OPANA Standards of PeriAnesthesia Nursing Practice

OPANA Standards of PeriAnesthesia Nursing Practice

LHSC Post Anesthesia Care ConferenceApril 10, 2010

Waking up is hard to do……

Objectives

1. To learn why Standards of Practice are important

2. To learn how the revised OPANA Standards of Practice were changed, and why….

3. To learn the contents of the book4. To test your knowledge of best

practice standards5. And to try to have some fun (and

stay awake while we’re doing it!)

What is a Standard?

o Standard: o Highest level of performance,

attainable and desiredo Resource: o Set of practice guidelines, for

specific disorders or conditionso Position Statement: o Statement on an issue, opinion of

the group: convincing or deterring?

Why do we need Standards?

To provide: Best practice patient care Highest level of performance,

attainable and desired Patient care that is based on the

evidence from results of research activities (and not ritual or habit)

Improved practice where errors are common

And…...

And because….(We’re not sure what the anesthetist has been doing or if the patient

is ok……)

What we know for sure!

We know anesthetics We know surgical procedures We know patient responses We know pain management We know PONV management We know normal vs. abnormal We know perianesthesia nursing

care! Or do we?

What we know for sure that we don’t know!

Better ways to do the same thing All of the effects of all medications All of the effects of the

environment (heat, noise, emissions)

All of the effects of stress All of the variables that affect

individual patient response All of the best practices in

perianesthesia patient care!!

What do we do about this?

We learn from others’ experiences We watch, read, listen and learn We are constantly open to new

insights, new information, new research results

We adapt to an environment that is constantly evolving

We share this knowledge with others…..

OPANA Standards of Practice 6th Edition: Revised

Why? Times have changed…new priorities New anesthetics, analgesics, surgery Anesthetic techniques have changed New members in the ACT New best practices….research based New ROPs….Accreditation Canada Sharing of knowledge!

How? Based on experience of the group

(cross-section across: the province, p/a phases, p/a roles, patient age groups)

Extensive literature search Built on other standards Looked to CNA and RNAO for

frameworks Advice from experts

OPANA Standards of Practice 6th Edition: Revised

OPANA Practice Standards, 6th Edition:

Contents include:1. Scope of Practice2. Standards of Practice:

Administrative Standards (5) Clinical Practice Standards (6)

3. Resources (13): Guidelines for improving performance

4. Position Statements (8): What’s new and how we feel about it!

5. Definitions: general and relevant6. Appendices (8): Samples and examples

for use in your environment

How are they designed?

Where relevant, reference to best practice in each of the 5 PeriAnesthesia Phases:

1. Preadmission2. Day of Surgery Admission3. Phase I Recovery4. Phase II Recovery5. Extended ObservationSome relevant to only one area…..

Administrative Standards

For use by Administrators to ensure a quality practice setting so that Clinical Practice Standards can be met.

Standards on: environment, equipment, nursing qualifications, orientation and education, documentation and CQI

To ensure the “highest quality workplace environments” (CNA)

Clinical Practice Standards

For clinicians, educators, administrators:

Include: Airway management Pain management PONV management Thermoregulation Assessment, monitoring and interventions Transfer of care and accountability Preparation for, and management of the

effects of anesthetic agents/techniques because these are given by…….

“Mr. Gasman”…..

Resources

PreAdmission Unit Specific (2) Staffing Guidelines OSA MH Latex Allergies Visitors Patient Safety Emergence Delirium Pain Management Infection Control Discharge Criteria Managing Patient Flow through the PACU

Position Statements

Minimum Staffing in all phases “Nurse Practitioner in Anesthesia” “Anesthesia Assistant” RPNs UCPs Phase I Recovery as a Critical Care Unit DNR Fast Tracking

References

Where available, the most recent literature: Some original references (Aldrete, Chung;

“Locus of Control”,1954) Other best practice nursing standards

(NAPANc, ASPAN) CNA framework; RNAO Guidelines Medical standards (CAS) CPSI (Safer Healthcare Now!) Accreditation Canada (ROPs)…..

ALL evidence-based! Because that is what we KNOW and it has been tested and proven to be so!

Question and Answer Period

Question and Answer Period

No, not for you!

I’m asking the questions here.

Let’s have some fun now and see how well you know YOUR Standards of

Practice!

Q: What is the temperature range that patients must be maintained at prior to,

during and following surgery?



A:

36 – 38 ° C



A:

36 – 38 ° C

WHY?We know now that hypo/hyper-thermia can cause

SSI, impaired platelet function, altered drug metabolism, negative cardiac events,

↑ventilatory support

Q: How do you know when a patient is ready to transfer to the next phase of

postanesthesia recovery?



A: When they meet a minimum score of 9 in the appropriate Discharge Criteria!



A: When they meet a minimum score of 9 in the appropriate Discharge Criteria!

(Where you going to say one hour?

We don’t use the clock anymore…)

Q: Who should escort a patient on Transfer?


“A PeriAnesthesia Nurse should accompany all patients following anesthesia or analgesia administration especially:


“A PeriAnesthesia Nurse should accompany all patients following anesthesia or analgesia administration especially:

All patients requiring continuous cardiac monitoring

All patients requiring ongoing assessment, evaluation and/or treatment during transport

All pediatric inpatients (under the age of 18).”

OPANA , 2009

Q: Name some reasons for encouraging Visitors into all Phases of PeriAnesthesia

care:

Q: Name some reasons for encouraging Visitors into all Phases of PeriAnesthesia

care:

Fewer iatrogenic errors! Shorter patient LOS Reduced side effects of anesthetics with

reduced requirements for analgesia and antiemetics (r/t anxiety)

Reduced patient care hours (RN, other) Better perception of healthcare system Better patient, family and staff

satisfaction scores

Q: How long have we known this?

Q: What is the definitive test for MH?


A: CHCT! (What does that stand for?)


A: The “Caffeine-Halothane Contracture Test”

Q: What is the NEW best practice length of time for monitoring an MH patient

postoperatively?


postoperatively?

One hour in Phase I Recovery (PACU)+

One and one-half (1 ½) hours in Phase II Recovery

= (a mere 2 ½ hours in total!!!!)


postoperatively?

Why is that?

There has never been a case of MH crisis occurring later than 40 minutes after induction of a triggering agent.

Q: How often should Postoperative Temperatures be taken?

MH Suspected:Immediately upon arrival; and upon discharge (one hour later) if no other symptoms of MH.

Non-MH: Immediately upon arrival. If normal range, not necessary again (unless fluid resuscitation has occurred).

If abnormal, q 30 minutes

Q: When does the temperature elevation appear in the MH crisis chain of events?

Q: When does the temperature elevation appear in the MH crisis chain of events?

A: Usually last! muscle rigidity, tachyarrhythmias (with fluctuation in

BP), tachypnea, ↑CO2, dark coloured urine output…… then elevated temperature!

Q: And the drug of choice in treating MH?

A: Dantrium (Dantrolene) (and sterile water without bacteriostatic agent)

Q: Other drugs to treat effects of the crisis?

A: Amiodarone, Sodium Bicarbonate, Regular Insulin, Dextrose (D50W), Lidocaine, etc.

Q: When a patient has an ARO….what is an ARO?

Q: When a patient has an ARO….what is an ARO?

Antibiotic Resistant Organism

Such as……..????

(name 4!)

Q: So when a patient has an ARO, what type of Isolation is used?

Q: So when a patient has an ARO, what type of Isolation is used?

A: Contact!

Q: And where is the patient (with ARO) cared for, and what is the nurse:patient ratio with

this patient?

Q: And where is the patient (with ARO) cared for, and what is the nurse:patient ratio with

this patient?

In the general population (a regular stretcher bay), and

Under normal nurse:patient ratio for the acuity of that patient and others…..

Let’s talk about nurse: patient ratios (one of your favourite topics):

Q: How many patients should each PeriAnesthesia Nurse be assigned to in Phase I Recovery (PACU)?

A: It depends….

……..it depends on:

1. Patient Classification (what is this?)

ASA Physical Classification System

P1: A normal healthy patient

P2: A patient with mild systemic disease

P3: A patient with severe systemic disease

P4: A patient with severe systemic disease that is a constant threat to life

P5: A moribund patient who is not expected to survive without the operation

P6: A declared brain-dead patient whose organs are being removed for donor purposes

……..it depends on:

1. Patient Classification (what is this?)

2. Acuity of patient(s)3. Invasiveness of the intervention4. Intensity of patient care and LOS5. Relative experience of the

PeriAnesthesia Nurse(s)6. Transportation of patients (gold

standard vs. sufficient)

1:1 Nurse:Patient Ratio

All patients on admission (1-5 minutes) (2nd nurse avail if nec)

Pt. requires ventilatory support, challenges to airway management, ↓ O2 Saturation, airway obstruction

Unconscious, airway not protected, ↓ O2 Saturation

Pt. develops life-threatening Sx complications

Pt. requires invasive procedures by MD Isolation except Contact Peds, until stable airway and

hemodynamics


Pt. stable, require numerous nursing interventions

Peds, awake, alert, stable, no complex monitoring, not ASA 3-4

Peds after airway and hemodynamics stable

Contact Isolation (or may be 1:3)


All other patients:

including post GA, ASA 1 or 2, may be day surgery have met discharge criteria, bed not

available


Extended Observation Phase:

including patients who have been discharged from PACU, have met d/c criteria for Phase I and II

Q: Should all patients have electrocardiographic monitoring in Phase I?

Q: Should all patients have electrocardiographic monitoring in Phase I?

A: Appropriate to patient condition

(CAS) Routine pulse, blood pressure with

electrocardiographic monitoring readily available (ASA)

OPANA recommends for ALL patients, but….

If that isn’t possible…..

Then as a minimum standard: BP, P, T and O2 Sat on ALL patients Cardiac monitoring with illnesses, conditions, surgical

procedures e.g.: History of cardiac disease Arrhythmia or changes in BP during procedure Extreme blood loss Serum electrolyte imbalance Suspected MH Blood dyscrasias Immunosuppressed (drug, disease) Former transplant Invasive surgery to one or more of the vital organs or brain C/o chest pain Sudden change in BP or P, ↓ O2 Sat, ↑ or ↓ T Genetically inherited disorders Trauma patients Negative reactions to recent interventions or medication Rescue pain management regional anesthesia

Q: Should all patients have electrocardiographic monitoring?

Patient Safety Questions

Q: Name potential areas for errorA: 1. Communication

2. Wrong patient/treatment/medication

3. Medications and high risk infusions

4. Infusion, instillation, ingestion sites

5. Falls

6. Transfer of ARO,HAI,SSI(what are these?)

7. Human Errors

Patient Safety questions


Transfer of care/accountability at admission and discharge: checklist

(When does it need to be verbal? written?) Knowledge transfer: Checklists (Preop, Surgical),

sharing




Pt identification (double identifiers) Tell the patient your name; ask pt. his! Knowledge transfer: Checklists (Preop,

Surgical), sharing PPOs Visitors!




3. Medication and high risk infusions Electrolytes, standardized/premixed infusions,

sound-alike medications, standardized infusion protocols (insulin)

Dangerous abbreviations (ISMP list) PPOs Independent double checks Phone orders: Read back and sign




3. Medication and high risk infusions

4. Infusion, instillation, ingestion sites Lines not disconnected Pump training, ongoing






5. Falls Guidelines Siderails, including transportation Management of ED/POCD






5. Falls

6. Transfer of ARO, HAI, SSI Single use equip., safety device injections Hand hygiene, IPAC Guidelines Thermoregulation






5. Falls

6. Transfer of ARO, HAI, SSI

7. Human Errors Nurse fatigue, overtime PPOs, independent double checks System checks, i.e. “smart pumps”

Q: Managing patient flow through the PACU…….

Q: Why?

A: 1. Delays/cancellation, ↑ anxiety, inconvenience

2. Pt. reversing from GA in OR: Surgery still underway? Lack of pain management Lack of pt comfort measures Lack of thermoregulation Lack of monitoring, postop complications

3. Delay in postop medical orders: diagnostic, radiological, medications, VS, IVs

4. ↑ workload of double transfer: patient transfer to PACU after recovering in OR: ready for Phase II; ICU pts transferred with team


Q: What is nurse’s role?

A: “ The PeriAnesthesia Nurse has an important role in, and takes responsibility for, maintaining patient flow.” OPANA, 2009


Q: How? ratios, and adjustments (use of physical

facility), discharge criteria (and documentation of

d/c criteria), updated constantly, preparation

staffing for volumes, with acuity factored in,

transferring appropriately (verbal with checklist) vs writing,

ancillary staff for non-nursing duties, managing discharged patients, breaks at peak periods

Q: DNR in the PeriAnesthesia Environment…

Is it ignored? Or is it still in effect?

A: It depends…. Don’t you love that non-committal answer?

But it does…..it depends on an in-depth discussion with the patient &/or SDM regarding when, where and how resuscitative measures should/should not be implemented…and DOCUMENTED!!!! (and of course, shared with all members of the IPT)

Q: DNR in the PeriAnesthesia Environment

Why?

1. It is unethical to expect the patient to agree to removing the DNR status if surgery required

And conversely:

2. It is unethical to deny the patient surgery/treatment because of the DNR status

Q: DNR in the PeriAnesthesia Environment

So basically it boils down to:

1. DNR status will be in effect entirely, or

2. DNR status will be removed entirely, or

3. DNR status will be revised: As to the measures taken (CPR/defib, fluid,

inotropes) As to the location (only in OR, only in PACU,

inpatient unit, during entire stay) CAS, ASA, OPANA, ASPAN, ORNAC, Ethicists

Q: What is the phrase most commonly used by a PACU Nurse?

A: Take a deep breath (dear)!

or

“Breathe!”

Q: What is the term most commonly used by a PACU Nurse?

Q: What is the name of the singing group?

Q: What is the name of the singing group?

A: The Laryngospasms!!!!

Q: What is the name of the cute blonde singer?

Q: What is the name of the cute blonde singer?

A: Keith!

Your turn to ask the questions!

Contact Information:

Paula Ferguson, RN, BScN, MN

Immediate Past President, OPANA, (2007-9)

President, National Association of PeriAnesthesia Nurses of Canada (2009-11)

Tel/Fax: (905) 257-7522

Email: [email protected]; [email protected]

OPANA Standards of PeriAnesthesia Nursing Practice

Health & Medicine

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