Secondary Logo

Safety priorities in the PACU

Luckowski, Amy, PhD, RN, CCRN, CNE

doi: 10.1097/01.NURSE.0000554246.74635.e0

Amy Luckowski is an assistant professor at Neumann University in Aston, Pa., and a clinical nurse in the PACU at Penn Medicine at Chester County Hospital in West Chester, Pa.

The author has disclosed no financial relationships related to this article.

ACCORDING TO THE World Health Organization, the chance of a patient being harmed during a healthcare stay is 1 in 300. In comparison, the chance of harm during airplane travel is 1 in a million.1 This stark statistic reinforces why patient safety remains an important concern for national healthcare organizations and a serious global public health issue.

In the postanesthesia care unit (PACU), safety concerns include issues surrounding patient identification, patient visualization, patient handoffs, alarm fatigue, postop analgesia, emergence delirium, and flexible staffing based on patient acuity. This article examines the role of nurses in minimizing and preventing these select safety risks in the PACU.

Back to Top | Article Outline


PACU nurses provide care to patients in the immediate postop period, when they are at greatest risk for respiratory and cardiovascular complications during recovery from surgery and anesthesia. PACU care is typically divided into two phases, Phase I as patients recover from anesthesia and Phase II as they prepare for discharge.2

A patient's length of stay in the PACU is determined by such factors as the type of anesthesia and the patient's response to it. Standard PACU discharge criteria are used to determine a patient's readiness to safely leave the PACU. Several scoring systems are available, such as the Aldrete score, which assesses activity, respirations, circulation, consciousness, and SpO2. As a patient's Aldrete score improves, he or she becomes eligible for discharge from the PACU.2

Back to Top | Article Outline

Patient identification

PACU nurses are responsible for providing safe patient care, and identifying the patient is always a top priority for patient safety. According to The Joint Commission, the number one patient safety goal is identifying patients correctly to make sure that each patient gets the correct medication and treatment. Two unique patient identifiers (such as name and date of birth) are required when patients arrive in the PACU.3 The identification and allergy bands should also be compared with the patient's medical records upon arrival to the PACU, and the bed should be in the low position with all side rails up. Additionally, blood transfusions and other patient procedures completed in the PACU require a timeout and use of two unique patient identifiers.

Back to Top | Article Outline

Patient visualization

The PACU environment must allow uninterrupted visualization of the patient. If possible, nurses should be able to both hear alarms and see patients. An open room setup that provides more than one vantage point for visualizing patients is very important. Additionally, PACU nurses may have another nurse care for patients who are out of eyesight.4

Back to Top | Article Outline

Patient handoffs

In the PACU, handoff occurs twice in a short period of time as PACU nurses receive reports from both the OR and anesthesiology departments. This information may be exchanged in a chaotic environment and can be misheard, miscommunicated, or misplaced.

The role of PACU nurses during the two handoffs includes identifying patients; placing patients on continuous cardiac monitoring and other monitoring equipment; obtaining vital signs; and performing targeted physical assessments, including evaluations of a patient's level of consciousness, incision sites, dressings, drains, and the presence of pain, nausea, or vomiting. After patients are initially assessed and stabilized, their respiratory rate, SpO2, and heart rate and rhythm are monitored continuously. Airway patency, BP, mental status, neuromuscular function, and temperature are also frequently reassessed (see Components of a PACU admission report).2,5

Back to Top | Article Outline

Alarm fatigue

Alarm management is an important safety issue in the PACU. According to ECRI, clinical alarm issues are ranked fourth and seventh of the 10 most common health technology hazards for 2019 (see ECRI Institute's 10 most common health technology hazards for 2019).6 Additionally, The Joint Commission's fourth overall goal for hospitals in 2019 is to make improvements to ensure that alarms on medical equipment are heard and responded to in a timely manner.3 Desensitized to the sound of alarms, staff members may begin to ignore them and thus miss crucial signals.7 Serious incidents, including deaths, have occurred due to alarms not being seen or heard and responded to appropriately. According to the American Society of PeriAnesthesia Nurses (ASPAN), factors contributing to alarm mismanagement include deactivation, intentional decreases in volume, programming issues, environmental noise, strict default settings, increased nuisance alarms, and inappropriate alarm device placement.8

Back to Top | Article Outline

Postoperative analgesia

Another PACU safety issue is the administration of postop analgesia. Patients receiving opioids, including I.V. morphine, hydromorphone, and fentanyl, are at an increased risk for respiratory depression. Comorbidities such as obesity and undiagnosed obstructive sleep apnea can further endanger patients.

According to ASPAN, nurses should be aware of the pharmacokinetics of medications that cause respiratory depression to help ensure safe administration.9 When determining a patient's PACU length of stay, nurses must consider the cumulative effects, such as the amount, type, and timing of a medication; any potential drug interactions; the medication's half-life and peak effect; the patient's response; and the monitoring capabilities of the receiving unit. Additionally, patients should stay in the PACU for at least 30 minutes following their last dose of a sedative or opioid.9



Back to Top | Article Outline

Emergence delirium

Emergence delirium (also known as emergence excitement and emergence agitation) may manifest as agitation (hyperactive subtype) or as somnolence with altered mental status (hypoactive subtype) occurring in the postop period after initial emergence from general anesthesia. Hyperactive delirium is more easily detected due to overt agitation, hyperexcitability, disinhibition, crying, restlessness, and mental confusion; some patients fluctuate between the hyper- and hypoactive subtypes. A 2015 study found that the overall incidence of emergence delirium was 4.3%, but, in patients over age 70, the incidence was 10.5%.10 Risk factors for emergence delirium include:11

  • volatile anesthetics
  • increased postop pain
  • specific surgical procedures, such as intra-abdominal and breast surgery in adults
  • longer duration of surgery, male gender, and age extremes.11

Patients are also at risk for emergence delirium if they have anxiety, are active duty military members with PTSD, or have a history of trauma. They may exhibit preoperative signs of hyperarousal, such as nervousness, sensitivity to noises, and unusual preoccupation with the surroundings. This information should be communicated to the OR and PACU staff.12

Several strategies are recommended to protect patients who are at an increased risk for emergence delirium.12 At-risk patients should be identified during the preoperative period, and this information should be communicated to the intraoperative and postop staff. PACU nurses must be vigilant for signs and symptoms of emergence delirium and have a safety plan in place. Acting preemptively is imperative in these circumstances.11

PACU nurses may advocate for a reduced assignment until their patients are fully awake. A one-to-one nurse-to-patient ratio is recommended, along with continuous verbal reassurance. Additional staff may help ensure the safety of patients who are pulling at lines or attempting to get out of bed. A calm demeanor, soothing voice, and active listening skills should be employed with these patients.

Emergence delirium resolves once the patient is fully awake postanesthesia.

Back to Top | Article Outline


A 2013 study demonstrated that nursing workloads in the PACU are influenced by the magnitude of the surgery, individual patient acuity, and length of stay.13 The medical diagnosis does not always accurately reflect acuity, however, and an adverse event can change the unit's workflow.14

PACU nurses typically care for one or two patients at a time, but clinical priorities can change on a moment-to-moment basis. For example, patients whose conditions deteriorate may require intensive one-on-one care. PACU nurses must adjust accordingly to meet the safety needs of their patients.

As patient acuity can change rapidly in the PACU, flexibility in staffing is a must. In a 2016 position statement on acuity-based staffing, ASPAN recommended that a nurse care for only one patient from the time the patient is first admitted until he or she is hemodynamically stable.15 Other patients may also have pressing needs, however, or new postop patients may be restless, combative, or hypoxic and require more than one nurse. In such circumstances, a floating charge nurse can be helpful to the PACU staff.

According to ASPAN, nurse fatigue due to on-call work schedules can negatively impact patient safety.16 Staffing is also an important consideration during on-call hours. At minimum, two RNs should be present as a patient in Phase I is recovering.16

Back to Top | Article Outline

Awareness and collaboration

PACU nurses should be aware of the safety issues that impact their patients daily. Collaboration with nursing management and anesthesia providers about alarms, handoffs, acuity, emergence delirium, staffing, and other patient safety risks is imperative. Similarly, education regarding PACU safety issues is necessary for all staff to ensure optimum care for the vulnerable patients entrusted to healthcare facilities.

Back to Top | Article Outline

ECRI Institute's 10 most common health technology hazards for 20196

  1. Hackers can exploit remote access to systems, disrupting healthcare operations.
  2. “Clean” mattresses can ooze body fluids onto patients.
  3. Retained sponges persist as a surgical complication despite manual counts.
  4. Improperly set ventilator alarms put patients at risk for hypoxic brain injury or death.
  5. Mishandling flexible endoscopes after disinfection can lead to patient infections.
  6. Confusing dose rate with flow rate can lead to infusion pump medication errors.
  7. Improper customization of physiologic monitor alarm settings may result in missed alarms.
  8. Injury risk from overhead patient lift systems.
  9. Cleaning fluid seeping into electrical components can lead to equipment damage and fires.
  10. Flawed battery charging systems and practices can affect device operation.

Used with permission from ECRI. Top 10 health technology hazards for 2019 executive brief. 2018.

Back to Top | Article Outline


1. World Health Organization. 10 facts on patient safety. 2018.

2. Glick DB. Overview of post-anesthetic care for adult patients. UpToDate. 2018.

3. The Joint Commission. 2019 Hospital national patient safety goals. 2019.

4. Grissinger M. Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit. P T. 2016;41(6):344–345.

5. Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2013:1559.

6. ECRI. Top 10 health technology hazards for 2019 executive brief. 2018.

7. ECRI. Executive brief: top 10 health technology hazards for 2016. Health Devices. 2015.

8. American Society of PeriAnesthesia Nurses. A position statement on alarm management. 2015.

9. American Society of PeriAnesthesia Nurses. A position statement on safe medication administration. 2015.

10. Winter A, Steurer MP, Dullenkopf A. Postoperative delirium assessed by post anesthesia care unit staff utilizing the Nursing Delirium Screening Scale: a prospective observational study of 1000 patients in a single Swiss institution. BMC Anesthesiol. 2015;15:184.

11. Zafirova Z. Emergence delirium and agitation in the perioperative period. MedScape. 2017.

12. Lovestrand D, Lovestrand S, Beaumont DM, Yost JG. Management of emergence delirium in adult PTSD patients: recommendations for practice. J Perianesth Nurs. 2017;32(4):356–366.

13. Lima LB, Rabelo ER. Nursing workload in the post-anesthesia care unit. Acta paul Enferm. 2013;26(2):116–122.

14. Halfpap E. Staff developed PACU acuity scoring grid. J Perianesth Nurs. 2016;31(4):303–308.

15. American Society of PeriAnesthesia Nurses. A position statement on acuity based staffing for phase I. 2016.

16. American Society of PeriAnesthesia Nurses. A position statement on “on call/work schedule.” 2015.

Back to Top | Article Outline


Wilson JT. Army anesthesia providers' perceptions of emergence delirium after general anesthesia in service members. AANA J. 2013;81(6):433–440.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.