Post Anesthesia Care Unit (PACU)

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Rotation Director (email) David Stoll ([email protected]) Rotation Name Post Anesthesia Care Unit (PACU)

COURSE OVERVIEW

Course Overview (75 – 100 words describing the course)

The Post Anesthesia Care Unit experience is a two contiguous week experience intended to provide the resident with the medical knowledge and clinical experience necessary to manage patients in the immediate postoperative period. The clinical experience will provide management opportunities for both adult and pediatric patients recovering from general anesthesia, conscious sedation, and regional anesthesia. Didactic instruction will consist of informal and guided self-directed study. Formal lectures on post anesthesia care are provided as part of the scheduled lecture series. This rotation challenges the resident to develop an understanding of common complications in the post anesthesia care unit and utilize this knowledge to practice prevention, early recognition and rapid intervention.

LEARNING OBJECTIVES

Knowledge Knowledge Recall

Basic Science Thorough understanding of physiology of all organ systems

Basic Science Thorough understanding of the pharmacology of pertinent drugs

Practical Knowledge Understand the components and requirements of a PACU

Clinical Knowledge Understand the admission and discharge criteria for patients

Clinical Knowledge Understand the nature of all pertinent surgical procedures

Clinical Knowledge Understand comorbidities related to all organ systems

Knowledge Analysis

Neurology Recognize and diagnose different causes for altered mental status

Cardiac Recognize and diagnos arrhythmias, blood pressure disturbances, and ischemia

Pulmonary Recognize and diagnose obstruction, hypoventilation, and hypoxemia

Pain management Understand proper analgesic techniques (regional anesthesia, opioids, and nonopioids)

Controversies Analyze controversies surrounding blood product, fluid, and glucose management as well as beta blockade

Knowledge Synthesis

Anesthesia and Surgery Understand how the surgical procedure and anesthesia can affect the patient and exacerbate comorbidities

Overall care Understand and recognize patients that can be properly discharged from the PACU to home, the hospital floor rooms, or need more intensive care

Knowledge Application

Airway Understand all airway complications relating to difficult airways and surgery involving the airway

Pulmonary Apply treatment for obstruction, hypoxemia, hypoventilation

Cardiac Ordering, interpreting, and initiating treatment of arrhythmias and ischemia, including the application of ACLS algorithms for code situations

Analgesia Initiate or maintain appropriate analgesia for post operative patients

Definitive Care After recognizing and diagnosing patient problems the resident should be able to initiate treatment and/or facilitate definitive care with the primary team

Skills Manage airway obstruction (pharyngeal and/or laryngeal obstruction as well as edema and hematoma) Proficient in the use of multiple intubating devices and techniques including fiberoptic techniques Placement of peripheral and central intravenous access

Placement of invasive hemodynamic monitoring devices (arterial lines and pulmonary artery catheters) Massive resuscitation

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Demonstrate proficiency in providing cardiopulmonary resuscitation

Demonstrate an understanding of clinical criteria for discharge from the PACU Attitudes Demonstrate respectful attitude toward nursing staff

Demonstrate respectful attitude toward surgical team

Coordinate and relay concerns about patient to both the surgical team and primary anesthesia team

Show compassion for patient concerns and modesty

Pleasant communication with the family in all situations and be able to diffuse difficult situations

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Patient Care: The resident will develop an understanding of the physiologic changes associated with surgery and anesthesia and the residual effects present in the immediate postoperative period. Early observation and evaluation of recovering patients will allow the resident to comprehend the significance of these changes and recognize, diagnose, and treat common PACU problems. Prevention of common complications through anticipation of associated physiologic changes, early recognition and proactive care are the goal of post anesthesia patient management.

After successful completion of this rotation the

resident will be able to: Methods of Evaluating Competency

Objective 1. Assess, diagnose, and initiate treatment with common PACU emergencies

Direct observation/Faculty Feedback Oral quiz

Simulation Lab Objective 2. _{Interpret laboratory data (cbc, chemistries, arterial blood}

gases)

Direct observation/Faculty Feedback

Objective 3. _{Interpret radiographic images (Chest radiographs, CT} scans)

Direct observation/Faculty Feedback

Objective 4. _{Interpret electrocardiograms} _{Direct observation/Faculty Feedback}

Objective 5. Demonstrate proficiency in providing cardiopulmonary resuscitation

Simulation Lab

Objective 6. _{Successfully troubleshoot equipment and monitors} _{Direct observation/Faculty Feedback} Simulation Lab

Objective 7. _{Successfully manage a patient’s acute and/or chronic} pain in PACU and the post-operative period

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Medical Knowledge: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to at the conclusion of the post anesthesia care unit rotation the resident should have an understanding of the following basic science and clinical knowledge and appropriately integrate this knowledge into patient management decisions.

After successful completion of this rotation the

Objective 1. _{Recall and utilize basic science knowledge, including,} but not limited to:

Physiology = respiratory, cardiovascular, central nervous system, renal, gastrointestinal,

thermoregulation, shivering, hyperthermia, and acid-base balance.

Written test Oral quiz

Objective 2. _{Recall and utilize basic science knowledge, including,} but not limited to:

Pharmacology = Opioids and opioid antagonists, benzodiazepines and benzodiazepine antagonists, NSAIDS, muscle relaxants and reversal agents,

inotropes and vasodilators, local anesthetics, inhalational anesthetic agents, and anti-emetics.

Written test Oral quiz

Objective 3. _{Recall and apply clinical science knowledge, including,} but not limited to:

A. PACU admission criteria

B. PACU discharge criteria including, discharge to floor and home, unanticipated admission planning, unanticipated ICU transfer, acute care unit (ACU) transfer, fast-tracking, phase I and II recovery, essentials of PACU admission report and discharge/transfer report C. Evaluation and management of common PACU problems such as:

• respiratory = airway obstruction,

hypoventilation, stridor, wheezing, aspiration, pulmonary edema, post-obstructive, volume overload, hypoxemia

• cardiovascular = hypertension, hypotension, myocardial ischemia, dysrhythmias, hemorrhage

• nausea and vomiting

• renal problems = oliguria, anuria, polyuria, hematuria, urinary retention

• electrolyte and metabolic abnormalities

• coagulopathy

• fluid management = crystalloid vs. colloid

• blood transfusion reaction

• delayed awakening

• postoperative agitation and delirium

Written test Oral quiz Simulation Lab

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• increased intracranial pressure

• postoperative seizure

• prolonged neuromuscular blockade

• hypothermia

• hyperthermia

• malignant hyperthermia

• anaphylaxis/allergic reaction

• postoperative pain management = PCA, parenteral opioids, NSAIDS, opioid agonist/antagonists

• continuous peripheral regional techniques = neuroaxial blockade

• ventilator management

• corneal abrasion protocol

• treatment of shivering

Practice-based Learning and Improvement:

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning

• Utilization of the CQI process to improve patient safety and personal performance.

• Active participation in furthering their knowledge by attending organized educational activities

After successful completion of this rotation the

resident will be able to: Methods of Evaluating Competency

Objective 1. _{Self-analyze his or her practice and compare their} practice to that of their peers. Residents should use this assessment to perform continual practice-based improvement.

Direct observation/Faculty Feedback Self Assessment

Objective 2. _{Understand of the role of information technology in th} practice of anesthesia and utilize this technology for self-education and management of patient information.

Objective 3. Accept constructive criticism from faculty and peers with demonstrated responsiveness by reflective clinical performance and practice improvement

Objective 4. _{Incorporate evidence-based practice into knowledge} base and clinical performance

Utilize the CQI process to improve patient safety and personal performance.

Actively participate in furthering their knowledge by attending organized educational activities

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Interpersonal and Communication Skills: Residents must be able to demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families and professional associates. Residents should develop:

After successful completion of this rotation the

Objective 1. _{Communicate skills that result in effective information} exchange between anesthesia providers, nursing staff, peers, attending physicians, and surgeons

Establish therapeutic doctor-patient relationships through appropriate, compassionate patient interactions

Direct observation/Faculty Feedback Nursing staff evaluations

Self Assessment

Objective 2. Recognize and overcome common barriers to effective communication

Oral quiz

Nursing staff evaluations Objective 3. _{Demonstrate verbal, non-verbal and written skills to}

accurately communicate patient care information

Nursing staff evaluations Objective 4. _{Adequately protect patient confidentiality and their}

rights in all levels of communication concerning patient information

Oral quiz

Nursing staff evaluations Objective 5 _{Deliver organized presentations of history and physical}

examinations, differential diagnosis, and proposed management to the attending anesthesiologist

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Professionalism

Residents must demonstrate commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate

Objective 1. Commit to carrying out professional responsibilities, adhere to ethical principles, demonstrate sensitivity to a diverse patient population

Objective 2. _{Understand of the role of the anesthesiologist in the} management of patients recovering from anesthesia and practice within the guidelines of the department, the institution and the American Society of Anesthesiologists

Objective 3. _{Understand HIPPA regulations as they pertain to the} management of patient care data

Objective 4. Demonstrate compassion and respect for patients and their families expectations and needs

Interact with colleagues, peers and staff in a respectful and conscientious manner

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Systems-based Practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Objective 1. Understand the flow of patients through the PACU Direct observation/Faculty Feedback Self Assessment

Objective 2. _{Understand how other areas or systems within the} institution impact patient flow through the PACU

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Objective 3. _{Demonstrate the ability to coordinate patient care in} order to meet the needs of the patient, surgical team, nursing staff and institution

Objective 4. _{Form effective relationships with other members of the} health care team to provide care that is of optimal value and quality

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TEACHING METHODOLOGIES

Students on this rotation will be expected to achieve and comprehend the learning objectives through the following methodologies and activities:

Various lectures Simulated scenarios

Daily direct one-on-one teaching at the bedside with attendings

Global evaluation scoring system by the faculty Director of PACU

3600 evaluation: Nursing staff evaluation of professionalism, interpersonal communication skills, and system based practice and general patient care interactions.

Self directed teaching = material provided by Dr. Stoll

Oral quiz at end of rotation

PATIENT ENCOUNTERS

Residents on this rotation will be expected to work up and/or manage the minimum number of patients/cases with the specified conditions as listed below: (e.g., 10 craniotomies, 20 vaginal deliveries with CLE, etc.)

Number Patient Condition / Case

10 Respiratory Compromise

15 Hemodynamic abnormality

30 Pain Control

10 Post Operative Nausea and Vomiting

FEEDBACK

Please identify when and how the student will receive feedback on his/her performance. Daily Written Verbal Final Written Verbal

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Educational Resources:

Residents are encouraged to read the general PACU chapters in their regular anesthesia textbooks. Review of the scheduling cases for the following day can help guide daily reading.