​A tool to classify the acuity of patient conditions in the postanesthesia care unit (PACU), as defined by nursing interventions, demonstrated reliability according to an original article published in the August 2016 Journal of PeriAnesthesia Nursing. A hospital needed an acuity scoring tool to help explain monthly payment volumes related to the salary variances of registered nurses. Patient volume alone did not demonstrate the degree or level of care required during a stay in the PACU, the author said. A scoring grid was created based on interventions completed by nurses (rather than on medical diagnosis) in order to determine nursing acuity. The grid includes five categories of severity, each of which is assigned an acuity value: no intervention (0 points), mild interventions (1 point), moderate interventions (2 points), substantial interventions (3 points), and severe interventions (6 points). The rationale behind the three-point difference between the substantial and severe categories was that in order to qualify as severe, the intervention required at least twice as many nurses. Examples of interventions and conditions that would fall into the mild (1-point) category include blood pressure monitoring requiring extended stay, respiratory treatments, analgesic or antiemetic administration, and the application of ice packs. Moderate (2-point) interventions include monitoring of vital signs more frequently than every 15 minutes, presence of chest tubes, a language barrier between nurse and patient, a child older than 8 years, and discontinuing arterial lines. Interventions falling into the substantial (3-point) category are ventilator protocol, chest pain requiring treatment, a patient who was discharged to the intensive care unit, invasive monitoring, and a combative or restless patient. Examples that fall into the severe (6-point) category are respiratory arrest, malignant hyperthermia, a patient in isolation, and a child younger than 8 years. The hospital studied has used the PACU acuity scoring grid for the past five years. The author said it has assisted the staff monthly in providing explanation for salary variances, as well as providing a validation for staff perceptions of patient acuity during care. Additionally, the authors found that a patient's length of stay was directly correlated to the nursing interventions he or she received. The authors also noted that staff view the scoring grid positively. It is not difficult for staff to understand it, and its benefits are easy to see.

HRC Recommends: Postanesthesia care deserves special risk management attention because of the potential for serious adverse outcomes. Risk managers should encourage implementation of formal quality improvement activities—such as the initiative above, which recorded the actual burden of care provided to support the financial realities of treating patients recovering from anesthesia—that promote continuous surveillance and improvement of postanesthesia care.