title: Anesthesiologist staffing considerations consequent to the temporal distribution of hypoxemic episodes in the postanesthesia care unit.
abstract: BACKGROUND
  Hypoxemia, as measured by pulse oximetry (SpO2), is common in postanesthesia care unit (PACU) patients. The temporal distribution of desaturation has managerial implications because treatment may necessitate the presence of an anesthesiologist.
  
  
  METHODS
  We retrieved SpO2 values recorded electronically every 30 to 60 seconds from 137,757 PACU patients over n = 80 four-week periods at an academic medical center. Batch mean methods of analysis were used. Onset times of hypoxemic episodes (defined, on the basis of previous studies, as SpO2 <90% lasting at least 2 minutes) were determined and resolution at 3, 5, and 10 minutes was assessed. Episodes beginning <30 minutes and ≥30 minutes after PACU admission were compared. Patients undergoing intubation in the PACU were identified by doing a free text search of electronically recorded nursing notes for phrases suggesting intubation, followed by a confirmatory manual chart review. Intervals from PACU admission to intubation were determined.
  
  
  RESULTS
  Fewer than half (31.2% ± 0.05%) of episodes of PACU hypoxemia lasting ≥2 minutes occurred <30 minutes after PACU admission. Most (i.e., >50%) occurred ≥30 minutes after admission (P < 0.0001). Few (<1%) anesthesia providers transporting patients to the PACU were still present in the PACU 30 minutes after arrival in the PACU. Fewer than half (37%; 95% confidence interval, 27.4% to 48.8%) of PACU intubations occurred <30 minutes after PACU admission. Most (i.e., >50%) occurred ≥30 minutes after admission (P = 0.029). Hypoxemic episodes in the PACU resolved more slowly than episodes in operating rooms (P < 0.0001). After 3 minutes, 40.9% ± 0.6% were unresolved in the PACU versus 23% (99% upper confidence limit) in operating rooms, and 32.6% ± 0.5% vs 9% (99% upper confidence limit) after 5 minutes.
  
  
  CONCLUSIONS
  Because most (68.8%) hypoxemic episodes in the PACU occur ≥30 minutes after admission, a time by which the anesthesia provider who transported the patient usually would no longer be present (>99% of cases), the PACU needs to be considered when anesthesiologist operating room staffing and assignment decisions are made.
authors.affiliation: From the *Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; †Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa; ‡Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee; and, §Departments of Anesthesiology, Bioinformatics, Health Policy and Surgery, Vanderbilt University, Nashville, Tennessee.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Epstein
authors.forename: Franklin
authors.initials: F
authors.lastname: Dexter
authors.forename: Marcos G
authors.initials: MG
authors.lastname: Lopez
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Ehrenfeld
mesh_terms: D000046:Academic Medical Centers; D000761:Anesthesia Department, Hospital; D000762:Anesthesia Recovery Period; D000776:Anesthesiology; D006301:Health Services Needs and Demand; D006801:Humans; D000860:Hypoxia / Q000175:diagnosis* / Q000628:therapy; D007442:Intubation, Intratracheal; D020380:Needs Assessment; D010092:Oximetry; D010561:Personnel Staffing and Scheduling; D011237:Predictive Value of Tests; D013997:Time Factors; D000078329:Workforce; D016526:Workload