The University Teaching Hospital (UTH) in Lusaka is the largest hospital in Zambia, with 1655 beds. It has several surgical specialties, whose patients recover in a theatre recovery suite. In October 2018, two of the authors (RA and LM) travelled to Lusaka to provide a quality improvement and mentorship project for the recovery nurses. The objective was to facilitate the implementation of changes in the recovery suites and to improve patient safety. While there on a two-week visit, we decided to focus on the following objectives:
Context
The theatre suite has eight theatres, which provide a wide range of procedures in minor and major surgical specialties. These include orthopaedic, general, ear, nose and throat (ENT), plastic surgery and urology. Patients having all these kinds of procedures are brought to the recovery room for postoperative care.
The recovery room has eight bays. At present, four are used for preoperative patients and the other four for postoperative care. However, only one bay has access to oxygen therapy via a mobile oxygen concentrator. There is no oxygen therapy or suction equipment available at any of the other bays.
The nursing staff have to ensure privacy for preoperative and postoperative patients. They do this by using mobile screens to shield anxious preoperative patients from those who are recovering.
Nursing staff have little access to monitoring and airway equipment. On our arrival, the following equipment was available in the room:
The recovery nurses have a challenging role in terms of providing care with limited resources. During busy periods, the equipment is routinely moved between patients, often permitting only one recording each of oxygen saturations, blood pressure and temperature to be performed. With patients arriving from multiple theatres to the recovery suite, the lack of monitoring shortens the recovery period and reduces patient safety as patients may be discharged too soon.
Taking observations at regular intervals allows staff to identify changes in vital signs so they can see whether a patient's condition is improving or deteriorating. This objective intervention can also indicate how patients are responding to treatment (Hatfield, 2014).
We observed that the provision of documentation on recovery was minimal. There were no formal recovery care plans to record the nursing care given and, equally, no structured process in place to document vital signs. There was no algorithm to recognise the signs and symptoms of a deteriorating patient and accepted adult normal vital sign values for the postoperative period. Finally, there was no information to refer to on adult discharge criteria.
However, on display were a paediatric recovery discharge guideline, an AVPU (alert, verbal, pain, unresponsive) scale, a Wong-Baker Faces Pain Rating Scale chart and a chart of accepted postoperative vital sign values that nursing staff can refer to.
Factors in the recovery area influencing patient safety included a lack of monitoring equipment, oxygen therapy and a strategy to recognise the signs and symptoms of a deteriorating patient. The Royal College of Nursing (2019) states: ‘Patient safety is an essential part of nursing care that aims to prevent avoidable errors and patient harm.’
The following case study shows examples of the challenges the nursing staff deal with daily.
CASE STUDY
The theatre suite PH3/5 comprises eight theatres, and it is used for performing general surgery, neurology, urology, orthopaedics and ENT procedures. The elective cases that are done here can bring many challenges to the perioperative environment.
During our visit, the following were recorded in the recovery admissions book: 61 procedures performed—41 major, 10 intermediate and 10 minor. Four cases were cancelled, some because of a lack of staffing; there were four admissions to intensive care, one of which was unplanned. This unplanned event is the basis of this case study.
Our aim was to highlight the challenges the recovery nurses face every day, with a high volume of complicated postoperative patients in a recovery room that is poorly equipped.
Background
A 67-year-old woman patient arrived at the recovery suite at 11:00.
The handover was given and the recovery nurses were informed of an uneventful intubation and extubation. The patient's medical history was as follows:
On arrival, a pulse oximeter was applied and the patient's oxygen saturations were recorded at 85%.
The patient had secretions that required suction but, although suction equipment was present, it was non-functional. The patient was on her right side with her head elevated as she attempted to expel some of the secretions.
Resources were limited. A nasal cannula was available and 5 litres of oxygen were started via the oxygen concentrator; this was the maximum the oxygen concentrator could deliver. An adult Hudson mask was located and applied soon after. The patient's oxygen saturations increased to 92%; however, they fluctuated persistently in the 80%-90% range.
The patient became verbally unresponsive, vomited secretions and started feeling she was having an asthma attack. At this point, help was called. An anaesthetist attended and listened to the patient's chest. Wheezing sounds were present and salbutamol was administered using a 10 ml syringe. In these situations, staff must be careful how they use resources, because equipment and drug containers are often used for more than one patient.
The patient's feeling of an asthma attack persisted. Adrenaline 1 mg/ml was administered, as well as dexamethasone 1 mg/ml diluted with 3 ml of saline via a nebuliser. Observing the resources in the recovery room, it was evident the only mask that could be attached to the nebuliser was a paediatric Hudson mask, and nebulisation was started using this. The nurse present was instructed to also administer 200 mg of hydrocortisone and 10 mg IV furosemide. Around six students were present during this event, some of whom assisted.
In a few minutes, the patient rapidly deteriorated, becoming unresponsive. Oxygen saturations dropped to 58% and the pulse felt weak. At this stage, one staff member was alerted to call for the anaesthetist immediately, as the patient was showing signs of a peri-arrest.
While waiting for the anaesthetist, an Ambu bag valve mask was used. Once the anaesthetist arrived, a Guedel airway and face mask were brought to the recovery room to provide an adequate seal while the patient was being ventilated. Staff had to go to theatres to collect the Philips monitor, an endotracheal tube, laryngoscope, guidewire and an adult C circuit.
Emergency drugs ketamine and suxamethonium were also required and brought from theatres. The patient was intubated and taken to ICU to be stabilised. A 12-lead ECG confirmed postoperative ischaemic changes. Three days later, the patient was extubated and returned to the ward.
This is a case that had a fortunate outcome: the patient made a full recovery. Sadly, this is not always the case in the recovery room. This year alone, several patients died.
The intention of this case study is to demonstrate why a functioning recovery room is imperative, and why it needs to be staffed by practitioners who feel empowered with knowledge and understanding of how to care for a patient postoperatively.
This episode highlights the importance of having an easily accessible emergency airway trolley that is fully equipped to intubate a patient within the recovery room. The lack of this was one of problems that the recovery nurses face every day.
This case study shows there is an urgent need for fully functioning equipment, such as an oxygen cylinder that will deliver high-flow oxygen, a functioning suction machine and a Philips monitor to be based permanently in the recovery room. These few pieces of equipment are essential for recovering a patient safely after anaesthesia.
Resources
On the day of the event, the following resources were available in the recovery room:
When this episode took place, it was fortunate that no other patients in the recovery room required oxygen therapy. An Ambu bag was attached to an adult Hudson mask initially, which would not provide an effective, efficient seal. Once the anaesthetist had arrived with the much-needed equipment from the theatres, a face mask was attached to the Ambu bag. An F circuit that had been taped so that it could be used as a C circuit was also available but was not used. There was one non-functional suction device in the recovery area.
There was a limited choice of emergency drugs available in recovery, so most of the drugs used in this event had to be sourced from the pharmacy and theatres. In case of emergency, these drugs should be kept to hand in the recovery room. The anaesthetic records show that blood pressure was taken once, and no pulse or respiration rate were documented.
This example clearly shows the need for improvements to postoperative monitoring and documentation of vital signs. It also demonstrates the importance of reinforcing to staff the need to manually count pulse and respiration rates, especially when monitoring equipment is limited, as in this environment.
Providing postoperative parameters is essential for recovery nurses. This shows nurses when it is appropriate to seek help. For example, if the patient is not meeting the criteria, the nurses will know to call for an anaesthetist immediately for a review.
Suggestions and changes
We compared anaesthetic documentation in use in Tayside and UTH. In the postoperative section in the Tayside documentation, there is space where the anaesthetist can provide parameters. These are the parameters that nurses should aim for regarding postoperative care. We suggested that this chart should be used by the recovery nurses while they are monitoring vital signs in the recovery room.
A chart to show discharge criteria that nurses can check to ensure patients are stable and safe to return to the ward is now in place in UTH. There is also a chart providing information on airway management and the signs and symptoms to observe for in the recovery room. This chart displays the early warning signs of the deteriorating patient.
It is hoped this case study will bring forward some objectives for the recovery room. The ultimate goal is to provide higher standards of care to the patients before and after surgery. Minimising postoperative risks in the recovery room by teaching simple scoring systems for vital signs and ensuring patients meet discharge criteria before leaving the recovery room have been introduced. We hope that providing support to the recovery nurses will allow them to deliver optimal nursing care.
Following consultations in Lusaka between the project team (all the authors) and the recovery staff in the second week of our visit, the following were implemented or discussed:
Recommendations
The following recommendations were also made after the initial needs assessment, with time frames and methods, which are not included in this report:
Conclusion
This report provides an analysis and evaluation of the postoperative facilities and resources available to nursing staff in a recovery room from the point of view of two experienced recovery nurses from the UK.
The Zambian nurses deal with challenging and sometimes life-threatening situations daily. They are very resourceful and do a great job with the equipment and resources available to them. However, the working environment can be stressful and affects patient safety because there are not enough resources available to care for the volume of patients.
Implementation of short-term objectives has started; for example, strategies for improving nursing documentation have been discussed and some changes brought in. The early signs and symptoms of the deteriorating patient have been disseminated to staff.
Long-term objectives to make the recovery room a safer environment have been drawn up. Taking the project forward, LK continues to champion the changes by sourcing equipment and funding. He is an integral part of the process to facilitate the recovery nurses' training and airway management development.
Reflecting on our time in UTH, this has been an incredible experience and we feel privileged to have been part of a team where staff members work relentlessly to provide safe care with minimal resources. It was a challenge witnessing a service that runs with such limited drug supplies and equipment.
Each day slowly changed our perception of our profession and nurses' capacity to function under such pressures, which we initially could not have fathomed. Adapting to this setting was difficult, given the resources at our disposal in the UK and being accustomed to working in a controlled environment.
That said, this experience has brought to light how versatile the nursing profession really is and how we successfully overcome such challenging environments. Returning to the UK, our positive experiences have followed us and will continue to do so.