THE FACTORS ASSOCIATED WITH LENGTH OF STAY OF PATIENTS AT BUNGOMA COUNTY REFERRAL HOSPITAL MAIN THEATRE POST-ANAESTHESIA CARE UNIT
STANLEY LIMO –KRPON
BUNGOMA COUNTY REFERRAL HOSPITAL
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Delay in discharge of patients from PACU is a common problem globally. A comparative study by Chikophe Idris( MMed Anaesth 2010) showed that the Bungoma County Referral Hospital PACU Length of Stay was the longest in comparison to the National Referrals hospitals PACU’s in Kenya.
This study intended to look into the factors that affected PACU length of stay at the Bungoma County Referral Hospital main theatre and also to give recommendations that could be of use in the improvement of patient discharge from PACU.
Determine the PACU Length of Stay of postoperative patients at the Bungoma county Referral Hospital theatre.
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3.3 Research Question
What is the average Length of Stay of post-operative patients at the Bungoma county Referral Hospital theatre PACU and what are the patient and logistical factors that contribute to the length of stay?
This was a cross-sectional observational descriptive study.
The study was carried out at the PACU of the Bungoma County Hospital main theatre.
ASA 1, 11 and 111 categories of adult patients admitted to the post-anesthesia care unit.
The sample size adequate for this study was calculated according to Yamane formula
n=N/ [1+N[e] 2]
n=sample size
[e] Margin of error =0.05[5%] Minutes Substituting into the
formula
n was 70
4.5 Sampling Procedure
Convenience sampling procedure was used. This technique involved non-random selection of patients while in PACU based on the availability of patients meeting the
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inclusion criteria, patients were consecutively enrolled into the study until the desired sample size was achieved.
Exclusion criteria
4.7 Data Collection Procedure
The researcher and research assistants collected the data.
The researchers were located in PACU throughout the study duration so as to be present during the admission and discharge of patients into and from PACU. It was necessary for the researchers to be in PACU during patients’ admission and discharge so as to capture
the patients’ to nurse ratios at the time of admission, any incidences of complications occurring in PACU as well as to observe the process of patient discharge by the PACU nurses so as to ascertain how the decision to discharge patients from the unit was arrived at. Once the study participants were admitted into PACU following anaesthesia and surgery, the data pertaining to the study was filled into the questionnaire by the investigator from: the patients’ medical records; observation of the patients in PACU for any complications that arose; observation and interviewing of the nurses as they discharged patients from the unit.
The data required in this study included: the patient’s bio data; the study participants intraoperative course, the duration of surgery and anesthesia; PACU data including the
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Majority of the study participants – 62.9% were between 18-34 years of age as shown in figure 1 below.
Figure 1- Age distribution
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18
16
14
12
10
8
6
4
2
0
18-24yrs 24-34yrs 35-44yrs 45-54yrs 55-65yrs >65yrs
Male patients were 33 % (23), while fe ma le pat ient s wer e 67 % [ 47 ] of the study participants as illustrated in the pie-chart below.
Figure 2- Sex Distribution
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58% of the study participants were of ASA category as shown in the figure below.
Figure 3 – ASA score distribution
Patient categories were as follows;
ASA I- made up 58% (39) of the study participants. ASA II- was 38 % (28) of the study participants.
ASA III- made up 4% (3) of the study participants.
58%
38%
4%
ASA I
ASA II
ASA III
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Elective surgical cases made up 33% of the study population while emergency cases were 67% as shown in the figure below.
Figure 4- Category of surgery
33%
Emmergency
Elective
67%
13
Opioids were used in 97% (68) of the patients, both in the general anaesthesia and the spinal anaesthesia groups as shown in the figure below.
Figure 6- Opioid use
Only 3% (2) of patients did not get any opioid during surgery.
Morphine was the main opioid of choice for the general anaesthesia group while Fentanyl was the choice is the spinal anaesthesia group as shown in the figure below.
3%
Yes No
97%
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Figure 7- Type of Opioid
40
35
30
25
20
15
10
5
0
Fentenyl Tramadol Morphine
Morphine alone or in combination with other opioids is the most commonly used drug for intraoperative pain control following general anaesthesia.
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Sedatives were used in 46% of this group of patients. The sedatives used were as follows;
Muscle relaxants were administered to 18.6%% (13) of all general anaesthesia patients As shown in the table below
Table 1- Other drugs used
Drug administered | %(frequency) |
Muscle relaxant given | 18.6( 13) |
Reversal given | 18.6(13) |
Doses of reversal given, median (IQR) | (1-1) |
The average Nurse: Patient ratio was 1 nurse to 4 patients as shown in the table below.
Table 2- Nurse to patient ratio at admission
Nurse- patient ratio | Time | ||
Morning (8am- 12;30pm) | Afternoon (1pm-6pm) | Night (7pm- 7am) | |
Nurse-patient ratio | 1:2 | 1:3 | 1:4 |
Postoperative complications | 0 | 2 | 3 |
Morning ratio- 1:2
Afternoon ratio- 1:3
Night ratio- 1.4
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Only 30% (21) of patients had postoperative complaints or complications as shown in the table below.
Table 3: Post-operative complications
Variable | %( Frequency) |
Postoperative complications/ | |
Complaints | |
Yes | 30(21) |
No | 70(49) |
Complaint/ Complications | |
Nausea and vomiting | 3 |
Hypotension | 0 |
Pain | 18 |
The mean time taken to achieve stability was 16.5 minutes as shown in the table below
Table 4– Time taken to achieve stability
Variables | Results in minutes | |
Mean(SD) | Range | |
Time to achieve stability | 16.8(14.2) | 70 |
Spinal Anaesthesia | 15.9(12.4) | 70 |
General Anaesthesia | 19.6(16.1) | 65 |
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The average length of stay of patients in PACU was 170 minutes as shown in the table below.
Table 5- PACU Length of stay
The PACU length of stay for majority of the patients was between 25- 200 minutes as shown in the figure below.
Minutes
41%
Expected time
Time taken
59%
18
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
No. Patients
1 hour 2 hour 3 hour 4 hour
Time
Figure 9- PACU length of stay patient distribution
Logistical factors that contributed to PACU stay longer than 2 hours were two in number as shown in the figure below
Figure 11- Logistical factors affecting LOS
Ward Nurses Unavailable to pick up patients
Non availability of beds/space
42%
58%
The two logistical factors were;
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6.0 DISCUSSION
The main aim of this study was to assess the length of stay of post-operative patients at the Bungoma County Referral Hospital main theatre Post Anesthesia Care Unit. This study used the duration of 2 hours as the cut-off to determine whether a patient’s stay in PACU was prolonged or not, this criteria was derived from previously published studies on PACU Length of Stay that had shown that majority of patients achieve a satisfactory discharge score during the first 2 hours after the conclusion of surgery
The average length of stay at the Bungoma theatre PACU was found to be at 50 minutes. A study by Waddle et al had a mean PACU length of stay at 95+_ 43 minutes, this shows that the Length of stay at BCRH is prolonged
Emergencies surgeries were the majority at 67.1% while Elective surgeries were at 23.9%, this is in keeping with the trend of surgeries at BCRH whereby majority are emergencies surgeries. The duration of surgery at BCRH was between 10-240 minutes with the mean duration of surgery being at 90 minutes. The study by Waddle et al had a mean surgical time of 118+_ 83 minutes, thus showing that the duration of surgeries at BCRH does compare to that found in this study.
There were three modalities of anaesthesia given to these patients, general anaesthesia at 19% [13] of the patients while spinal anaesthesia was used in 78% [55]of the patients while Regional anaesthesia 3% [2]. The duration of anaesthesia was between 15-270 minutes with a mean duration of 100 minutes. The study by Waddle had a mean anaesthetic time of 181+_ 96 minutes, showing that the mean duration of anaesthesia is comparable to that found in this study .Intra-operative opioid use was at 51.4%. Morphine alone or in combination with other opioids was the most commonly used drug in the spinal anaesthesia group with Tramadol and Fentanyl being the least used opioids. Fentanyl was the only opioid given to the spinal anaesthesia group; it was used in combination with bupivacaine. In the Waddle study Narcotics were used by themselves without inhalation agents as a spinal anaesthetic technique as well as for intra-operative analgesia purposes
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Sedatives were only given to the spinal anaesthesia group of patients; their use was at 46% (13) in this group. Midazolam was the most used agent given to 25% (7) of these patients followed by Ketamine at 17% (5) and the least used mode of sedation was the Midazolam-Ketamine combination in 4% (1) of these patients. The use of sedation following successful regional anaesthesia is mainly for the awake patient who may be too anxious during the surgery. This is also the practice in other setups.
It is noted from this study at BCRH that age was the only patient variable that significantly contributed to the length of stay of post-operative patients at PACU, all other patient variables that included length of anaesthesia and surgery, opioid and sedative use, PACU complications did not contribute to prolonged stay at the unit. In a study by Roberta et al complications did cause prolonged stay in the unit 23
The Nurse: Patient ratios at PACU were noted to worsen as the day progressed. This was due to patients’ congestion at PACU as theatre activity progressed while the discharge of patients from PACU slowed down. This resulted in a longer process of handing over of patients to the PACU nurses with delay of the anaesthesia team and resultant delay in starting the next case. The ratios were optimum in the morning at 1:2, while at afternoon there was an increase in nurse: patient inequality at 1:3, they were worst in the night at 1:4. The mean nurse: patient ratio was 1:4. This shows that our PACU practice of patient nursing is below the recommended nurse: patient ratios and the current situation should be corrected urgently to ensure safe and efficient patient stabilization; it will also ensure early recognition and handling of post-operative complications. A study by Cohen et al showed that higher numbers of adverse effects require higher numbers of PACU staff
The complications were under-reported in this study due to inequality of the nurse: patient ratio, they were noted to increase as the nurse: patient inequality worsened ,this is also the case in other studies that showed that inadequate staffing was a contributing factor in all unanticipated events that resulted in patient death, injury or permanent loss of function
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The time taken to achieve patient stability was between 4-90 minutes with an average of
16.5 minutes. The spinal anaesthesia group of patients took an average of 15.9 minutes, while the general anaesthesia group’s average was at 19.6 minutes. The patient who took 90 minutes to achieve stability was of ASA III category and had undergone osteotomy
and excision of the left foot, the patient’s stay in PACU was uneventful, no complications or complaints were reported by the patient. All the study participants were stabilized within 2 hours of completion of surgery; this is also the case in other setups as shown by Waddle et al
The entire time taken for patients to leave PACU was between 90-120 minutes with an average of 170 minutes. Majority of the patients were in PACU for between 25-200 minutes. 1 patient was in the unit for 440 minutes (7 hours 20 minutes). The patient in PACU for the 440 minutes had undergone exploratory surgery.
Delay in the discharge of post- operative patients at the Bungoma County Referral theatre PACU was found to be at 37.4%, this delay was caused mainly by logistical factors and is noted to be less than that demonstrated by Waddle whose study showed a PACU delay of 68%.
All other patient factors such as gender, ASA classification, type of anaesthesia, duration of anaesthesia and surgery, opioids and post-operative complications were not associated with the length of stay at PACU in this study.
Logistical factors were found to be the main reason for the prolonged stay of post- operative patients in the BCRH 1. Limited space/Bed 42% [11]. 2. Non availability of nurses to pick the patients 58% [15] at PACU beyond the 2 hours; these factors were only two in this study. The study by Waddle et al showed that multiple logistical factors contributed to the delayed discharge of patients, the logistical factors included; awaiting physicians’ release, bed unavailability, nurse unavailable for patient transport.
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7.0 CONCLUSIONS
Hospital main theatre PACU was found to be at 37.4% and worsened as the day progressed.
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8.0 RECOMMENDATIONS
operative patients from PACU.
9.0 LIMITATIONS
1. Complications in PACU are under-reported in this study as this data was retrieved from the patients’ files most of which were not completely filled.
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REFERENCES
Quantifying and assessing independent factors. Anesthesia Analgesia 1998; 87: 628-633.
1995; 25: 253-254.
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APPENDIX 1
CHARGED FROM PACU………………
PATIENT’S DATA SHEET
DATE……………
PATIENT’S BIODATA
PATIENT’S NUMBER…………… PATIENT’S AGE.
a) 18- 24 yrs | |
b) 25-34 yrs | |
c) 35-44 yrs | |
d) 45-54 yrs | |
e) 55- 65 yrs | |
f) > 65 yrs | |
PATIENT’S GENDER:
MALE [ ]
FEMALE [ ]
ASA CLASSIFICATION: ASA …………
DIAGNOSIS………………………………………………………………..
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INTRAOPERATIVE DATA
CATEGORY OF SURGICAL PROCEDURE
a) Emergency | |
b) Elective | |
TYPE OF SURGERY…………………………………
DURATION OF SURGERY……………
TYPE OF ANAESTHESIA………………………
i. Were Opioids used?
a) Yes | |
b) No | |
If yes, which one (s)?
………………………………
………………………………
……………………………..
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ii. Was a sedative added?
a) Yes | |
b) No | |
If yes, which one?
……………………………….
iii.
Was a muscle relaxant given?
a) Yes | |
b) No | |
If yes, which one?
……………………………………
iv. Was Reversal given?
a) Yes | |
b) No | |
………………………………
………………………………
DURATION OF ANAESTHESIA…………………
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PACU DATA
TIME OF ADMISSION……………
AT TIME OF PATIENT ADMISSION,
DID THE PATIENT COMPLAINTS?
DEVELOP ANY POSTOPERATIVE
COMPLICATIONS/
a) Yes | |
b) No | |
If yes, tick the appropriate box.
a) Nausea and vomiting | |
b) Breathing difficulties | |
c) Apnoea | |
d) Hypotension | |
e) Cardiac arrest | |
f) Other (specify)………… | |
TIME WHEN PATIENT WAS FOUND FIT FOR DISCHARGE……………
TIME WHEN PATIENT WAS DISCHARGE………………………………..