Can a PACU nurse extubate a patient? Must an anaesthetist always be present?
Association of Anaesthetists of Great Britain and Ireland [1]:
‘The removal of tracheal tubes is the responsibility of the anaesthetist, who may delegate the removal to an appropriately trained member of the PACU team who is prepared to accept this responsibility’.
Royal College of Anaesthetists [3]:
‘The anaesthetist is responsible for ensuring that the endotracheal tube is removed safely. Nurses who are trained in the management of supraglottic airways may remove them, although an anaesthetist should be immediately available.’
BARNA [Standards of Practice] [2]:
‘Both recovery and anaesthetic nurses must continuously update their knowledge and skills as new techniques and drugs are introduced into perianaesthetic practice. Recovery nurses acting autonomously in the absence of the anaesthetist, must ensure that they work within their established and recognized scope of practice’.
BARNA comment :
Both AAGBI and RCOA state that it is the anaesthetist’s responsibility to remove the endo-tracheal tube. However, the AAGBI statement includes the proviso that an ‘appropriately trained member of the PACU team’ may extubate the patient if they are prepared to accept the responsibility. While BARNA supports both statements as they stand, this appears to be an area of practice which requires further investigation in the UK. The following questions must be asked:
Sources:
[1] Association of Anaesthetists of Great Britain and Ireland [2012,] Draft report of the AAGBI Immediate Post-anaesthetic Recovery Working Party. Association of Anaesthetists of Great Britain and Ireland, London
[2] British Anaesthetic and Recovery Nurses Association:Standards of Practice [reviewed 2012] British Anaesthetic and Recovery Nurses Association, London
[3] Royal College of Anaesthetists [2009] Guidance on the provision of anaesthesia services, Chapter 4: Post-operative care. Royal College of Anasthetists, London
‘The removal of tracheal tubes is the responsibility of the anaesthetist, who may delegate the removal to an appropriately trained member of the PACU team who is prepared to accept this responsibility’.
Royal College of Anaesthetists [3]:
‘The anaesthetist is responsible for ensuring that the endotracheal tube is removed safely. Nurses who are trained in the management of supraglottic airways may remove them, although an anaesthetist should be immediately available.’
BARNA [Standards of Practice] [2]:
‘Both recovery and anaesthetic nurses must continuously update their knowledge and skills as new techniques and drugs are introduced into perianaesthetic practice. Recovery nurses acting autonomously in the absence of the anaesthetist, must ensure that they work within their established and recognized scope of practice’.
BARNA comment :
Both AAGBI and RCOA state that it is the anaesthetist’s responsibility to remove the endo-tracheal tube. However, the AAGBI statement includes the proviso that an ‘appropriately trained member of the PACU team’ may extubate the patient if they are prepared to accept the responsibility. While BARNA supports both statements as they stand, this appears to be an area of practice which requires further investigation in the UK. The following questions must be asked:
- What is happening in units around the country? Are nurses extubating patients with or without anaesthetic supervision? A national audit on this would be helpful.
- If PACU nurses are allowed to extubate as a delegated task from the anaesthetist, the following measures should be set up locally: a) local policy stating that PACU nurses may extubate patients under certain conditions; b) extubation competency should be in place for all nurses who wish to accept this responsibility
Sources:
[1] Association of Anaesthetists of Great Britain and Ireland [2012,] Draft report of the AAGBI Immediate Post-anaesthetic Recovery Working Party. Association of Anaesthetists of Great Britain and Ireland, London
[2] British Anaesthetic and Recovery Nurses Association:Standards of Practice [reviewed 2012] British Anaesthetic and Recovery Nurses Association, London
[3] Royal College of Anaesthetists [2009] Guidance on the provision of anaesthesia services, Chapter 4: Post-operative care. Royal College of Anasthetists, London
What are the minimal staffing recommendations for PACU?
BARNA Standards of Practice [2]:
‘Reception of patient:(the patient may be unconscious or emergent from that state) Staff ratio: 1:2 (one patient/two nurses) – to undertake handover/prioritise immediate care/set up monitoring). The skills of the first nurse must be appropriate for the acuity of case. The helper may be a novice nurse or member of the perioperative team.
Stabilisation period:(self ventilating with no airway adjuncts or needing respiratory assistance; the patient’s clinical condition stabilises through this period to full recovery but may regress back along the clinical continuum). Staff ratio: 2:1 (two patients/one nurse) skills of nurse must be appropriate to acuity of cases. If patient’s condition deteriorates staff must be reallocated promptly.
Fit for discharge:(has met all local discharge criteria – is stable and comfortable). Staff ratio: 3:1 (three-patients/1 nurse). The nurse looking after three patients must be experienced and may be assisted by novice nurse or member of the perioperative team’.
Association of Anaesthetists of Great Britain and Ireland [1]:
‘No fewer than two staff [of whom at least one must be a registered practitioner] should be present when there is a patient in PACU who does not fulfill the criteria for discharge to the ward’.
Royal College of Anaesthetists [3]:
‘Until patients can maintain their airway, breathing and circulation they must be cared for on a one-to-one basis
At least two appropriately trained staff should be present in the recovery room while there is a patient who does not fulfill the criteria for discharge to the ward.
It is difficult to give guidance on the exact numbers of staff required for any particularly recovery area. The staffing levels will depend on factors such as the case mix, numbers of patients and the number of operating lists per session.’
BARNA advice:
Staffing the PACU is an ongoing intractable problem. All statements on staffing are based on minimal staff to patient ratios which are dependent on the clinical status of the patient. However, to adjust staff numbers to patient throughput accurately throughout the shift, matching patient acuity to staff expertise is very difficult. It remains doubtful that a ‘magic formula’ can be developed to fit this constantly changing, dynamic clinical area. BARNA has developed work around this topic [see audit section]. BARNA would recommend auditing variables that affect staff –patient ratios [delayed discharge being one important factor]. Safe staffing the PACU is still dependent on the expertise of the PACU manager who can adjust staffing if necessary on a day to day basis.
*
Sources:
[1] Association of Anaesthetists of Great Britain and Ireland [2012,] Draft report of the AAGBI Immediate Post-anaesthetic Recovery Working Party. Association of Anaesthetists of Great Britain and Ireland, London
[2] British Anaesthetic and Recovery Nurses Association:Standards of Practice [reviewed 2012] British Anaesthetic and Recovery Nurses Association, London
[3] Royal College of Anaesthetists [2009] Guidance on the provision of anaesthesia services, Chapter 4: Post-operative care. Royal College of Anasthetists, London
‘Reception of patient:(the patient may be unconscious or emergent from that state) Staff ratio: 1:2 (one patient/two nurses) – to undertake handover/prioritise immediate care/set up monitoring). The skills of the first nurse must be appropriate for the acuity of case. The helper may be a novice nurse or member of the perioperative team.
Stabilisation period:(self ventilating with no airway adjuncts or needing respiratory assistance; the patient’s clinical condition stabilises through this period to full recovery but may regress back along the clinical continuum). Staff ratio: 2:1 (two patients/one nurse) skills of nurse must be appropriate to acuity of cases. If patient’s condition deteriorates staff must be reallocated promptly.
Fit for discharge:(has met all local discharge criteria – is stable and comfortable). Staff ratio: 3:1 (three-patients/1 nurse). The nurse looking after three patients must be experienced and may be assisted by novice nurse or member of the perioperative team’.
Association of Anaesthetists of Great Britain and Ireland [1]:
‘No fewer than two staff [of whom at least one must be a registered practitioner] should be present when there is a patient in PACU who does not fulfill the criteria for discharge to the ward’.
Royal College of Anaesthetists [3]:
‘Until patients can maintain their airway, breathing and circulation they must be cared for on a one-to-one basis
At least two appropriately trained staff should be present in the recovery room while there is a patient who does not fulfill the criteria for discharge to the ward.
It is difficult to give guidance on the exact numbers of staff required for any particularly recovery area. The staffing levels will depend on factors such as the case mix, numbers of patients and the number of operating lists per session.’
BARNA advice:
Staffing the PACU is an ongoing intractable problem. All statements on staffing are based on minimal staff to patient ratios which are dependent on the clinical status of the patient. However, to adjust staff numbers to patient throughput accurately throughout the shift, matching patient acuity to staff expertise is very difficult. It remains doubtful that a ‘magic formula’ can be developed to fit this constantly changing, dynamic clinical area. BARNA has developed work around this topic [see audit section]. BARNA would recommend auditing variables that affect staff –patient ratios [delayed discharge being one important factor]. Safe staffing the PACU is still dependent on the expertise of the PACU manager who can adjust staffing if necessary on a day to day basis.
*
Sources:
[1] Association of Anaesthetists of Great Britain and Ireland [2012,] Draft report of the AAGBI Immediate Post-anaesthetic Recovery Working Party. Association of Anaesthetists of Great Britain and Ireland, London
[2] British Anaesthetic and Recovery Nurses Association:Standards of Practice [reviewed 2012] British Anaesthetic and Recovery Nurses Association, London
[3] Royal College of Anaesthetists [2009] Guidance on the provision of anaesthesia services, Chapter 4: Post-operative care. Royal College of Anasthetists, London
Is ECG monitoring a national requirement for routine recovery?
Association of Anaesthetists of Great Britain and Ireland [1]:
‘An appropriate standard of monitoring should be maintained until the patient is fully recovered from anaesthesia. Clinical observations should therefore be supplemented as in the operating theatre by a minimum of pulse oximetry, non-invasive blood pressure monitoring, ECG and, if patients tracheas remain intubated or have their airways maintained with a supraglottic or other similar airway device, continuous capnography.’
Royal College of Anaesthetists [3]:
‘Currently acceptable standards of patient monitoring should be available for all patients. This includes pulse oximetry, and non-invasive blood pressure monitoring. An electrocardiograph, nerve stimulator, thermometer and capnograph should be readily available’.
BARNA advice:
BARNA supports the recommendation from the RCOA that mandatory basic monitoring includes pulse oximetry and non-invasive blood pressure monitoring. ECG monitoring equipment must be available for each bed area in PACU however, for any patient requiring monitoring. PACU nurses should be competent in basic ECG rhythm recognition.
*
Sources:
[1] Association of Anaesthetists of Great Britain and Ireland [2012,] Draft report of the AAGBI Immediate Post-anaesthetic Recovery Working Party. Association of Anaesthetists of Great Britain and Ireland, London
[2] British Anaesthetic and Recovery Nurses Association:Standards of Practice [reviewed 2012] British Anaesthetic and Recovery Nurses Association, London
[3] Royal College of Anaesthetists [2009] Guidance on the provision of anaesthesia services, Chapter 4: Post-operative care. Royal College of Anasthetists, London
‘An appropriate standard of monitoring should be maintained until the patient is fully recovered from anaesthesia. Clinical observations should therefore be supplemented as in the operating theatre by a minimum of pulse oximetry, non-invasive blood pressure monitoring, ECG and, if patients tracheas remain intubated or have their airways maintained with a supraglottic or other similar airway device, continuous capnography.’
Royal College of Anaesthetists [3]:
‘Currently acceptable standards of patient monitoring should be available for all patients. This includes pulse oximetry, and non-invasive blood pressure monitoring. An electrocardiograph, nerve stimulator, thermometer and capnograph should be readily available’.
BARNA advice:
BARNA supports the recommendation from the RCOA that mandatory basic monitoring includes pulse oximetry and non-invasive blood pressure monitoring. ECG monitoring equipment must be available for each bed area in PACU however, for any patient requiring monitoring. PACU nurses should be competent in basic ECG rhythm recognition.
*
Sources:
[1] Association of Anaesthetists of Great Britain and Ireland [2012,] Draft report of the AAGBI Immediate Post-anaesthetic Recovery Working Party. Association of Anaesthetists of Great Britain and Ireland, London
[2] British Anaesthetic and Recovery Nurses Association:Standards of Practice [reviewed 2012] British Anaesthetic and Recovery Nurses Association, London
[3] Royal College of Anaesthetists [2009] Guidance on the provision of anaesthesia services, Chapter 4: Post-operative care. Royal College of Anasthetists, London
Are Nurse Anaesthetists allowed to work in the UK?
- Nurse Anaesthetists deliver anaesthesia to patients in many countries around the world, usually under direct or indirect supervision from trained anaesthetists.
- The UK does not employ Nurse Anaesthetists to perform this role.
- The UK employs Anaesthetic Nurses or Operating Department Assistants [ODPs] to work alongside the anaesthetist in the delivery of anaesthesia. While this involves working as a team to successfully deliver anaesthesia, preparing drugs and equipment, and anticipating the needs of the anaesthetist, it does not allow the actual administration of anaesthesia by the nurse or ODP.
- In order to work as an Anaesthetic Nurse or ODP in the Anaesthetic Room the practitioner must have received formal training in a Higher Education Institute [see Education Section of this website].
- Nurse Anaesthetists trained abroad, and wishing to work in the UK in this capacity will not be able to do so as there is no means of accrediting their advanced practice training and experience within the UK.
- Nurse Anaesthetists may work in the UK as Anaesthetic Nurses as their training will be recognised and accredited by the NMC.
- The only non-physician practitioner allowed to deliver anaesthesia in the UK is the Anaesthetic Associate [or Physicians Associate [PA(A)]. These two new roles emerged as a result of a government led initiative, New Ways of Working in Anaesthesia project [terminated in 2009]. Currently Birmingham University offers both courses which take around 27 months to complete [see Education Section, Training Courses].
- Nurse Anaesthetists from abroad, wishing to practice in the delivery of anaesthesia in the UK may think about completing the course of Anaesthetic Associate which would automatically allow them to work under supervision from a consultant anaesthetist.
What is the scope of practice for Nursing Associates working in PACU?
Nursing Associate training lasts for 2 years full time to achieve an NMC validated Foundation Degree. On graduating the Nursing Associate works in an area of choice, and potentially in the PACU. In January 2019 Nursing Associates were admitted onto the NMC Register. The role is a new one designed to bridge the gap between Healthcare Assistant [HCA] and Registered Nurse.
Duties of the Nursing Associate in general are likely to include :
Ref : NHS : Nursing Associate https://www.healthcareers.nhs.uk/explore-roles/nursing/roles-nursing/nursing-associate [accessed 17.03.21]
The scope of nursing for the Nurse Associate is broad based as shown above. In a specialist area such as PACU the way these practitioners are used will develop over time. As trained practitioners however, they will care for the routine patient from admission to discharge under the direct, or indirect supervision of the Registered Nurse or Operating Department Practitioner in charge of the unit.
Work on this the scope of this new role is currently being undertaken by the Perioperative Care Collaborative. As we receive more evidence of their practice – this section will be updated.
Duties of the Nursing Associate in general are likely to include :
- undertaking clinical tasks including venepuncture and ECGs
- supporting individuals and their families and carers when faced with unwelcome news and life-changing diagnoses
- performing and recording clinical observations such as blood pressure, temperature, respirations and pulse
- discussing and sharing information with registered nurses on a patients’ condition, behaviour, activity and responses
- ensuring the privacy, dignity and safety of individuals is maintained at all times
- recognising issues relating to safeguarding vulnerable children and adults
Ref : NHS : Nursing Associate https://www.healthcareers.nhs.uk/explore-roles/nursing/roles-nursing/nursing-associate [accessed 17.03.21]
The scope of nursing for the Nurse Associate is broad based as shown above. In a specialist area such as PACU the way these practitioners are used will develop over time. As trained practitioners however, they will care for the routine patient from admission to discharge under the direct, or indirect supervision of the Registered Nurse or Operating Department Practitioner in charge of the unit.
Work on this the scope of this new role is currently being undertaken by the Perioperative Care Collaborative. As we receive more evidence of their practice – this section will be updated.
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