Abstract

NM-201

A Pilot Analysis of The "Gray Zone" Unit: A New PACU Model of Care for High Risk ENT Surgical Patients

Vargas md A, Sawardekar, md mba A, Suresh md S, Sohn md ms L, Jagannathan, md mba N
Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA

Introduction:
We have identified several high risk otolaryngology (ENT) patients that require ICU level of care for a brief period of time post-surgery (<24 hours). Given the lack of a “Stepdown Unit” at our institution we have developed and implemented a pilot of a new PACU Phase 1 Observation Unit (the Gray Zone Unit (GZU) as an alternative location for immediate and efficient postoperative care for these patients. The initial project goals included identifying ENT patients that required an increased level of care for a short period of time, developing the workflow and staffing requirements, and provision of various respiratory support and resources for these patients. The Gray Zone Unit would function similarly to the PICU.

Methods:
The initial pilot was initiated July 2017 with the maximum amount of two patients per day. Patients that meet “Gray Zone Criteria” include high risk tonsillectomy and adenotonsillectomy patients and complex ENT cases without significant co-morbidity as outlined below in Table 1. Patients are designated a with “Gray Zone disposition by ENT surgical attending preoperatively, and monitored with 1:1 nursing staff for up 6 hours until they declare their best postoperative destination is determined. Depending on the clinical scenario, patients were discharged from unit GZU to PICU, an inpatient floor, 23 hr. extended recovery, or home. The PACU Phase 1 Unit was staffed by an otolaryngologist and an anesthesiologist. The success criteria of the study pilot, included less than 5% reintubation rates in the PACU, overall reduction of admission to ICU and cancelled ICU beds, and decreased number of ICU denials from ENT service. The failure criteria included any code event in phase II, increased staff assists than evaluations by anesthesiologist, and/or any event in this patient population that results in patient harm.

Results:
Between the dates of July 21st 2017 and September 28th, 2017 a total of 21 patients have been designated as “Gray Zone Patients.” The disposition of these patients was 19% to PICU, 43% to 23hr extended recovery, and 38% met criteria for discharge home. There was one case that met failure criteria for a patient requiring a staff assist in Phase II and ultimately admitted to PICU. Analysis showed a decreased number of cancelled PICU beds, and therefore, an increased number of PICU beds available for other critically ill patients. Projected cost savings per year is approximately $3 million to our institution.

Discussion:
To date, implementation of this PACU care model appears to have reduced the total amount of ENT patients admitted to the PICU from the OR. This Gray Zone unit seems .to be a feasible model of care for post- ENT surgical patients who require intensive care for a brief period of time. Data analysis and utilization of this model is ongoing with the hopes to increase patient capacity and expand to other surgical services.