I. POSTANESTHESIA CARE UNITS QUALITY ASSURANCE

A. Introduction

Postanesthesia care units (PACUs) often vary in the scope and the nature of practice as a function of the services provided in a given institution. The spectrum of operational requirements ranges from ambulatory surgical centers, where a PACU can serve as an admission, recovery, and discharge facility, to the largest of medical centers with multiple PACU, often providing services to a unique subset of patients, to include an integrated function to the surgical intensive care units. Moreover, in the setting of extreme operational demands, such as seen with natural disasters or mass casualty/emergency response situations, the PACU may be required to expand the scope of practice to serve in capacities ranging from general care units to ICU.

Regardless of the nature of services provided by the PACU, it is vital that all units maintain an active program in quality assurance and patient safety. Although the design, implementation, and maintenance of such programs are driven by the practice within the institution or medical group, the requirement for a comprehensive system is critical to every facility. Although individual PACUs are organized to serve the unique need(s) of a specific practice site, there are commonalities of program structure and function that are present in all programs.

B. Definition

In the domain of health care, quality assurance and patient safety activities and programs are designed to assure or improve the quality of care in either a defined medical setting or a program. This concept encompasses the assessment and/or evaluation of the quality of care, identification of problems or shortcomings in the delivery of care, designing activities to correct/overcome these deficiencies, and monitoring processes to ensure effectiveness of corrective steps.

Health care facilities commonly maintain a department or functionality in quality assurance and patient safety. Most often, major services, such as medicine, surgery, and neurology, will also organize a quality assurance/patient safety process that will provide an ongoing system of surveillance and oversight germane to the quality and safety challenges of a given department/specialty. These local activities are often subordinate to institutional quality programs and depend upon a coordinated process at higher levels of management to ensure that events with potential interdepartmental implications are appropriately managed in a timely manner.

PACUs present a unique challenge with regard to the organization of quality and safety programs, in that the PACU represents the operational domain of several departments within a hospital, all functioning in a close and coordinated fashion. Typically, the departments of anesthesia and nursing maintain key leadership roles in the operation of the
PACU and collaborate closely with the department of surgery, as well as other subspecialties (interventional radiology, gastroenterology, etc.).

As such, any program designed to oversee unit functionality must be represented by experienced personnel from all disciplines. As previously suggested, this may also be further complicated by the unique role many PACUs play in providing clinical services to specialties outside of the typical surgical domains, such as the endoscopic services of the department of medicine and the interventional services of the department of radiology. Institutions may approach such challenges of coordination by developing a robust reporting system to organizational functions from departments that may function as a component of an integrated service, or a middle-level functionality that serves as a perioperative oversight service described as a perioperative quality assurance committee.

Regardless of the structure and organization of the quality assurance programs, it is critical to maintain a clear and discrete process for reporting and evaluation of events related to quality assurance. Furthermore, it is essential that the system be designed to facilitate any subsequent analysis in a manner that serves institutional quality assurance and patient safety requirements, as well as providing the opportunity to contribute to departmental and institutional quality improvement processes.

C. Operational Significance

Industry has utilized quality assurance and quality control programs for decades. However, the manner in which quality assurance has been embraced by the health care industry has its roots in the safety programs that have emerged from the world of aviation with a clear pioneer of the process resident in the military aviation community beginning around the World War II era.

The adoption of checklists and policies to engage and empower personnel at every level of clinical care, now seen as commonplace in the practice of medicine, evolved directly from the experiences of army and navy aviation programs. With roots in the years preceding World War II, these processes have been refined over decades in both the military and civilian communities and have been recognized as providing the fundamentals of quality and safety programs in professions ranging from manufacturing to law enforcement to medicine.

Capitalizing on the ability to learn from experience gained, not only in clinical care but also in industrial applications, has resulted in the development of a systems-based approach to analysis, employing the fundamental concepts of root cause analysis. Coupled with the philosophy that quality assurance and patient safety are institutional priorities, these programs have provided the ability to bring the vital elements of direct patient care to an integrated process engaging institutional expertise and resources.

In addition, adopting a philosophy where the culture of blame is replaced by an approach driven by evaluation of data in a manner that can separate performance versus system’s based challenges offers the ability to optimize processes of assessment without attaching any stigma related to individual execution. This practice results in a more complete evaluation in that personnel are more comfortable offering details associated with an event, without fear of retribution, as well as positioning the process in a manner that can better offer assistance to individuals involved in what may often be emotionally challenging events. Programs such as peer support and peer counseling have grown from the evolution of quality assurance and patient safety programs over
the past decade or more, and now provide a vital service to caregivers involved in quality-related events.

D. Structure/Development of a Quality Assurance Program

Although the requirements for a formal quality assurance program reflect the nature of practice in a given institution, basic program elements fall into a set of common components as follows:

1. Concept of operations

The concept of operations is ordinarily a reflection of institutional values that are stipulated by departmental leadership and, although variable, generally address the spirit of a comprehensive program to improve care and evaluate and improve shortcomings in practice at the individual and departmental levels. Interests in the integration of quality improvement functions are often specified as an element of operational concepts, as are relationships within a department. It is important to appreciate that operational concepts are often dynamic, adjusting to address changing practice(s).

2. Structure

The organization of a quality assurance activity may range from a dedicated administrative activity, staffed by permanent personnel, to a function within a clinical care unit, with personnel assigned to the process by additional/ancillary duties. Regardless of the structure, it is imperative that personnel possess appropriate clinical insight and are provided with adequate time and resources to effectively manage the program.

3. Reporting system

The design and implementation of a reporting system is integral to the success of any quality assurance program. Systems range from the most simple and straightforward, using a simple form and transfer to a database, to computerized systems, integrating key elements of clinical care over the spectrum of perioperative services, with automated elements directly providing information to institutional leadership. Regardless of the degree of sophistication, the reporting system must be simple to use, comprehensive in scope, and accessible to all, yet appropriately protecting patient confidentiality and offering anonymity to personnel. Although typically engaged by staff involved in direct patient care, the ability to accept input from leadership, as well as to integrate reports from elements such as patient advocacy offices, offers the best chance to ensure all issues are evaluated in the most comprehensive fashion.

4. Data acquisition/analytic function

In the setting of a reported event, or that of an occurrence that is directed to the quality assurance functionaries, the ability to obtain accurate information comprehensively is vital to any successful quality assurance activity. Information is often obtained from multiple sources. In addition to the event notice, critical information may often involve perioperative records (perioperative evaluation, intraoperative records, etc.) as well as interviews with involved individuals, often including the patient. Personnel involved in the analysis must possess
appropriate clinical experience, as well as the ability to consult with individuals with expertise germane to the event being evaluated.

5. Review process

A systematic process must be utilized in the evaluation of all safety-related issues. Institutions will maintain a quality assurance/safety office often providing format and guidance to subordinate departments regarding specific requirements for process review and reporting. Individuals at the unit level assigned to a quality/safety function must have relevant clinical experience and must be provided with the opportunity for education/training in quality and safety areas. The review process can be straightforward, examining any deviation from a standard of care, or may require in-depth and interdepartmental analysis and collaboration. Unit leadership must maintain an oversight function through all phases of the process.

6. Determination/findings

At the completion of the analytic phase(s), the quality and safety personnel must determine whether an issue is, in fact, of concern, as well as the root cause factors that contributed to the compromise. This component will require a formal report to leadership, often set in a standardized format specifying the event, individuals involved, findings of fact, and recommendations for follow-up.

7. Dissemination

Leadership personnel, at the unit, departmental, or institutional levels, are responsible for the dissemination of the results of analysis. Because those elements of a quality or safety issue may involve issues of confidentiality, it is vital that those involved in quality and safety processes not only maintain detailed records but also ensure that the patient, as well as the clinician’s personal information, remains protected. This anonymity of sorts both safeguards sensitive information and provides a sense of reassurance on the part of all involved individuals that are concerned about retribution associated with reporting of incidents.

8. Review

All programs addressing quality and safety issues must be reviewed by clinical leadership with unit/clinical responsibilities, as well as by departmental and institutional elements responsible for pertinent quality and safety programs. This process provides the ability to review findings, as well as the process used in all steps of the analysis.

Many clinical units schedule a regular review session, with appropriate attention to confidentiality, for staff personnel and leadership to present key cases for discussion. This can afford opportunities for improvement in reporting, analysis, and, perhaps most importantly, implementing necessary change(s) to ensure that avoidable events do not reoccur.

II. PACU ORGANIZATION, MANAGEMENT, AND POLICIES

A. Introduction

Recovery of patients after procedures requiring anesthesia or sedation is most commonly performed in a PACU or recovery room. As specialized areas designed for the observation, treatment, and discharge of postoperative patients, a PACU’s role(s) and function can be as varied as the scope of practice within the individual institution. An ambulatory care/day surgery clinic may maintain a PACU staffed by perioperative nurses, with medical oversight provided by an anesthesiologist who may also be involved in supervising cases in the operating room; whereas a large-scale academic hospital, such as a Level I trauma center, may have multiple, geographically distinct PACUs. These units, supporting
various functions, often with subspecialty segregation, can provide intermediate critical care requirements, with medical oversight provided by dedicated anesthesiologists and/or surgical intensivists.

Optimally located near the operating room, thereby minimizing transport time for the patient, and affording rapid access to anesthesiologists and surgeons, the PACU is staffed by specially trained nurses and nurse practitioners proficient in the care of patients in the immediate postoperative period. Under the supervision of an anesthesiologist, the PACU provides care to a broad crosssection of postprocedural patients, with the majority being subsequently transferred in a timely manner from the PACU to a general care floor of the hospital, or, as in the case of an ambulatory care facility, discharged home. A broad diversity characterizes patients admitted to the PACU as well as the surgical procedures. Many patients are healthy and have an uneventful hospital course, whereas some experience a more complex perioperative course influenced by their preexisting medical history and/or a complicated intraoperative course.

Patients are admitted into the PACU at the conclusion of procedures requiring anesthesia or sedation. Patients are most often admitted after surgical procedures in the operating room. However, interventions under anesthesia may also take place outside of the main operating rooms in other departments such as radiology, cardiology, or gastroenterology. In such cases, care can be provided in areas removed from the hospital’s main recovery areas and may require coordination with the PACU. Personnel trained and experienced in the recovery of these patients should be present to oversee the recovery phase and must be able to obtain immediate help in the event of an urgent or acute change in a patient’s condition.

Given the wide range of patients undergoing recovery in the PACU, the potential issues are also quite varied. Being able to anticipate common issues in advance may facilitate the initiation of appropriate action(s) in a timely manner and may help avoid the complications associated with more urgent interventions.