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Starbucks In India
Great brands know no boundaries, once again demonstrated as Starbucks opens its first store in India. Some great brands have rapid success going into new markets, others take more time to get established, and some ultimately fail. Those that don't succeed right from the start face certain problems in common. If you find yourself in a similar situation—a great brand entering a new market—consider the following:
- Don't Assume Consumers Know You: Sure, in your home markets almost everyone may know the brand and products or services you offer. But don't let your perceptions and past experience inadvertently prevent you from seeing and fully understanding what you are getting into. Far too often, even great brands run by very, very smart and successful people apply the same approach to sales and marketing in a new market as they do in existing ones. Compounding matters, corporate headquarters unrealistically puts pressure on the local team to deliver the same financial results using an existing sales and marketing approach.
- Rethink: Usually everything has to be rethought: the messages, marketing spend levels, how and what information is communicated, how sales explains the product, and even who sales should pitch. One of the world's greatest brands struggled for years in China until yet another new team arrived from the US headquarters and realized that instead of advertising in media then selling to newly emerging retail chains and existing distributors as was done in the US, they needed to go direct to consumers. Feet-on-the-ground sales people went into villages to show consumers how to use the product with very straightforward marketing collateral. Following the villages' initiative, sales and marketing effectively transitioned to a media and retail chain approach leading the brand to a huge success.
- Warning Sign: You know you have trouble if the marketing and sales plan (including the financial plan) for a new market looks the same as for an existing one. Bring people in who know the new market well to develop market-specific plans, then guard that nobody in the organization—from finance to the current sales force—accidentally changes it later to conform to their view of the world.
For more information firstname.lastname@example.com.


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|Home > Jaime
♀ Jaime
What does Jaime mean?
Jaime [jaime]▼ as a girls' name (also used more regularly as boys' name Jaime) is of Spanish origin. Variant of James (Hebrew) "he who supplants". "J'aime" is the French expression for "I love". Also used in modern times as a respelling of Jamie,
VARIANTS Jamee, James▼, Jamey, Jamie▼, Jayme▼, Jaymee
OTHER FORMS VIA JAMIE Jaima, Jaimee, Jaimey, Jaimi, Jaimie▼, Jaimy, Jama, Jamei, Jamese, Jami▼, Jamia, Jammie, JaymieCREATIVE FORMS
(female) Jaimea, Joyme, ..
(male) Jaige, Jaije, .. MIDDLE NAME PAIRINGS
Jaime Adelina (J.A.), ..
How popular is Jaime?
Jaime is a very popular first name for females (#498 out of 4276, Top 12%) and also a very popular surname for both adults and children (#3232 out of 150436, Top 2%). (2000 U.S. DEMOGRAPHICS)
Jaime entered the list in 1950-1959 and reached its top position of #133 in the U.S. during the years 1970-1979, but is not listed at the moment. (TOP BABY NAMES, 2015)
Which version is better?with its variant forms and related girl names. Prominent alternative forms of Jaime are Jamie (#498 FROM CURRENT RECORDS), Jamia, Jammie, Jayme, Jaymie, Jaymee, Jami, Jamey, Jaimie, Jaimee, Jama, Jamee and James. Usage of these forms of Jaime was common during the years 1980-1989 (ADOPTION OF 0.9%) and has become much reduced since, with forms such as Jamie falling out of fashion.
Similar Names
Jaime▼ is pronounced similarly to Jaimee and Jaimey. Other suggested similar names are Aime, Blime, Jacee, Jacie, Jacine, Jade▲, Jadee, Jadine, Jae, Jaicee, Jaida, Jaide, Jaidee, Jaiden▼, Jaima, Jaimi, Jaimie▼, Jaimy, Jaina, Jaine, Jainee, Jaline, Jama, Jamei, Jami▼, Jammie, Janae, Jane▼, Janee, Janice▼, Janie▼, Janine▼, Janise, Janne, Jarae, Jaxine, Jayde▲, Jaye, Jaymie, Jayne▼, Jazma, Joice, Joie, Maime, Mame▼, Maxime, Mayme▼ and Padme. These names tend to be less commonly used than Jaime.

subset: commoncrawl


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Difference between revisions of "User:Jmanico"
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My name is Jim Manico. Thank you for electing me as your Global Board Member as of January 1, 2013.
My name is Jim Manico. Thank you for electing me as your Global Board Member as of January 1, 2013.
Revision as of 20:51, 21 March 2014
My name is Jim Manico. Thank you for electing me as your Global Board Member as of January 1, 2013.
I've been an active member of OWASP since 2008. Professionally, I'm a secure coding instructor and author. I also do a great deal of OWASP-centric travel around the world. My main passion at OWASP is supporting projects that help developers write secure code.
You can reach me at email@example.com. You also reach me on twitter at @manicode.
What are your most notable accomplishments over the past three years as an OWASP contributor?
- I am the project manager and significant contributor of the OWASP Cheatsheet Series. I've worked on the XSS, DOM XSS, SQL Injection, Cryptographic Storage, Forgot Password and other topics in this series.
- I am the founder of the OWASP Podcast Series. As of March 2014 I have published 98 shows and have spent over 500 hours making the OWASP Podcast a reality. I am grateful to my many guests who have made the show a success. I plan to end my participation in the show after OWASP Podcast 100 is released.
- I am also spearheading several ESAPI-like projects that provide modular single-use controls for ease of use. These include the OWASP Java Encoder, the and the OWASP HTML Sanitizer project.
- I recruited the team who created and maintain the OWASP Mobile Project.
- I have traveled to OWASP chapters all over the world providing free developer training
What are the most significant challenges OWASP is facing?
- Financial
- Keeping basic IT services running well and securely
- vendor neutrality
If you become elected, what would the top three things be that you would focus on?
- Fundraising
- Expand membership (developers).
- Content Reorganization. In order to support increased membership, we need to increase quality and remove old content that is not pertinent or out of date - make OWASP more consumable for the masses!
What do you want to do as a board member that you can't do as an OWASP leader or committee member?
- As a board member I will have more opportunities to serve as an ambassador for the organization evangelizing the importance to web security to both the security and the developer communities.
- One of a board members main roles is too maintain a vendor-neutral stance when representing OWASP. I feel I have demonstrated a commitment to putting the mission of OWASP before my personal and business interests.
How does your past experience relate to this position?
- Travel internationally speaking at 30+ OWASP chapters through much of Europe and the US
- Have had a chance to "hear out" and interface with OWASP members on a global scale
- Provide secure coding training as talks and free seminars emphasizing vendor neutral open source information
- Interaction with several OWASP projects and committees
- Worked with or partnered with several existing board members


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Check out this flat located in Mile End, East London. This apartment has five bedrooms, a shared bathroom and a kitchen. The bedrooms are small, but perfectly furnished for any student and the kitchen is fully equipped.
- Bethnal Green London Underground Station (Tube station - Central line ) - 5 minutes walk away.
- Queen Mary University of London - 11 minutes walk away.
- University of Liverpool London - 16 minutes away on public transport;
- City University London - 26 minutes away on public transport.
- University Of East London, Stratford Campus - 24 minutes away on public transport.
Local Amenities
- Restaurants and supermarkets - 5 minutes walk away.
- Mile End Park - 7 minutes walk away.
- Victoria Park - 10 minutes walk away.
Area Description
Nowadays, like most of East London, Mile End is known for its cool, stylish character, making it an area more and more affluent with students. The neighbourhood is full of gritty pubs and bars, where you'll find lots of students, as well as some of the Cockney locals, who will always have an interesting story to them.
Find out more about this property's common areas in our photo gallery.
Looks like no one had the time to review this place yet!
These conditions were defined by the Provider and are subject to change.
This is one of our most trusted properties. It has fulfilled all of our verification criteria and earned the Uniplaces Verified badge. We only award this badge to the properties and landlords who we trust the most.
Getting Around
Your new neighbourhood
Mile EndDiscover more about Mile End
Path to university
At Uniplaces we make the process of booking an apartment as easy as possible for both tenant and landlord.
That's why we have our own team of professional photographers that verify our properties and pick our landlords carefully in order to save time on viewings: we think it's old-fashioned and time-consuming.
You can look at forty different apartments on our platform in the same amount of time that it takes to see a room.
The pictures you see here haven't been photoshopped, so they'll be really accurate.
If you've still got any doubts, we'll keep the money that you transfer us until 24h after your move-in date.
If something's not exactly what you saw online, we'll help you move somewhere else and return your money.
We can only give you the contact details of your landlord after your booking is accepted. But we can guarantee that Uniplaces chooses the landlords it works with very carefully.
Besides, we've had students whose favourite part was living with a local!
Landlords and host families can be great city guides, help you out with translations and even become your friends.
As soon as your booking is accepted, you're given the landlord's contact details. Then, you can discuss all details directly with them, such as when you'll be moving-in.
Students move in and out at different times, so your flatmates might change during your stay.
It's a great opportunity to make new friends!
We personally speak to students who we place in Uniplaces apartments and are sure we will find the right place for you as well!
At the bottom of the property page, you have a calendar where you can see the availability of that room/apartment, according to the landlord.
But if you're still unsure about that we're happy to help.
Tell us your move-in and move-out dates and we will double-check if the place is available for you!
There are two different types of deposits: the Holding and Security deposits.
By clicking on "Deposit" at the bottom of the offer page you will get more information about each type of deposit.
In general, the deposit is paid to cover for any potential damages that may occur during your period of stay or will be used as rent compensation in case you leave earlier than originally planned.
If no damages occur and you leave on the agreed move-out date, your deposit should be refunded by the landlord in a way you both agree on.


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Scroll down the page to read answers to some of the most frequently asked clinical practice questions received by ASPAN. These questions will be modified periodically as practice issues change.
If you do not find the answer to your question, please feel free to submit it to ASPAN's Clinical Practice Network or post it on the ASPAN Forum.
The primary responsibility for Phase I PACU is to provide the optimal standard of care to the Postanesthesia patient and to effectively maintain the flow of the surgery schedule…
Phase I PACUs are by their nature critical care units, and as such staff should meet the competencies required for the critically ill patient. These competencies should include, but are not limited to, ventilator management, hemodynamic monitoring and medication administration, as appropriate to their patient population…
Management should have a multidisciplinary plan to address appropriate utilization of ICU beds. Admission and discharge criteria should be utilized to evaluate the necessity for critical care and to determine the priority for admission" (p. 82-83).
Advance notice of transfer allows the receiving provider the opportunity to prepare for the patient's arrival. Handoff report should be completed before or at the time of transfer. There should be an opportunity for the provider assuming care of the patient to ask the transferring nurse questions. Keep in mind that responsibility for effective hand off communication belongs to both providers. Not only does the current caregiver have a responsibility to cover all of the pertinent information, the receiving caregiver has the duty to actively listen to the handoff report or to read it carefully and request clarification as needed. Whether handoff report is in verbal or written format, it is a critical process which requires each individual caregiver to be fully engaged.
In summary, each institution should hardwire the handoff process. Using a standardized system or tool discourages miscommunication and failed communication. Guidelines designed to meet the needs of the population optimize safe transition of care.
Susan Russell, BSN, RN, JD, CPAN, CAPA
ASPAN Director for Clinical Practice
The ASPAN Perianesthesia Nursing Standards and Practice Recommendations 2010-2012 include Resource 3, the "ANA Position Statement: Role of the Registered Nurse in the Management of Analgesia by Catheter Techniques (Epidural, Intrathecal, Intrapleural or Peripheral Nerve Catheters)."1 The American Nurses Association (ANA) states that RNs may not insert the device, administer a test/initial dose of medication through the device, confirm placement, or establish the dose parameters necessary to achieve analgesia/pain relief.1 Only credentialed practitioners, usually anesthesiologists, prescribe and insert these devices. State nurse practice acts (NPA) may differ in how the RN's scope of practice is defined regarding participation during insertion. Before developing facility policies, procedures and competencies, review the applicable nurse practice act for your state.3,4
In many facilities, nurses do assist during insertion of peripheral nerve blocks. Minimally, the RN should facilitate patient safety. Safety factors include completing a preprocedure checklist, and also verifying informed consent, IV access and patency, procedural timeout, and emergency equipment availability.3
When assisting with the procedure, a 1:1 nurse/patient ratio applies. Duties may include gathering supplies such as ultrasound equipment, administering physician-ordered moderate sedation, monitoring the patient, and in some cases, adjusting the stimulator's amplitude at the direction of the anesthesiologist.4 Frequency of vital signs ranges from every two to 15 minutes, depending on the patient's response and overall condition.4 Recognition of adverse reactions and timely intervention is critical.3,4,5 Nurses assisting with blocks should maintain current ACLS/PALS credentials.
Depending upon state nurse practice act and facility policy, a nurse may inject local anesthetic through the peripheral nerve catheter under the direct supervision and instruction of the anesthesiologist.4 The anesthesiologist should maintain the position of the needle and the catheter while the nurse injects the medication. The nurse effectively serves as the anesthesiologist's extra pair of hands.3
Nursing documentation reflects the nurse's participation in the procedure. Note the patient's condition on arrival and departure from the procedure area. Complete the preprocedure checklist and timeout. Chart vital signs with oxygen saturation. Document the cardiac rhythm, and where possible, include rhythm strips. Record medications administered and the response of the patient. Note adverse reactions. Document neurovascular and neurological checks. Include the patient's position, noting protective devices used as well as padding. The anesthesiologist should complete a physician procedure note.
Nursing competencies should include ACLS/PALS, moderate sedation, intralipid protocol, recognition of signs and symptoms of toxicity including cardiac arrhythmias and seizures, pharmacology of local anesthetic agents, and neurovascular/neurological checks. Nurses should be familiar with each type of block performed, its therapeutic effects, associated side effects, possible adverse reactions associated with the specific block performed and any indicated emergency interventions.4 These competencies are necessary to ensure the patient's optimal safety during the peripheral nerve block procedure.
The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements do not include a definition of "responsible adult." The dictionary defines 'responsible' as an "individual who is able to answer for his conduct and obligations; someone who is trustworthy; someone who knows right from wrong; someone who is accountable."1 An "adult" is an individual 18 years or older. There are facilities where the word "adult" has been changed to "party" or "person."
Determinants of Responsible Adult
When determining whether or not an individual can be the responsible adult, age is not the only factor. Sometimes, it is the relationship of the parties. Parents are presumed to have authority to act on behalf of their minor children. A minor who is a parent caring for his/her own child may be the "responsible adult," even if the minor and his/her child live with parents or other adult relatives.
The ability to drive is not a prerequisite, although it may be necessary to ascertain whether the mode of transportation is safe for the patient. The patient cannot be the driver after sedation, but taking a taxi when accompanied by a non-driving "responsible party" may be an acceptable option. A blind or deaf person can be the responsible person. Discharge instructions may be carried out through an interpreter. In today's society, many people live alone or are single parents. If the patient's "responsible adult" is a teenage child, you must consult the facility's policy regarding the discharge. It may be reasonable to discharge the patient with a teenager who understands the discharge instructions, and is willing and able to provide the necessary care.
Caregiver Support
What if the patient is not accompanied by a responsible adult? It is best to verify discharge arrangements prior to the procedure. At the time of admission, ask who will be caring for the patient after discharge, and what transportation arrangements are planned. Make sure the designated caregiver understands that the patient should not be left alone for the first 12-24 hours, depending on the procedure and the type of sedation.
Occasionally, the person driving the patient home is not the designated caregiver. If possible, contact the caregiver to review the discharge instructions and to answer any questions. If the caregiver does not comprehend the discharge instructions, or is unable to perform the tasks necessary to care for the patient, it may be necessary to consult the physician and obtain an order for home healthcare. Occasionally, unaccompanied patients state they have someone to help them at home. Some facilities allow patients to leave via taxi with a physician's order. Consider notifying the caregiver when the taxi leaves the facility. Document the telephone number, the name, and the relationship of the individual.
It may be necessary to obtain an order for the patient to spend the night in the facility (if that is an option). If no alternatives can be identified, the physician may need to cancel the procedure. When discharging a patient to a group home, review the discharge instructions with the group home supervisor. When discharging a patient to assisted living, contact the caregiver to determine what arrangements can be made for overnight care if a family member or friend is not going to be with the patient. With elderly patients, the accompanying spouse may require more care than the spouse having the procedure. When the patient is the spouse's caregiver, determine who else may be available to assist the couple after the procedure.
Never hold a patient against his will. False imprisonment is not an option. The patient could file both civil and criminal charges, depending on state laws. Consult the facility risk manager or administrator regarding leaving Against Medical Advice (AMA). AMA departures should be carefully documented in the medical record.
The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements do not require ACLS/PALS for nurses working in Preop or Phase II perianesthesia care. ACLS and PALS recommendations are addressed in "Standard III, Staffing and Personnel Management" with the following statement: "It is recommended that the perianesthesia nurse providing Phase II level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served."1
"Practice Recommendation 4, Recommended Competencies for the Perianesthesia Nurse," includes ACLS, and PALS or PEARS (Pediatric Emergency Assessment Recognition Stabilization) training for nurses working in either preanesthesia or Phase II settings, depending on the scope of services provided in the unit.1 "Practice Recommendation 5, Competencies of Perianesthesia Support Staff," recommends that even unlicensed personnel maintain BLS.1
Facility Considerations
In determining whether preop and phase II nurses are required to maintain ACLS and PALS/PEARS, it may be best to assess the patients and community served. Age and acuity are only two factors. Other factors include the type and location of the facility, ancillary staff on site, and types of procedures performed. Are ACLS/PALS trained staff available to respond to a code in preop and Phase II whenever patients are present in those areas? In a unit or facility where critically ill children are rarely admitted, would PEARS, if available, be a reasonable choice for preanesthesia and phase II nurses caring for pediatric patients? PEARS trains healthcare providers to recognize and respond appropriately to pediatric emergencies such as respiratory distress, shock, and cardiac arrest until advanced life support providers arrive. ACLS, PALS, and PEARS courses are offered through the American Heart Association.2
Economic factors also affect the decision to require ACLS/PALS/PEARS. These include course cost and availability, access to qualified instructors, and the expense of scheduling extra staff to cover during classes. Outpatient facilities may not have ancillary staff, such as respiratory therapists, to assist in emergencies. Ambulatory surgery center (ASC) RNs are frequently cross-trained to work in more than one perioperative area. Competencies in every facility should reflect all cross-training, including the requirement for ACLS/PALS.
ASPAN's 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements do not require ACLS/PALS for nurses working in preop or phase II perianesthesia care. Each facility should evaluate their preoperative and phase II scope of service to determine whether to require nurses to maintain ACLS/PALS.
ASPAN Standards
The American Society of PeriAnesthesia Nurses (ASPAN) does not currently have a practice recommendation requiring continuous monitoring of etCO2 in the Phase I PACU. "Practice Recommendation 2, Components of Assessment for the Perianesthesia Patient," states that vital signs are monitored, including "end-tidal CO2 (capnography) monitoring if available and indicated," and to monitor, maintain, and/or improve "airway and respiratory/ventilation status."
ASA Standards
Monitoring etCO2 has long been a standard of care for anesthesiologists delivering general anesthesia for intubated patients in the operating room.2 This practice has expanded to areas outside of the operating room. The American Society of Anesthesiologists (ASA) recently updated their standards for Basic Anesthetic Monitoring.3 The Standards state that "the adequacy of ventilation will be continuously evaluated……...continual monitoring for the presence of expired carbon dioxide shall be performed."3 The ASA goes on to state that "during moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide."3 This applies to nurse monitored sedation as well.2
The ASA state in the Standards for PostAnesthesia Care that "particular attention should be given to monitoring oxygenation, ventilation, level of consciousness and temperature."4 The ASA does not specifically state that capnography is required in the post anesthesia care unit, but that ventilation is monitored. The most effective way to monitor ventilation is through capnography.
Future of Capnography
Capnography can be valuable in the post anesthesia care unit for heavily sedated patients, those receiving high doses of opioids, and those with diagnosed or undiagnosed obstructive sleep apnea. "Practice Recommendation 10, Obstructive Sleep Apnea in the Adult Patient," in the 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretative Statements, discusses Phase I and II care as including "routine monitoring and the addition of capnography when available" for obstructive sleep apnea patients."1 In situations where the patient's respiratory status has been compromised, capnography monitoring and assessment may prompt the PACU nurse to intervene for patient safety as the patient transitions from PACU care. He/she may advocate for a higher level of care when the patient is discharged from the PACU.5
Capnography may be also useful for a period of time after the patient leaves the PACU. Post anesthesia nurses are aware that medical/surgical floors have increased nursing work loads which limit the frequency of the nurse's presence at the bedside. A trend is for patient-controlled analgesic pumps to incorporate both pulse oximetry and capnography into the pump mechanics. These additional monitors alarm to give earlier warnings of potential respiratory issues and/or a potential crisis.2
Trends in perianesthesia nursing are regularly discussed as potential additions to the ASPAN Standards. Capnography increases safety and has proven its value in better patient outcomes in anesthesia and sedation venues. With the increasing vigilance needed in Phase I PACU for patients in such a vulnerable state, capnography is a monitoring tool that may be beneficial and recommended in the very near future.5
Barbara Godden, MHS, RN, CPAN, CAPA
Revised November 11, 2012
ASPAN's Non-Endorsement Statement:
The American Society of PeriAnesthesia Nurses (ASPAN) does not endorse any specific postanesthesia scoring tool or system. ASPAN's 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements includes "Practice Recommendation 2, Components of Assessment for the Perianesthesia Patient." This recommendation states that a component of postanesthesia assessment includes "Postanesthesia scoring system if used." Practice Recommendation 8, Fast Tracking the Ambulatory Surgery Patient, includes the following statement in the recommendations for bypassing the Phase I PACU, "Scoring systems are one way of assessing readiness for Phase II level of care and can include White's Fast Tracking Scoring System, Modified Aldrete, or the Post Anesthetic Discharge Scoring System (PADSS)."
What the ASPAN Standards State
The use of a scoring system is not required by ASPAN Standards. Each facility should develop assessment and discharge criteria for each level of postanesthesia care and may include a postanesthesia scoring system as a component of the assessment and discharge criteria. Facilities are encouraged to work with the Department of Anesthesia to develop and implement appropriate discharge criteria which meets the needs of the population served.
Common Scoring Systems
Scoring systems commonly used include Aldrete, Modified Aldrete (also known as PARSAP), PADSS, and White, to name a few. Aldrete scoring is traditional, was developed in 1970, and includes scoring for activity, respiration, circulation, consciousness and color, now changed to oxygen saturation. The maximum score for Aldrete is 10. The Modified Aldrete was developed in response to ambulatory surgery trends. This scoring system includes 10 elements consisting of activity, respiration, circulation, consciousness, oxygenation, dressing, pain, ambulation, feeding, and urine output. The maximum score for Modified Aldrete is 20. This scoring system is useful where Phase I and Phase II are combined units. The White scoring system was developed in 1999 to use for fast-tracking patients. The elements for the White scoring system include level of consciousness, activity, hemodynamic stability, respiratory stability, oxygen saturation, pain, and emetic symptoms. The White system has a maximum score of 14.2,3 Many facilities use the Post Anesthetic Discharge Scoring System (PADSS) for Phase II patients. The elements include vital signs, activity, nausea and vomiting, pain, and surgical bleeding. The maximum score for this system is 10.3 Policies addressing the total discharge score for each scoring system should be established in consultation with the anesthesia department.1,4 Deviations from the established discharge scores should be addressed in the facility policy and may require a specific order from the anesthesia provider for discharge to the next level of care.
Individual Facility Practices
The use of scoring systems varies widely across perianesthesia practice. Many facilities use one or more of the above mentioned scoring systems. Still others do not use a scoring system at all, but instead use defined discharge criteria from each phase of care. Many other facilities use a combination of a scoring system along with defined discharge criteria.
ASPAN Clinical Practice Committee members are ASPAN volunteers working in a variety of perianesthesia settings and for many different employers. Because of the variety of settings and work-related affiliations, individual committee members may have experience with specific scoring systems and may answer questions about scoring systems based on personal experience. This does not constitute an endorsement from ASPAN.
Additional Considerations
Additional questions ask how to score certain elements. One example is how to score activity for a patient with a history of stroke. It may be helpful to have a preoperative score to establish a baseline. Another common question is how to score a patient who is drowsy but arousable. Do you score the patient as a 1 or a 2? An assessment that is helpful in determining this score and readiness for discharge to the floor is, does the patient arouse on his own, look around, and go back to sleep? This would be a score of 2 and would indicate that the patient could progress to the next level of care if all other criteria are met. If the patient is going to a floor bed, the nurse wants the patient comfortable, but not necessarily wide awake and hurting. If the patient is going to Phase II, the discharge policy regarding the assessment may require that patients be more awake, off supplemental oxygen, comfortable, and have stable vital signs.
The bottom line is that the discharge criteria are developed in consultation with the anesthesia department.1,4 A scoring system should not be used exclusively as the discharge criterion for a postanesthesia patient. If using a scoring system, clinical assessments must also be considered. Because each patient's condition varies and must be assessed individually, time frames for discharge cannot be stated and are not prescribed by ASPAN. Critical thinking and nursing judgment are essential factors in determining readiness for discharge.3,4
Barbara Godden, MHS, RN, CPAN, CAPA
Susan Russell, BSN, RN, JD, CPAN, CAPA
Revised November 11, 2012
To state it simply, there is no definitive answer to this question. Practices vary from facility to facility, and should be driven by a preoperative testing policy that is developed in conjunction with the anesthesiology department.
American Society of Anesthesiologists
The American Society of Anesthesiologists (ASA) includes in its Statement on Routine Preoperative Laboratory and Diagnostic Screening Standard that "No routine laboratory or diagnostic screening test is necessary for the preanesthetic evaluation of patients. Appropriate indications for ordering tests include the identification of specific clinical indicators or risk factors (e.g., age, pre-existing disease, magnitude of the surgical procedure). …. Anesthesiologists, anesthesiology departments or health care facilities should develop appropriate guidelines for preanesthetic screening tests in selected populations after considering the probable contribution of each test to patient outcome. Individual anesthesiologists should order test(s) when, in their judgment, the results may influence decisions regarding risks and management of the anesthesia and surgery. Legal requirements for laboratory testing where they exist should be observed. The results of tests relevant to anesthetic management should be reviewed prior to initiation of the anesthetic. Relevant abnormalities should be noted and action taken, if appropriate."1 In other words, tests should only be conducted when there is a clinical indication to do so.
Individual Facility Practice
Some facilities have policies that state that all females from menarche to menopause require a pregnancy test. Other facilities state that the only exemptions from being tested are those women who have had sterilization such as a tubal ligation or a total hysterectomy. Still other facilities have a policy that has nursing staff ask the patient if there is any chance that they could be pregnant. If the patient states "no", they accept the patient's word and document as such. While many facilities do not require pregnancy tests, many individual anesthesiologists may require one in their specific preoperative orders for a particular patient.
Additional Considerations
Even among individual anesthesiologists, the issue of preoperative pregnancy testing remains highly controversial. Randomized control trials will never be done due to ethical considerations.2 For this reason, some physicians feel that all patients should be tested.2 According to some literature, there is insufficient evidence to support that a single exposure to modern anesthetics causes teratogenic effects on a fetus.3 Additionally, if all patients are tested, there may be issues related to legal requirements for patients who are minors, HIPAA considerations, and potential financial considerations.3 Some physicians believe that informed consent of all females to conduct testing is the best option. Some physicians will write the order for preoperative pregnancy testing if their own personal practice patterns dictate that the test be completed, no matter what the facility policy states.
There is no national standard for preoperative pregnancy testing. The ASA Position Statement indicates that the anesthesiologist needs to consider each individual patient, patient needs, and individual risk factors when ordering preoperative tests. Each facility needs to develop a preoperative pregnancy testing policy in collaboration with the Department of Anesthesiology.
The answer to the first question is yes, depending on several things. First of all, are there any restrictions in your state Nurse Practice Act that prohibit nurses from extubating patients? Second, do you have a policy in your department that states whether you can extubate patients in the PACU? And third, do you have an extubation competency in place that all PACU nurses must complete before they can extubate a patient?
These three items must all be present before you can consider whether or not you can extubate a patient. Most state Nurse Practice Acts are fairly vague when it comes to specific skills. Many practice acts have statements in them saying that the nurse must be "deemed competent" in a skill to perform it. With this criteria met, the next step is to work with your anesthesia department to develop a policy. Extubation policies can be very simple and straight forward, stating that a PACU nurse may extubate a patient once they have been checked off on a unit competency. Other extubation policies actually include the policy along with the procedure, step by step. And the third piece is to have a competency in place for ensuring that PACU nurses know how to extubate a patient correctly and safely. There are several resources available to assist in developing a competency for extubation. In addition to the extubation criteria and skills, the competency should include post extubation assessment skills, including monitoring for complications such as hypoventilation, respiratory stridor, and laryngeal edema.1,2,3
The answer to the second question, "must an anesthesia provider be present?", lies in your policy. Your policy needs to include criteria in which an anesthesia provider needs to be present. In many facilities, it is not mandatory for an anesthesia provider to be physically present in the PACU when a patient is extubated, provided that the criteria for extubation are very strict and the nurses adhere to these criteria. However, in all situations, there must be someone who can re-intubate the patient if complications arise after extubation. In dire situations, the nurse can "ambu" (bag/valve/mask) the patient until an anesthesia provider is available, This is not ideal, nor the safest option for the patient. Again, in most facilities, the practice is to have an anesthesia provider available within a couple of minutes to re-intubate the patient if necessary.
Reviewed November 11, 2012
This question comes up frequently through the questions sent into the Clinical Practice Network.
One of the recommended assessments prior to discharge per the ASPAN Standards is "arrangement for safe transportation from the institution."1 The Registered Nurse also determines the "mode, number and competency level" for transport personnel and method of transportation from the institution.1
With these practice recommendations and after considering facility policy, it is up to the RN to use his/her nursing judgment to determine if a patient can ambulate to the car or should be discharged via wheelchair. Patients having general anesthesia may still be drowsy upon discharge and may require a wheelchair. If a patient has only sedation or monitored anesthesia care, they may be capable of ambulating to the car. In all cases whether discharge is via wheelchair or ambulation, it is important for a nurse or tech to accompany the patient. Again, per the ASPAN Standards, the RN determines the mode of transportation from the facility as well as the competency level of the accompanying facility personnel.1 Often, having a patient ambulate to the car is a way to assess steadiness of gait and the patient will do at home. Part of the regular discharge instructions should include having someone with the patient the first few times he ambulates at home. If necessary, additional instructions can be given for safe ambulation at home when the patient is escorted to the car. Instructions may include telling the patient to get up at regular intervals and walk around to get his "sea legs" back. Another example is a patient who had local infiltration into an inguinal hernia site where ambulation prior to discharge is important to ensure that the local anesthetic did not cause weakness or numbness in the lower extremities, limiting the ability to ambulate. Following a laparoscopic procedure, ambulation may enhance elimination of the carbon dioxide used in the procedure. Ambulation also enhances oxygenation and elimination of inhalation anesthetics.
Other patients may require a wheelchair. Examples are lower extremity orthopedic procedures, the elderly, patients who are still a little drowsy, patients who have pre-existing respiratory or cardiac conditions, or facilities where the exit is a long way from the recovery area.
In summary, the decision regarding mode and method of discharge ultimately falls within facility policy and procedure. The ASPAN Standards allow the registered nurse to use his/her patient assessment and clinical judgment regarding mode of discharge for the patient.
This question comes up almost weekly through the questions sent into the Clinical Practice Network. In fact, this question is asked so frequently, that ASPAN reviewed the literature to see if there was any evidence to support a recommendation or define how frequently vital sign should be obtained during perianesthesia care. The result of the search was presented at the Fall 2009 Standards Strategic Work Team revision meeting.
Team leaders from the Standards and Guidelines Strategic Work Team and members from the Evidence Based Practice Strategic Work Team met face to face in October 2009. In preparation for this meeting, the question put to the Evidence Based Practice Strategic Work Team was "How often should vital signs be taken?" The team reviewed 521 articles, including 2 abstracts. Rankings and consensus were completed. No evidence at all was available to guide the practice of how often to take vital signs to promote optimal outcomes.1
The discussion continued. Perianesthesia nurses want to know what is best practice related to vital sign frequency. Clinical judgment is the essential element in determining frequency of vital signs. Expert opinion from perianesthesia nurses indicates that most units take vital signs every five minutes for the first 15-30 minutes of patient stabilization, and then decrease to once every 15 minutes for the duration of the patient's Phase I stay. If the patient is placed into a "holding pattern" for some reason such as waiting for an inpatient bed, the frequency of vital signs can be the same as the standard used on the destination nursing unit. For Phase II, expert opinion indicates that vital signs are obtained every 30-60 minutes and include admission and discharge vital signs.1
Because of this discussion and the lack of evidence and specific literature stating what the vital sign frequency should be, the ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, "Practice Recommendation 2- Components of Assessment for the Perianesthesia Patient", states the following:
"Frequency of adult vital sign assessment during Phase I is institution specific. Practice varies across the country with frequency ranging from every five to every fifteen minutes. Expert opinion recommends that the frequency of vital sign assessment occurs a minimum of every fifteen minutes during Phase I as clinical condition requires."
With regard to pediatric vital sign assessment, the ASPAN Pediatric Specialty Practice Group was surveyed. Survey responses revealed:
"In terms of postoperative pediatric assessment, close to 74% of survey respondents admitted that an initial blood pressure is always obtained from the pediatric patient on arrival to Phase I."
This question has been debated since the advent of ambulatory surgery over 20 years ago. Varying opinions continue as to whether patients should void prior to discharge. At this time, there is little research and evidence pointing one way or another. If a patient does not void prior to discharge, does this alter the outcome for him? Or does requiring the patient to void an unnecessary practice that merely prolongs his hospitalization and may add to his bill?1
Postanesthesia patients are often not well-hydrated when they arrive in the PACU. This results from their NPO status, limited amounts of intravenous fluid, and third spacing, even in routine and seemingly small procedures. These patients have not had time to produce adequate urine. Another factor to consider is that most people void every four to six hours. This amount of time may not have passed by the time they are ready to be discharged. Couple that with the potential dehydration, and they do not have enough urine to stimulate voiding.
On the other hand, certain conditions may predispose a patient to urinary retention, such as prostatic hypertrophy. Some surgical procedures may stun the bladder or the nerves surrounding the bladder. Urological procedures may result in hematuria with the potential for clots which may obstruct urinary flow. Other procedures which place patients at risk for urinary retention include rectal procedures, inguinal herniorrhaphy, and lower abdominal and pelvic procedures. These patients often have no urge to void because of manipulation of the nerves surrounding the bladder, and consequently may be at higher risk for urinary retention. Therefore, voiding under these conditions is advisable, according to experts.1, 2
Spinal or epidural anesthesia is another factor to consider when determining if a patient should void prior to discharge. Recovery from a blockade is in the reverse order from onset. Therefore patients regain first motor, then sensory, and finally sympathetic. The sympathetic nervous system controls bladder function. So the ability to void indicates total resolution of the block. Prior to this, patients usually cannot tell whether their bladder is distended.1,2
Many PACUs now have bladder scanners as standard equipment. This tool can be used in conjunction with other assessments to evaluate patients for bladder volume and potential urinary retention prior to discharge home.3 In addition, if patients are not required to void, they and their care providers should be instructed on symptoms which might indicate a full bladder, the importance of avoiding over distention of the bladder, and how long to wait before seeking care for a full bladder.4
This question comes up frequently in the ASPAN Clinical Practice network. Many nurses asking this question work in facilities where the staff members of preop and PACU may be one and the same. The question also arises when facilities are trying to make the most of the available staff later in the day.
"Standard II- Environment of Care," in ASPAN's 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements states that "Preanesthesia patients are separated from patients undergoing procedures and/or recovering from anesthesia/sedation."1
In addition, this requirement for separation comes from the Centers for Medicare and Medicaid Services (CMS). "The conditions for coverage at 42 CFR 416.44(a)(2) state that an "ASC must have a separate recovery room and waiting area." We consider a "recovery room" to be an area where patients are brought to recover from procedures and are not yet discharged. A "waiting area" is considered to be the area set aside for patients and families outside of the areas used to prepare patients for their procedure, the procedure area itself, or recovery from their procedure. Each ASC must have a distinct "waiting area" and distinct "recovery room" that are not used by patients for other purposes. Medicare regulations do not address specific requirements for a preop area." 2
The implementation of this requirement can take several different forms. The most common scenario involves a setting where the number of staff is decreasing for the day and it is desirable to combine resources. In this case, preoperative patients may be in the same physical space as patients recovering from anesthesia or sedation. But they should be cohorted and separated as far away as physically possible from postanesthesia patients. Curtains should be used for privacy for the patient and family, and the level of noise should be kept down in the postanesthesia section of the room, so that patients waiting for their procedures do not hear activity related to patients waking up. It is also desirable to have separate staff, that is, a preop nurse is not also caring for a postanesthesia patient. These methods allow the facility to meet the standard while making practical use of resources and providing the appropriate environment for the patient.
This is a very frequent question that comes through the Clinical Practice network. The questions range from "What are the differences between Phase I, Phase II, and Phase III?" to "Can I get a patient up in Phase I?" to "Can I discharge a patient home from Phase I?"
The ASPAN Standards define Phase I, Phase II, and Extended Care (Extended Observation / Phase III) as levels of care, not physical places. Therefore, the care that is provided is dependent on where the patient is in their physical recovery, not the physical location that they are in.1
"Postanesthesia Phase I – The nursing roles in this phase focus on providing postanesthesia nursing in the immediate postanesthesia period, transitioning to Phase II, the in-patient setting, or to an intensive care setting for continued care. Basic life-sustaining needs are of the highest priority. Constant vigilance is required during this phase."1
"Postanesthesia Phase II – The nursing roles in this phase focus on preparation for care in the home or an extended care environment."1
"Extended Care – The nursing roles in this phase focus on providing care when extended observation/intervention after discharge from Phase I or Phase II is required."1
Phase I is the level of care in which close monitoring is required, including airway and ventilatory support, progression towards hemodynamic stability, pain management, fluid management, and other acute aspects of patient care. When the patient has progressed beyond these elements of care, they can progress to Phase II level of care. Phase II is the level of care in which plans and care are provided to progress the patient home. This may be in the same location as Phase I care. Many PACU's are providing blended levels of care, in which all levels of care are provided in the same location. This is often done for staffing reasons or for continuity of care. So if a patient is ready to go the bathroom and is awake and stable enough, they are not necessarily a Phase I patient anymore. They have progressed to Phase II level of care, even if they are in the same location. The same goes for discharging a patient home from Phase I. If a patient is ready to go home, they have progressed beyond Phase I level of care, into Phase II level of care, and may go home if they meet discharge criteria. Again, the Phases are NOT locations, but LEVELS of care.
Extended Care, previously Extended Observation / Phase III, may also occur in the same physical location as care provided to Phase I and Phase II patients. This phase is for patients who have met criteria to leave Phase I, but are not able to go to another place. The most common reason for this is that there is no floor bed. In this case, the patients may stay in the location where they received Phase I level of care if there is nowhere else to move them. The difference is that these patients are basically a medical-surgical patient at this point, and the assessments and care required are different from that of a Phase I patient. The staffing expectations would also be different, as defined in the ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, Practice Recommendation 1 – Patient Classification/Staffing Recommendations.1
The elements to consider for assessments as well as discharge from Phase I, Phase II, or Extended Care levels of care are found in the ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, Practice Recommendation 2-Components of Assessment for the Perianesthesia Patient."1 These elements help determine the patient's phase of care and whether the patient is ready to progress to the next level, regardless of where the care will be provided.
The simple answer to this question is yes. The belief that oral pain medications are reserved for Phase II PACU or for when the patient reaches the postoperative unit, is one of those sacred cows often found in PACUs.
Many years ago, when anesthetic agents had a longer duration, the inhalation agents given were stronger and more often caused nausea and vomiting in the postanesthesia patient, so oral pain medications were avoided. Patients were not usually awake enough, nor did they feel well enough to take oral medications in Phase I PACU. The postanesthesia nurse avoided giving oral medications and withheld oral fluids hoping to prevent or minimize postoperative nausea and vomiting (PONV).
With the advent of propofol and newer inhalation agents such as Sevoflurane and Desflurane, patients awaken quickly, often have little or no nausea, and are ready for oral fluids and medications in Phase I. Many patients are pre-treated with antiemetics. Preemptive treatment is a result of education on best practices related to PONV.1 Patients are usually able to tolerate ice chips, juice or soda shortly after they wake up. These interventions are also helpful in addressing rehydration.
Another advantage of giving oral pain medications in Phase I is that it promotes early evaluation of the patient who is going home. By giving the oral pain medication in Phase I, often the medication the patient will take at home, along with crackers or other light food, the nurse has time to evaluate whether the oral pain medication will work for the patient. In addition, there is time to observe for adverse reactions if this is the patient's first experience with the medication. Timing the oral medication shortly after the last IV dose of narcotic allows time for the oral medication to start taking effect. The patient can then be transferred to Phase II for further care, observation, and discharge instructions.
Oral medications do have a place in the Phase I PACU. Each patient should be evaluated for this intervention, as it can be an effective method for transition to the next level of care.
When evaluating a patient for discharge from Phase I or Phase II after a narcotic, several factors need to be kept in mind. These factors include what is the dosage, what is the route, what is the onset of action, when does the medication' peak, what is the duration of the medication, and what is the half-life of the medication.1,2,3
With IV medications, obviously there is a quicker onset and a shorter duration of action. Most IV medications, including Morphine, Dilaudid, and Fentanyl, have an onset of action of 1-5 minutes and peak within 5-20 minutes. The duration of action with Morphine and Dilaudid is 2-4 hours, while the duration of action of Fentanyl is 30 minutes to 1 hour. Morphine and Fentanyl have a half-life of 3-4 hours, while Dilaudid has a half-life of 2 hours.1,2,3
Oral narcotics have an onset of 30-60 minutes, and peak in 60-90 minutes.1,2,3
With this information in mind, the nurse must consider what is safe in terms of when the patient can transition to the next level of care. Since IV medications peak in 5-20 minutes, it is prudent for the nurse to use this interval to assess the patient for adverse respiratory effects. The nurse should also monitor the patient without any stimulation to determine how the patient may respond when moved to a quiet patient room without the added PACU environmental stimuli. Patients will generally desaturate when unstimulated. Ensuring that the patient can handle a narcotic without episodes of oxygen desaturation is a key to determining when it is safe to discharge/transfer a patient.
With oral narcotics, the nurse should ask the patient if he has taken the medication previously and if it was effective. If yes, the nurse can give the patient the narcotic with relative assurance that the patient will not suffer adverse effects and that it will provide pain relief. If the patient has not received the oral narcotic previously, the nurse can give it shortly before transitioning to Phase II. This allows time for the narcotic to take effect over 30-60 minutes and time for the nurse to evaluate the patient's response.
So with this information in mind, what is the time frame for discharge after narcotics? Since most IV narcotics peak in 20 minutes, 30 minutes should allow sufficient time to observe for adverse respiratory effects. Waiting 30 minutes is generally a safe post administration interval before discharge from Phase I. With oral narcotics, the nurse can observe for effectiveness within 30-60 minutes of administration and the patient can transition home. These time frames allow the patient to progress to the next phase of care in a safe and effective manner.
The 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements speak to assessments that are recommended in Phase I PACU. The Standards state in "Practice Recommendation 2-Components of Assessment for the Perianesthesia Patient" that "Cardiac monitor rhythm [is] documented per institutional protocol."1
Many experienced nurses can look at a monitor and quickly tell what rhythm is displayed. To accurately interpret the rhythm, it is necessary to calculate the PR and QRS intervals, along with the rate. These calculations can be performed by running a six second strip and doing the measurements. Some monitors have built in calculators for performing these functions; the monitor may need to be "instructed" to perform these functions on a specific segment of the patient's rhythm strip. "Mounting a strip" is an individual facility policy and many facilities still subscribe to the motto that if it's not documented, it's not done. Stating the rhythm in the nursing notes is fine, but the "proof" is not in written words, it is in the visual documentation of the actual ECG strip.
With electronic documentation, many ask, "where do I put the strip?" The best advice is to use a blank sheet of paper for mounting, if there is no hard copy of the PACU record.
Another frequently asked question is why ECG rhythm interpretation is even necessary. "We just need to be able to tell that something isn't right" some nurses say.
As critical care nurses, we need to be able to accurately assess the patients, and then share that information with the anesthesia provider. Perianesthesia nurses know that anesthetic agents affect the cardiac muscle and can slow cardiac conduction and/or cause increased ventricular excitement. Medications such as catecholamines and anticholinergics can alter the balance between the sympathetic and parasympathetic nervous systems. Lighter anesthesia during emergence can cause cardiac dysrhythmias. Research indicates that about 60% of all patients undergoing anesthesia develop some type of dysrhythmia in the perianesthesia period.2
Fluid status affects heart rate and rhythm. One of the most common causes of tachycardia in the PACU is hypovolemia. Premature ventricular contractions are often a sign of hypoxia in the PACU patient. Pain and bleeding can affect cardiac rate and rhythm as well. The perianesthesia nurse must recognize the rhythm and intervene appropriately. Some interventions may not require additional physician orders.3
Along with respiratory assessment and airway management, cardiac assessment is one of the most important elements of perianesthesia nursing practice. Hemodynamic stability is a component of safe discharge. Thorough cardiac assessment, including interpreting the ECG rhythm, is one of the best ways to assess patient status.
The Emergency Care Research Institute (ECRI) changed the temperature setting recommendations for cabinet blanket warmers in 2009. Cabinet blanket warmers can now be set up to 130º F (54ºC). Fluid warming cabinets should continue to be limited to 110º F (43ºC).1
The change to the recommendation stems from recognition in the healthcare community that blankets and fluids should be warmed separately. The original 2005 recommendations from ECRI for 110º F for both blanket and fluid warmers were based on information that many facilities placed blankets and fluids in the same warmer simultaneously. As a result of this dangerous practice, some patients sustained burns from the fluids which hold significantly more heat than blankets and present a greater burn risk. To promote safe practice for all patients, in 2005 ECRI recommended the lower temperature of 110º F for both blankets and fluids.1
Discussions with healthcare facilities over the past several years indicate a growing awareness and recognition that separate cabinets should be used to warm fluids from those used to warm blankets. ECRI and healthcare facilities also recognized a concern for patient comfort related to warming blankets. Because of this concern, ECRI changed its recommendations for blanket cabinet warmers to 130º F (54º C).1
The ECRI recommends separate warming cabinets for blankets and fluids. For facilities using one cabinet with 2 compartments, each compartment must have its own temperature control. If a facility chooses to use the same cabinet/compartment for both blankets and fluids, the temperature should be limited to 110º F (43º C).1
Perioperative normothermia is critical in promoting the well-being and comfort of all perianesthesia patients. ASPAN updated its Clinical Guideline on Hypothermia, now entitled ASPAN's Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia.2 The guideline includes new evidence for warming practices and promotion of optimal outcomes for patients. The reader is directed to the clinical guideline, which can be accessed on the ASPAN Web site at www.aspan.org
Revised November 23, 2012
"Standard II - Environment of Care," found in the 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, states: "Personnel and visitor dress codes are determined by proximity and frequency of access to operating rooms."1 Unfortunately, no other recommendations in the Standards address attire worn by perianesthesia personnel.
In 1999, the Centers for Disease Control and Prevention (CDC) published a "Guideline for the Prevention of Surgical Site Infection." This guideline indicated there were no well-controlled studies relating surgical site infections to laundering of scrubs. Where and how to launder scrubs was described as an unresolved matter, and no specific recommendation was issued.2 At the time this guideline was published, it implied that scrubs laundered at home and worn from home did not pose a risk to patients. It also suggested that, at the end of the day, those same scrubs posed no health threat in the home environment.
In 2003, the CDC and the Healthcare Infection Control Practices Advisory Committee issued guidelines for infection control in healthcare facilities. Although clothing contact is not known as a significant mechanism for transmission of pathogens, the guidelines recommend control measures to prevent healthcare associated infections related to contaminated clothing, i.e., clothing soiled by blood or body fluids while at work. These control measures were founded in hygiene principles, common sense, and consensus,3 and recommended that when clothing is contaminated with blood, emesis, urine, or any other body fluid, the clothing should be immediately removed and laundered at the healthcare facility.3
The Association of PeriOperative Registered Nurses (AORN) does not support home laundered attire being worn in the operating rooms, citing a lack of evidence related to safety of healthcare workers, their families, and patients during surgical procedures.4 In revised practice guidelines published in 2011, AORN took a stronger stand on surgical attire. AORN now recommends that surgical attire be laundered in a healthcare accredited laundry facility.4
As to laundering scrubs worn by perianesthesia nurses, a general survey of clinical practice constituents from across the country revealed wide variations in opinion and practice. It is obvious that each healthcare institution has a tailored approach to handling scrubs based on knowledge of related research, associated costs, perceptions of staff and consumers, and cost/benefit breakdowns. Some perianesthesia staff function in expanded clinical roles, including but not limited to providing occasional clinical support for bedside invasive procedures and emergency support in the operating room. The possible exposure of staff and/or patient to potentially infectious contaminates must also be considered. Clearly, the current state of the evidence indicates an opportunity for further studies related to laundering methods. Such studies are needed to further support the decision process related to the question, "home laundered or hospital laundered scrubs?"
Perioperative hypothermia has been associated with increased morbidity and mortality. Promoting normothermia in the perioperative setting is a designated quality measure under the Surgical Care Improvement Project.1 Normothermia is defined as a core temperature of 36° – 38° C (96.8° - 100.4°F). Achievement of this core measure is met when a patient is normothermic within 30 minutes before or 15 minutes after anesthesia end time.1 Because maintaining core temperature is associated with better patient outcomes, the accuracy of the instrument used to obtain the measurement is of concern to perioperative nurses.
On April 19, 2009 the ASPAN Representative Assembly adopted a Clinical Practice Guideline, ASPAN's Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. The guideline can be accessed on the ASPAN Web site at www.aspan.org.2 The recommendations include a section on temperature measurement and the class of supporting evidence.2
Perianesthesia nurses began using the temporal artery thermometer in their practice settings several years ago. ASPAN began fielding questions related to the accuracy of this device compared with other types of thermometers as perianesthesia nurses were introduced to the technology. The popularity of the temporal artery thermometer has grown because it is quick, relatively easy to operate, noninvasive, and can be used for pediatric and adult populations. Both tympanic and temporal artery thermometers use infrared technology to assess temperature. The temporal artery reading is obtained by scanning the thermometer across the patient's forehead. Tympanic temperatures are obtained by inserting a probe tip into the ear canal. The tip does not fit into the ear canal of smaller patients, limiting their use in pediatric populations. Tympanic thermometers should not be used on patients after head, neck and facial surgeries which alter blood flow to the area. User error is the most commonly cited cause of temperature inaccuracy for both tympanic and temporal artery instruments.
Early studies evaluating the accuracy of the temporal artery thermometer were funded by the device manufacturer.3 Subsequently, studies have compared the accuracy of measurements taken with the temporal artery, tympanic, digital axillary, digital oral, and chemical dot thermometers as well as more invasive methods such as esophageal, bladder, and rectal measurements.4 In 2008, S. Fetzer and A. Lawrence published their prospective study on temporal artery and tympanic instruments in the perianesthesia setting. The authors stated that their intent was not to determine superiority of one instrument over another and no bias or preference was reported. They did recommend that perianesthesia nurses use the same temperature measurement method consistently rather than switch from one method to another.4 L. Barringer, et.al, conducted a study comparing temporal artery, oral, and axillary temperature measurements in the perioperative period. This study was conducted in part, to determine whether or not the temporal artery thermometer was an acceptable replacement for electronic oral/axillary thermometers. The authors concluded that the temporal artery thermometer provided a first attempt reading on all subjects. They also concluded that temporal artery measurements more closely correlated with electronic oral temperatures than with electronic axillary temperatures.5
In conclusion, current evidence supports the use of a consistent route of temperature measurement in the perianesthesia setting. Temporal artery thermometers are relatively safe and easy to use although they require some staff training. Temporal artery thermometers may not be as reliable in patients who are outside normothermic parameters. Tympanic thermometers are not recommended in perianesthesia settings.2
From what we understand, if the use of restraint is part of the customary post procedure care, the standard for restraint does not apply. For example, devices employed during medical, diagnostic, or surgical procedures that are considered a regular part of the procedure are not considered restraints. These would include the restraining of an arm when undergoing intravenous therapy, the placement of a body restraint during surgery, and restraint during recovery from anesthesia that occurs in the critical care or post anesthesia care unit. It is advisable to visit The Joint Commission (TJC) Web site (www.jointcommission.org) to review their restraint standards. Type "restraint" into the search box, then select the "Restraint and Seclusion" link, which leads to a 'frequently asked questions' page which includes restraint use information.
The Joint Commission lists some exceptions to the applicability of the Behavioral Health Care Restraint and Seclusion Standards. According to TJC, "The standards for restraint and seclusion do not apply to the following: The use of restraint associated with acute medical or surgical care, which is covered under standards PC 12.10 through PC 12.190."1
Regarding the use of restraints for protection of surgical and treatment sites in pediatric and adult patients, TJC indicates the standards do not apply to usual "practices that include limitation of mobility or temporary immobilization related to medical, dental, diagnostic, or surgical procedures and the related post-procedure care processes."2 Examples of the usual practices include: protection of surgical and treatment sites in pediatric patients; radiotherapy procedures; intravenous arm boards; and surgical positioning.2
Many facilities consider short term use of restraint to protect tubes and lines during the recovery process to be medical immobilization, and in this situation do not implement the Behavioral Health Care and Seclusion Restraints standard and interventions. However, in many perianesthesia settings staff may try to avoid the application of restraints at any time. This is often accomplished by staying at the bedside, talking with the patient, and offering pain medication and/or sedation. If a patient emerges from anesthesia and continues to need restraints to keep him from pulling at lines or tubes or harming himself, some institutions may require the perianesthesia staff to initiate restraint protocols and adhere to facility policies regarding application of restraint devices including physician orders and assessments.
The use of restraints is strictly regulated and should be limited as much as possible. Patients in restraints require frequent monitoring and specific documentation related to monitoring and assessments. In some facilities, restraints are permitted only in an ICU setting where appropriate monitoring can be assured. Use of restraints in the post anesthesia care unit should be reviewed with the facility's Risk Management department. Individual facility policies should address the permissible use of restraints in the PACU.
The ASPAN Standards do not specifically address this issue. Dose ranging is a topic of review with regulatory agencies, and the reader is directed to regulatory resources and their facility risk management experts for direction on dose ranging. What ASPAN does discuss in its "Pain and Comfort Clinical Guideline" is a multimodal approach for pain management in Phase I PACU. This Clinical Guideline can be accessed on the ASPAN Web site at www.aspan.org. 1 Pasero and McCaffery also discuss multimodal pain management as an effective means for treating postoperative pain.2
Dose ranging is a challenge in many facilities, and consequently, regulatory agencies, boards of nursing, and hospital policies are addressing this issue., Because of the regulatory requirements and changes, ASPAN has several broad statements in "A Position Statement on Safe Medication Administration" stressing the importance of assessment, interventionwith multimodal therapy, reassessment, and adherence to regulatory and facility standards and policies.3
The ASPAN Standards also do not describe specific interventions, such as correlating medication doses to pain scales. ASPAN's pain guidelines basically follow the World Health Organization pyramid of mild to moderate and moderate to severe, and stress the importance of a multimodal approach. In an article by Manworren, a discussion concerning data reporting between 1995 and 2003 indicated that 276 sentinel events involved a 21% medication error rate related to opioids administration, and the overwhelming majority of these opioid errors resulted in death.3 However, it could not be determined whether range orders contributed to the events, or in what environment of care the errors occurred.4
Manworren also cites a consensus paper published by the American Society for Pain Management Nursing and the American Pain Society. This document stresses the importance of the critical judgment and empirical knowledge of a nurse in determining the right dose of the right drug to relieve the patient's pain.4
Revised November 24, 2012
ASPAN is the Society that represents perianesthesia nurses working in the preanesthesia phase, postanesthesia care units, ambulatory settings, extended observation settings, special procedures (cardioversion, ECT, endoscopy, invasive radiology), pain management, etc. Regardless of the environment of care, the patient undergoing anesthesia for surgical interventions require the same standards of care provided by like-competent staff.
The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements "Standard III - Staffing and Personnel Management," addresses ACLS and PALS. With regard to ACLS/PALS certification, the Standard states: "The perianesthesia registered nurse providing Phase I level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served."1
The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements "Standard III, Staffing and Personnel Management," also states that "It is recommends that the perianesthesia nurse providing Phase II level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served."1
Phase I is defined as "the immediate postanesthesia period" during which time "basic life-sustaining needs are of the highest priority and constant vigilance is required ... as the needs of the patient are neither minimal nor episodic." "Phase II level of care focuses on preparing the patient/family/significant other for care in the home, extended observation, or care in extended care environment" (i.e. admission in this case). It is not the "1-hour" time frame, but the meeting of criteria that is essential.1
Having stated ASPAN's position, we acknowledge the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) which provides standards of practice for labor and delivery nurses. AWHONN suggests that the requirement for L&D nurses to have ACLS should be guided by factors such as "the acuity of the patient population served, the availability of the code team within a facility, and the frequency with which ACLS skills may actually be used by those nurses."2 This position poses the question, is this standard being met in another way? One suggestion is having a CRNA or physician ACLS provider stay in the room with the L&D nurse continuously until the patient reaches the predetermined criteria for discharge.
Theresa Clifford, MSN, RN, CPAN
Revised August 3, 2011
Revised November 24, 2012
Three part formula for calculating fluid to be replaced intraoperatively:
Estimation of Evaporation and Third-Space Losses—additional maintenance fluid based on amount of tissue trauma
First hour: 1/2 the deficit + maintenance + replacement for blood loss
Second hour: 1/4 the deficit + maintenance + replacement for blood loss
Third hour: 1/4 the deficit + maintenance + replacement for blood loss
80 kg patient scheduled for total hip replacement, NPO for 10 hours
Deficit = 10 hours NPO X 120 = 1200 ml
Maintenance = 120 ml/hr
Blood loss replacement (EBL = 300 ml) = 3 ml crystalloid X 300 = 900 ml
1st hour = 600 (1/2 the deficit) + 120 (maintenance*) + 300 ml LR (blood loss replacement) = 1020 ml
2nd hour = 300 (1/4 the deficit) + 120 (maintenance*) + 300 ml LR (blood loss replacement) = 720 ml
3rd hour = 300 (1/4 the deficit) + 120 (maintenance*) + 300 ml LR (blood loss replacement) = 720 ml
Total = 2460 ml
*Additional fluid may be added to the hourly maintenance to account for evaporation and tissue trauma losses
Estimated adult blood volumes
Male = 70-75 ml/kg
Female = 55-67 ml/kg
Fluid Resuscitation Guidelines
ASPAN's 2012-2014 Perianesthestia Nursing Standards, Practice Recommendations and Interpretive Statements has a Practice Recommendation for the care of patients on isolation precautions." Practice Recommendation 1A, Staffing Recommendations and Management of the Patient on Precautions, (PR1A)" offers general guidelines and stresses throughout that each facility must have an infection control plan. The perianesthesia area must follow that plan while using this Practice Recommendation as a reference for adaptation to the PACU and Pre-op setting as appropriate.
Regarding contact isolation, it is a given that Standard Precautions are used on all patients. According to PR1A: "When a patient known or suspected to be infected with epidemiologically important or highly transmissible pathogen, the appropriate transmission precaution is utilized."1 This statement allows each institution to make its own policy and determine if these infections are of special significance requiring special precautions and handling.
PR1A further states that "in the event that a facility allows patients in main PACU, the best way to prevent the spread of organisms it to follow standard infection control measures." In addition, "Nurse to patient ratios should be one to one upon arrival of the patient. Ratios may advance based on ASPAN's recommended staffing guidelines, providing that the preoperative or Phase I or Phase II care needs of the patients allow sufficient time for donning and removing respiratory protection and other protective barriers, and washing hands between patients."1
"Practice Recommendation 6, Safe Transfer of Care: Handoff and Transportation" in the 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements states, among other things:
Revised November 25, 2012
ASPAN supports family visits in PACU. Guidelines certainly need to be in place to assist with incorporating family visits in the Phase I level of care. The ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements discuss family visitation in "Practice Recommendation 9 – Visitation in the Perianesthesia Care Unit."1
This practice recommendation is evidence-based, and the supporting literature can be found in the reference section of this practice recommendation. In units that have adopted family visitation practices, the results have been positive for all. It is reassuring to family members to see their loved ones and patients also find it comforting. This practice requires education for the family and nursing staff, and requires measures be taken to provide patient confidentiality and privacy.
The answer to these questions can be found by going to the ASPAN home page at www.aspan.org. Click on the Clinical Practice tab at the top of the page and "pull down" to Patient Classification. Here, you can read the staffing recommendations in its entirety.1 This is "Practice Recommendation 1 – Patient Classification/Staffing Recommendations" that can also be found In the ASPAN 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements.2
In a nutshell, the Standards state that "Two registered nurses, one of whom is an RN competent in Phase I postanesthesia nursing, are in the same room/unit where the patient is receiving Phase I level of care."2
In Drain's Perianesthesia Nursing: A Critical Care Approach, the sixth edition, space planning is discussed: "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."1
Other considerations listed are how the bays will be used, that is, for preoperative, Phase I or Phase II care, how many surgical cases per day, are they short or long cases, how many other procedural areas send patients to PACU for care (e.g., endoscopy, cardiac catheterization patients, ECTs, pain services, chronic and acute, etc.). What kind of procedures are done in the facility, is the facility a high acuity/level 1 trauma center, is there a large pediatric population, what is the bed capacity and the average wait time for an inpatient bed?1 When these questions can be answered, it becomes easier to determine the number of beds needed for a particular institution.
This issue has been debated for years, and ultimately, it is up to each hospital to decide based on staffing of both PACU and ICU. ASPAN Standards cannot dictate where the ICU patient will be recovered or by whom. It really is imperative to consider the needs of the patient and how much care he/she will require. Collaboration between the two units can clearly benefit both units in most hospitals.
Frequently, if the patient came from ICU and is returning to ICU intubated, the ICU nurse recovers without a PACU nurse unless the patient is very unstable and ICU has limited available staff. If a PACU nurse is available, the PACU nurse can help as needed.
If the patient is extubated, some anesthesia departments prefer that a PACU nurse care for the patient either in ICU or PACU. During the day, the ICU patients may come to the PACU as PACU may have co-workers present to assist as needed. When PACU staff is on call, some prefer to recover the patient in the ICU as there are more resources immediately available.
There are also discussions in some facilities about having ICU nurses recover all ICU patients. There are two potential drawbacks:
Thanks to Nancy O'Malley, MA, RN, CPAN, CAPA, for her contribution to this response.
Reviewed November 25, 2012
"Postoperative phone calls are not a requirement of any regulatory agency, including The Joint Commission. What The Joint Commission requires is that reassessment is done on all patients at intervals determined by the facility."1 Reassessment is necessary in order to evaluate patient treatment and response to treatment.
How this reassessment is performed should be defined in writing by each institution. Policy can also define whether calls are done "the following day" or the "next business day," which covers the time frame when nurses may not be scheduled to work, such as over the weekend.
Some facilities do follow-up with a survey or postcard. Most continue to do follow-up phone calls as their means of reassessment. These calls not only serve to evaluate the patient, but can be helpful in answering patient questions that have come up since discharge regarding their care. The calls also provide an opportunity to obtain feedback regarding the care and services provided, can lead to accolades for staff, and provide opportunities for improvement.1
There is varying research on the best time to do the postoperative calls. Some research suggests waiting a day or two, as that is when the patient is feeling a little better, and questions may have come to mind. Other data suggests that if calls are delayed, the patient may be unavailable, leading to lack of opportunity for feedback or the ability to answer questions.1
Time is usually the major barrier to getting calls completed. It is generally best to assign the calls each day to one or two staff members to ensure that this important element of patient care is completed.1
This is addressed in "Standard III-Staffing and Personnel Management" in the 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretative Statements. It states:
Phase I
"The perianesthesia registered nurse providing Phase I level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served,"1
Phase II
"It is recommended that the perianesthesia nurse providing Phase II level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served."1
American Society of PeriAnesthesia Nurses
90 Frontage Road, Cherry Hill, NJ 08034-1424
877.737.9696 / 856.616.9601 fax / email@example.com


text:
I haven't tried to contact them, but they did process an ammo order for me just fine just 2-3 weeks ago.
This is a discussion on Palmetto State Armory within the General Firearm Discussion forums, part of the Related Topics category; Has anyone had success trying to get through to Palmetto State Armory's customer service? I call, and all I get is a message that states ...
Has anyone had success trying to get through to Palmetto State Armory's customer service?
I call, and all I get is a message that states they are helping other costumers and to try my call again latter. I get this message repeatedly (over 20 attempts to date). I also get ZERO responses from their email.
Does anyone have an idea of what is going on?
"Gun Free Zones" is where only criminals carry guns.
I haven't tried to contact them, but they did process an ammo order for me just fine just 2-3 weeks ago.
I've been quite satisfied with purchases I have made from them. I haven't even tried to call them or email them.
E-mail is much more reliable than the phone for contacting them.
They will respond to e-mails within 1-2 days usually.
Fortes Fortuna Juvat
Former, USMC 0311, OIF/OEF vet
NRA Pistol/Rifle/Shotgun/Reloading Instructor, RSO, Ohio CHL Instructor
Yeah same here, got the same email your order SHOULD, not will... ship in the next few days... and its been over a week already. Not happy, but yeah they are backed up...thats fine... at least shoot out some emails saying what the deal is, but thats just me. OH well.. We shall see, its a LPK for my AR... so not many other choices.
Gun and ammo sales are through the roof lately, Im sure they're just a bit behind.
Luckily, I have been 100% satisfied with everything I have bought from them.
Its a crazy time right now for gun companies, im sure they really are helping others. I would keep emailing and calling until you get a response.
NRA Member
Certified Kitchen Gunsmith
"Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive."
- C.S. Lewis
PSA offered free shipping throught most of this past summer and the response was overwhelming... they were weeks behind in fullfilling orders, but fulfill them they did.
I imagine they're just as overwhelmed with frantic buyers in fear of the current political climate and probably struggling to keep up.
I've been a regular customer of PSA for quite a while and have always been happy in the end.
The Second Amendment *IS* Homeland Security
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They are slammed busy so getting anyone is like winning the lottery; it can happen but it probably won't be you!
As someone else posted, I'd suggest email (especially if you are simply looking for a status update). Not that being busy is a good excuse, but I gather they are just too few people trying to do too much stuff and they have orders piling up around them.
LOL, you know what would be great for the gun/ammo industry? Another liberal "anti gun" president! If we elect Clinton profits will be unbelievable.....If I owned a gun store Id vote dem every time.
Wow, Emails I have sent get an auto response saying they it takes two business days to respond. 7 business days latter, no response to several attempts. When I try to call all I get is "No one is available to take your call right now, please try again latter" On one of my many attempts, I was able to leave a voice mail, with no response (4 business days ago).
Their web site states their system does not allow for back order-I placed my order, and a day or two latter they showed it as being "out-of-stock". And I have no idea on the status of my order with the exception of it saying it is stuck as "Processing" for a significantly long period of time.
I wish I knew what gives - granted Christmas season etc, but although they are booming right now, it will drive me away as a returning customer in the future unless they get in control of their customer service capabilities (or lack thereof).
"Gun Free Zones" is where only criminals carry guns.
I got an auto-response when I ordered with order number, invoice, etc. That was 3 weeks ago and the order shipped and was received in less than a week. I hope they are just swamped with orders now.
I PMed them on Arfcom with a concern when I got my rifle and the head of their rifle division called me from his own number in the building. Now I've got a direct line to him should I ever need it. In fact, I think Arfcom is the best way of communicating with them.


text: LOS ANGELES, Feb. 14, 2013 /PRNewswire/ -- In 1996, Cameron Brock founded the Law Offices of Burg and Brock, Inc. The firm – and the team of dedicated legal professionals who came together to build it – was based on one simple credo: everyone has the right to high-quality personal injury lawyer Los Angeles-based representation. There was a time when only the wealthiest and most privileged Americans could afford a personal injury lawyer of Mr. Brock's caliber, but no longer. Mr. Brock and his team believe strongly that people from all walks of life, and with budgets of every size and scope, should be able to enjoy the services of a skilled and experienced lawyer. The Law Offices of Burg and Brock, Inc. have become the number one most trusted source for a California head injury lawyer. Cameron Brock himself is, among other things, a premier motorcycle lawyer with years of hands-on trial experience. He also has a solid track record with product liability, car accident, wrongful death, and a variety of other personal injury cases. Indeed, the law firm as a whole has amassed a phenomenal track record. With over 5,000 personal injury cases under their belts, the team at Bug and Brock, Inc. has a 98% success rate and over $100 million won on behalf of their deserving clients. What is it about the Law Offices of Burg and Brock, Inc. that sets them apart from the leagues of other personal injury attorneys out there? Cameron Brock and his team take great pains to make their services affordable, all without sacrificing the passion and expertise you should expect from superior legal representation. How does it work? It's actually quite simple: the lawyers at Burg and Brock, Inc. work on a no recovery, no fee basis. Essentially, that means you don't owe them a dime unless and until they secure a successful verdict or settlement for you. The priority for you right now is to get healthy and put back together the pieces of your life that were shattered by circumstances beyond your control. In order to accomplish this, you need the compensation you deserve to pay your medical bills and get back on your feet. Now you can get the personal injury attorney you need at a rate you can afford.


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Our team is here to help 24 hours a day, 7 days a week.
New York City is in the north-east of the USA, at the mouth of the Hudson River, and is the perfect place to go for a city break. Although public transport in New York is excellent, if you hire a car, you can get much more out of your holiday. You can use your rental car to visit attractions in the New York area or break up your holiday by spending a few days in another city.
Booking a rental car with easyCar, the low cost, online, car hire specialist, is simple. easyCar has car rental facilities at John F. Kennedy International Airport in New York City and Newark Airport in New Jersey, as well as in downtown New York.
New York – The City
New York City covers a vast area and is divided into five different boroughs: The Bronx, Manhattan, Brooklyn, Queens and Staten Island.
For a relaxing start to your New York car hire holiday, head for Manhattan and take a stroll in Central Park, which covers 843 acres and has 58 miles of paths. Visit the Central Park Zoo, dine at the Tavern on the Green, and explore the Shakespeare Garden. In the summer, you can enjoy the Victorian Gardens mini-amusement park, and in winter, you can go ice-skating on the Wollman Rink.
Whilst in Manhattan, don't forget to visit the Empire State Building; on a clear day, you can see for miles from the observation tower on the 102nd floor. For the best views of the Statue of Liberty, park your rental car at the Whitehall Ferry Terminal and take a trip on the Staten Island Ferry. Manhattan is also known for its array of stores, which include Bloomingdale's and Tiffany & Co.
Visit some of New York City's many museums and galleries, which include the American Museum of Natural History and the Museum of Modern Art (MoMA), or use your rental car to get to Jamaica Bay Wildlife Refuge in Queens.
As the sun goes down, head to Times Square, with its flashing neon advertisements and late opening shops, or make your New York car hire holiday extra special by seeing a show on Broadway.
Attractions in the New York Area
With a rental car, you can head off to some of the attractions outside of New York City. Atlantic City, famous for its casinos, is only 2 hours' drive from New York, so it's easy to get there in a rental car. The Boardwalk is Atlantic City's equivalent to the Las Vegas Strip, and has shops and attractions such as Ripley's Believe It or Not! Museum, as well as the casino-hotels. Other attractions in Atlantic City include the Atlantic City Aquarium and the historic Absecon Lighthouse, and there are also several beaches and piers.
It will only take about an hour and 40 minutes to get from New York to Philadelphia in your rental car, so you could spend a day there. However, there is so much to see and do in Philadelphia that it's worth breaking up your New York car hire holiday and spending a few days there. Attractions include Independence Hall, The Liberty Bell Center and Franklin Square. Alternatively, head off in your rental car to Boston, in Massachusetts, and spend a few days exploring this historic university city.
Low Cost Car Rental in New York
If you are planning a New York car hire holiday, you can book a rental car online with easyCar now and take advantage of great low cost car hire deals.


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Rich Zeoli Talks To Author About Air Force OneOn Talk Radio 1210 WPHT, Rich Zeoli talked with Author Kenneth Walsh about his book, Air Force One: A History of the Presidents and Their Planes, and the recent proposal to replace the current planes being used to fly the President.
PHL Reminds Residents It Has No Direct Flights From West Africa; Says It Will Continue To Monitor Ebola SituationOn Monday, PHL released a statement that says it "continues to coordinate" with the CDC and U.S. Customs and Border Protection to identify travelers arriving in Philadelphia displaying symptoms of illness.
How To Never Lose Your Luggage AgainWhile fewer bags are being lost by the airlines these days, people are still stealing them! Which is why Air France and KLM have spent the last year developing two gadgets that help prevent luggage from being lifted.
It's Father v. Son In Court Case Out Of Lancaster CountyJay Stout, owner of the now defunct Flying Tigers air maintenance company in Lancaster County, has denied allegations he cheated customers by falsely claiming safety inspections had been done by certified inspectors.
The Jet Of The Future Only Has Window SeatsThe jet of the future has faster travel times and huge digital screens that feel as if every seat is a window seat.
Airline Says It Will NOT Allow In-flight Calls, Regardless Of Potential FCC RulingIn a memo from the CEO, Delta notes that "a clear majority" of travelers and company employees polled in a 2012 survey made it clear that voice calls on flights "would detract from – not enhance – their experience."
FCC Vote Could Allow Cell Phone Use During Commercial FlightsThe FCC has decided to take a big step toward ending the ban on in-flight cell phone calls.
3 On Your Side: Airlines Bundling ServicesAs 3 On Your Side Consumer Reporter Jim Donovan finds, packaging the perks is a trend that's taking off. From bundles to subscription services, there are a number of offers out there.
Justice Department To Allow Merger Of US Airways And American Airlines The Justice Department reached an agreement to allow merger of US Airways and American Airlines.
Study On Airport Noise Reveals Potential Health Risks For Those Living Near AirportsThe study, which analyzed data from 3.6 million people living near London's busy Heathrow Airport, showed that those living in the noisiest areas had an elevated risk of stroke, coronary disease and cardiovascular disease.
Plane Finder 3DPlaneFinder 3D shows you live air traffic overhead, letting you pan and zoom to get a sense of how many flights are within close proximity to you.
FAA Orders No-Fly Zone Over Boston Explosion Site The Federal Aviation Administration created a no-fly zone over the site of two explosions at the annual Boston marathon on Monday, and briefly ordered flights bound for Boston's Logan International Airport held on the ground at airports around the country.