There are several clinical and non-clinical causes of delayed discharge of patients from Post Anesthesia Care Unit (PACU) in the operation theatre to the wards or High Dependency Unit (HDU) [1,2]. One, often ignored, non-clinical reason for delayed discharge of patients from PACU to the HDU or hospital wards is when the receiving nurse from the HDU or the ward is unable to accept the transfer of patients from PACU, either because of workloads, shortage of staff, absence of the nurse during meal break or the non availability of transport to accompany the nurse. This system fault is a universal problem [3,4], but seldom addressed by the hospital administrators. A timely arrival of ward/HDU nurse to the PACU and discharge of the patient may increase the efficiency of the PACU functioning. 

Restructured staffing, and alterations in ward nurse duty roster may minimize this nonclinical discharge delays from PACU. As a first step towards implementing a smooth and efficient transfer of our postoperative patient from PACU to their respective ward/HD/ICU was to identify the magnitude of the problem in our hospital by conducting an Audit and to know the main reasons for receiving nursing staff delays. 

This prospective Audit in the PACU of Khawla Hospital was conducted over a 5-week period from last week of March, 2023 to the end of April, 2023. We hope, through this Audit, to identify and address one of the modifiable factors like late arrival of the ward nurse that results in delayed discharge of patients from our PACU. 

The primary objective of the Audit was to determine the incidence of delayed discharge from PACU secondary to late arrival of the ICU/HDU/ward receiving nurse. The secondary objective was to identify the non-clinical factors that contributed for delayed arrival of the HDU/ward nurse to receive the patient from PACU and to identify wards/HDU with maximum late discharges. 

As part of hospital efficiency drive by the Quality Department, we aimed to determine the magnitude and reasons for late discharge of the patients who had undergone surgical procedures from PACU to ICU/HDU/ward due to late arrival of the receiving nurse. 

This prospective observational study was done through an audit conducted from March 26, 2023 to April 30, 2023. This audit was conducted in the main operating room suite that has ten operating rooms attached to a 7 bedded PACU. All patients transferred to the PACU from operation theatres immediately after elective or emergency procedures over a 5-week period were consecutively sampled and included in this study. 

Patients were assessed every 15 min, and were considered ready for discharge to HDU or ward from the PACU after they had achieved a satisfactory Aldrete discharge score of ≥ 9.0 [5]. The nursing staff of the HDU or the ward to which the patient is to be transferred was now called to come to the PACU and transfer the patient. A waiting period of 10-15 min was considered acceptable for the ward or HDU OR ICU nurse to arrive and transfer the patient. Anything > 15 min was considered delay in arrival of the ward nurse that ultimately lead to delay in patient discharge from the PACU. 

The discharge data of patients from PACU to wards was accessed from the Discharge Register kept in the PACU. 

Parameters recorded for this Audit were:

• Incidence of late arrival of HDU or ward nurse to receive the PACU patient from different ward /HDU locations.

• Various reasons that contributed to late arrival of ward/HDU nurse from different ward/HDU locations.

• Mean delay time from each ward, HDU > 15 minutes. 

Data were entered by the staff nurse in the PACU in the Discharge Register. The data from the Discharge Register were checked and entered in a data sheet by one of the auditors. Unfortunately, there were significant absence in data entry leading to poor data recovery for analysis. However, attempt has been made to perform descriptive analysis of the collected data. Results have been expressed in frequencies and percentage.

A total of 147 patients were admitted to our PACU over a 5-week period. However, in most of these 147 patients, data were missing and incomplete, due to PACU nurses being too busy. 

Average time to discharge the 147 patient from the PACU was 22.2min. The incidence of delayed discharge of the patients was 82/147 (55.8%). Of the patients who had a delayed discharge of over 15 min, the delay ranged from 25-90 min. The total time lost due to delays was 3087 min (Table 1). 

Table 1: Incidence and the mean delay time of late arrival of receiving ward/HDU/ICU staff nurse

MPW: Male plastic ward, FPW: Female plastic ward, OW: Orthopedic ward, ICU: Intensive care unit, Obst/Gyn ward: Obstetric and gynecology ward, PSW: Pediatric surgery ward, MNSW: Male neurosurgery ward, FNSW: Female neurosurgery ward

The 3 commonest locations that resulted in delayed discharges were – ICU with incidence of 69.2%, Orthopedic wards-1 and 3 with incidence of 66.7 and 68.7% respectively [Table 1]. 

Of the 81 instances where there was late arrival of the receiving nurse, NO REASON was given by 62 nurses (76.5%) for their late arrival in the PACU resulting in delayed discharge of the patient. Of the 19 nurses who gave reason for their late arrival, majority (8/19, 42.1%) attributed it to workload or shift change time (Table 2).

Table 2: Showing responsible factors ward wise for the late arrival of the receiving nurse.

MPW: Male plastic ward, FPW: Female plastic ward, OW: Orthopedic ward, ICU: Intensive care unit, Obst/Gyn ward: Obstetric and gynecology ward, PSW: Pediatric surgery ward, MNSW: Male neurosurgery ward, FNSW: Female neurosurgery ward, PACU: Post anesthesia care unit, HD: High dependency

Discharge of patients from PACU is often delayed for nonclinical reasons. This includes organizational issues such as patient transport, times of heavy workload for the ward and PACU nursing staff, surgical wards being unable to admit the patient, and clerical or administrative delays. In this study we looked at only one of these factors i.e. late arrival of receiving nurse staff. In our study, majority of patients, 55.1%, had prolonged length of stay beyond 15 min in the PACU after having achieved Aldrete discharge score of ≥ 9.0 due to late arrival of receiving ward/HDU nurse. Unfortunately, details of factor responsible for late arrival or nurse were incomplete in many cases. 

The late arrival of receiving nurse, as a factor affecting the PACU delay discharge identified in this study, has also been identified in previous studies. In one audit, the proportion of delay discharge due to non-availability of nurse or being busy was 7.2%, while delay discharge attributed to meal break time was 3.9% [3]. Another similar study revealed that a delay in discharge due to the receiving nurse being unable to accept the transfer of patients from PACU and during meal breaks was 7.3% and 2.9% respectively [4].

Cowie & Corcoran carried out an audit over a 4-month period, looking at discharge of 2,783 patients from RR. Delayed discharge occurred in 421 (15%) patients. The median time of their delayed discharge was 70 minutes (range, 25 to 420 minutes). The incidence of ward nurses being too busy to accept the patient (32%), and ward nurses' meal breaks (10%) were the main reasons [1]. 

In contrast, the present audit revealed that in our PACU, delay in patient transfer to ward/HDU was noted in 55.1% (81/147). 76.5% (62/81) of these late arriving receiving nurses did not give any reason. Of those who gave reason for late arrival, majority of these was due to non-availability of nurse due to work load or shift change time (42.1%, 8/19). Our figures are lesser than that reported by Tessler et al. [6]. They had a figure of 76% for late transfers from PACU. The main cause of their delay in patient transfer were orderly too busy (41%) and awaiting anesthesia assessment (36%). 

Besides the causes mentioned in Table 2, there were some other causes of delay in shifting of the patients noted in this audit (7/19). These included surgical notes being incomplete, oozing from operative site, patient in pain, and communication gap. 

The high incidence of late transfers in this audit as compared to few others is possibly due to our cutoff figure of 15 min as a criteria of late transfers. The difference in reason for late arrival of nurses in our audit from other previously reported audits may also be attributed to poor documentation of reasons for late nurse arrival by our PACU nurses due to them being overburdened with patient care. Whatever be the reason, this audit has revealed that we have a high incidence of late transfer of our patients from PACU resulting in unnecessary congestion in PACU.

The findings of this audit are invaluable. It has helped us to understand the high incidence and causes of delayed transfers due to late arrival of receiving nurse. Based on our findings, we make the following recommendations to rectify this issue of late transfers of PACU patients:

• All the nursing staff in each ward should not begin and end their shift at the same time. At least 15-20% of the nurses should begin and end their shift with a gap of at least one hour from rest of the nursing staff members. This would enable few nurses to be available for patient transfer within 15 min as and when requested by PACU. 

• Late arriving ward nurses must have a valid reason for their late arrival. NO REASON should not be accepted, if we are to improve the system.

• Lastly, nursing in-charges of the wards with high incidence of late transfers should take appropriate corrective steps and be monitored by nursing superintendent.

   

In conclusion, receiving nurse’s late arrival account for a considerable delay of a patient's time in the PACU. The extra time spent by the patient in the PACU is avoidable and should be decreased where possible by taking appropriate corrective measures.

1. Aldrete, J.A. "The Post-Anesthesia Recovery Score Revisited." Journal of Clinical Anesthesia, vol. 7, no. 1, 1995, pp. 89–91.

2. Cobbe, K.A., and S. Barford-Cubitt. "Nonclinical Factors Affecting PACU Discharge: A Clinical Audit in a One-Day Surgery Unit." Journal of PeriAnesthesia Nursing, vol. 33, no. 5, 2018, pp. 676–680.

3. Cowie, B., and P. Corcoran. "Postanesthesia Care Unit Discharge Delay for Nonclinical Reasons." Journal of PeriAnesthesia Nursing, vol. 27, no. 6, 2012, pp. 393–398.

4. Ego, B.Y. et al. "Magnitude and Associated Non-Clinical Factors of Delayed Discharge of Patients from Post-Anesthesia Care Unit in a Comprehensive Specialized Referral Hospital in Ethiopia, 2022." Annals of Medicine & Surgery, vol. 82, 2022, p. 104680.

5. Strang, I., et al. "Patients in Acute Surgical Wards: A Survey in Glasgow." British Medical Journal, vol. 1, no. 6060, 1977, pp. 545–548.

6. Tessler, M.J. et al. "Patient Flow in the Post Anesthesia Care Unit: An Observational Study." Canadian Journal of Anesthesia, vol. 46, no. 4, 1999, pp. 348–351