239

Section 3 Surgical and Anesthesia Practice Management

Postanesthesia Care Unit Management

Chapter

23 Building a Safe and Efficient Service

Henry Liu, Longqiu Yang, Michael Green, and Alan David Kaye

Contents PACU Design and Staffing 243

Phases of Postanesthesia Recovery 239 Financial Considerations in the PACU 244
PACU Admission, Fast-​Tracking, and Discharge 241 References 246

Quality perioperative care of surgical patients takes

comprehensive and integrated approaches, which may
Phases of Postanesthesia Recovery
The concept of recovery phases from general anes-
involve many functional departments and specialized
thesia was initially developed for ambulatory sur-
teams. Surgeons, anesthesiologists, operating room
gery. Nowadays, some of the concepts are gradually
(OR) nurses, postanesthesia care unit (PACU) nurses,
being adopted for hospital-​based surgical procedures.
and nurses in the surgical ICUs and regular wards, all
Hospital-​based anesthesiologists usually focus pri-
must work together to assure the very best care of sur-
marily on the initial recovery phases in PACU, while
gical patients. In general, identification of a director
the ambulatory anesthesia providers will have to plan
of the PACU, an anesthesiologist, can effectively com-
for, to observe, and to manage patients’ extended
municate with all stakeholders as to policy, systems,
recovery and their readiness to be discharged from
compliance, and ongoing improvements. In this
PACU to return home [3]. This three-​ phase con-
regard, a nurse director of the PACU can implement
cept has not only helped surgeons, nursing staff, and
these ongoing activities and further enhance commu-
anesthesia service providers to better understand the
nication when problems arise.
importance of the surgical patient’s step-​by-​step post-
PACU, therefore, refers to those all activities
operative care, but also their continual recovering
undertaken to manage patients after the completion
process, to dedicate more time, resources, and efforts
of a surgical procedure and the concomitant primary
to the patient’s recovery, and to better prepare patients
anesthetic. PACU is a critical care unit where the
for their discharge from the PACU. By realizing that
patient’s vital signs are closely observed, pain manage-
patient recovery from anesthesia is a continual pro-
ment begins, temperature is corrected, and fluids are
cess, there will be some overlapping between the arbi-
given as needed. The nursing staff is skilled in recog-
trary recovery phases.
nizing and managing problems in patients after they
Phase I recovery, or early recovery, is the transition
have received anesthesia [1]. PACU nurses play an
from the care mainly provided by anesthesia providers
important role in the postsurgical period; they affect
to that predominantly provided by PACU nurses.
not only the patient’s continuing emergence from gen-
This phase spans from the discontinuation of anes-
eral anesthesia and the recovery of cognitive, sensory,
thesia to the point at which the patient recovers from
and motor functions following anesthesia, but also the
their mental cognitive ability, respiratory function,
turnover rate of ORs and ambulatory surgery clinics
and protective air-​way reflexes. The patient usually
or outpatient surgery, the patient’s length of hos-
undergoes a return of basic physiological functions
pital stay, gate-​keeping the discharge of ambulatory
with in this period of postsurgical time. In addition,
patients, and the overall efficiency of surgical services
during this phase of recovery, patients will demand a
of a modern medical facility [1, 2]. PACU may ultim-
significant amount of attention from PACU nurses,
ately affect the profitability of a hospital and overall
and potentially from anesthesia or surgery providers
patient satisfaction in a medical facility [1, 2].
as well. Indeed, the intensity of care of this phase is

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240
Section 3: Surgical and Anesthesia Practice Management
Table 23.1 The Original Aldrete Scores [4]
2 points
Activity Move four extremities
Respiration Able to breathe deeply and cough
freely
Circulation BP changes within 20% of baseline
level
Consciousness Fully awake
Color Pink
almost equivalent to ICU care and requires similar
monitoring equipment as ASA standard care in the
OR, except for gas spectrometry. The PACU phase
I monitoring includes at least electrocardiogram
(EKG), noninvasive blood pressure, pulse oximetry,
temperature, and urine output.
Patients in phase I are likely to begin responding
to verbal stimulations when alveolar anesthetic
concentrations are decreased to about 0.5 minimum
alveolar concentration (MAC) or less for the volatile
anesthetic drug (MAC awake) if not impeded by other
factors. The MAC is defined as the concentration of an
inhalational anesthetic in pulmonary alveoli in which
50 percent of patients will not move in response to
surgical stimulation. Increased ventilation results in
a more rapid decline in alveolar anesthetic concen-
tration, which hastens recovery, provided that the
arterial carbon dioxide pressure is not so low that it
may decrease cerebral blood flow and slow down the
removal of anesthetic agent from the central nervous
system. Recovery from neuromuscular blockade may
need to be monitored by peripheral nerve stimulation
and by clinical indices. Recovery from intravenous
opioids and hypnotics may be more variable and dif-
ficult to quantify than recovery from inhalation anes-
thesia and neuromuscular blocking agents.
The most common practice in most institutions in
determining whether to have a postanesthetic patient
to the ICU or not is consensus between the surgery
team and the anesthesia team, based on patient’s
pathophysiological conditions. Often times it may be
also determined by ICU bed availability. Commonly
agreed criteria for admitting a patient to ICU include,
but are not limited to, the following: (1) unstable
hemodynamic parameters, which require meticulous
monitoring and pharmacological intervention(s);
(2) expecting prolonged intubation and mechan-
ical ventilation; (3) long surgery time, significant
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1 point 0 point
Move two extremities Cannot move
Limited breathing, dyspnea Apneic
BP changes in 20–​50% of baseline BP changes over 50% of
level baseline
Arousable on calling Not responding
Pale, dusky, blotchy, jaundiced Cyanotic
intraoperative blood loss, and a large quantity of fluid
shifts; (4) multiple invasive monitoring and multiple
inotrope/​vasoactive medications.
Phase II recovery, or intermediate recovery, is the
phase of anesthesia recovery needed to get the sur-
gical patient ready to be discharged from the med-
ical facilities. Many different scoring systems have
been used to evaluate the patient’s recovery status in
this phase. The Aldrete Score is a 10-​point scale based
on extremity movement, respiration, blood pressure,
consciousness, and oxygen saturation (Table 23.1)
[4]. Originally published in 1970, the Aldrete Score
has been widely used as a guideline for PACU care for
many years. However, the original Aldrete Score is not
an ideal guideline for postoperative patient recovery,
especially for the ambulatory surgery patient, because
the Aldrete Score ignores the importance of post-
operative pain and postoperative nausea and vomiting
(PONV). Thus the modified version of the Aldrete
Score (1995) is probably the most commonly used
scoring system, with a score of 9 or higher required for
patient discharge [5]. In the modified Aldrete Score,
a patient who is able to maintain oxygen saturation
above 92 percent on room air scores 2 points, a patient
needing oxygen inhalation to maintain oxygen satur-
ation above 90 percent scores 1 point, and a patient
with oxygen saturation less than 90 percent even with
oxygen supplementation scores 0 point. The modi-
fied Aldrete Score seems to work better than the ori-
ginal Aldrete Score for the recovery from phase I to
phase II.
Other also widely accepted scoring systems are
the postanesthesia discharge scoring system (PADSS)
and the White–​Song score [6, 7]. The PADSS serves
as the scoring system getting the patient ready to
be discharged home (Table 23.2). The White–​Song
score, which was published in 1999 (Table 23.3), was
designed to qualify patients to bypass phase I recovery
241

Chapter 23: Postanesthesia Care Unit Management

Table 23.2 The Postanesthesia Discharge Scoring System for Home Readiness [6]

2 points 1 point 0 point

Vital signs BP and SpO2 change <20% BP and SpO2 change 20–​40% BP and SpO2 change >40%
Activity Steady gait, no dizziness, meets preop Requires assistance Unable to ambulate
level
Nausea and vomiting Minimal, treated with p.o. medication Moderate, treated with Severe, continue despite
parental medication treatment
Pain Controlled with p.o. medication and No = 1
acceptable to patient; yes = 2
Surgical bleeding Minimal, no dressing change Moderate, up to two dressing Severe, three or more
changes required dressing changes
SpO2, transcutaneous pulse oximetry; p.o., per os.

Table 23.3 The White-​Song Recovery Scores [7]

2 points 1 point 0 point

Mental status Awake Arousable Unresponsive
Motor Move all extremities Some weakness No movement
Blood pressure Within 15% of baseline 15–​130% >30%
Respiration Deep breathing Tachypnea Dyspnea
Pulse oximetry >90% room air Requires O2 SpO2<90 with O2
Pain No pain Moderate pain Severe pain
PONV No to mild nausea Transient vomiting Persistent vomiting

and be discharged from the OR directly to the less
intensive phase II recovery area. The PADSS uses five
parameters with a score of 0–​10, while the White–​
Song score includes seven parameters with a total
score of 0–​14 and takes into account of PONV [8].
These two scoring system and the PADSS seem to be
more acceptable than many other scoring techniques
published in the last decade.
However, there continue to be many controver-
sies regarding the currently used scoring systems and
discharge criteria. For example, requiring patients to
take oral fluid before discharge may not be necessary
according to some recent observations. Eliminating
drinking as a requirement before discharge can
slightly shorten the phase II recovery without convin-
cing evidence of significant adverse effects, and there
are studies supporting this practice [9, 10]. If a prac-
tice can reach universal agreement, recovery room
nurses should be educated to remove the drinking
requirement before discharging patients home.
Another controversy is whether the ability to void
is truly necessary before discharge. Several studies
have demonstrated that even patients at high risk
of urinary retention can be discharged before they
have voided in the recovery room [11]. Eliminating
the voiding requirement before discharge can signifi-
cantly shorten recovery room stay without adding a
negative impact to the clinical outcome.
Phase III recovery, or late recovery, and psycho-
logical recovery extend from the discharge from
hospital or ambulatory surgery center to full psy-
chological, physical, and social recovery and return
to work. This phase of recovery can have significant
individual variations due to various factors. Phase III
recovery usually occurs outside the medical facility.
PACU Admission, Fast-​Tracking,
and Discharge
ASA guidelines state that all patients who have
received general anesthesia, regional anesthesia, or
monitored anesthesia care, should receive appro-
priate postanesthesia management in a PACU, where
intense monitoring almost equivalent to ICU care is
offered [1], with the potential exceptions of following
patients: all open heart surgery patients, who will

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242
Section 3: Surgical and Anesthesia Practice Management
generally be transported to ICU directly from the OR
after surgery; all patients who have undergone major
surgical procedures (prolonged intubation and mech-
anical ventilation, large quantity of volume resusci-
tation, delicate hemodynamic maneuvering, such as
liver transplantation patients) and patients with sig-
nificant vital organ dysfunction who will potentially
need a longer period of ICU care; and patients who
had obstetric procedures, cardiac special procedures,
gastroenterological procedures; these patients will
usually be transferred to their own PACU-​equivalent
recovery area, where PACU guidelines generally
apply [1]. There are recent studies showing that even
cardiac surgery patients can be safely recovered in
PACU [12].
Fast-​
track/​PACU bypass refers to discharging
a patient from the OR to phase II recovery directly,
bypassing phase I recovery. According to the White–​
Song scoring system, the criteria for a patient to be a
candidate for fast track or PACU bypass is a score of
12 or higher (Table 23.3) [7].
The following procedures are generally considered
to be qualified for fast tracking [13]:
• Most eye procedures
• Some cesarean sections
• Some cardiac catheterizations
• Most gastroenterological endoscopy
• Most radiological special procedures with
monitored anesthesia care
• Most patients with regional block as surgical
anesthesia for their procedures
• Some surgical patients with local anesthetic
infiltration under minimal intravenous sedation
There are institutional variations in criteria for dis-
charging patients from the PACU.
Criteria to discharge patients from PACU can
depend upon where the patients are discharged,
patient age, and coexisting medical conditions. Box
23.1 shows the acceptable criteria for PACU discharge
[14]. These criteria can be used alone or in com-
bination with the PADSS, to enhance patient safety
during discharge from phase II to phase III recovery.
The criteria for discharging a patient from the
PACU to the hospital ward can be slightly different
from discharging a patient to home. The patient does
not need to be able to ambulate, void, or prove oral fluid
intake. It is much safer to send a patient to the hospital
ward than to discharge the patient home for recovery.
Also, the criteria can be different for the pediatric
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Box 23.1. Clinical Criteria for PACU Discharge [14]
• Stable vital signs for at least 1 h
• Alert and oriented to time, place, and person
• No excessive pain, bleeding, or nausea
• Ability to dress and walk with assistance
• Discharged home with a vested adult who will
remain with the patient overnight
• Written and verbal instructions outlining
diet, activity, medications, and follow-​up
appointments provided
• A contact person and circumstances that
warrant seeking the assistance of a healthcare
professional clearly outlined
• Voiding before discharge not mandatory, unless
specifically noted by physician (i.e., urological
procedure, rectal surgery, history of urinary
retention)
• Tolerating oral fluids not mandatory, unless
specified by physician (i.e., patient is diabetic, frail,
and/​or elderly; not able to tolerate an extended
period of NPO status)
patient population and the geriatric population. In
Europe, the International Association for Ambulatory
Surgery adopts the following guidelines [15].
Essential invariant criteria for patient discharge:
• Stable vital signs
• Oriented to preoperative stage
• Minimal nausea and vomiting
• Controlled pain
• Without significant bleeding related to the
procedure(s)
• Variable criteria for discharging patient
from PACU
• Micturition prior to discharge; essential following
epidural or spinal anesthesia; may be deemed
essential following certain surgical procedures
• Fixed length of stay in day unit following
surgery; plays no part in the generality of
surgical procedures; may be deemed necessary
after certain procedures to minimize the risk
of reactionary hemorrhage at home, e.g.,
tonsillectomy, thyroidectomy
• Individual for certain specific procedures
There are many strategies to minimize PACU stay
time. These should be considered whenever the oppor-
tunity avails itself. Decreased PACU stay time will lead
243
to a lower requirement for PACU beds. These strat-
egies should include PONV prevention and prompt
treatment, multimodal pain management, choice of
shorter-​
acting anesthetic agent, nurse reeducation
[16], etc. Delays in discharge from the PACU due
to systems errors should be kept to a minimum. In
addition, fast track should be considered whenever
possible.
PACU Design and Staffing
Many factors need to be taken into consideration in
designing a PACU. The design, equipment and staffing
of the PACU shall meet requirements of the facility’s
accrediting and licensing bodies.
• Functionality: Most PACUs are responsible
for the recovery of postsurgical patients and
discharge them either to home or to general
wards. Some PACUs are used strictly for phase
I and early phase II recovery. Other PACUs
function as the patient’s room throughout his or
her stay for the day, beginning as a preoperative
assessment room, then becoming the phase
I recovery room, and progressing through
phase II and early phase III until the patient
is discharged, and either home or to the floor.
In addition, some hospitals have specialized
PACUs for general surgical patients, pediatric
patients, interventional radiology patients,
gastroenterological patients etc.
For the convenience of transportation of patients, OR
and PACU are generally located on the same floor of
the hospital. Automatic doors should be installed for
the ease of transferring patients. PACU should have
indirect lighting, soundproof ceiling, noise control
mechanisms, and walls and ceiling painted in soft,
pleasing colors. The precise recommendations on the
design of the PACU are still lacking, unfortunately.
• Beds: The number of PACU beds is determined
by the hospital’s surgical volume and the nature
of its surgical procedures. The generally accepted
ratio of PACU beds–​OR is 1.5–​2:1.
This recommended ratio of PACU beds to ORs is
not clearly defined [17]. Patient demographics and
types of surgical cases affect those needs. Surgical
procedures with quicker turnover will require
more PACU beds due to greater number of patients
admitted into the PACU over a shorter period of time.
And generally longer and more extensive surgical
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Chapter 23: Postanesthesia Care Unit Management
procedures will decrease the PACU admission rate
and thus decrease the PACU bed requirement, while
increasing ICU admission. On the other hand, sicker
patients admitted into PACU will have the potential
of requiring greater nursing care and a longer stay
in PACU than relatively healthier patients, resulting
in greater bed requirements. Obviously simpler sur-
geries should require less postoperative care routinely
than complicated surgeries, which should decrease
the PACU bed needs. In one study with unlim-
ited resources available for the PACU patients, the
required PACU bed to OR ratio came to less than 1:1
[17]. However, this result was from a simulated situ-
ation with unlimited resources, which is far from the
reality in which most practitioners find themselves.
• Size: Physical size or area of PACU depend upon
the number of beds, equipment to be installed,
and any special needs like isolation room etc.
• Equipment: Basic equipment requirement
should include monitors for respiration
(SpO2, respiratory rate), circulation (BP, EKG,
HR), temperature, urine output and voiding,
neuromuscular function, etc.
Adequate PACU nurse staffing is undoubt-
edly critical to quality and safe patient care. The
American Society of Perianesthesia Nurses (ASPAN)
offers Standards of PACU Nursing Practice. ASPAN
recommends staffing ratios that correlate to the level of
care required in PACU phase I, phase II, and extended
observation settings [18]. In addition, ASPAN has
established minimum staffing guidelines to provide a
safe environment for patients during nonpeak hours, as
well as a “position statement on on-​call/​work schedule”
to address issues related to nursing fatigue and patient
safety: ASPAN recommends that one nurse can only
safely care for up to two healthy, adult, conscious
patients not requiring frequent cardiopulmonary
intervention [19]. These recommended staffing ratios
are based on the best available expert opinion and con-
sensus. Although the nursing literature claimed evi-
dence on the relationship between nurse staffing ratios
and nursing-​sensitive outcomes, there was a paucity of
scientific postanesthesia evidence that related to safe
staffing ratios or nursing-​sensitive indicators specific
to the specialty practice [20].
Precise calculation of adequate PACU nursing
staffing is very difficult. Whereas other hospital units
(ICU, regular wards, and emergency department)
have relatively consistent daily patient census, PACU
243
244
Section 3: Surgical and Anesthesia Practice Management
should start and end the day with a census of zero
while throughout the day PACU may have a large vari-
ation in the census. The best way to figure out proper
staffing level for each PACU may be through computer
modeling and historical data [21]. Many other factors
may potentially affect PACU staffing requirements.
One of these is the sequence of surgical cases. Proper
surgical sequencing should bring more predictable
staffing requirements in PACU. Small facilities with
just a few ORs will generally benefit proper surgical
case sequencing, while in larger PACUs, the benefits
of case sequencing are unclear when compared with
the good performance of adjusting staffing and beds
to match workload using statistical optimization [22].
Other factors may also affect PACU nursing staffing
requirements. Delays in patient flow before and after
PACU may subsequently change PACU staffing. These
delays can be due to system errors, such as receiving
units not ready, patients awaiting radiological imaging
and/​or interpretation, unevaluated patients waiting for
anesthesia assessment [23]. Process engineering and
corrections of these systems errors should potentially
decrease PACU staffing requirement and lead to a
smoother flow of patients throughout the postsurgical
period.
Financial Considerations in the PACU
To cut health expenses, all institutions must reduce
their human and financial costs. The evaluation of costs
is an essential part of medicoeconomic analysis. The
PACU is a major component of perioperative patient
flow. As reimbursement for surgical procedures con-
tinues to decline, the costs of perioperative services
continue to increase. Efforts to improve the profit-
ability in perioperative services depend on improving
efficiencies in each perioperative component. Many
strategies have been applied to decrease costs in the
PACU [24]. The effect of these strategies on fixed costs
versus variable costs varies considerably. Fixed costs
refer to those that do not vary in relation to the sur-
gical volume (e.g., capital equipment, physical plant,
salaried personnel); variable costs include those costs
that vary directly with the surgical volume (e.g., dis-
posable supplies, pharmaceuticals, laboratory tests,
and hourly personnel). The strategies for decreasing
the PACU costs include following [24]:
1. OR scheduling changes to decrease the daily
PACU peak number of patients admitted from
the ORs
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2. Improvement of PACU nurse productivities
by optimizing nurse working hours and shift
adjustment, i.e., increasing patient care hours
without increasing work hours
3. Cost-​reducing interventions, such as modifying
the medical practice patterns to reduce PACU
length of stay, cutting variable costs, etc.
4. Use of short-​acting anesthetic agents or drugs
with favorable pharmacology, including
multimodal management of PONV and
postoperative pain
5. Fast-​tracking patients whenever possible by
bypassing PACU or discharging patients home
directly from the PACU
6. OR patients bypassing the phase I recovery being
directly admitted to phase II PACU
7. Improving phase I PACU process and inpatient
bed availability
8. Timely transporting patient out of PACU
9. Optimizing PACU discharge criteria or hospital
policies
10. Avoiding communication problems
Numerous studies and computer models were
attempted to predict or suggest the effect of cost-​
cutting strategies for decreasing the PACU costs. The
applicability and success of these strategies may vary
greatly in different institutions and practice envir-
onments (i.e., ambulatory surgical centers, specialty
surgery centers, tertiary care facilities, low-​volume
or high-​volume facilities). The largest portion of the
PACU costs is nursing staff wages. Nurse staffing level
is primarily dependent upon the daily peak number
of patients admitted to the PACU from the OR [25].
Therefore, the most effective strategies in decreasing
the PACU costs involve those that decrease the
amount of nurse staffing (i.e., FTEs) either directly
or indirectly. The standards set by ASPAN state the
number of patients that each nurse can simultan-
eously care for (i.e., one nurse per intubated patient or
per two extubated patients) may prevent or decrease
the ability to maximize nursing productivity in facil-
ities with frequent high patient acuity levels [24, 26].
Other factors affecting productivity include the
increasing use of the PACU as an overflow location
for ICU, step-​down care, and patient wards. Ziser
et al. prospectively studied patient overflow admission
to the PACU over a 33-​month period and found that
lack of an available bed was the most common reason
245
for PACU stay (85.5%) [27]. This undoubtedly results
in variable acuity needs and can interrupt patient flow
from OR to PACU, contributing to inefficiencies in sur-
gical services and increased pertinent costs [28]. The
ASPAN statement on overflow patients in the PACU
raises additional staffing concerns regarding main-
tenance of appropriate competencies for the patient
population, maintenance of patient safety, coordin-
ation of OR scheduling, and appropriate staff utiliza-
tion, further complicating this recurrent problem in
some facilities [29]. Dexter et al. have suggested use of
computer optimization methods to determine staffing
level for phase I recovery because of the complexity of
staffing, especially when variability in patient acuity
occurs [26].
PACU nursing staff wages generally fall into four
categories [24]: hourly employees with no minimum
numbers of hours worked each week; “full-​time” sal-
aried employees (no overtime pay); “full-​time” hourly
(not salaried) employees with no minimum number
of hours of work each day; “full-​time” hourly (not sal-
aried) employees with frequent overtime.
Creative and flexible scheduling of PACU nurses
in proportion to the predicted daily peak number
of patients admitted to the PACU may allow some
cost savings by reductions in staff hours during low
admission periods [30]. However, the practice envir-
onment may not be conducive to the needed flexi-
bility and creative scheduling that may be required
for a given nursing staff wage category. Avoidance of
frequent overtime and use of hourly employees with
no minimum number of work hours may improve
efficiencies. Other strategies may include the use of
a combination of more than one wage category in a
particular PACU staffing model to add flexibility in
scheduling. Improvements in surgical sequencing of
cases, the sequence in which surgeons perform their
cases in an OR on one day, may also result in reduced
PACU staffing needs [30]. Unfortunately surgeons
may not be agreeable to loss of control over the order
of their cases [24]. Waddle et al. studied medically
appropriate PACU length of stay (LOS), defined as the
time required achieving a medically stable condition
for safe PACU discharge, compared to actual LOS in
340 patients [31]. They revealed the actual LOS to be
>30 min longer than the medically appropriate LOS
in 20 percent of patients. The most frequent causes
of prolonged LOS were waiting for physician release
or waiting for laboratory or study results (i.e., radio-
graph and laboratory results). Some studies have
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Chapter 23: Postanesthesia Care Unit Management
implicated PACU nurses being too busy, lack of trans-
port, procedures performed in PACU, postoperative
monitoring, pain management, bed availability, and
PONV as additional causes of increased LOS [32, 33].
Improvements in the efficiencies in the administrative
issues that have resulted increased LOS may lead to
significant cost reductions. However, because of diffi-
culty in scheduling full-​time PACU nursing staff and
wide variability in increased LOS, it is very difficult
to fully assess the benefit of any single intervention
aimed at decreasing LOS [24, 25, 34].
Some studies suggested that strategies such as use
of short-​acting drugs, multimodal antiemetics, and
regional anesthesia, fast-​tracking of patient discharge
directly from the PACU or bypassing of phase I PACU
to phase II PACU, may directly or indirectly decrease
PACU costs [34–​36]. Regional anesthesia techniques
have been shown to reduce costs in the ambula-
tory setting as a result of reduced postoperative
complications, fewer unintended hospital admissions,
and earlier home readiness of the patients [37].
However, the effectiveness of these strategies may vary
significantly with the practice environment and PACU
staffing needs. It is often difficult to measure the true
costs of implementation (i.e., drug, equipment, and
staffing costs) when evaluating presumed cost savings
[36–​39].
Use of standard operating procedures and alter-
native definitions of discharge criteria may reduce
surveillance time and improve fast-​ tracking and
bypassing of phase I recovery, resulting in cost savings
[40, 41]. Many discharge criteria and policies (i.e., oral
fluid intake, voiding, awaiting full return of motor
function after regional block) may be modified based
on outcome studies or planned location of discharge
(i.e., inpatient versus home) [23, 40].
In summary, this chapter emphasizes the key
players in an effective PACU, the three phases of
postanesthesia recovery, criteria of PACU discharge,
PACU design, and staffing-related issues. The financial
implications of the PACU, especially those involving
cost savings, are complicated and mostly a function
of nurse staffing, owing to its overwhelming propor-
tion of cost in PACU operation. Leadership in the
PACU at the level of the physician rests solely on the
shoulders of the Anesthesiology Department. When
anesthesia training and rotations are designed in the
PACU, a curriculum and didactics will strengthen
a learning atmosphere. A weekly or monthly con-
ference of stakeholders can be beneficial in many
245
246
Section 3: Surgical and Anesthesia Practice Management
aspects, much like Morbidity and Mortality/​Grand
Rounds conferences are invaluable for an OR or ICU
team. Finally, many strategies to decrease costs may
have potential benefits, especially if they result in
improved OR process flow efficiencies. Future strat-
egies to decrease PACU costs will probably require
incorporation of the total OR process flow. It will be
important that these strategies also incorporate main-
tenance of patient safety and good ​quality outcomes.
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Chapter 23: Postanesthesia Care Unit Management
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