Purpose of the space

Flexibility is an important consideration. One of the first factors for consideration is how the space will be used. Will the bays be used strictly for postoperative care, or will the unit need the flexibility of preoperative use? Many institutions have a separate area dedicated to preadmission testing or screening. This area is best located near the surgical clinics and testing areas (i.e., blood draw station, radiology and cardiology [electrocardiography] departments). However, consideration should be given to how the preoperative holding area will be designed and used. Because of the cost of construction and the limited hours of use, many administrators are reluctant to build space that has only a single function and that does not lend itself to change as the users or programs evolve. Therefore all disciplines that use or expect to use the area need to engage in the discussion related to space usage so that future needs can be anticipated.

Perianesthesia nurses have knowledge of the entire process from preadmission testing to discharge the day of surgery. The staff members in the surgery department need to have input regarding types of operations, new surgical techniques, and the need for prolonged observation before discharge. The anesthesiology department medical staff members will have input regarding preoperative needs (e.g., a preadmission testing or screening area, day-of-surgery preoperative procedures area). Clerical services personnel should have input related to the flow of patients and record and paperwork systems. Input from environmental services personnel is related to needs of janitorial space and house cleaning supplies and equipment. Central supply personnel should be consulted regarding the space needed for storage of disposable supplies and linen for ready availability on the unit. Patient equipment personnel should give input regarding space needed to deliver and store reusable equipment, such as stretchers, beds, wheelchairs, infusion pumps, intermittent or sequential pneumatic compression devices, patient-controlled analgesia pumps (intravenous [IV] or epidural), and implantable cardioverter defibrillators.

Adequate time for consultation with all of the potential users and ancillary personnel who will use or provide services in the space is wise. One needs only a brief conversation with staff who have had to work in a poorly designed space to understand the importance of this first step in the design process.

Determine the location

The same factors that influence the building of a housing development or retail shops in one place versus another can be applied to this discussion of perianesthesia space needs. A new construction design typically offers greater probability of optimization of design than remodeling does. The first consideration before construction should be ease of access for the patients and families. Parking should be easily accessible and plentiful, and the entrance should be located adjacent to the parking garage or lot. The patient reception and waiting area should be near the entrance to decrease the patient anxiety and frustration that results from searching for an area.

The second consideration should be egress. A logical patient flow—with adjacent areas that naturally follow the patients’ transit through the unit—should be established for maximization of staff efficiency and decreased steps between areas. The waiting area should be adjacent to the preoperative holding area. PACU Phase I and PACU Phase II should be adjacent but with separate entrances from the ORs for safety and efficiency. In an inpatient setting, a separate elevator is ideal for patients of the OR to be transported to general care and intensive care units (ICUs). This separate elevator is a matter of safety for patients going to an ICU, and it maximizes staff efficiency for patients going to general care. With remodeling, great care should be taken to determine that the design shows consideration of these factors and incorporation whenever possible.

Components of the space

Several key components must be incorporated into the design of the space. The first element that needs determination is the number of patient bays. Before this number can be calculated, consideration must be given to several key factors that influence that number.^2,3

For an inpatient hospital PACU that services a combined patient population of inpatients and same-day admission patients, a ratio of 1.5 to 2 PACU bays per OR is necessary to safely care for the patients and not back up the OR. For an ambulatory surgery center with a limited number of surgical services and types of procedures, 2.5 to 3 PACU Phase I and PACU Phase II (combined) bays are necessary. The shorter surgical procedures necessitate an increased number of PACU slots because the recovery time may be two to three times the length of the procedure. If pediatric patients receive care in either setting, the number of bays may need to be increased, because this patient population necessitates 1:1 nursing care for a longer time than does a solely adult population.

Cases of antibiotic-resistant organisms and tuberculosis infections have been on the rise over the past several years. As a result, the need for negative pressure isolation or body substance isolation should be considered in the design. Geographic location and patient population demographics should be reviewed to determine the number of isolation rooms needed. Every PACU should have at least one negative pressure room. However, more rooms may be necessary if the institution services a more susceptible population. Consultation with the institution’s infectious diseases department is advisable to ensure that the design meets institutional policy and is prepared to serve the patient population.⁴

Another consideration in the design of patient bays is size and means of separation. Most states have building codes that define the minimum square footage of each bay (e.g., Minimum Design Standards for Health Care Facilities in Michigan requirement is 80 square feet).⁵ However, consideration should be given to how the bays are to be used. If they are strictly for patients requiring a PACU Phase I level of care, the minimum required square footage may be adequate. If the bays are to be used for anesthesia preoperative procedures or anesthesia pain procedures that necessitate equipment such as fluoroscopy or bronchoscopy, the size may need to be increased (to as much as 150 square feet). Also, if the bays are to be used alternatively as PACU Phase I or PACU Phase II levels of care and then as observation for 23-hour admissions, they may need to be large enough to accommodate a patient bed, table, lounge chair, or other equipment. Building some of the bays larger to accommodate these future needs may also be wise, but it is important to realize that the size of the bays affects the configuration of the space.

Patient privacy needs to be considered in determination of the means of separation between patient bays. Typically, PACU bays are open spaces defined only by a curtain that can be pulled for privacy. The open floor plan maximizes patient safety and staff efficiency in the higher acuity PACU Phase I setting. With preoperative and PACU Phase II care, patient acuity is typically lower and continual observation of patients is usually not necessary. Patients are more alert and families are generally present; therefore the need for privacy is increased. Half walls may be considered in these spaces. A half wall (i.e., floor-to-ceiling wall one third to half the depth of the bay) gives more privacy to the patient and family from the sights and sounds of the adjacent bays. However, this configuration still allows the clinicians to observe patients and be readily available for acute needs.