role modeled collegial behavior, they were able to influence the staff on the frontlines prompting innovation at the bedside. They worked as a team to set forth the expectation for all staff to be proactive and work as a larger team with a focused goal of increased throughput. During the education, the method used to present the learning tool that comprised the ASPAN Standards2 and hospital policy, specifically the criteria for which a patient could be moved from Phase I to Phase II PACU, made a huge impact. This information was created and presented in a manner that would elicit the interest of the staff nurses and was also reinforced during all briefs and huddles. Using these methods of delivery, the staff gained a
sense of partnership and empowerment. Every staff nurse on all shifts was included in the re-education process and a resource binder was created and was housed on the units as reinforcement. The most significant finding was the result of NDNQI RN Survey and the Press Ganey Survey results for both Phase I and Phase II PACU units. The NDNQI results were the two highest increases in the perioperative department. The overall hospital results were significantly higher in 2013, and the perioperative department as a whole showed the greatest improvement among all of the nursing departments in the hospital. The data related to the decrease in OR holds speak to the measurable success and financial impact of this project saving at least $46,000 in a 3-month period. In addition to re-education and the shadow experience, we believe that other factors that may have contributed to improved patient satisfaction scores were hourly rounding by the nurse managers and the implementation of an open visitation policy. The open visitation policy was adopted by the hospital administration owing to new regulatory policies. Family members were provided an opportunity for more frequent bedside visits, and the nursing leadership was visible to patients and families owing to the hourly rounding. Anecdotally, family members were expressing praise for
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services provided where patients may not have recalled the high-quality care they received owing to anesthetic medication.
Implications for Nursing Improvement in the relationship of staff members through the shadowing experience, cross-training, and increased collaboration between the nurses in the two distinct units has assisted in the dramatic improvement of scores on the NDNQI RN Survey as noted. Regular meetings between staff and management of Phase I and Phase II PACU will continue to ensure open lines of communication among the nursing staff. The hospital has a ‘‘rave award’’ that recognizes units with the most improvement. Both Phase I and Phase II PACU received this award after the educational initiative. This bolstered the morale of the nurses, thereby further strengthening their relationship.
Limitations Although the results shows a 20% decrease in LOS for the two types of surgical procedures analyzed in the project, we did not do a subanalysis of the three variables, such as nausea/vomiting, pain, and voiding, but we concluded that re-education of the nurses according to the ASPAN Standards2 improved throughput. The nurses were more aware of how to manage the patient’s pain, voiding, and nausea/vomiting. We recommend further study using these variables. We also did not analyze patients who were admitted to in-patient status and patients who had delayed discharge in Phase II. These are other factors to be considered for future study.
Conclusion The team achieved the goals as evidenced by the significant decrease in OR hold rates, indicating improvement in perioperative throughput. In the end, the team was most proud of the improved morale, improved efficiency, and increased teamwork between the perioperative team. Empowering nurses with knowledge led to increased efficiency, decreased costs, and increased throughput. In addition, the opportunity to shadow a colleague was an important part of this process to create a positive culture change. To sustain the plan, a continuing education program is in place for Phase I and II staff nurses, along with hourly rounding by the nurse managers to assure continued adherence. The team will continue to conduct audits on a regular basis to measure sustainability. This initiative resulted in increased throughput in the perioperative area of a tertiary teaching hospital, which performs 20,000 cases a year. In conclusion, by surveying the RNs before implementing the education, using the ASPAN Standards2 to educate the staff and analyzing LOS before and after education, we were able to decrease the LOS in Phase I PACU by 20%, which resulted in a cost savings of $46,000 over a 3-month period. The initiative produced cost savings by decreasing overtime for the entire perioperative department, and decreased costs for the institution and improved OR utilization. We expect that the improved PACU throughput will continue to result in improved nursing, patient, and family satisfaction.
References 1. Culture. (n.d.) Webster M. Merriam-Webster Online Dictionary. Chicago, IL: Encyclopaedia Britannica Company; 2006. 2. American Society of Perianesthesia Nurses. Perianesthesia Nursing Standards, Practice Recommendations and Interpretive statements. Cherry Hill, NJ: American Society of Perianesthesia Nurses; 2012-2014. 3. Kujala J, Lillrank P, Kronstr€ om V, Peltokorpi A. Time-based management of patient processes. J Health Organ Manag. 2006;20:512-524. 4. Frazer E. Culture and change. Air Med J. 2012;31:194-196. 5. Ferrara-Love R. Changing organizational culture to implement organizational change. J Perianesth Nurs. 1997; 12:12-16.
6. Ziser A. The postanaesthesia care unit as a temporary admission location due to intensive care and ward overflow. Br J Anaesth. 2002;88:577-579. 7. Schweizer A. Opening of a new postanesthesia care unit: Impact on critical care utilization and complications following major vascular and thoracic surgery. J Clin Anesth. 2002;14:486-493. 8. Samad K. Unplanned prolonged postanaesthesia care unit length of stay and factors affecting it. J Pak Med Assoc. 2006;56: 108-112. 9. Mamaril M. Fast-tracking the postanesthesia patient: The pros and cons. J Perianesth Nurs. 2000;15:89-93. 10. Fairbanks CB. Using Six Sigma and Lean methodologies to improve OR throughput. AORN J. 2007;86:73-82.
DECREASING LOS IN PHASE I PACU 11. Brown I, Jellish WS. Use of postanesthesia discharge criteria to reduce discharge delays for inpatients in the postanesthesia care unit. J Clin Anesth. 2008;20:175-179. 12. White PF. Fast-track anesthetic techniques for ambulatory surgery. Curr Opin Anaesthesiol. 2007;20:545-557. 13. Mamaril ME. Safe staffing for the post anesthesia care unit: Weighing the evidence and identifying the gaps. J Perianesth Nurs. 2007;22:393-399.
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14. Heuston MM, Wolf GA. Transformational leadership skills of successful nurse managers. J Nurs Adm. 2011;41: 248-251. 15. Johnson K, Johnson C. Make an impact with transformational leadership and shared governance. Nurs Manage. 2012; 43:12-17. 16. Tinkham MR. The road to magnet: Encouraging transformational leadership. AORN J. 2013;98:186-188.
Janet M. McLaren, MSN, RN, is the Nurse Educator, Department of Perioperative Services, Long Island Jewish Medical Center, New Hyde Park, NY; Joan A. Reynolds, MBA, RN, is a Staff Nurse, Postanesthesia Care Unit, Long Island Jewish Medical Center, New Hyde Park, NY; Margaret M. Cox, DNP, RN, NP-C, is an Assistant Director of Nursing Education, Long Island Jewish Medical Center, New Hyde Park, NY; Julie S. Lyall, BSN, RN, CAPA, is an Assistant Director of Nursing, Department of Perioperative Services, Long Island Jewish Medical Center, New Hyde Park, NY; Maureen McCarthy, BSN, RN, is the Nurse Manager of the Postanesthesia Care Unit, Long Island Jewish Medical Center, New Hyde Park, NY; Ellen M. McNoble, BSN, RN, CAPA, is the Nurse Manager of the Ambulatory Surgery Unit, Long Island Jewish Medical
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Center, New Hyde Park, NY; and Veronica R. Petersen, MSN, RN, CNOR, ANE, is the Associate Executive Director of Perioperative Services, Long Island Jewish Medical Center, New Hyde Park, NY. Conflict of interest: None to report. Address correspondence to Janet M. McLaren, Department of Perioperative Services, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040; e-mail address: [email protected]. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.05.010
Journal of PeriAnesthesia Nursing, Vol 30, No 2 (April), 2015: pp 116-123
DECREASING LOS IN PHASE I PACU
CULTURE IS DESCRIBED AS THE SET OF SHARED ATTITUDES, values, goals, and practices that characterizes an institution or organization.1 The culture that had evolved over time in this particular Phase I and Phase II postanesthesia care unit (PACU) was one of finger pointing and blame, and both units worked in silos. The Phase I PACU receives patients directly from the operating room (OR) with patients requiring constant nursing observation and basic life-sustaining needs for the immediate postoperative period. Patients are stabilized in Phase I PACU and are then moved to Phase II PACU according to criteria set by the American Society of PeriAnesthesia Nurses (ASPAN) Standards. Efficiently moving patients from Phase I to Phase II PACU is termed throughput.2 The concept of throughput was developed in the industrial world and has been adopted in health care to describe effective and efficient patient processes.3 The efficient flow of patients from Phase I to Phase II decreases the length of stay (LOS) in Phase I resulting in decreased holds in the OR, time that patients are held in the OR owing to lack of space in the PACU. Before this educational initiative, evidence-based practice guidelines were not consistently used for patient throughput from Phase I to Phase II. Over time, the nurses who worked in both units developed an attitude of ‘‘us versus them.’’ A sense of teamwork between the staff of the two units was nonexistent and an overwhelming lack of trust between the units prevailed. Inconsistent practice of the ASPAN standards as related to the discharge criteria from Phase I to Phase II created further negativity between staff members of the two units. For example, if the staff members were not familiar with discharge criteria, they sometimes felt the patient was prematurely transferred from Phase I to Phase II. The effect of decreased patient throughput resulted in a negative culture and dissatisfaction among staff nurses and low patient satisfaction scores. A lack of collaboration permeated the interactions of the staff, which led to frustration of the perioperative team. Often times, it created a chaotic atmosphere in both units, resulting in patients not moving appropriately from Phase I to Phase II PACU. The ripple effect was evidenced by the PACU placing the OR on hold, which then required the OR staff to continue to care for the patient in the OR after the completion of the surgical
117
procedure. Even in the midst of this negative culture, patient safety was always maintained. The congestion of patient throughput from Phase I to Phase II created delays for the preoperative patients as well. This led to an increase in anxiety among patients when their surgical procedure times were delayed due to a backlog in the OR, and patients verbalized their dissatisfaction to the staff. Increased OR costs were incurred for staffing and operations in addition to the dissatisfaction and frustration of surgeons, anesthesia providers, and OR nurses. A poor work environment led to financial ramifications for the institution. As a result of these long-standing issues, the leadership team was compelled to evaluate the multiple factors affecting perioperative throughput, which led to this project. After extensive analysis of the factors that negatively impacted throughput, the team recognized that addressing re-education of the staff nurses was crucial. A plan was implemented using ASPAN’s evidence-based practice standards to reeducate the staff nurses. In addition, the existing management team was restructured and several current staff nurses, who were considered informal leaders, were promoted to management positions. The new leadership team supported a shadow experience for Phase I and Phase II nurses to assist in transforming the negative culture and improving the work environment. Together the team envisioned a new culture for the future of the perioperative department.4,5
Purpose The main purpose of this project was to improve perioperative throughput from Phase I to Phase II resulting in decreased patient LOS in Phase I PACU. Other goals were to implement a plan that would result in decreased LOS and financial expenditure, an increase in patient throughput, and a change in culture. Literature Review The purpose of the literature review was to ascertain whether other tertiary facilities were experiencing similar challenges and if so, what solutions were implemented. The challenges faced on a daily basis were OR holds, low nurse
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satisfaction scores, and decreased throughput from Phase I to Phase II. Before the start of the project, a comprehensive literature search was conducted using the Cumulative Index to Nursing and Allied Health Literature and Google Scholar search engines with the following keywords: ‘‘PACU,’’ ‘‘throughput,’’ ‘‘operating room traffic patterns,’’ ‘‘Phase I,’’ and ‘‘Phase II.’’ The search yielded limited data in the above areas. The greatest impact on Phase I PACU was inefficient patient flow from Phase I to Phase II PACU and the use of Phase I PACU for in-patient overflow when the hospital had no bed availability. Ziser et al6 identified the use of the PACU for intensive care unit (ICU) patient overflow and the lack of bed availability as a reason for delays. Schweizer et al7 report that PACU beds decrease the need for more ICU beds. Another cause for the retention of patients in PACU was the acuity of the patients. Samad et al8 stated that delays and overstays are caused by factors such as further monitoring, anesthesia sign out, pain management, and surgical complications. The next challenge was related to the lack of adherence to evidence-based guidelines to move patients through the different PACU phases. Studies such as Mamaril’s evaluated fast-tracking patients9 where a patient is transferred directly from the OR to Phase II when meeting PACU discharge criteria. Fairbanks10 implemented a Six Sigma methodology to improve OR throughput. Six Sigma is a methodology that has been adopted by health care systems to improve workflow and streamline a process. Brown et al11 implemented a set of predetermined discharge criteria to reduce PACU LOS. This study attributed some of the delays and inability to obtain physicians order and also supported the nurse determining the patient’s readiness for discharge. White et al12 stated that anesthesiologists play an important role in implementing fast-track programs. Better planning can improve patient care such as premedication, anesthetic choice, and pain management. Staffing is another significant challenge.13 Owing to the increased acuity of patients, there is a greater need for critical care educated nurses, a challenge in an environment of a nursing shortage.14 A change in staffing patterns throughout the day was suggested as a solution. Based on the results
of the literature search, our team decided to create this staff nurse–focused project.
Methods Re-education An anonymous survey was completed by the staff nurses of both units, which identified an educational deficit related to the standards of care in Phase I and Phase II PACU. The survey was designed to identify problems and consisted of questions on the following topics: (1) the discharge criteria, as defined by the hospital policies and procedures and the ASPAN Standards for patients in Phase I and Phase II PACU; (2) the staff nurses’ perception of their colleagues’ responsibilities; and (3) the staff nurses’ perceptions of collaboration among Phase I and Phase II PACU nurses. Analysis of the results identified the need to address the issues through education. The leadership team developed an in-service education for the staff nurses in Phase I and Phase II PACU. Education was developed based on hospital policies and ASPAN Standards for the perianesthesia patient. We focused on the components of ASPAN Phase I and Phase II discharge criteria. An educational tool was created that defined Phase I and Phase II and the level of patient care that should be provided by the Registered Nurse (RN). Components of the tool included assessing the postoperative patient, including the Aldrete score, and the transition process leading to discharge from Phase I and Phase II. The RNs also participated in a shadowing experience where they worked a shift in the opposite unit (eg, Phase I RN shadowed a Phase II RN and vice versa). The goal of the shadow experience was to promote a culture of collegiality and foster teamwork. The education was conducted using mini inservices in small groups, lasting 20 to 30 minutes. Each unit received the same information, which was presented by both a staff nurse and the leadership team. The staff nurses were also given handouts of the ASPAN Standards and hospital policies on caring for patients in Phase I and Phase II PACU, and the educational tool created was placed in a binder that is kept on each unit. Often, the gold standard of PACU throughput is LOS. The leadership group attempted to measure
DECREASING LOS IN PHASE I PACU
the success of the re-education project by measuring the LOS of specifically identified patients. The identified patients were ambulatory surgery cases undergoing either hernia repair or cystoscopy with stent implantation. Culture Change Senior leadership recognized that a need existed to change the culture of the perioperative services and the first step was to change the nursing leadership. The new leadership team began by modeling behaviors that use the theory of transformational leadership to effect change. Transformational leadership is described as ‘‘leader behaviors that transform and inspire followers to perform beyond expectations while transcending self-interest for the good of the organization.’’15,16 The leaders created an atmosphere of trust by respecting the staff and empowering them to be part of the process. Several approaches were used to transform the culture. The shadow experience program began in September 2012 and was conducted over the course of a 7-month period, ending in March 2013. During this time frame, staff nurses from Phase II rotated to Phase I and shadowed the RN through the Phase I PACU process. The Phase II staff nurse was present from the patient’s admission to Phase I from the OR and remained with the patient until the patient met discharge criteria based on ASPAN Standards to move to the Phase II area. The same scenario played out for the Phase I PACU nurse with the shadow experience process in Phase II. The staff nurses were able to see the workflow of the Phase II area once the patient arrived from Phase I and up to the point of discharge to home or other environment of care. Shared governance was employed by conducting daily briefs to allow the staff an opportunity to provide their input related to throughput solutions. A buy-in of the staff was needed for the culture change not only to take place but also to be a success. The Nurse Managers of the Phase I and Phase II PACU wanted the staff to share the same vision and goals as the organization. The negative implications for the institution due to delayed throughput of patients from Phase I to Phase II PACU was discussed with the staff at daily huddles
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and staff meetings. Leadership presented this in a positive manner again ensuring staff that they are part of the process. The nurse managers modeled the desirable behavior that they wanted to create. Change from the top down would send a clear message to all staff that we were a team working toward the same outcomes. The leadership team was frequently in contact to promote the collaboration in each unit, which fostered a sense of teamwork. Rounding in the units by leadership became vital in expediting throughput, and teamwork was essential for the busy units to be successful in achieving their goals.
Results The results of the pre-survey of the RNs revealed that the top three reasons for patient delay in moving from Phase I to Phase II were nausea/vomiting, pain, and voiding. These three variables were the reasons for the delay in patient throughput. After implementation of educational inservices, which included ASPAN Standards and criteria for management of these variables, the time from Phase I to Phase II decreased by 20% for patients who underwent a cystoscopy with stent or hernia repair. Other results from the pre-survey indicated that nurses on both units had a misconception of the other’s roles. For example, there was a resistance from the Phase II RNs regarding the transfer of the patient from Phase I if the patient had not voided or was not tolerating oral intake of fluids. These criteria are not required for the transfer of care from Phase I to Phase II PACU. The shadow experience was instrumental in the staff nurses appreciation of the workflow in both units. It also highlighted some of the challenges in the PACU process that could occur throughout the recovery continuum. The shadowing experience not only brought about appreciation of the workflow, but also more importantly, it brought about camaraderie and respect, something that was lacking before the implementation of this project. Another outcome noted was a significant decrease in OR holds from the first quarter to the second quarter of 2013. In the first quarter of 2013, there were 132 cases placed on hold. These OR holds were directly related to the lack of availability of
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Figure 1. Operating room holds versus expenditures. This figure is available in color online at www.jopan.org.
PACU beds, indicative of poor throughput. The 132 cases placed on hold in the OR translated into 99 hours at a baseline OR cost of $68,805. During the second quarter of 2013, there was a reduction of OR holds to 100 cases. These cases translated into 34 hours of OR time at a cost of $23,630 resulting in a $45,175 reduction in perioperative expenditure (Figure 1). Also noted was that the volume of cases in the first quarter of 2013 was 403 fewer patients than that of the second quarter of 2013 (Figure 2). Further data supporting the implementation of this plan included the National Database of Nursing Quality Indicators (NDNQI) RN Survey related to Practice Environment Scale and Job
Satisfaction from April 2012 through April 2013. The Phase II PACU nursing results showed an increase of 9.77% and the Phase I PACU nursing results showed an increase of 20.15% (Figure 3). Improved patient satisfaction was also noted as a result of this project. The hospital’s Press Ganey results for both the Phase I and Phase II PACU had significant improvements in ‘‘Likelihood to recommend.’’ The Phase II unit increased by 1.40% and Phase I PACU increased by 5.60%.
Discussion During this 1-year period, the elements of this problem were identified and interventions were
Figure 2. Total patient volume in 2013. This figure is available in color online at www.jopan.org.
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Figure 3. 2012-2013 NDNQI Perioperative Practice Environment Scale. NDNQI, National Database of Nursing Quality Indicators. This figure is available in color online at www.jopan.org.
implemented. The goals of the leadership team were to increase the staff nurses knowledge of Phase I and Phase II PACU, decrease OR holds, and ultimately improve perioperative throughput. The most distinguishable outcome was a culture change. As a result of the nursing education and the staff nurse shadow program, not only did the nursing staff gain valuable knowledge and empathy for their colleagues in the respective units but they were also empowered by the leadership team to participate in the changes creating the buy-in atmosphere that was ultimately the teams’ goal. The leadership team also role modeled the behavior of collaboration among themselves. As the new managers’ role modeled collegial behavior, they were able to influence the staff on the frontlines prompting innovation at the bedside. They worked as a team to set forth the expectation for all staff to be proactive and work as a larger team with a focused goal of increased throughput. During the education, the method used to present the learning tool that comprised the ASPAN Standards2 and hospital policy, specifically the criteria for which a patient could be moved from Phase I to Phase II PACU, made a huge impact. This information was created and presented in a manner that would elicit the interest of the staff nurses and was also reinforced during all briefs and huddles. Using these methods of delivery, the staff gained a
sense of partnership and empowerment. Every staff nurse on all shifts was included in the re-education process and a resource binder was created and was housed on the units as reinforcement. The most significant finding was the result of NDNQI RN Survey and the Press Ganey Survey results for both Phase I and Phase II PACU units. The NDNQI results were the two highest increases in the perioperative department. The overall hospital results were significantly higher in 2013, and the perioperative department as a whole showed the greatest improvement among all of the nursing departments in the hospital. The data related to the decrease in OR holds speak to the measurable success and financial impact of this project saving at least $46,000 in a 3-month period. In addition to re-education and the shadow experience, we believe that other factors that may have contributed to improved patient satisfaction scores were hourly rounding by the nurse managers and the implementation of an open visitation policy. The open visitation policy was adopted by the hospital administration owing to new regulatory policies. Family members were provided an opportunity for more frequent bedside visits, and the nursing leadership was visible to patients and families owing to the hourly rounding. Anecdotally, family members were expressing praise for
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services provided where patients may not have recalled the high-quality care they received owing to anesthetic medication.
Implications for Nursing Improvement in the relationship of staff members through the shadowing experience, cross-training, and increased collaboration between the nurses in the two distinct units has assisted in the dramatic improvement of scores on the NDNQI RN Survey as noted. Regular meetings between staff and management of Phase I and Phase II PACU will continue to ensure open lines of communication among the nursing staff. The hospital has a ‘‘rave award’’ that recognizes units with the most improvement. Both Phase I and Phase II PACU received this award after the educational initiative. This bolstered the morale of the nurses, thereby further strengthening their relationship.
Limitations Although the results shows a 20% decrease in LOS for the two types of surgical procedures analyzed in the project, we did not do a subanalysis of the three variables, such as nausea/vomiting, pain, and voiding, but we concluded that re-education of the nurses according to the ASPAN Standards2 improved throughput. The nurses were more aware of how to manage the patient’s pain, voiding, and nausea/vomiting. We recommend further study using these variables. We also did not analyze patients who were admitted to in-patient status and patients who had delayed discharge in Phase II. These are other factors to be considered for future study.
Conclusion The team achieved the goals as evidenced by the significant decrease in OR hold rates, indicating improvement in perioperative throughput. In the end, the team was most proud of the improved morale, improved efficiency, and increased teamwork between the perioperative team. Empowering nurses with knowledge led to increased efficiency, decreased costs, and increased throughput. In addition, the opportunity to shadow a colleague was an important part of this process to create a positive culture change. To sustain the plan, a continuing education program is in place for Phase I and II staff nurses, along with hourly rounding by the nurse managers to assure continued adherence. The team will continue to conduct audits on a regular basis to measure sustainability. This initiative resulted in increased throughput in the perioperative area of a tertiary teaching hospital, which performs 20,000 cases a year. In conclusion, by surveying the RNs before implementing the education, using the ASPAN Standards2 to educate the staff and analyzing LOS before and after education, we were able to decrease the LOS in Phase I PACU by 20%, which resulted in a cost savings of $46,000 over a 3-month period. The initiative produced cost savings by decreasing overtime for the entire perioperative department, and decreased costs for the institution and improved OR utilization. We expect that the improved PACU throughput will continue to result in improved nursing, patient, and family satisfaction.
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