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Critical incidents in PACU lead to longer stay, greater postoperative care

Stephen Padilla
20 Sep 2017

Several critical incidents happen in the postanaesthesia care unit (PACU), of which many are linked to the cardiovascular and respiratory systems, a Singapore study has found. These incidents strongly affect healthcare utilization and lead to longer PACU stays and higher levels of postoperative care than initially planned.

“[T]he current review documents the various critical incidents that were recorded over a 2-year period in a major tertiary hospital and highlights the importance of a PACU in managing patients in the postoperative period,” researchers said.

A total of 701 incidents involving 364 patients occurred in the PACU. Of these, 203 (55.8 percent) had American Society of Anesthesiologists (ASA) physical status I or II. [Singapore Med J 2017;58:497-501]

“Most patients with critical incidents were of ASA physical status I or II, suggesting that significant critical incidents may occur in patients with relatively few comorbidities and in whom clinicians might not expect the occurrence of critical incidents,” researchers explained.

These results were similar to a prospective study by Hines and colleagues involving more than 18,000 patients, which aimed to identify adverse events occurring in the PACU. They found that more than three-quarters of complications involved patients categorized as ASA physical status I or II. [Anesth Analg 1992;74:503-9]

“The large number of critical incidents involving such patients in our study might also be partly due to the fact that the majority of our surgical patients were of ASA physical status I or II,” researchers of the current study said.

“Furthermore, in our institution, the general practice for patients requiring intensive postoperative care is to transfer them directly from the operation theatre (OT) to the ICU, thereby reducing the number of patients with ASA physical status III and IV categories in the PACU,” they added.

The most frequent critical incidents were cardiovascular-related (n=293; 41.8 percent), respiratory (n=155; 22.1 percent), neurological (n=52; 7.4 percent), surgical (n=47; 6.7 percent) and airway-related (n=34; 4.9 percent). Two incidents of cardiac arrest and 25 incidents of unexpected reintubations in the PACU were recorded.

Due to these incidents, 186 patients (51.2 percent) stayed in the PACU for over 4 hours and 186 needed a higher level of care postoperatively than initially anticipated. For some patients (n=34; 9.3 percent), a return to the OT for further management was required.

In addition, there were unplanned admissions to intensive care unit (ICU) in some patients (n=64; 17.6 percent) due to adverse events in the PACU.

“The majority of critical incidents identified in our study were seen in patients who underwent general surgery. These patients had a higher incidence of PACU complications when compared to those from other disciplines (p<0.001),” researchers said.

This finding was comparable to other studies, which reported that patients undergoing major open abdominal procedures had a higher number of complications and longer mean length of stay in the PACU. Also, those who underwent vascular surgery were more likely to have a critical incident in the PACU (p<0.001). [Anesth Analg 1992;74:503-9; Anaesthesia 2002;57:1060-6; J Clin Anesth 1998;10:579-87; Circulation 2009;120:e169-276]

“Critical incidents in the PACU can impact healthcare utilization by prolonging patients’ length of stay in the PACU and resulting in the need for higher levels of postoperative care than anticipated. Regular audits of critical incidents in the PACU are important to maintain the quality of immediate postoperative care, particularly in the context of an ageing population,” researchers said.

In this study, a retrospective review was conducted of patients in the PACU over a 2-year period from 24 June 2011 to 23 August 2013. A standardized data form was used to record data on critical incidents in the administrative database.

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Most Read Articles
22 May 2017
Chronic obstructive pulmonary disease (COPD) is currently the 10th commonest cause of death in Singapore, with a disease burden of 5.9 percent according to a 2015 population-based survey (EPIC-Asia survey) in Singapore. Pearl Toh spoke with Dr Augustine Tee, chief and senior consultant of the Department of Respiratory and Critical Care Medicine at Changi General Hospital (CGH) in Singapore, on how COPD is often underdetected in the primary care population as symptoms are not specific and diagnosis requires a combination of clinical risk factors, symptoms and spirometry testing.
15 Aug 2017
New drug applications approved by US FDA as of 1 - 15 August 2017 which includes New Molecular Entities (NMEs) and new biologics. It does not include Tentative Approvals. Supplemental approvals may have occurred since the original approval date.
04 Aug 2017
Chronic obstructive pulmonary disease (COPD) is the fourth cause of global mortality, with experts predicting a potential future rise in the prevalence rates of COPD. 
11 May 2016

In conjunction with World Asthma Day which falls on 3rd May 2016, MIMS Doctor speaks to a renowned respiratory medicine specialist, Dato' Dr. Hj Abdul Razak Abdul Muttalif, regarding the chronic airway disease.