NR 513 Week 2 Standards Analysis, Phase I Staffing Example

Standards Analysis: The Two-Nurse Rule for Phase I Recovery, Set Beside Thirteen Weeks of Night Call at a Community Hospital PACU, and Who Is Bound to Close the Gap

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College of Nursing, Chamberlain University

NR 513: Professional Role Enhancement

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Month Day, Year

Standards Analysis: The Two-Nurse Rule for Phase I Recovery, Set Beside Thirteen Weeks of Night Call at a Community Hospital PACU, and Who Is Bound to Close the Gap

The Requirement

The American Society of PeriAnesthesia Nurses (ASPAN) publishes perianesthesia nursing standards and practice recommendations every two years. Its staffing recommendation for Phase I, the period immediately after anesthesia when airway, breathing and circulation are still being stabilized, states that two registered nurses, one of whom is a perianesthesia registered nurse competent in Phase I postanesthesia nursing, are in the same room or unit where the patient is receiving Phase I care (American Society of PeriAnesthesia Nurses, 2025). The same document says the Phase I nurse must have immediate access and direct line of sight to the patient, that the second nurse must be close enough to hear a shout for help and able to come at once, and that these recommendations should be kept during on-call situations.

The requirement is precise about three things: the number of nurses, their license, and their location. It is not a general statement about safe staffing.

Whom the Requirement Binds

A staffing standard is easy to attach to a unit's culture, which is to say to nobody. This one binds two people in particular. The first is the Phase I nurse who accepts the patient, because accepting a patient in Phase I without a second nurse in the unit is a decision she makes, even at 0300. The second is the nurse manager who writes the on-call schedule, because the schedule decides whether a second perianesthesia-competent nurse is on call at all or whether the plan relies on someone elsewhere in the hospital. The anesthesia provider shares responsibility for the patient but does not staff the PACU, and the requirement is a nursing standard written for nurses.

What Practice Looks Like on Night Call

At my hospital, the PACU closes at 2300. After that, emergency cases are recovered by one on-call PACU nurse who comes in from home. The written plan names the house supervisor as the second nurse. The house supervisor is a registered nurse, but during a night shift she covers the whole hospital, carries a phone and is usually on another floor. When she is called, she comes, but she is not in the unit, and she cannot hear a call for help without the phone.

To describe the gap in countable terms, I reviewed the on-call log for the thirteen weeks from April through June. There were 34 on-call Phase I recoveries between 2300 and 0700. In 21 of them, the plan's second nurse was the house supervisor, working somewhere else in the building. In 9, a second PACU nurse had been called in because two cases overlapped. In 4, an intensive care nurse was recovering the patient in the intensive care unit, which meets the requirement by location. No names or patient details were recorded for this paper, and the counts are from my own tally, not an official report.

The Size of the Gap

On 21 of 34 nights, or 62%, the requirement was not met: the second registered nurse was neither in the same room nor in the same unit. On those nights, the Phase I nurse was alone with a patient in the first hour after anesthesia. The gap is not a matter of degree, such as a second nurse who was slow to arrive. The written plan itself does not meet the requirement, because it relies on a nurse who by design is somewhere else.

The distance matters because of what happens in Phase I. In an analysis of 43 malpractice claims arising from PACU events, Kellner et al. (2018) found that respiratory injuries were the most common, at 32.6% of cases, and that a diagnosis made late or not at all figured in 56.3% of the claims involving a death. A nurse managing a laryngospasm alone cannot give positive-pressure ventilation, draw up a drug and call for help at the same time.

Why the Gap Persists

The gap persists for reasons that are real. A small hospital has few emergency cases after 2300, and paying a second PACU nurse to take call every night costs money for nights with no cases. The house supervisor plan was probably written as a reasonable compromise. The ASPAN standard anticipates exactly this argument and rejects it by stating that the recommendation applies during on-call situations (American Society of PeriAnesthesia Nurses, 2025).

The cost argument also rests on a narrow view of what staffing buys. In a study of hospitals in nine European countries, Aiken et al. (2014) reported that every extra patient added to a nurse's load carried about 7% greater odds of death in the thirty days after an operation. That study concerned general surgical wards, not a PACU at night, and it cannot be moved directly to this setting. What it does show is that nurse staffing is not a comfort measure. It is one of the conditions under which nurses notice deterioration in time, which is the entire purpose of Phase I care.

The gap also persists because nobody owns it. The Phase I nurse assumes the schedule has been checked against the standard. The manager assumes the house supervisor arrangement satisfies it. Neither is asked to sign anything that says otherwise.

What Would Close It, and Who Could Act

Education is not the answer here. Every nurse on the call rotation knows the standard; the problem is the schedule. Three changes would close the gap. First, a second perianesthesia-competent nurse on call for every night, or an agreement that an intensive care nurse will come to the PACU and stay for the whole Phase I period. Second, a rule in the on-call policy that the Phase I nurse does not accept the patient until the second nurse is physically present. Third, a quarterly count, like the one in this paper, reported to the perioperative committee.

If the gap were left as it stands, the body that could act first is the hospital's nurse practice council, which approves unit policies, and after that the perioperative quality committee. If a patient were harmed on one of those nights, the Ohio Board of Nursing could review whether the nurse's practice met the standard expected of a reasonably prudent perianesthesia nurse. That is the body the Phase I nurse should keep in mind at 0300, because it will not ask what the schedule allowed.

References

Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., McHugh, M. D., Moreno-Casbas, M. T., Rafferty, A. M., Schwendimann, R., Scott, P. A., Tishelman, C., van Achterberg, T., & Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. The Lancet, 383(9931), 1824-1830. https://doi.org/10.1016/S0140-6736(13)62631-8

American Society of PeriAnesthesia Nurses. (2025). 2025-2026 perianesthesia nursing standards, practice recommendations and interpretive statements. https://www.aspan.org/Publications-Resources/ASPAN-Publications/ASPAN-Standards

Kellner, D. B., Urman, R. D., Greenberg, P., & Brovman, E. Y. (2018). Analysis of adverse outcomes in the post-anesthesia care unit based on anesthesia liability data. Journal of Clinical Anesthesia, 50, 48-56. https://doi.org/10.1016/j.jclinane.2018.06.038