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Pre-theatre and post anaesthetic care unit (PACU)

The Pre-theatre /Post Anaesthetic Care Unit (PACU) team is an integrated team of nurses, health care assistants, physiotherapists, and porters. The Pre-Theatre /PACU team provides information in the pre-operative and post-operative phase of the patient’s journey. The service is an efficient approach to elective orthopaedic surgery, utilising enhanced recovery principles and evidence-based practice. The enhanced recovery pathway focuses on early mobilisation and aiming for same day discharge for appropriate patients. Service provision is individualised based on patient need e.g., some patients are admitted to the unit the day prior to their surgery for preparatory procedures, such as line insertion or a blood transfusion.      

The nurses in pre-theatre are responsible for telephoning all patients listed for surgery, 4 to 5 days prior to the list, to offer advice/ support to both patients and relatives prior to their admission.  In addition, instructions are shared for: 

  • Medication (including which medications to continue and which to omit);
  • Fasting instruction;
  • Skin care;
  • Nutrition and hydration;
  • Digestion;
  • Where to arrive and what to wear;
  • Staff answer any queries patients may have in respect of their impending surgery. They check for understanding of instructions given and advise patients to document advice specified to minimise risk of cancellation;
  • Expectation setting around length of stay and day case joint arthroplasty discharge.
  • Patients wait in the reception area prior to being guided to the pre-theatre area by nursing staff. Once in pre-theatre, the patient changes into a hospital gown. Possessions and clothes are labelled and taken to the allocated bed by Post-Anaesthetic Care Unit (PACU).
  • Blood pressure and other vital signs are measured, an intravenous (IV) line is fitted, and the patient is offered a warming blanket.
  • A member of the surgical team reminds the patient of the potential benefits, risks and complications of undergoing their specific surgery and patient consent is gained.
  • The anaesthetist will discuss the type of anaesthetic options suitable for the patient and explain how pain will be managed after the procedure.
  • Additional checks include blood results / X-ray to ensure they are in date in line with local policy and COVID test result is checked if required. MRSA status is documented, and other predetermined instructions are actioned e.g., if the patient needs an interpreter to ensure informed consent prior to surgery, if the patient requires any reasonable adjustments based on the vulnerable adult pathway.
  • The team ensures that the correct medical notes for the patient are on site and transport is booked if it is required.
  • Cancellation letters are generated, personnel informed and Datix process started for patient cancellations.
  • Liaison with the Anaesthetist/Surgeon if there are any queries about patient’s condition/ past medical history (PMH)/medication/investigations.
  • Co-ordination of professionals from other areas as required e.g., radiographer/cardiac technician.
  • Report defective equipment and remove from patient use.
  • To assist in ensuring that the appropriate and efficient use of supplies is made and exercise economy in the use of consumables.
  • Continuous liaison with the Ward Manager ensuring open and effective communication is maintained.
  • Attend and participate in ward/departmental meetings to enable integrated approach to patient care e.g., theatre planning, cancellation meetings etc.
  • Supervision, support, teach and motivate qualified and unqualified junior members of staff including students, nursing students and health care assistants.
  • Communication of knowledge and information to other staff and implement any changes.
  • Management of the clinical area in the absence of the Ward Manager or Sister/Charge Nurse.
  • Report all serious untoward clinical incidents in the appropriate manner to the Lead Practitioner and Associate Director of Nursing.
  • Ongoing promotion of evidence-based practice.
  • Liaise with reception and ensure patients are escorted in a timely and professional fashion to the appropriate cubicle in pre-theatre.
  • If patients have had PCR tests, ensure their results are printed off and negative. Should the result be positive, ensure patient has been informed and a cancellation letter has been sent to the appropriate people.
  • Confirmation of correct patient identity, identify allergies, and fill in appropriate paperwork. If a female patient (55 and under) is having surgery, ensure they have signed a pregnancy disclaimer. Upload lateral flow test result in clinical manager if required.
  • All staff must have an awareness of local policy in connection with Advance Directives, Respect Form and Personalised Treatment Escalation Plan.
  • The Property Disclaimer is adhered to, understood by the patient and signed. If not, a full property check is completed and signed.
  • If a patient requires a Sick Certificate, this is completed in Pre-Theatre.
  • Ensure a thorough skin assessment is conducted and documented in the appropriate chart. If there are any areas with broken skin or moisture lesions these are photographed and uploaded to Bluespier.
  • If a pressure relieving mattress is required, this is requested via the Trust portal manager.
  • The Pre-theatre staff perform Arterial Blood Gases, blood glucose, HemoCue, coagulation tests or take blood samples.
  • If specific bloods are required, e.g., group and save and crossmatch, this is performed promptly by the pre-theatre team and sent to the Trust pathology department.
  • Should the patient have consented to bone donation, the required blood tests are performed, and the paperwork completed.
  • A comprehensive hand over occurs between the pre-theatre nurse, anaesthetic nurse/Operating Department Practitioner, and PACU nurse for each patient.
  • To prepare and attend the daily Safety huddle;
  • develop a therapeutic relationship by establishing trust and ensuring that patients are active participants in their post operative recovery;
  • check controlled drugs twice a day ensure all entries are signed appropriately and countersigned if required;
  • ensure all bed spaces are stocked appropriately, but to avoid over stocking;
  • accept all patients from theatre in a professional and timely manner, always ensuring patient safety;
  • effective hand over from the anaesthetist and surgical team is required for patient safety and quality of care. This hand over should include type of anaesthetic, blood loss, wound closure, and any adverse incident that occurred;
  • staff ensure that the surgical notes are documented correctly and in a timely fashion and correspond with the Theatre Module in Bluespier;
  • patients who have an advanced airway in place should have continuous capnography monitoring;
  • assess the behavioural and physical status of post-surgical patients utilizing interview, observations, physiological parameters and physical examinations;
  • interpret overt and subtle data appropriately to determine any physiological risk;
  • continue to use A to E assessment, ensuring that any discrepancies are dealt with;
  • all medications must be given as prescribed and to ensure MR Oxycodone is administered alongside IR Oxycodone if the patient has recovered minimal lower limb movement;
  • ensure discharge criteria is achieved prior to patient being discharged home or to the ward;
  • staff ensure that the surgical notes are documented correctly and in a timely fashion and correspond with the Theatre Module in Bluespier.

Pre-theatre:

The service was set up in 2004 where pre-theatre was managed by the theatre team. They were a group of five nurses and two Health Care Assistants.  They were responsible for managing the patient’s admission into hospital once they have been given a date for their surgery. Pre-theatre was run from an area adjacent to the theatres, using five curtained cubicles.  The pre-theatre team was managed by the theatre team.

As part of the 6th theatre construction, a new pre-theatre was built with six pre-theatre cubicles, each numbered according to the corresponding operating theatre. These cubicles were built in line with the provision of the Sex Segregation policy (patients were always segregated prior to their surgery however privacy and dignity were provided via curtains rather than walls). Achieving single sex accommodation plays a pivotal role in upholding patients’ privacy. Now, each patient has their own walled cubicle with a frosted glass privacy door.  The cubicles provide a more restful environment for patients prior to their surgery. This has been achieved through improved lighting, reduced sound transmission, better ventilation and appropriate material finishes. Research has shown that a quality environment helps patients to recover more quickly, they require less medication and permits staff to give their best in providing individualised, high-quality care.

The pre-theatre service has evolved from having one pre-theatre nurse per cubicle to currently having 2-3 cubicles allocated to each pre-theatre nurse. Cubicle allocation has evolved from random allocation in the next available space to admission following a pattern i.e. All patients having their operation in theatre 1 are admitted to cubicle 1. 

The pre-theatre team and PACU team have merged to become 1 team. This allows for the movement of staff across both areas, making staffing more sustainable and joined up.

Peri-operative: 

Historically, patients were transferred to the ward post recovery. The discharge pathway for day case joint arthroplasty patients has evolved to being discharged from PACU rather than the ward, to minimise duplication, prevent delay and promote enhanced recovery principles. A section of PACU is run as a day case unit and day case joint arthroplasty patients will be discharged from PACU once they have met all discharge criteria. 

  • Cardiac Technicians;
  • Anaesthetists;
  • Intensivists;
  • Surgeons;
  • Anaesthetic Nurses/ ODP’s;
  • Medical records;
  • Reception Staff;
  • Interpreters;
  • Language Line;
  • Pathology;
  • Transport;
  • Scheduling;
  • Theatre Co-Ordinator;
  • Theatre Matrons;
  • Pharmacy;
  • PACU/ Wards;
  • Pre-Assessment;
  • Patients and their families.

The team undertakes its work in a new state of the art, pre-theatre area. It contains six cubicles, one for each theatre, office space for four nurses, large notes trolley to keep medical notes secure and locked, two toilets and storage space to accommodate everything required by pre-theatre. It has two outside phone lines, four internal lines and four desk top computers. It is fully air conditioned. 

Initially PACU consisted of a main recovery/HDU area with 10 beds including a side room, and one- four bedded, and one-three bedded area for day cases to allow for sex segregation. However, the service has now extended, and it has 16 bed spaces with one side room. 

  • Clinical Manager;
  • Bluespier;
  • IPM;
  • ICM;
  • Pacs;
  • Lifebox;
  • Health Roster.
  • It would be beneficial to have a visitor’s room where family could wait. It could also be used if a doctor wanted to speak to relatives.
  • A separate phone call area for the pre-theatre nurses would be beneficial so that the nurses have a dedicated, quiet space to contact patients/relatives.

Inpatient: 

  • If the patient has not followed the correct fasting regime and their surgery must be delayed;
  • patients who have a high blood sugar and need management prior to their surgery;
  • repeat X-rays required;
  • increased surgical time;
  • late starts due to unforeseen circumstances;
  • cubicle capacity in pre-theatre;
  • delayed patient flow from PACU to the ward due to bed and staffing pressure.
  • To move the patients to PACU from pre-theatre:
  • Upskilled the PACU nurses to discharge from PACU;
  • Dedicated physiotherapy staffing allocation dependant on patient numbers in PACU.  
  • Nurse prescribers were unable to prescribe TTO’s;
  • inconsistent communication: it is extremely important that all staff communicate the same message to the patient. This helps manage their anxiety, manages their expectations and improve patient confidence in the system taking care of them.
  • Change fatigue – as SWLEOC is a Centre of Excellence, the team constantly strives to improve and streamline care delivery, thus change is inevitable. There has been an increase in the pace and extent of change following COVID due frequent changes to Infection Control policies and pathway changes;
  • there are delays in recruitment and national shortage of trained nursing workforce;
  • the fluctuating change in pace and demand makes predicting staffing levels difficult and may require staff to change their shifts at short notice. This is time consuming for the Rota coordinators.
  • Having specialist nursing with experience in critical care and recovery. This allows SWLEOC to treat most patients regardless of their medical comorbidities (being able to care for patients with ASA grades 1-4);
  • ring-fenced beds within pre-theatre and PACU and thus are not affected by emergency admissions;
  • patients are admitted directly to pre-theatre on the day of surgery rather than the ward which streamlines patient flow;
  • having a ring-fenced SWLEOC owned X-ray department to facilitate Day 0 X-ray for joint replacements and those patients that require an X-ray prior to their surgery on the day;
  • PACU nurses are upskilled to discharge day case patients from PACU, working very closely with the Therapy Team;
  • having own TTO cupboard to dispense drugs for more efficient discharge, with TTOs being prescribed by anaesthetist in theatre to prevent delay.  
  • The ability to discharge patients from PACU;
  • combining pre-theatre and PACU;
  • developing collaboration and encouraging staff to spend time in other areas of SWLEOC i.e., pre-assessment to develop a greater awareness on how the centre works and provide a more holistic approach to the patient;
  • develop, train and support Band 4 nurses, increasing the nursing team workforce;
  • having Nurse prescribers on the in-patient workforce. Ensure all nurses are trained to Group/Save and crossmatch blood;
  • patient information. Provide clear information in the preoperative period to minimise cancellation on the day.

  • Ensuring single sex accommodation for day care patients is maintained as they are unable to be discharged from PACU and require transfer to the wards. This could lead to delay. Since then, the team have allocated two areas within PACU that can segregate male and female day cases to facilitate discharge from PACU.

    Is there anything special to the service that would be useful for new centres to know about:

    It would be highly beneficial to have a dedicated day case unit to be able to have inpatients and day cases cared for in separate areas.

It would be highly beneficial to have a dedicated day case unit to be able to have inpatients and day cases cared for in separate areas.

Staff

Staff Member: PACU Matron (Band 8a x 1 WTE)

Role:

  • responsible for the PACU and pre-theatre service;
  • Patient care: 24 hours per week;
  • Leadership: 4 hours per week;
  • Rota Management: 3 hours per week.

Staff Member: PACU/pre-theatre Nurse (Band 7 x 6 WTE, Band 6 x 6 WTE)

Role:

  • Patient care: 24 hours per week;
  • Leadership: 4 hours per week;
  • Rota Management: 3hours per week;
  • Deputising for Matron: 2 hours per week;
  • Requesting X-rays etc: 2 hours per week;
  • Organising Complex PACU work: 2.5 hours per week.

Staff Member: PACU/pre-theatre Nurse (Band 5 x 10 WTE)

Role:

Band 5 nurses spend most of their day on nursing care with a small amount of time spent on administration duty.  

Staff Member: Associate Practitioner (Band 4 x 1 WTE)

Role:

 Associates spend most of their day on nursing care with a small amount of time spent on administration duty.  

Staff Member: Health Care Assistant (Band 3)

What this staff member does in relation to this activity:

HCAs spend most of their day on nursing care with a small amount of time spent on administration duty.  

Pre-Theatre Daily Staffing Model:

In pre-theatre daily there 3 nurses: this is made up of 1 x Band 6 and 2 x Band 5s.

Their daily work consists of the following:  

  • inpatient caseload of mixed complexity i.e., admitting the patients prior to surgery (4 hrs per day);
  • outpatient Caseload, i.e., phone calls to pts, ordering transport, speaking to pathology (6 hours per day.).