It’s one of the most dreaded things you hear as an outpatient PACU nurse: “You’re being floated to the main PACU.” This time, though, I had no one to blame but myself—I willingly signed up to work the day after Christmas because, as a Per Diem Nurse, I dont get holiday pay. And guess what? The outpatient clinic was closed. So, begrudgingly, I braced myself for eight hours of facing the unknown.
Part of my job requirement was to float to the main PACU when needed. As outpatient PACU nurses, we still need to maintain our acute and critical care skills because, even in an outpatient setting, patients emerging from anesthesia can, on very rare occasions, experience sudden hypotension, respiratory distress, airway compromise, or cardiac events, requiring rapid assessment and intervention. However, since emergencies occur so infrequently at my ASC PACU, most of our patients are fairly stable, and I’ve only floated to the main PACU a handful of times—five or six at most, my critical care skills are pretty rusty.
The Day Arrives: Dec. 26, 2024
I navigated my way to the main hospital, trying to find the PACU. And by “navigate,” I mean I got lost. I hadn’t even stepped foot in the main hospital since COVID.
When I finally found the unit, I nervously clocked in and presented myself to the charge nurse. She was a middle-aged, soft-spoken Filipina. To my relief, she instantly made me feel at ease. I told her, “I’m nervous about working here today; I haven’t been here in ages.” She reassured me, “Don’t worry, it’s fine. It’s post-holiday—there aren’t many OR cases today.” Apparently, a normal day involves 60-70 cases. Today? Just 40.
That did make me feel a little better. I found my cozy spot in the PACU, with 2 side-by-side patient pods because sometimes you will have to care for 2 post op patient at a time. The thing about being a PACU nurse is that you spend a lot of time waiting. Sometimes, you wait 30 minutes to an hour and a half for the next OR patient. Assignments are staggered, so the nurse who clocked in the earliest gets the first patient, and the next nurse on the list gets the next one. If you’re lucky, there’s a gap where no patients come out for hours, and you can take an early break—or just sit around aimlessly.
First Patient: A Rectal Exam Under Anesthesia
My first patient was easy—a rectal exam under anesthesia. The patient came out drowsy but awake. I hooked him up to the monitor, made sure he was comfortable and warm (PACUs are always freezing), and let him sleep off the anesthesia. His vitals were stable, so I entered them into EPIC and wandered over to check out the supply area, which was conveniently within sight of my patient.
There it was: the legendary PureWick. Or, as I prefer to call it, the “cooter canoe.” Honestly, I was relieved I didn’t know much about using it—most of the patients I take care of are continent.
After about 45 minutes, my patient woke up. Still drowsy but functional, I propped him up in bed and gave him the universal signal: “Time to wake up, buddy.” Some patients, even after the simplest procedures, will try to sleep in the PACU all day. Not on my watch. I started explaining the discharge instructions. Usually, I prefer to go over them with the responsible party, but his ride was chilling in the car. Since it was a simple case, I assessed his alertness and ability to retain information and decided it was fine to review instructions directly with him.
Second Patient: A Teen With a Helicopter Parent
My next patient was a 17-year-old who had undergone a right knee arthroscopy. Sweet kid, very cooperative. The father, on the other hand, was… a lot. The CRNA had already warned me he’d be a handful, with endless questions and a tendency to forget the answers. While my patient was comfortably resting and pain-free, I walked the father through the discharge instruction.
He interrupted me a dozen times, asked irrelevant questions, and made me want to call a timeout. But I endured through it, answered every question, and ensured he understood everything before a relief break nurse insisted I take a quick break. After my break, I returned to find out from the relief nurse that she’d had to repeat all the discharge instructions because “apparently” I hadn’t given any. Great!
Main PACU vs. Outpatient PACU: The Differences
The hours stretched on, and I spent a lot of time waiting for another patient. One of the PACU nurses explained that because main PACU cases are more complex and take longer, there’s more downtime. They usually handle 4-5 patients per shift, compared to the 6-7 quick-turnover cases we manage in outpatient PACU (think cataracts or epidurals).
The size of the main PACU was overwhelming—19 operating rooms compared to our seven. Even finding the breakroom felt like a hike. At my outpatient center, it takes a minute to get to the breakroom. Here? I practically needed Google Maps.
Final Patient: A Post-Whipple Recovery
My last patient of the day, a post-pancreatic Whipple, rolled in with exactly an hour left in my shift. I had never recovered a patient after this procedure before, but I trusted the charge nurse’s judgment. The only issue? Setting up an arterial line. The last time I touched an A-line was seven years ago in the ICU. I fumbled my way through it, but with the help of some veteran PACU nurses, I managed to set it up correctly.
I did everything in my power—and with the limited time I had—to complete all the nursing tasks ordered in EPIC. At least, that’s what I thought. As if shift report doesn’t already give me the heebie-jeebies, the oncoming nurse opened the chart, and there it was: a laundry list of unfinished tasks. Blood draws, IV fluids, antibiotics… basically all the stuff we never have to do in an outpatient PACU. Thankfully, the oncoming nurse was chill and didn’t give me a hard time about it.
Final Thoughts
And that’s how my day went as an outpatient PACU nurse floating to the main PACU. It wasn’t terrible, but it could’ve been worse if it had been a busier day. I’ve grown so accustomed to the easier, more routine cases of outpatient surgery that I felt way out of my depth with the complexities of inpatient PACU.
Still, as I clocked out, I reminded myself: our jobs in outpatient PACU are tremendously easier than inpatient PACU, and we’re paid the same. So, I went home, let it go, and forgot about it.
