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The recovery room as special procedures unit
Marilyn Schneider, RN
The recovery room as special procedures unit
Recovery rooms throughout the nation are being used for various procedures scheduled by anesthesiologists or specialty physicians. These are procedures such as epidural blocks, elective cardioversion, and electroconvulsive therapy, that, in most hospitals, are performed in operating rooms, coronary care units or other special units. What is the impact of this activity on the patient, the recovery room staff, and the operating room staff! Special care needs of patients undergoing these procedures must be identified and met when special procedures are a routine recovery room function. At the Florida Society of Anesthesiologists 11th Annual Seminar for Recovery Room Nurses in Orlando, Fla, on Oct 31, 1980, a questionnaire was
Marilyn Schneider, RN, is assistant clinical supervisor of the postanesthesia recovery room at Doctors’Hospital of Prince Georges County, Lanham, Md. She is an associate degree graduate of Brooklyn (NY) College.
490
distributed informally to attendees (Table 1). This questionnaire was developed to identify special procedures being performed in recovery rooms the extent to which these procedures are being performed patient care needs associated with each specified procedure nurses’ responsibility in assisting with the procedures staffing needs due to the added workload legal implications. Of almost 100 questionnaires returned, 53 indicated that at least one special procedure was being performed in that recovery room. These questionnaires represented hospitals in 33 states, including the District of Columbia. The balance of the questionnaires were returned unanswered or with the comment, “We don’t do any of these,” and no other information was provided. Although the survey was informal, it did bring to light a recovery room nursing activity that has not been addressed previously. Procedures being performed routinely are listed in Table 2. A number of respondents indicated that more than one special procedure was being performed in that recovery room. The majority of these procedures were performed by an anesthesiologist, who assumed full medical responsibility for the patient in the postprocedure period.
AORN Journal, September 1981, Vol34, No 3
Table 1
Questionnaire 1. Do you
perform any special procedures routinely in your postanesthesia recovery room? a. electroconvulsive therapy (ECT) b. elective cardioversion c. epidural blocks d. nerve blocks e. outpatient blood transfusions f. other 2. Is this a permanent or a temporary situation? 3. What are your responsibilities for these patients? a. initiate procedure? b. assist physician with procedure? c. recover patients? d. comments ~
6.
What are the nursing care needs of these patients?
7. Do you have medical or nursing care
guidelinesfor the care of these patients? 8. Do you
feel you have adequate staff to care for these patients? If not, how would you supplement your staff needs? ~
9. Do you assign a particular nurse to special
procedures? 10. If ECT is one of
your special procedures, what anesthetic agents are used? __ ~
4.
Who is medically responsible for these patients?
5. If the attending physician is medically
responsible, does an anesthesiologist assume responsibility for the patient if the attending physician is not available?
The elective cardioversions were performed by a cardiologist, and the postcardioversion responsibility was shared by the anesthesiologist and the cardiologist. When no anesthesiologist was in attendance for the procedure, the physician who performed the procedure assumed medical responsibility. The responses were clear in indicating that no nursing concerns arose as to medical responsibility for the patient. Comments of some nurses, many of whom were recovery room supervisors, indicated that these procedures are perceived to be an extreme burden on the staffing needs of their departments. Others expressed a feeling that these procedures were scheduled at the convenience of the department’s schedule.
~
Who administers the anesthesia? 11.
___
Other comments Name Hospital affiliation Work telephone number
In these cases, the procedures were used to fill time at the beginning and end of the day’s work, without disrupting the major portion of the day’s activities. Most nurses indicated that the procedures were being done regularly and routinely, as a permanent situation, and none were trying to alter this circumstance. A frequent comment was t h a t there was inadequate staff to accommodatethe care of these patients, in addition to the care requirements of the postoperative anesthetized patients. Because many recovery room staffs seem to be participating in these procedures, it is important to address the specific nursing responsibility and patient care needs.
dAORN Journal, September 1981,Vol34, No 3
491
Nerve blocks and epidural blocks. The nurse is responsible for assembling the equipment necessary for the procedure. Prepared and prepackaged trays are usually used. A physician’s preference card or department procedure should be developed by the staff if prepackaged trays are not being used. The anesthesiologist or attending physician has the responsibility of explaining the procedure to the patient. The nurse assists with positioning the patient and assists the physician during the procedure. Following completion of the procedure, the patient’s vital signs are monitored until stable; the site of the block is observed for bleeding; and the extremity or extremities distal to the block are observed for movement, sensation, and the absence of pain. Postural hypotension, numbness, tingling, paralysis, and pain are untoward effects one might anticipate. The patient is offered liquid refreshment. He is gradually ambulated if he is an outpatient and discharged to home in the care of a competent adult, by physician’s order. An inpatient can be returned to his room according to the discharge policy of the recovery room. Elective cardioversion. Many of the respondents to the questionnaire reported t h a t having the necessary equipment assembled and tested prior to the patient’s arrival facilitates completion of the procedure with minimum delays and complications. The patient’s safety and comfort throughout the experience are the primary consideration. A procedure should be developed by each recovery room staff for performing this procedure, delineating equipment and drugs to be prepared and available. The cardiologist has explained the procedure to the patient before he is transported to the recovery room. Upon the patient’s arrival, the nurse inserts an intravenous (IV)line, if one has not already been inserted. The cardiologist
494
Table 2
Special procedures done in recovery rooms Number of recovery rooms Procedure performing procedures Nerve blocks 34 Epidural blocks 23 Elective cardioversion 8 Electroconvulsive therapy (ECT) 7 Blood patch 5 Manipulations 3 Central and arterial line insertions, preoperatively 3 Outpatient blood transfusions 1 Impression for cleft palate 1 under anesthesia Sleep electroencephalogram 1 Sleep treatment for migraine 1 Removal of orthopedic hardware 1 Spinal injections for chemotherapy 1 Pain clinic activities 1
performs the cardioversion. In the postcardioversion period, the recovery room nurse continues to monitor the cardiac status and vital signs, and she maintains an airway, as necessary. Oxygen is administered. When the patient reaches a stable condition, he is transferred to the coronary care unit for continued observation. Electroconvulsive therapy (ECT or EST). The psychiatist generally accepts the responsibility for explaining the procedure to the patient. A series of ECT treatments is usually administered over a time span of several weeks t o several months, depending on the patient’s condition. The patient usually experiences memory loss following ECT and may not recall the nurses, the recovery room, or the previous experience. The responsibility of the nurse is to assemble the necessary equipment, as prescribed by the individual institution; to confirm the NPO status of the pa-
AORN Journal, September 1981,Vol34, No 3
motional support was seen as an essential nursing role.
E
tient; and to assist the physician during the procedure. The IV anesthetics are oRen administered by an anesthesiologist, and a muscle relaxant is usually employed. Following the “shock,”the patient is monitored as any postintravenous anesthetic patient. Specific observation should be made for cardiac arrhythmias, respiratory distress, and airway maintenance. For the other procedures listed in Table 2, the nurse assembles equipment, assists the physician during the procedure, and monitors the patient after the procedure. In the hospitals represented in the survey, generally no particular nurse was assigned to assist with special procedures. Rather, assignments are done on random basis, determined by nursing personnel available at the time needed. Presumably, orientation of the nurses in these recovery rooms includes care and responsibilities related t o these procedures. One hospital was planning to hire a nurse full-time to assist with special procedures only. Several comments indicated that the recovery room supervisor wished to have more control over the scheduling of the procedures, so that the staff would be adequate to ensure safe patient care for all patients. Frequently, OR staff are temporarily assigned to the recovery room to assist in these procedures. The number of special procedures performed daily will in-
fluence staffing needs of both departments. Performing these procedures in the recovery room may ease the scheduling burden of the operating room. Emotional support of the patient through all these procedures was perceived as an essential nursing role by an overwhelming majority of respondents. The emotional needs of the patient’s family were noted, too, as well as the patient’s need for emotional support from the family. Providing a calm, quiet environment; taking an interest in the patient; talking with the patient and family in a pleasant, unhurried manner; responding to questions; being aware of the importance of eye contact, and conveying warmth and understanding are some ways to offer emotional support. Keeping the family members informed, permitting visiting to the extent possible, and helping to make the family comfortable, welcome, and part of the patient’s experience will provide them with additional emotional support. In the legal domain, most respondents felt they were supported by adequate hospital and nursing policies to permit the performance of these procedures in their recovery rooms. There was no indication that physicians’ responsibility for these patients was an issue. Each hospital determines its own policies for consent forms. A specific signed consent may not be required by
AORN Journal, September 1981, VoL 34, No 3
495
policy in all hospitals for all special procedures. The nurse is responsible for being aware of which procedures require a separate consent form in that hospital. Ultimately, the physician is responsible for providing information so the patient may sign an informed consent. In some hospitals, the nurse may be responsible for verifying that the signed consent is on the chart, including the correct time, date, physician’s name, and a n accurate description of the planned procedure. In specific comments, some expressed frustration with “special” categories of patients. These included patients to be admitted by the recovery room staff for ambulatory surgery, patients destined for the intensive care unit but kept in the recovery room because of unavailable beds, and patients who have not received an anesthetic but are brought to the recovery room for observation. These frustrations reflect the philosophy of Joseph M Civetta, MD, who said: There will never be adequate intensive care beds (for the critically ill) There will never be sufficient operating rooms (for the surgeons) There will never be a right time to move a patient (for the floor personnel) There will never be a right time to move a patient (for the ICU staff) There will never be enough money to build adequate facilities (for the taxpayers) There will never be enough money t o hire more people (for the administration) But there will always be the recovery room.’ Many recovery rooms are functioning as special procedures units. If this is the case in your institution, responsibility
498
for patient care has to be delineated. The comfort and emotional support of patients must be considered. Adequate staffing should be ensured, and the legal aspects associated with these special procedures given serious consideration. 0 Note 1. Joseph M Civetta, “Recovery room: Past, present, and future,”AORNJournalZl (April 1975) 81 1.
Suggested reading Fink, Max. “Electroshock therapy: Myths and realities.”Hospital Practice 13 (November 1978) 77. Minshull, Don. “Outpatient ECT.” Nursing Mirror 148 (February 1979) 28. Mulaik, Jane S. “Nurses’ questions about electroconvulsive therapy.” Journal of Psychiatric Nursingand MentalHealth Services 17 (February 1979) 15.
Outpatient surgery growing, AHA finds Ambulatory surgery is widespread in all sizes of hospitals except those with less than 100 beds, the American Hospital Association reports in a recent survey. The results were described in Hospitals (April 16). A total of 1,506 hospitals offer ambulatory surgery. Of these, 87% use the
main operating suites for both inpatient and outpatient surgery. Fifty-four percent have organized ambulatory surgery programs. One factor responsible for the growth has been ”developmentof sound perioperative teaching by nurses and physicians,”the report said. Other reasons cited were increased acceptance by the medical community, rapid-acting anesthetics,and the practice of ambulating patients soon after surgery.
AORN Journal, September 1981, Vol34, No 3
The recovery room as special procedures unit
Recovery rooms throughout the nation are being used for various procedures scheduled by anesthesiologists or specialty physicians. These are procedures such as epidural blocks, elective cardioversion, and electroconvulsive therapy, that, in most hospitals, are performed in operating rooms, coronary care units or other special units. What is the impact of this activity on the patient, the recovery room staff, and the operating room staff! Special care needs of patients undergoing these procedures must be identified and met when special procedures are a routine recovery room function. At the Florida Society of Anesthesiologists 11th Annual Seminar for Recovery Room Nurses in Orlando, Fla, on Oct 31, 1980, a questionnaire was
Marilyn Schneider, RN, is assistant clinical supervisor of the postanesthesia recovery room at Doctors’Hospital of Prince Georges County, Lanham, Md. She is an associate degree graduate of Brooklyn (NY) College.
490
distributed informally to attendees (Table 1). This questionnaire was developed to identify special procedures being performed in recovery rooms the extent to which these procedures are being performed patient care needs associated with each specified procedure nurses’ responsibility in assisting with the procedures staffing needs due to the added workload legal implications. Of almost 100 questionnaires returned, 53 indicated that at least one special procedure was being performed in that recovery room. These questionnaires represented hospitals in 33 states, including the District of Columbia. The balance of the questionnaires were returned unanswered or with the comment, “We don’t do any of these,” and no other information was provided. Although the survey was informal, it did bring to light a recovery room nursing activity that has not been addressed previously. Procedures being performed routinely are listed in Table 2. A number of respondents indicated that more than one special procedure was being performed in that recovery room. The majority of these procedures were performed by an anesthesiologist, who assumed full medical responsibility for the patient in the postprocedure period.
AORN Journal, September 1981, Vol34, No 3
Table 1
Questionnaire 1. Do you
perform any special procedures routinely in your postanesthesia recovery room? a. electroconvulsive therapy (ECT) b. elective cardioversion c. epidural blocks d. nerve blocks e. outpatient blood transfusions f. other 2. Is this a permanent or a temporary situation? 3. What are your responsibilities for these patients? a. initiate procedure? b. assist physician with procedure? c. recover patients? d. comments ~
6.
What are the nursing care needs of these patients?
7. Do you have medical or nursing care
guidelinesfor the care of these patients? 8. Do you
feel you have adequate staff to care for these patients? If not, how would you supplement your staff needs? ~
9. Do you assign a particular nurse to special
procedures? 10. If ECT is one of
your special procedures, what anesthetic agents are used? __ ~
4.
Who is medically responsible for these patients?
5. If the attending physician is medically
responsible, does an anesthesiologist assume responsibility for the patient if the attending physician is not available?
The elective cardioversions were performed by a cardiologist, and the postcardioversion responsibility was shared by the anesthesiologist and the cardiologist. When no anesthesiologist was in attendance for the procedure, the physician who performed the procedure assumed medical responsibility. The responses were clear in indicating that no nursing concerns arose as to medical responsibility for the patient. Comments of some nurses, many of whom were recovery room supervisors, indicated that these procedures are perceived to be an extreme burden on the staffing needs of their departments. Others expressed a feeling that these procedures were scheduled at the convenience of the department’s schedule.
~
Who administers the anesthesia? 11.
___
Other comments Name Hospital affiliation Work telephone number
In these cases, the procedures were used to fill time at the beginning and end of the day’s work, without disrupting the major portion of the day’s activities. Most nurses indicated that the procedures were being done regularly and routinely, as a permanent situation, and none were trying to alter this circumstance. A frequent comment was t h a t there was inadequate staff to accommodatethe care of these patients, in addition to the care requirements of the postoperative anesthetized patients. Because many recovery room staffs seem to be participating in these procedures, it is important to address the specific nursing responsibility and patient care needs.
dAORN Journal, September 1981,Vol34, No 3
491
Nerve blocks and epidural blocks. The nurse is responsible for assembling the equipment necessary for the procedure. Prepared and prepackaged trays are usually used. A physician’s preference card or department procedure should be developed by the staff if prepackaged trays are not being used. The anesthesiologist or attending physician has the responsibility of explaining the procedure to the patient. The nurse assists with positioning the patient and assists the physician during the procedure. Following completion of the procedure, the patient’s vital signs are monitored until stable; the site of the block is observed for bleeding; and the extremity or extremities distal to the block are observed for movement, sensation, and the absence of pain. Postural hypotension, numbness, tingling, paralysis, and pain are untoward effects one might anticipate. The patient is offered liquid refreshment. He is gradually ambulated if he is an outpatient and discharged to home in the care of a competent adult, by physician’s order. An inpatient can be returned to his room according to the discharge policy of the recovery room. Elective cardioversion. Many of the respondents to the questionnaire reported t h a t having the necessary equipment assembled and tested prior to the patient’s arrival facilitates completion of the procedure with minimum delays and complications. The patient’s safety and comfort throughout the experience are the primary consideration. A procedure should be developed by each recovery room staff for performing this procedure, delineating equipment and drugs to be prepared and available. The cardiologist has explained the procedure to the patient before he is transported to the recovery room. Upon the patient’s arrival, the nurse inserts an intravenous (IV)line, if one has not already been inserted. The cardiologist
494
Table 2
Special procedures done in recovery rooms Number of recovery rooms Procedure performing procedures Nerve blocks 34 Epidural blocks 23 Elective cardioversion 8 Electroconvulsive therapy (ECT) 7 Blood patch 5 Manipulations 3 Central and arterial line insertions, preoperatively 3 Outpatient blood transfusions 1 Impression for cleft palate 1 under anesthesia Sleep electroencephalogram 1 Sleep treatment for migraine 1 Removal of orthopedic hardware 1 Spinal injections for chemotherapy 1 Pain clinic activities 1
performs the cardioversion. In the postcardioversion period, the recovery room nurse continues to monitor the cardiac status and vital signs, and she maintains an airway, as necessary. Oxygen is administered. When the patient reaches a stable condition, he is transferred to the coronary care unit for continued observation. Electroconvulsive therapy (ECT or EST). The psychiatist generally accepts the responsibility for explaining the procedure to the patient. A series of ECT treatments is usually administered over a time span of several weeks t o several months, depending on the patient’s condition. The patient usually experiences memory loss following ECT and may not recall the nurses, the recovery room, or the previous experience. The responsibility of the nurse is to assemble the necessary equipment, as prescribed by the individual institution; to confirm the NPO status of the pa-
AORN Journal, September 1981,Vol34, No 3
motional support was seen as an essential nursing role.
E
tient; and to assist the physician during the procedure. The IV anesthetics are oRen administered by an anesthesiologist, and a muscle relaxant is usually employed. Following the “shock,”the patient is monitored as any postintravenous anesthetic patient. Specific observation should be made for cardiac arrhythmias, respiratory distress, and airway maintenance. For the other procedures listed in Table 2, the nurse assembles equipment, assists the physician during the procedure, and monitors the patient after the procedure. In the hospitals represented in the survey, generally no particular nurse was assigned to assist with special procedures. Rather, assignments are done on random basis, determined by nursing personnel available at the time needed. Presumably, orientation of the nurses in these recovery rooms includes care and responsibilities related t o these procedures. One hospital was planning to hire a nurse full-time to assist with special procedures only. Several comments indicated that the recovery room supervisor wished to have more control over the scheduling of the procedures, so that the staff would be adequate to ensure safe patient care for all patients. Frequently, OR staff are temporarily assigned to the recovery room to assist in these procedures. The number of special procedures performed daily will in-
fluence staffing needs of both departments. Performing these procedures in the recovery room may ease the scheduling burden of the operating room. Emotional support of the patient through all these procedures was perceived as an essential nursing role by an overwhelming majority of respondents. The emotional needs of the patient’s family were noted, too, as well as the patient’s need for emotional support from the family. Providing a calm, quiet environment; taking an interest in the patient; talking with the patient and family in a pleasant, unhurried manner; responding to questions; being aware of the importance of eye contact, and conveying warmth and understanding are some ways to offer emotional support. Keeping the family members informed, permitting visiting to the extent possible, and helping to make the family comfortable, welcome, and part of the patient’s experience will provide them with additional emotional support. In the legal domain, most respondents felt they were supported by adequate hospital and nursing policies to permit the performance of these procedures in their recovery rooms. There was no indication that physicians’ responsibility for these patients was an issue. Each hospital determines its own policies for consent forms. A specific signed consent may not be required by
AORN Journal, September 1981, VoL 34, No 3
495
policy in all hospitals for all special procedures. The nurse is responsible for being aware of which procedures require a separate consent form in that hospital. Ultimately, the physician is responsible for providing information so the patient may sign an informed consent. In some hospitals, the nurse may be responsible for verifying that the signed consent is on the chart, including the correct time, date, physician’s name, and a n accurate description of the planned procedure. In specific comments, some expressed frustration with “special” categories of patients. These included patients to be admitted by the recovery room staff for ambulatory surgery, patients destined for the intensive care unit but kept in the recovery room because of unavailable beds, and patients who have not received an anesthetic but are brought to the recovery room for observation. These frustrations reflect the philosophy of Joseph M Civetta, MD, who said: There will never be adequate intensive care beds (for the critically ill) There will never be sufficient operating rooms (for the surgeons) There will never be a right time to move a patient (for the floor personnel) There will never be a right time to move a patient (for the ICU staff) There will never be enough money to build adequate facilities (for the taxpayers) There will never be enough money t o hire more people (for the administration) But there will always be the recovery room.’ Many recovery rooms are functioning as special procedures units. If this is the case in your institution, responsibility
498
for patient care has to be delineated. The comfort and emotional support of patients must be considered. Adequate staffing should be ensured, and the legal aspects associated with these special procedures given serious consideration. 0 Note 1. Joseph M Civetta, “Recovery room: Past, present, and future,”AORNJournalZl (April 1975) 81 1.
Suggested reading Fink, Max. “Electroshock therapy: Myths and realities.”Hospital Practice 13 (November 1978) 77. Minshull, Don. “Outpatient ECT.” Nursing Mirror 148 (February 1979) 28. Mulaik, Jane S. “Nurses’ questions about electroconvulsive therapy.” Journal of Psychiatric Nursingand MentalHealth Services 17 (February 1979) 15.
Outpatient surgery growing, AHA finds Ambulatory surgery is widespread in all sizes of hospitals except those with less than 100 beds, the American Hospital Association reports in a recent survey. The results were described in Hospitals (April 16). A total of 1,506 hospitals offer ambulatory surgery. Of these, 87% use the
main operating suites for both inpatient and outpatient surgery. Fifty-four percent have organized ambulatory surgery programs. One factor responsible for the growth has been ”developmentof sound perioperative teaching by nurses and physicians,”the report said. Other reasons cited were increased acceptance by the medical community, rapid-acting anesthetics,and the practice of ambulating patients soon after surgery.
AORN Journal, September 1981, Vol34, No 3