Policies,Clinical,UW Health Clinical,General Care and Procedures,Admission, Discharge, Transfer

Admission, Care and Discharge of Patients to and from Inpatient Post-Anesthesia Care Unit (PACU) (2.1.9)

Admission, Care and Discharge of Patients to and from Inpatient Post-Anesthesia Care Unit (PACU) (2.1.9) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer


Policy Title: Admission, Care and Discharge of Patients to and from Inpatient Post-
Anesthesia Care Unit (PACU)
Policy Number: 2.1.9
Category: UW Health
Type: Inpatient
Effective Date: December 1, 2015


To establish a uniform policy for the admission and discharge of patients age 16 and older to and from the
Inpatient Post-Anesthesia Care Unit; and to identify responsibilities of care during the recovery period. This
policy does not apply to the American Family Children's Hospital (AFCH) Post-Anesthesia Care Unit (PACU)
and does not apply to The American Center.


The Inpatient Post-Anesthesia Care Unit exists to:

A. Provide services and facilities so that patients can be constantly monitored w hile they recover from the
effects of anesthesia as w ell as their surgical or procedural intervention.
B. Centralize appropriate personnel and equipment in proximity to the operating rooms, thus reducing the time
needed to transport patients and to facilitate the immediate availability of medical assistance should post-
operative complications or emergencies arise.
C. Provide a model training environment for a variety of undergraduate students in the health care professions
and surgical and anesthesia residents as related to the discipline of post-anesthesia care.
D. Facilitate the development of improved techniques for monitoring during the immediate post-operative


A. For admission, care and discharge of patients age 16 and older:
i. The PACU exists for immediate post-operative and post-anesthetic care. Patients w ho have
received a general or regional anesthetic may be monitored in the PACU. Exceptions to this policy
include those patients w ho require direct transport from the operating room to an intensive care
unit. (See Addendum A for patients w ho bypass PACU.)
ii. Any patient w ho receives monitored anesthesia care (MAC) may be recovered in the PACU post-
procedure, if the patient requires Phase I recovery.
iii. Any patient w ho received a local anesthetic w ith or w ithout sedation and w ho in the opinion of the
surgeon requires close post-operative observation may be admitted to the PACU after consultation
w ith the Operating Room Anesthesiology Coordinator.
iv. A member of the anesthesia team w ill call the PACU Care Team Leader/Senior Team Member
(CTL/STM) approximately 30-45 minutes prior to his/her anticipated arrival to communicate any
special needs/requests and to ensure bed/staff ing availability.
v. All patients being admitted to the PACU from the operating room are to be accompanied by an
anesthesiologist/anesthesiology resident, or a clinical anesthetist w ho w ill "hand-off" to nursing
personnel the status of the patient. SBAR (refer to UW Health clinical policy #3.3.1 Hand-Off
Communication) w ill be the framew ork for communication betw een members of the health care
team. Medical records need to be available to caregivers providing direct care.
vi. All narcotic, sedative, vasodilator, and inotropic drugs, and/or blood products administered to a
patient during his/her PACU care must be authorized by an anesthesiologist or anesthesiology
vii. All nursing procedures w ill conform to UWHC Nursing Patient Care Policies.
viii. The performance of elective specialized procedures in the PACU is discouraged.
ix. PACU visitation for adult patients w ill be coordinated according to the PACU Visitation Guidelines.
If the 16 – 18 year old patient is enrolled in the Child Life Program), parents/guardians (no more
than tw o) w ill be accompanied by the Child Life specialist after receiving phone call from PACU RN.
Exceptions may be for patients w ith special needs such as interpreters for foreign language,
signers for a deaf patients, etc. or in special circumstances w here a patient has had a prolonged
PACU stay due to operational issues and it w ould be in the best interest of the patient and family to
allow visitation. The PACU Care Team Leader/Senior Team Member or PACU Supervisor should

Policy Title: Admission, Care and Discharge of Patients to and from Inpatient Post-Anesthesia Care Unit (PACU)
Policy Number: 2.1.9

be notif ied as soon as possible so arrangements can be made. Refer to Surgical Services
Departmental policy #1.44 (Child Life Policy in PACU).
x. Family members w ill be notif ied if the patients' stay in the PACU is extended. Updates w ill be
provided as needed.
xi. Patients w ill be discharged from the PACU utilizing the Inpatient PACU discharge criteria. If the
staff anesthesiologist or anesthesia resident requests not to discharge by criteria and requests to
assess the patient prior to discharge, this w ill be noted on the physician order set reflected in
Health Link.
xii. When the patient is ready for discharge from the PACU setting a verbal report "hand off" from the
PACU RN to the receiving RN w ill be provided. SBAR w ill be the framew ork for this communication.
xiii. Infected cases requiring isolation procedures w ill be admitted and recovered in a PACU isolation
room as per UWHC policy #13.07. Standard Precautions & Transmission based Precautions
(Isolation) for Inpatient Settings.
xiv. A limited number of ICU patients (tw o) may be cared for in the PACU for an extended period of
time due to the unavailability of ICU beds, (refer to UWHC policy #7.45 - Triage of Critically Ill
Patients). If ICU patients are to be cared for in the PACU, the nursing coordinator, patient
placement nurse and ICU staff w ill communicate w ith the PACU CTL/STM to select the most
appropriate patient(s) for placement.
B. Resolution of conflicts:
i. The Department of Anesthesiology has overall responsibility for the coordination of medical care of
the patients in the PACU.
ii. Conflicts regarding the admission, discharge and care of patients w ill be directly resolved by the
parties involved, under the direction and/or mediation of the O.R. or PACU Medical Director and the
Surgical Services Supervisor of the PACU as appropriate.
iii. Chronic unresolved problems w ill be brought to the Operating Room Committee for resolution.
iv. Unresolved conflicts w hich require immediate action w ill be addressed through departmental
channels to the Director of Perioperative Services and the Director of Surgical Services for
arbitration as appropriate.


Post-Anesthesia Room Record, UWH #1280126 or Electronic Version of the Post Anesthesia Room Record


Author(s): Nursing Supervisor, PACU
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: Director, Surgical Services; Director, Perioperative Services; Medical Director, PACU
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: October 19, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Jeff Grossman, MD
UW Health CEO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


UW Health clinical policy #3.3.1, Hand-Off Communication

Policy Title: Admission, Care and Discharge of Patients to and from Inpatient Post-Anesthesia Care Unit (PACU)
Policy Number: 2.1.9

Surgical Services Departmental policy #1.44, Child Life Policy in PACU
UWHC policy #13.07, Standard Precautions and Transmission based Precautions (Isolation) for Inpatient
UWHC policy #7.45, Triage of Critically Ill Patients


Version: Revision
Next Revision Due: April 1, 2018
Formerly Know n as: UWHC policy 7.24