多元化带教方法在PACU带教中的应用

【摘要】目的：探讨多元化带教方法在PACU临床实习护生带教工作中的应用效果。方法：选取2018年6月—2019年2月在安徽省某三甲医院PACU实习的44名护生,按照实习时间阶段分为传统组和多元组。传统组采用传统一对一带教方法,多元组采用多元化带教方法。实习结束后,比较两组的带教效果。结果：多元组护生理论和操作考核成绩、对带教的满意度以及老师对护生的评分均优于传统组（P＜0.05）。结论：在PACU临床实习护生带教工作中,应用多元化带教方法能充分调动护生自主学习能动性,从而使护生对理论知识和临床操作有更好的掌握,提高临床带教质量。     

麻醉恢复室护理质量敏感性指标的构建

目的 构建适用麻醉恢复室的护理敏感指标,为麻醉恢复室护理质量的监测与评价提供标准化的专科依据。方法 检索国内外文献借鉴护理专家的研究成果,在“结构质量—过程质量—结果质量”的理论基础上初步拟定敏感指标框架,运用德尔菲法进行2轮专家函询,确定最终麻醉恢复室护理质量敏感性指标。结果 专家权威系数>0.80,各指标变异系数<0.30。经过2轮专家函询,构建了包含5项结构指标,10项过程指标及5项结果指标的麻醉恢复室专科敏感指标体系。结论 基于德尔菲法构建的麻醉恢复室护理质量敏感指标具有敏感性、科学性与实用性,对提高麻醉恢复室护理质量安全具有指导意义,有利于麻醉恢复室持续发展。     

麻醉恢复室入室护理流程的应用

目的探讨麻醉恢复室(post-anesthesia care unit,PACU)入室护理流程的临床实践效果。方法建立PACU入室护理流程,内容包括连接呼吸机、连接监护仪、管道交接、皮肤交接等流程和对PACU护士进行培训、考核。结果流程应用前,术后患者入室护理时间从7.0 min降至流程应用后4.0 min,无1例发生护理风险及不良事件。结论 PACU入室护理流程的应用提高了护理质量,加强了患者安全。     

麻醉后监测治疗室患者护理记录指标体系的构建

目的 构建科学系统的麻醉后监测治疗室患者护理记录指标体系,为麻醉恢复期的患者安全与护理行为提供依据。方法 基于循证理念拟订麻醉后监测治疗室患者护理记录指标体系初稿,采用Delphi专家咨询法向17名专家进行2轮函询,并利用优序图法和百分权重法确定各指标权重。结果 2轮专家函询问卷回收率分别为89%、100%,专家权威系数为0.91,变异系数分别为0～0.225、0～0.244,肯德尔协调系数分别为0.209、0.214(P<0.01)。最终形成的麻醉后监测治疗室患者护理记录指标体系包括3项一级指标,10项二级指标和62项三级指标。结论 本研究构建的麻醉后监测治疗室患者护理记录指标体系具有良好的科学性和实用性,可为麻醉复苏室护士的临床护理行为与记录具有较好的指导与规范作用。     

Developing Core Competency-Based Learning Objectives for Postgraduate Curricula for Postanesthesia Nurses—A Delphi Study

PurposePostanesthesia care unit (PACU) nurse competencies involve the ability to care for patients receiving complex treatment. Well-educated PACU nurses are required to provide safe patient care, and accordingly, they require investment in their education. However, core competencies for PACU nurses that are based on systematic methods for curriculum development and consensus have not been established. The purpose of this study was to develop a nationwide consensus on core competency–based learning objectives for a postgraduate PACU nursing curriculum.DesignNationwide Delphi Study using Kern's six steps of curriculum development as a framework.MethodsForty-one anesthesiologists and 38 PACU nurses from 37 Danish departments of anesthesiology were invited to participate. In Delphi round 1, the participants listed core competencies for PACU nurses within 12 predefined categories. We analyzed the responses using an inductive and manifest approach to content analysis and developed learning objectives in accordance with the Structure of Observed Learning Outcomes and Simpson taxonomies. In Delphi round 2 and 3, the participants rated and rerated the learning objectives on a 7-point Likert scale, measuring statements of agreement. Consensus was predefined as a median score of 6 and or greater. The main outcome was a prioritized list of competency-based learning objectives for a postgraduate PACU nurse curriculum.FindingsTwenty-six nurses and 14 anesthesiologists (51%) completed all Delphi rounds, representing 22 (60%) departments of anesthesiology. Consensus was reached on 180 learning objectives. The learning objectives described competencies ranging from basic to complex nursing tasks and emphasized the knowledge and skills needed to identify and initiate treatment of postoperative complications.ConclusionsNationwide consensus on core competencies for postgraduate curricula for PACU nurses was achieved through the Delphi method. Our study exemplifies the range of complex knowledge and skills needed to work as a PACU nurse. The learning objectives are applicable in postgraduate curricula designed for PACU nurses.     

麻醉后监护室护理质量敏感指标的构建

目的构建适用于麻醉后监护室(post anesthesia care unit,PACU)的护理质量敏感指标,为PACU治疗监测及管理提供标准、量化的依据。方法以"结构-过程-结果"理论模式为依据,借鉴美国国家护理质量指标数据库及其他国内外麻醉护理专家的研究成果形成指标初稿,运用德尔菲技术进行3轮专家咨询,结合帕累托定律确定指标的内容和科学的测量方法。结果构建了包含复苏时间中位数、收治各类麻醉患者比例、低体温干预有效率、术后疼痛干预有效率等11项指标的PACU护理质量敏感指标体系。3轮专家咨询的问卷有效回收率均为100%,专家权威系数分别为0.86、0.84、0.90,专家意见的肯德尔和谐系数分别为0.245、0.256和0.356 (P<0.01)。结论 PACU护理质量敏感指标涵盖麻醉后监护的关键内容,可操作性强,专科特色鲜明,具有科学性和实用性,可为基于数据的持续质量改进和提高PACU护理质量提供参考。     

PDCA循环在麻醉恢复期躁动患者护理中的应用

[摘要] 目的 探讨PDCA 循环在麻醉恢复期躁动患者护理中的应用效果。 方法 选择2015在我院全身麻醉手术后转入麻醉恢复室的120例患者,将1至6月60例患者作为对照组,7至12月60例患者为观察组。对照组按照PACU常规进行复苏护理,观察组在PACU常规护理基础上应用PDCA 循环通过计划、实施、检查、处理四个阶段进行护理和干预,密切观察两组患者在全麻恢复期出现躁动情况及不良事件进行比较。结果 观察组的躁动发生率显著低于对照组,差异有统计学意义（P<0.05）;观察组的因躁动引起的不良事件发生率低于对照组,差异有统计学意义（P<0.05）。结论 实施PDCA 循环管理能够降低全麻恢复期患者躁动发生率,提高护理安全性,值得临床推广应用。     

Use of postanesthesia care unit for purposes other than postanesthesia observation.

Postanesthesia care units (PACUs) were originally developed to care for patients who needed monitoring until they recovered from anesthesia. As new treatment options are developing, however, the role of PACU is changing and the scope of PACU nurses is expanding. We performed a study to find out the proportion of patients who were admitted to the PACU for reasons other than postoperative observation and care and analyzed the resources, observation, and interventions these patients required in PACU facilities. These patients were a heterogeneous patient population who required variable monitoring, care, and nursing activities and, therefore, considerably increased the workload of PACU nurses. A small proportion of these patients suffered from problems that further increased the demand for special care.     

Evaluation of a Standardized Sedation Assessment for Opioid Administration in the Post Anesthesia Care Unit

The impact of opioid-related sedation progressing to respiratory depression in the Post Anesthesia Care Unit (PACU) can be extensive; however, there is a paucity of research on the subject of standardized assessment tools to prevent adverse events. The purposes of this study were: (1) to measure the efficacy of a standardized method of assessing sedation and administering opioids for pain management via the Pasero Opioid-Induced Sedation Scale (POSS) with interventions in the PACU; (2) to increase PACU nurses’ confidence in assessing sedation associated with opioid administration for pain management and in the quality of care provided in their clinical area; and (3) to facilitate PACU and postoperative clinical unit nurses’ communications during patient handoffs regarding safe opioid administration. A quasi-experimental design was used to evaluate the POSS protocol. Two PACUs and six nursing units receiving postsurgical patients in a Midwestern inner-city hospital served as the setting for this research. Medical records were surveyed for outcome data to evaluate the efficacy of the care protocol in two patient cohorts before and after implementation of the POSS protocol. Nurses completed a written survey to identify changes in satisfaction with nurse-to-nurse communication, perceptions of quality of care, and confidence with opioid administration. The final sample included 842 PACU patients and 67 nurses from the PACU and clinical units. The intervention did not significantly change PACU length of stay or amount of administered opioids and patients were noted to be more alert at time of discharge from the PACU. Nurses reported increased perceptions of quality of care and confidence in opioid administration. The findings from this study support the use of the POSS Scale with interventions in the PACU care protocols.     

What is new with inhaled anesthetics: Part 2

Since the 1800s, inhaled agents have been administered to produce surgical anesthesia. Although inhaled anesthetics are commonly known to produce a state of sleep, they also influence many physiologic processes. This article explores the pharmacodynamics of the inhaled anesthetics used in current anesthesia practice. Equipped with this knowledge, the PACU nurse will be better prepared to anticipate the nursing care needs of patients recovering from inhaled anesthetics.     

Nurses' Perceptions of Patient Participation in the Postanesthesia Care Unit—A Qualitative Focus Group Study

PurposeTo explore postanesthesia care unit (PACU) nurses' experiences and perception of patient participation during PACU care.DesignQualitative focus group study based on a phenomenological hermeneutic approach.MethodsWe conducted three focus group interviews with 18 nurses from three different PACUs. Themes were created based on interpretive theory inspired by Ricoeur.FindingsFour themes and 11 subthemes were found. Patients’ clinical condition and situation, time management, ethical aspects, and the patient-nurse relationship all had a high impact on postanesthesia nursing practice and conditions for involving patients.ConclusionsPACU nurses want patients to participate in their own treatment and care in the PACU; however, nurses perceive patient participation differently. Nurses experience challenges including patients’ impaired autonomy, absence of a holistic approach, and lack of time and resources. Nurses highlight that these barriers should not become an excuse for noninvolvement.     

What can the postanesthesiacare unit manager do to decrease costs in the postanesthesia care unit?

The economic structure of the PACU dictates whether a cost-reducing intervention (e.g., reducing the length of time patients stay in the PACU) is likely to decrease hospital costs. Cost-reducing interventions, such as changes in medical practice patterns (e.g., to reduce PACU length of stay), only impact variable costs. How PACU nurses are paid (e.g., salaried v hourly) affects which strategies to decrease PACU staffing costs will actually save money. For example, decreases in PACU labor costs resulting from increases in the number of patients that bypass the PACU vary depending on how the staff is compensated. The choice of anesthetic drugs and the elimination of low morbidity side effects of anesthesia, such as postoperative nausea, are likely to have little effect on the peak numbers of patients in a PACU and PACU staffing costs. Because the major determinant of labor productivity in the PACU is hour-to-hour and day-to-day variability in the timing of admissions from the operating room, a more even inflow of patients into the PACU could be attained by appropriate sequencing of cases in the operating room suite (e.g., have long cases scheduled at the beginning of the day). However, this mathematically proven solution may not be desirable. Surgeons, for example, may not want to lose control over the order of their cases. Guidelines for analysis of past daily peak numbers of patients are provided that will provide data to predict the minimum adequate number of nurses needed. Though many managers already do this manually on an ad hoc basis statistical methods summarized in this article may increase the accuracy.     

Strategies to reduce delays in admission into a postanesthesia care unit from operating rooms.

The authors performed a systematic review of strategies to reduce delays in admission into PACUs from ORs. The purpose of this article was to evaluate for managers how to choose interventions based on effectiveness and practicality. The authors discuss optimization methods that can be used to sequence consecutive cases in the same OR, by the same surgeon, on the same day, based on the objective of reducing delays in PACU admission due to the unavailability of unfilled PACU beds. Although effective, such methods can be impractical because of large organizational change required and limited equipment or personnel availability. When all physical beds are not full, PACU nurse staffing can be adjusted. Statistical methods can be used to ensure that nursing schedules closely match the times that minimize delays in PACU admission. These methods are effective and practical. Explicit criteria can be applied to assist in deciding when to assign other qualified nurses to the PACU, when to ask PACU nurses to work late, and/or when to make a decision on the day before surgery to add more PACU nurses for the next day (if available). The latter would be based on statistical forecasts of the timing of patients' admissions into the PACU. Whether or not all physical beds are full, the risk of delays in PACU admission is relatively insensitive to economically feasible reductions in PACU length of stay. Such interventions should be considered only if statistical analysis, performed by using computer simulation, has established that reducing PACU length of stay will reduce delays in admission at a manager's facility.     

Extubation of pediatric patients by PACU nurses.

Traditionally, the role of the PACU nurse has been to evaluate patient readiness for extubation, with the responsibility of tracheal extubation performed by the anesthesiologist or Certified Registered Nurse Anesthetist (CRNA). In our PACU, registered nurses routinely evaluate and extubate the majority of surgical cases. Our experience has shown that extubation by the PACU nursing staff improves airway management skills without compromising patient safety and facilitates OR turnover time. In this article, tracheal extubation performed by PACU nurses is detailed and a case study is presented.     

Statistical power analysis to estimate how many months of data are required to identify PACU staffing to minimize delays in admission from ORs.

When each nurse in the Phase I setting is caring for the maximum number of patients allowed by hospital staffing standards (typically 2 per ASPAN standards), patients may have to be held in the OR until a PACU nurse becomes available. Previously, the authors described a statistical method to determine the process of scheduling existing nurses without increasing staffing hours (Dexter et al. Anesth Analg. 92:947-949, 2001). The end result was to minimize the percentage of future workdays during which at least one patient would wait in his or her OR for Phase I PACU admission. In this study, the authors performed a statistical power analysis to determine how many months of PACU workload data are needed to optimize PACU staffing by using this "set covering" algorithm. One year (232 workdays) of data was available from a PACU employing up to 10 nurses working a total of 72 clinical hours a day. The data were divided into 2 subsets. Using the first subset, which varied in size between 20 and 140 days of data, the authors identified the optimal staffing solutions. These solutions were tested on the second subset of data. This process then was repeated thousands of times. There was a marked improvement in the performance of the staffing solutions at preventing "PACU hold" by increasing from 20 to 80 historical workdays of data, a slight but statistically significant improvement between 80 and 100 workdays, but no significant improvement in further increasing the number of workdays of data. PACU nurse managers should use at least 4 months of data when choosing a staffing solution to minimize the chance of patients waiting in ORs for PACU admission. Tampering with PACU staffing more often than every 4 months is unlikely to result in improvements in OR efficiency and may harm recruitment and retention of nursing staff.     

Nursing activities and use of time in the postanesthesia care unit.

Specialty areas, such as the PACU, are currently characterized by a shortage of qualified nursing personnel along with the pressure for a most cost-conscious function of services. These, in combination with both the increasing acuity of patients and the advances of science and technology, have rendered necessary the investigation of how existing personnel can be better used. The work sampling approach has been widely used in different clinical settings to offer data about the amount of time nurses devote to specific activities. The aim of the current study was to categorize and quantify the activities of nurses employed in the PACU of the General University Hospital of Patras, Greece, and to identify differences with regard to shifts, varying nurse-patient ratios, and nurses' experiences. In the first phase, a classification form, which included all nursing activities, was constructed. This was based on literature review, researchers' experience, and semistructured personnel interviews. In the second phase, the researchers observed all PACU nurses, and activities were recorded on an hourly check sheet. A total of 4,320 observations were collected from 9/1/2004 to 9/30/2004. Nurses spent 35.2% of their time on direct clinical care, 11.6% on patient assessment, 7.0% on communication with patients, 7.2% on communication with other persons, 8.6% on clerical nursing duties, 9.3% on documentation, 2.3% on non-nursing duties, and 18.8% on personal activities. Variations in the use of time were found between shifts, different nurse-patient ratios, and PACU experience. Methods of decreasing time when the nurse-patient ratio is inappropriate and increasing time allocated to direct care activities are proposed.     

Aromatherapy Blend for Postoperative Nausea in Ambulatory Surgery Patients

PurposePostoperative nausea (PON) is one of the most common undesirable outcomes after surgery and increases patient dissatisfaction, hospital costs, and risk for postoperative complications. This quality-improvement project implemented and evaluated the effect of aromatherapy on nausea in adult postoperative patients.DesignQuality improvement project evaluating the inhalation of a blend of essential oils through an individual stick via an aroma stick.MethodsThis quality-improvement project was implemented in a postanesthesia care unit (PACU) in the Northeastern United States that averages 300 adult patients per month. Over the course of 12 weeks in the Fall of 2019, the project sample included all PACU registered nurses and patients with PON without allergies to inhalation agents or nasal surgery.FindingsOne hundred percent of PACU registered nurses (n = 20) were educated and demonstrated competence in the aromatherapy intervention; 70.6% (n = 36) of patients with PON used an aroma stick for PON treatment. Of the patients receiving the aroma stick for PON, 94.4% (n = 34) had improved PON scores.ConclusionsAromatherapy is an effective nonpharmacological treatment in reducing PON score for patients recovering from surgery. These results offer support for nursing practice to use aromatherapy as an additional method to enhance patient experience, improve outcomes, and reduce cost in recovery rooms.     

Impact of average patient acuity on staffing of the phase I PACU.

The authors consider methods for determining staffing requirements for a Phase I PACU. Given that the total number of nursing hours per day is limited by budgetary constraints, PACU staffing can be adjusted to minimize the percentage of days that the PACU is full and cannot accept additional patients from the OR. Except for very small PACUs, the number of staffing options is so large that computer optimization methods must be used. In addition, patient acuity must be incorporated into the staffing plan. Methods are described for adjusting staffing requirements when some patient acuities differ from 1 nurse:2 patients, when patients transition from one acuity to another, and when acuity is not known for all patients.     

A history of the PACU.

The specialized intense nursing care provided in the PACU is now well recognized as crucial to optimize outcomes for the patient undergoing modern anesthesia and surgical techniques. However, this fact has not always been recognized. Although anesthetic techniques have evolved since the mid-1800s, the widespread establishment of PACUs only began about 50 years ago, shortly after World War II. This article provides an historical review of the development of the PACU in the United States.