Patients suitable for extended stay in PACU at Heatherwood hospital:

• Should be discussed with a consultant anaesthetist at the pre-operative assessment stage
• Should be booked for extended stay with the nurse-in-charge for PACU as early as possible, prior to the day of surgery
• Should have surgery as early as possible in the morning and preferably early in the week
• Will remain under the care of the responsible anaesthetist and surgeon while they remain in PACU
• Must have a plan documented in Epic with a clear handover at every stage of care
• Will be cared for by an appropriately trained nurse
• At 17:00, the clinical team must decide if the patient is suitable for step-down to ward care at Heatherwood or requires transfer for ongoing care at an acute site.

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Abbreviations

Extended Recovery Stay - (also known as an ‘enhanced perioperative care’) is a model of care for surgical patients who will benefit from an enhanced level of care for the first few hours following surgery. It provides the best pathway for patients with monitoring, treatment or care needs which are greater than those provided in normal postoperative wards, but who are not expected to require Level 2 or 3 (critical care) interventions or staffing to meet their care needs. The aim of the service is to improve quality of care and safety for this group of surgical patients.

Planned extended recovery stay - patients are identified to benefit from extended recovery care prior to the day of surgery due to co-morbidities or complexity of surgery.

Unplanned extended recovery stay - patients are identified to benefit from extended recovery on the day of surgery due to clinical concerns that have arisen during or after the surgical procedure.

• To provide additional monitoring and therapy that is not available in the postoperative ward areas

• To allow timely interventions and escalation of treatment, as required, as a result of enhanced monitoring and optimal staffing with access to senior anaesthetist and surgeon

• To allow administration of medicines and therapies which cannot be delivered safely in a postoperative ward environment

Services offered by Extended Recovery Care

• Enhanced monitoring, e.g., short term invasive monitoring to facilitate peri-operative haemodynamic management or management of epidural related hypotension

• Additional medical support, e.g., correction of an acute arrythmia or treatment of difficult to manage pain

• Safe management of existing co-morbidities, e.g., cardiovascular or respiratory conditions

Services not offered by Extended Recovery Care

• Invasive Ventilation

• Long-term inotropic support

• Invasive renal support

• Total Parenteral Nutrition

Extended Stay

Patients suitable for extended stay in PACU at Heatherwood should be discussed with a consultant anaesthetist at the pre-operative assessment stage (preferably with one of the Heatherwood pre-operative consultants).

Suitable patients should be booked for extended stay with the nurse in charge for PACU as early as possible, prior to the day of surgery (Ext 144157/58).

These patients should have surgery as early as possible in the morning to provide enough time for recovery. Where possible, their surgery should be scheduled for early in the week. There is no on-site anaesthetic support at Heatherwood at the weekend to aid post-operative ward care upon discharge from PACU.

Unplanned Extended Stay

These patients will be discussed directly with the PACU NIC on the day.

Ownership

The responsible anaesthetist and surgeon will maintain overall responsibility for the patient and be expected to participate in the postoperative management whilst the patient remains in PACU.

The responsible anaesthetist and/or surgical team will regularly review the patient and provide medical advice.

The decision to return the patient to the ward or to transfer to the acute sites will be made by 1700 on the day of the surgery.

A PACU nurse with appropriate skills, training and experience will deliver clinical care for these patients, with ongoing support from PACU NIC.

The Heatherwood bleep holder anaesthetist should also be informed of the patient and may be asked to provide assistance as necessary.

If the responsible anaesthetist is leaving Heatherwood prior to discharge of the patient from PACU, they must formally handover care to the ‘starred’ consultant anaesthetist. The responsible or ‘starred’ anaesthetist must remain onsite until it is clear the patient will be safely discharged from PACU.

A written plan of care for the Extended Recovery Stay patient must be clearly documented in Epic for the PACU nurses to adhere to. Where appropriate, include suitable targets for vital parameters, e.g. BP, urine output, etc.

Duration of Extended Recovery Stay

To be decided by the anaesthetist and/or surgical team. It can range from 2 hours until 17:00 on the day of surgery.

If patients require level 1-2 care beyond 17:00, then a definite plan must be instigated to transfer to Wexham Park or Frimley Park Hospital in consultation with anaesthetist and surgical team, together with the on-call anaesthetist at the base hospital.

Transfer to the acute site will be in accordance with the Transfer of Deteriorating Patients from Heatherwood Elective Hub guideline.

1. Patients must be discussed and/or reviewed by the anaesthetic and/or surgical team prior to discharge.

2. Any extended stay patients in PACU at 17:00 must be reviewed by the anaesthetic and surgical team to decide if they are suitable for ward care at Heatherwood hospital or require transfer to an acute site. This decision should be made by 17:00 on the day of surgery to facilitate safe transfer.

Please refer to Trust CPAP Pathway for discharge criteria for patients with OSA requiring CPAP (Appendix 1, below).

3. A clear plan must be documented in the notes for ongoing care in the ward area.

4. The responsible anaesthetist must provide a verbal handover to the anaesthetic bleep holder and RMO who will be caring for the patient overnight.

Handover process for patients requiring transfer to acute site for ongoing care.

Follow the process for transfer in the Transfer of Deteriorating Patients from Heatherwood Elective Hub guideline.

• Provide a clear written summary for the receiving team

• The NIC will co-ordinate the transfer by liaising with the ambulance service

Ensure the patient is kept updated of their planned care and inform next of kin, as appropriate.

Patients may be identified for Extended Recovery stay during Pre-op assessment (‘Planned’) or on the day of surgery (‘Unplanned’).

Anaesthetist and surgical team to liaise with PACU Nurse-In-Charge

• To ensure appropriate level of staffing and adequate resources prior to PACU admission of the patient.

Clear plan for Extended Recovery care must be documented prior to PACU admission

• All patients will be under the care of the responsible anaesthetist and surgeon whilst they remain in PACU.

Extended Recovery patient must be reviewed by anaesthetist and surgical team no later than 17:00 on the day of surgery to make a decision on destination for discharge.

Patient Suitable for Ward in Heatherwood Hospital

• Patient can be safely stepped down to ward.

• Ensure clear written and verbal handover of patient to anaesthetic bleep holder/ward staff and RMO.

Patient to be Transferred to the Acute Site

• Patient will require ongoing Level 1-2 care.

• Responsible anaesthetist and surgeon to refer patient to anaesthetist on-call and surgical team respectively in the acute site. PACU NIC to arrange transfer of patient from Heatherwood hospital as per guidance. All relevant information and documentation must be handed over during the transfer.

• Remember to keep patient and NOK informed of planned events.

Postoperative

During an extended recovery period of up to 4hrs, patients should be observed for:

• Bradypnoeas (<8 breaths/minute; >2 episodes),

• Apnoeas (>10 seconds; at least 1 episode)

• Desaturations with nasal cannulae oxygen (<90%; >2 episodes)

• Pain-sedation mismatch with on-going opioid requirements

PACU Discharge criteria

• Physiological stability (cardiac, respiratory, neurological)

• Non-major surgery (e.g., joint arthroplasty without regional requiring iv opioids)

• Physical and mental ability to manage their own CPAP therapy with minimal assistance

• Free of respiratory events without stimulation (as highlighted above)

• No need for major opioids (i.e., parenteral (PCA) or oral causing excessive sedation)

• O2-dependance ≤4L nasal O₂

If above criteria are not met, patient will need transfer to acute site for continuous SpO₂ monitoring.

OSA criteria

• Severe - AHI >30

• Moderate AHI 15-30

Respiratory event

• Bradypnoeas (<8 breaths/minute; >2 episodes)

• Desaturation with nasal cannula oxygen (SpO₂< 90%; >2 episodes)

• Apnoea >10 seconds

High risk surgery

• Laparotomy

• Bowel resection

• Joint arthroplasty without regional requiring IV opioids

Significant uncontrolled comorbidities

• Heart failure, hypertension, low GCS

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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