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From Aldrete to PADSS: Reviewing Discharge Criteria After Ambulatory Surgery
From Aldrete to PADSS: Reviewing Discharge Criteria After Ambulatory Surgery Heather Ead, BScN, RN
Nurses working in perianesthesia care areas use discharge scoring criteria to complete patient assessments and ensure patient readiness for discharge or transfer to the next phase of recovery. However, all discharge criteria have both advantages and disadvantages. Comparative studies on the reliability of the different discharge criteria in use are extremely limited. As the acuity of our aging population increases, as well as the number of annual surgeries performed on an outpatient basis, it is most timely to ensure that we are following evidence-based discharge criteria. © 2006 by American Society of PeriAnesthesia Nurses.
ALMOST A CENTURY has passed since the surgeon Dr James Nicoll endorsed the benefits of sending patients home to recuperate on the same day of the operative procedure.1 Dr Ralph Waters, an anesthesiologist during this same time period, also supported this practice.2 Dr Waters indicated that, by following certain ambulatory procedures, the patient could return home a few hours postoperatively to recover.1,2 Today, patients continue to benefit from having procedures done on an ambulatory basis. The annual number of ambulatory surgeries performed continues to grow, and growth in ambulatory surgery is projected to continue. Fifty to 70% of all surgeries are performed on an outpatient basis,3 and it is anticipated that in a few years as much as 85% of surgeries will be performed on an outpatient basis.4 Many advantages are associated with ambulatory surgery. Reduced health care–acquired infections, hospital costs, and waits for bed availability, as well as improved patient comfort are a few of the reported advantages of ambulatory surgery.5 Due to faster-acting anesthetic agents such as remifentanil and sevoflurane, improved options in treating postoperative nausea and Journal of PeriAnesthesia Nursing, Vol 21, No 4 (August), 2006: pp 259-267
vomiting (PONV)—as well as preemptive, multimodal analgesia—patients recover faster.6 These patients can return home to continue with late, phase-three recovery in the comfort of their own homes.3,7,8 Also facilitating efficient and safe discharge are clear and concise discharge criteria. The Aldrete scoring system and the Post Anesthetic Discharge Scoring System (PADSS) have received widespread acceptance in assessing postanesthetic recovery.1,9 The Aldrete scoring system originated in 1970 by Dr J. A. Aldrete; the PADSS originated in 1991 by Dr Frances Chung (Table 1). As the popularity of ambulatory surgery grows, appropriate discharge criteria must be followed to ensure patient-centered care. With the acuity
Heather Ead, BScN, RN, is a Clinical Educator, PACU and Day Surgery, Trillium Health Centre, Mississauga, Ontario. Address correspondence to Heather Ead, BScN, RN, 3735 Densbury Drive, Mississauga ON L5N 6Z2, Canada; e-mail address: [email protected]. © 2006 by American Society of PeriAnesthesia Nurses. 1089-9472/06/2104-0005$35.00/0 doi:10.1016/j.jopan.2006.05.006 259
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Table 1. Discharge Scoring Systems The Aldrete Scoring Systemⴱ
The Post Anesthetic Discharge Scoring System (PADSS)†
Respiration Able to take deep breath and cough ⫽ 2 Dyspnea/shallow breathing ⫽ 1 Apnea ⫽ 0 O2 saturation Maintains ⬎92% on room air ⫽ 2 Needs O2 inhalation to maintain O2 saturation ⬎90% ⫽ 1 O2 saturation ⬎90% even with supplemental oxygen ⫽ 0 Consciousness Fully awake ⫽ 2 Arousable on calling ⫽ 1 Not responding ⫽ 0 Circulation BP ⫾ 20 mm Hg preop ⫽ 2 BP ⫾ 20–50 mm Hg preop ⫽ 1 BP ⫾ 50 mm Hg preop ⫽ 0 Activity Able to move 4 extremities ⫽ 2 Able to move 2 extremities ⫽ 1 Able to move 0 extremities ⫽ 0
Vital signs BP & pulse within 20% preop ⫽ 2 BP & pulse within 20–40% preop ⫽ 1 BP & pulse within ⬎40% preop ⫽ 0 Activity Steady gait, no dizziness or meets preop level ⫽ 2 Requires assistance ⫽ 1 Unable to ambulate ⫽ 0 Nausea & vomiting Minimal/treated with p.o. medication ⫽ 2 Moderate/treated with parenteral medication ⫽ 1 Severe/continues despite treatment ⫽ 0 Pain Controlled with oral analgesics and acceptable to patient: Yes ⫽ 2 No ⫽ 1 Surgical bleeding Minimal/no dressing changes ⫽ 2 Moderate/up to two dressing changes required ⫽ 1 Severe/more than three dressing changes required ⫽ 0
ⴱInformation obtained from references †Information obtained from references
1,9,10,13-16,22-24,29
.
1,9,10,13,14,16,19,22-24,29
of outpatient surgery increasing, the aging population, and expansion of inclusion criteria for day surgery, it becomes even more significant to have clear, evidence-based discharge criteria in clinical use.10-12 The following article discusses the history leading up to current discharge criteria, the modifications made to ensure continued practicality and accuracy, the benefits and limitations with discharge criteria, and the resulting implications to the perianesthesia nurse.
The History of Aldrete Scoring and PADSS How was today’s current discharge criteria determined? Reviewing the history of discharge criteria, postambulatory surgery is of interest to nurses involved in perianesthesia care. This includes nurses in PACUs, day surgery/ambula-
.
tory care areas, ambulatory surgery centers (ASCs), endoscopy, dental offices, and plastic surgeons’ offices. Reviewing the history of postanesthesia scoring systems identifies the improvements that have been made over the years, as well as reinforces the value of abiding by discharge criteria to maintain high standards of care. The Aldrete scoring system, a modification of the Apgar scoring system used to assess newborns, has been used in many PACUs since its introduction 35 years ago.13 This system is designed to assess the patient’s transition from Phase I recovery to Phase II recovery, from discontinuation of anesthesia until a return of protective reflexes and motor function.14 At most institutions, Phase I recovery occurs in the PACU. Once Phase I recovery is completed,
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homeostasis has been regained. To assess the patient’s transition from Phase II to Phase III recovery, the PADSS is used.10 Phase II recovery is judged to be complete when the patient is ready for discharge home. Phase III recovery continues at home under the supervision of a responsible adult and continues until the patient returns to preoperative psychologic and physical function.14 Both the Aldrete system and PADSS evaluate five key parameters to ensure safe transfer or discharge of the patient postoperatively. Patients achieving a total score of 9 or 10 are considered fit for transfer or discharge to the next phase of recovery. The individual institution indicates if such scores are necessary for transfer or discharge, or if a score of 8 is acceptable (Table 1). The original Aldrete scoring system of 1970 used color as an indicator of oxygenation by assessing the color of the patient’s mucous membranes and nail beds. With the advent of oximetry, the Aldrete scoring system was updated in 1995 to include this technological improvement.15 Although monitoring the patient’s mucous membranes and nail beds is still included in the nurse’s assessment, oximetry is a more reliable indicator of oxygenation.1 Before the clear objective, numerical scoring of the Aldrete and PADSS, a number of psychomotor tests were used to assess discharge readiness postanesthesia.9 In the late 1960s, a modified Gestalt test (the Trieger dot test) was proposed to measure recovery. Patients demonstrated recovery by connecting a series of dots on paper to form a pattern. The more dots the patient missed, the lower their recovery score.9 Not only was this test tedious in nature; it did not account for the presence of dizziness, hypotension, pain, bleeding, nausea, vomiting, and other parameters included in current discharge scoring systems. Other psychomotor tests that have been used are reaction time tests, driving simulator tests,
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peg board tests, and a Maddox wing test, which involves a device to test extraocular balance.9 These psychomotor tests have limited value in assessing discharge readiness, but can be useful tools in conducting research.6,17 The R.E.A.C.T. assessment tool is another scoring system that was developed in Chicago in the early 1980s. This acronym includes the parameters of: Respiration, Energy, Alertness, Circulation, and Temperature18 Several limitations have been observed with the R.E.A.C.T. assessment tool. Its creators acknowledge that it is not appropriate for monitoring acute changes such as the onset of oxygen desaturation, dysrhythmias, or bleeding.18 This tool is recommended for use after such problems have been resolved. This is a serious limitation because cardiac and respiratory complications occur more frequently in the PACU than in ambulatory care areas.12,19 The R.E.A.C.T. scoring tool also lacks a parameter to score oxygenation, a parameter included in the Aldrete scoring system. Before numerical scoring criteria, clinical criteria checklists were used to assess patient discharge readiness. Although these checklists are used today in conjunction with the Aldrete and PADSS scoring systems, their use alone does not permit quantification of discharge readiness. The checklists also do not facilitate follow-up quality assurance audits.4 Standard discharge criteria are listed in Table 2. Although standard discharge criteria are useful to assess discharge readiness, the criteria is broad without specifications as to vital sign ranges or expected pain levels. Therefore, such guidelines should be used along with the PADSS to ensure the patient is safe for discharge to Phase III recovery.14
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Table 2. Clinical Discharge Criteriaⴱ ● ● ● ● ● ● ● ●
●
Stable vital signs for at least one hour Alert and oriented to time, place, and person No excessive pain, bleeding, or nausea Ability to dress and walk with assistance Discharged home with a vested adult who will remain with the patient overnight Written and verbal instructions outlining diet, activity, medications, and follow-up appointments provided A contact person and circumstances that warrant seeking the assistance of a health care professional clearly outlined Voiding before discharge not mandatory, unless specifically noted by physician (ie, urological procedure, rectal surgery, history of urinary retention) Tolerating oral fluids not mandatory, unless specified by physician (ie, patient is diabetic, frail, and/or elderly; not able to tolerate an extended period of NPO status) Abbreviation: NPO, nothing by mouth. ⴱData from references 1,2,10,14.
Drinking and Voiding Before Home Discharge Requiring all patients to void and tolerate oral fluids is no longer supported and has been shown to lead to unnecessary patient delays.1,4,9,14,20,22 A patient who has not voided postoperatively, has no urge to do, has no bladder distention, or is not at high risk of urinary retention may be discharged home if given clear guidelines on when to seek medical assistance. Patients who are at high risk of urinary retention are those who have undergone a procedure involving the pelvic or genitourinary system, rectal or urological procedures, hernia repairs, had urinary catheterization perioperatively, have a history of urinary retention, or received neuroaxial anesthesia.1,9,14,20,21 This group of patients has a higher risk of urinary retention and are generally required to void before discharge.22 Current literature remains inconsistent regarding the requirement to void after postneuroaxial
anesthesia. Both neuroaxial and general anesthesia can interfere with the detrusor muscle function and predispose the patient to urinary retention.21 If the bladder becomes distended while anesthesia is blocking the contraction ability of the detrusor muscles, voiding function can be impaired.22 The mechanism of urinary complications is related to anesthetic agents blocking parasympathetic fibers in the sacral region of the spine, which control the muscles of micturition.23 Gupta and others found that as many as 17.5% of patients had postspinal urinary retention.21 Kang and others found that urinary complications occur in less than 1% of spinal anesthetics.23 Urinary retention may occur with elderly men, whereas urinary incontinence can occur with female patients. Even with the low occurrence of urinary complications, these problems usually subside in the PACU, and intermittent urinary catheterization is rarely needed.23 The choice of opioid used with spinal anesthesia is a factor in postoperative urinary retention. Hydrophilic opioids, such as morphine, may cause urinary retention, whereas lipophilic opioids, such as fentanyl are less likely to cause this side effect.20 A suggested practice is for the patient to remain in the ambulatory care area for another hour if the patient is at risk of urinary retention and has more than 400 mL of urine in the bladder (determined by an ultrasonic bladder scanner), or if bladder distention is present. If after one hour the patient still has not voided, an intermittent catheterization can be done.22 If the patient is not at increased risk of urinary retention, discharge should not be delayed if postoperative voiding does not occur in the hospital. Such patients are given clear discharge instructions on when to seek medical assistance, eg, if they are not able to void at home eight hours after discharge.14 Patients are no longer required to drink fluids before discharge home. Current recommendations are that postoperative hydration status is
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assessed and managed in the PACU.6 Current practice guidelines set out by the American Society of Anesthesiologists Task Force on PostAnesthetic Care recommend that drinking clear fluids should not be a part of a discharge protocol, but may only be necessary for selected patients, such as diabetics.6 Not abiding by such recommendations will unnecessarily delay discharges, reduce patient satisfaction, and increase the incidence of nausea and vomiting when patients are encouraged to drink to be discharged.1,4,9,14,16 Although the initial PADSS of 1991 did include voiding and drinking in the discharge criteria, the revised PADSS of 1993 removed these criteria to avoid unnecessary delays and support patient-focused care.24 Clinical practice and some clinical studies support using the Aldrete scoring criteria to ensure discharge readiness from Phase I recovery, and PADSS to ensure discharge readiness from Phase II recovery.4,9,14,15,19,24 Institutions should also have clear guidelines on discharge criteria, and requirement for all patients to void or tolerate oral fluids should not be part of such a protocol.1,4,6,9,14,22,24
Fast-Tracking/Bypassing the PACU The practice of fast-tracking patients to the ambulatory care area— bypassing the PACU— has been practiced in some institutions since the late 1990s.25 With fast-tracking, patients must meet discharge criteria to illustrate completion of Phase I recovery before transfer from the operating room to the ambulatory care area.26,27 The fast-tracking criteria suggested by White26 appear to be a union of the Aldrete scoring system and the PADSS. To meet fast-tracking criteria, the patient must score a minimum of 12 (maximum score is 14), with no score ⬍1 in any parameter.26 As mentioned previously, this scoring criterion may vary slightly according to the facilities’ individual protocols (Table 3). Although fast-tracking is possible due to factors such as minimally invasive tech-
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Table 3. Criteria for Fast-Tracking After Ambulatory Anesthesiaⴱ Level of Consciousness: Awake and oriented Arousable with minimal stimulation Responsive only to tactile stimulation Physical Activity: Able to move all extremities on command Some weakness in movement of extremities Unable to voluntarily move extremities Hemodynamic Stability: BP ⫾ 15% of baseline BP ⫾ 30% of baseline BP ⫾ 50% of baseline Oxygen Saturation: Maintains value ⬎90% on room air Requires supplemental oxygen to maintain oxygen saturation ⬎90% Saturation ⬍90% with supplemental oxygen Pain: None/mild discomfort Moderate to severe, controlled with IV analgesics Persistent to severe Emetic Symptoms: None/mild nausea with no active vomiting Transient vomiting controlled with IV antiemetics Persistent moderate to severe nausea & vomiting
2 1 0 2 1 0 2 1 0 2 1 0 2 1 0 2 1 0
Abbreviation: IV, intravenous. ⴱData from references 2,3,7,14,25,26.
niques and short-duration anesthetics, there is inconsistent support in the literature supporting its use.14,28 Not all patients are appropriate for fast-tracking. In one study, only 31% of patients were eligible for fasttracking.14 Thus, a large number of patients still required traditional postanesthesia care in the PACU. The PACU needs to be staffed appropriately to receive patients who are not eligible for fast-tracking; therefore cost savings by reducing staffing in the PACU could not be guaranteed.27 The Ontario Perianesthesia Nurses Association (OPANA) Practice Standards indicate there is currently very little data addressing patient outcomes related to fast-tracking.28 Another concern regarding fast-tracking is that there
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Table 4. Advantages and Limitations of Discharge Scoring Criteria Advantages of Discharge Scoring Criteriaⴱ
Limitations of Discharge Scoring Criteria†
1. A well designed clinical scoring system provides a reliable guide for nursing assessment. 2. Using scoring criteria follows standards set out by the JCAHO and OPANA. 3. The reliability of scoring criteria is superior to clinical discharge criteria. 4. Scoring systems are efficient and user friendly for varying age groups. 5. Individualized scoring promotes patient-focused care. 6. Scoring criteria (Aldrete and PADSS) are widespread in acceptance, providing consistency among health care providers. 7. Unnecessary delays related to lack of voiding or fluid intake can be avoided. 8. Using scoring criteria follows the recommendations of the CAS. 9. Scoring systems are practical, easy to retain and repeat throughout the patient’s stay. 10. Progress is quantified, and the scores can be tracked or used in patient’s stay. 11. Progress is quantified, and the scores can be tracked or used in follow-up chart audits/studies. 12. The scoring criteria assess all parameters of recovery to ensure patient safety and readiness to be transferred to the next phase of recovery.
1. A definitive tool that is sensitive to the patient, surgical procedure, and anesthetic technique has yet to be finalized. 2. Scoring systems do not include criteria for specific requirements, eg, a required increased length of stay if M.H. susceptible, patient at high risk of urinary retention has not voided. In these cases, additional guidelines need to be established and followed. 3. The postoperative vital sign parameter may be inaccurate if preoperative values were abnormally high for the patient. (eg, elevated blood pressure preoperatively, related to anxiety).
Abbreviations: JCAHO, Joint Commission on Accreditation of Health Care Organizations; OPANA, Ontario Perianesthesia Nurses Association; CAS, Canadian Anesthetists Society; MH, malignant hyperthermia. ⴱInformation obtained from references 1,4,5,9-11,13-16,19,22-24,28. †Information obtained from references 1,2,14,29.
is no one agreed-upon practice guideline or definition of the factors involved in fasttracking.28 Further clinical studies are required for its validation and benefits.9 It is clear that there is a need for caution in implementing fast-tracking, and that a learning curve exists with this practice.
Advantages and Limitations of Discharge Scoring Criteria Although working in the perianesthesia area is often demanding and hectic, it is important to regularly review current processes to ensure that up-to-date standards of care are in place.
There are many benefits for both the patient and nurse in consistently using evidenced-based discharge scoring criteria. However, with all discharge criteria, there are limitations. Table 4 illustrates how the benefits of using numerical discharge criteria are more numerous than the limitations. Using criteria such as the Aldrete scoring system and the PADSS is supported by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), the Canadian Anesthetists Society (CAS), and OPANA.1,14,28 Using numerical scoring is also user-friendly and easily repeated during the patient’s stay to monitor
DISCHARGE CRITERIA: ALDRETE TO PADSS
improvement. Tracking improvements in clinical status allows a patient-focused approach, and confirms when the patient is ready to be transferred to the next phase of recovery. Limitations exist that have important implications for nursing with any discharge criteria. Although scoring criteria are reliable tools, they do not replace the critical thinking or professional judgment of the nurse. For example, the patient may fit all discharge criteria, yet the surgeon indicates that the patient must stay a minimum of four hours postoperatively because of susceptibility to malignant hyperthermia.12 Another example of a limitation is the elderly postoperative patient who is frail, diabetic, has some renal insufficiency, and resides a long distance from a medical facility. In this case it is better to err on the side of caution, and ensure the patient can tolerate oral fluids before discharge because the preoperative health status indicates that this patient may not tolerate an extended period of “nothing-by-mouth” status if unable to tolerate fluids at home. Long distances to accessing medical assistance and age are relative factors that the critical-thinking nurse keeps in mind when using scoring systems to assess discharge readiness. Scoring systems focus on discharge goals; however, such systems can still fail patients if we blindly look at the scoring criteria.1 Other limitations to keep in mind are the occurrence of postoperative complications requiring re-admission to the hospital. The complication rate after ambulatory procedures remains low. Most complications are transient, such as pain, sore throat, and nausea. Some complications can be managed before discharge. The rates of unanticipated admissions after day surgical procedures range between 0.3 to 1.4%.29,30 Discharge teaching is key to the patient and family understanding which situations will warrant return to the hospital or further medical assistance. Calculating scores on the vital sign parameters of both the Aldrete scoring system and the
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PADSS can be an area of uncertainty. Although the patient’s vital signs may be within normal range for age, the blood pressure should be compared with that of preoperative value to ensure the patient’s return to homeostasis. However, if the preoperative value was abnormally elevated because of anxiety or pain, expecting the postoperative blood pressure to be within 20% of an elevated blood pressure may not be appropriate. Again, an individualized patient assessment by the nurse and consultation with the surgeon or anesthesiologist, as needed, will confirm that the patient is suitable for discharge in such situations. Discharge readiness does not assume street fitness.14 If the patient does not understand the activity restrictions required as they continue Phase III recovery at home, there is risk for overexertion and adverse reactions occurring. Again, it is recognized that scoring criteria are an important part of assessing discharge readiness, but they must be used with approved discharge criteria, health teaching, and follow-up telephone calls. Using discharge criteria as well as appropriate patient selection for ambulatory surgery are key factors to ensure the patient’s ability to meet discharge criteria.28,29
Common Complications After Ambulatory Surgery Ambulatory surgery is safe, with adverse events occurring at low rates, less than 2%.31 Cardiovascular events (such as hypotension, hypertension, and dysrhythmias) occur most frequently, followed by respiratory events (such as laryngospasm, bronchospasm, and oxygen desaturation).31 Cardiac or respiratory comorbidities are strongly associated with such postoperative complications.5,28 Pain, PONV, and minor sequela such as sore throat and shivering, are other concerns that arise after surgery.5 Follow-up telephone calls to the patient’s home have an large role in ensuring safety throughout late recovery5,28; concerns such as continued PONV, pain, and bleeding can be addressed. These phone calls can also confirm the patient’s
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understanding and compliance to the verbal and written discharge instructions provided.1,28 Follow-up phone calls can also be used in quality assurance studies.
Conclusion The pillars of efficient, safe ambulatory surgery include appropriate patient selection and timely discharge.12,14 Assessment of the patient with the aid of scoring criteria such as the Aldrete scoring system and the PADSS can facilitate safe transition of care throughout the three phases of recovery. Chung, Chan, and Ong demonstrated increased reliability using PADSS versus a criteria checklist.10 The requirement to void and tolerate fluids is no longer considered part of standard discharge criteria.1,4,6,9,14,20,24
However, because the scoring criteria is only part of the discharge assessment, patients at higher risk of complications such as dehydration and urinary retention can be assessed on a case-by-case basis.6,14,22 Patients with such risks would be instructed to return to the hospital if postoperative concerns continue at home. Follow-up phone calls are of particular importance for high-risk patients to ensure patient-focused care. Once discharge protocols are established and approved, it is mandatory that they are consistently followed. By including discharge scoring criteria, such as those outlined in this article, patients can continue to benefit from ambulatory surgery and home recovery with the comfort of their family’s supervision.
References 1. Marley RA, Moline BM. Patient discharge from the ambulatory setting. J Post Anesth Nurs. 1996;11:39-49. 2. Fessey E. Implementing nurse-led discharge from day surgery. Nurs Times. 2005;101:32-33. 3. Apfelbaum J, Walawander C, Thaddeus M, et al. Eliminating intensive postoperative care in same-day surgery patients using short-acting anesthetics. Anesthesiology. 2002;97:66-74. 4. Beatty A, Martin D, Couch M, et al. Relevance of oral intake and necessity to void as ambulatory surgical discharge criteria. J Post Anesth Nurs. 1997;12:413-421. 5. The Joanna Briggs Institute. Management of the day surgery patient. Best Practice Supplement 1. 2003;1-4. Available at: http://www.joannabriggs.edu.au/pdf/BPISSup2004.pdf. Accessed January 2006. 6. Silverstein J, Apfelbaum J, Barlow J, et al. Practice guidelines for postanesthetic care. Anesthesiology. 2002;96: 742-752. 7. White P, Song D. New criteria for fast-tracking after outpatient anesthesia: A comparison with the modified Aldrete’s scoring system. Anesth Analg. 1999;88:1069-1072. 8. Casati A, Cappelleri G, Berti M, et al. Randomized comparison of remifentanil-propofol with a sciatic-femoral nerve block for out-patient knee arthroscopy. Eur J Anesthesiol. 2002;19:109-114. 9. Marshall S, Chung F. Discharge criteria and complications after ambulatory surgery. Ambulat Anesth. 1999;88: 508-517. 10. Chung F, Chan V, Ong D. A post anaesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth. 1995;7:500-506. 11. Friedman Z, Chung F, Wong D. Ambulatory surgery adult patient selection criteria—A survey of Canadian anesthesiologists. Can J Anesth. 2004;51:437-443.
12. Bryson G, Chung F, Cox R. Patient selection in ambulatory anesthesia—An evidence-base review: Part II. Can J Anesth. 2004;51:782-794. 13. Suddarth B. Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott, William & Wilkins; 2004:303-306. 14. Kamming D, Chung F. What criteria should be used for discharge after outpatient surgery? In Fleisher L, ed. EvidenceBased Practice of Anesthesiology. Philadelphia: Saunders; 2004:247-252. 15. Aldrete JA. The post-anesthetic recovery score revisited. J Clin Anesth. 1995;7:89-91. 16. Chung F. Discharge criteria—A new trend. Can J Anesth. 1995;42:1056-1058. 17. Saunders LD. Recovery of psychological function after anaesthesia. Int Anesth Clin. 1991;29:105-115. 18. Fraulini K, Murphy P. R.E.A.C.T.—A new system for measuring postanesthesia recovery. Nursing. 1984;14:12-13. 19. Ang P, Pagan A, Lewis M. Determining patients’ readiness for release from the postanesthesia recovery unit. AORN J. 2002;76:664-666. 20. Korhonen A, Valanne J, Jokela R, et al. Intrathecal hyperbaric Bupivacaine 3 mg ⫹ Fentanyl 10 g, for outpatient knee arthroscopy with tourniquet. Acta Anaesthesiol Scand. 2003;47:342-346. 21. Gupta A, Axelsson K, Thorn S, et al. Low-dose Bupivacaine plus Fentanyl for spinal anesthesia during ambulatory inguinal herniorrhaphy: A comparison between 6 mg and 7.5 mg of bupivacaine. Acta Anaesthesiol Scand. 2003;47: 13-19. 22. Mulroy M, Salinas F, Larkin K, et al. Ambulatory surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia. Anesthesiology. 2002;97:315319.
DISCHARGE CRITERIA: ALDRETE TO PADSS 23. Kang S, Rudrud L, Nelson W, et al. Postanesthesia nursing care for ambulatory surgery patients post-spinal anesthesia. J Post Anesth Nurs. 1994;9:101-106. 24. Chung F. Recovery pattern and home readiness after ambulatory surgery. Anesth Analg. 1995;80:896-902. 25. Song D, Joshi G, White P. Fast track eligibility after ambulatory anesthesia: A comparison of desflurane, sevoflurane and propofol. Anesth Analg. 1998;86:267-273. 26. White P. Criteria for fast-tracking outpatients after ambulatory surgery. J Clin Anesth. 1999;11:78-79. 27. Dexter F. Computer simulation to determine how rapid anesthetic recovery protocols decrease the time of emergence or increase the phase one postanesthesia care unit bypass rate
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affect staffing of an ambulatory surgical centre. Anesth Analg. 1999;88:1053-1063. 28. Casey V, Kitowski T, Nahorney S, et al. Standards of Perianesthesia Nursing Practice, 5th ed. Ontario, Canada: Ontario PeriAnesthesia Nurses Association; 2005:5–31. 29. Chari P, Sen I. Paediatric ambulatory surgery-perioperative concerns. Indian J Anaesth. 2004;48:387-394. 30. Fortier D, Chung F, Su J. Unanticipated admission after ambulatory surgery—A prospective study. Can J Anesth. 1998; 45:612-619. 31. Chung F, Mezei G, Tong D. Adverse events in ambulatory surgery: A comparison between younger and older patients. Can J Anesth. 1999;99:309-321.
ASPAN 2008 National Conference
CALL FOR PROPOSALS Proposals are now being accepted for presentations at the
ASPAN National Conference Dallas, Texas May 4 – 8, 2008 Lecture topics will be selected for the following categories: Clinical Research Education Geriatrics Pediatrics Preoperative Assessment Leadership/Management Legal/Ethical Alternative/Integrative Therapies To obtain a proposal packet, please contact Carol Hyman at the ASPAN National Office: 877-737-9696 ext. 19 or [email protected]
Proposals must be postmarked by May 15, 2007.
Nurses working in perianesthesia care areas use discharge scoring criteria to complete patient assessments and ensure patient readiness for discharge or transfer to the next phase of recovery. However, all discharge criteria have both advantages and disadvantages. Comparative studies on the reliability of the different discharge criteria in use are extremely limited. As the acuity of our aging population increases, as well as the number of annual surgeries performed on an outpatient basis, it is most timely to ensure that we are following evidence-based discharge criteria. © 2006 by American Society of PeriAnesthesia Nurses.
ALMOST A CENTURY has passed since the surgeon Dr James Nicoll endorsed the benefits of sending patients home to recuperate on the same day of the operative procedure.1 Dr Ralph Waters, an anesthesiologist during this same time period, also supported this practice.2 Dr Waters indicated that, by following certain ambulatory procedures, the patient could return home a few hours postoperatively to recover.1,2 Today, patients continue to benefit from having procedures done on an ambulatory basis. The annual number of ambulatory surgeries performed continues to grow, and growth in ambulatory surgery is projected to continue. Fifty to 70% of all surgeries are performed on an outpatient basis,3 and it is anticipated that in a few years as much as 85% of surgeries will be performed on an outpatient basis.4 Many advantages are associated with ambulatory surgery. Reduced health care–acquired infections, hospital costs, and waits for bed availability, as well as improved patient comfort are a few of the reported advantages of ambulatory surgery.5 Due to faster-acting anesthetic agents such as remifentanil and sevoflurane, improved options in treating postoperative nausea and Journal of PeriAnesthesia Nursing, Vol 21, No 4 (August), 2006: pp 259-267
vomiting (PONV)—as well as preemptive, multimodal analgesia—patients recover faster.6 These patients can return home to continue with late, phase-three recovery in the comfort of their own homes.3,7,8 Also facilitating efficient and safe discharge are clear and concise discharge criteria. The Aldrete scoring system and the Post Anesthetic Discharge Scoring System (PADSS) have received widespread acceptance in assessing postanesthetic recovery.1,9 The Aldrete scoring system originated in 1970 by Dr J. A. Aldrete; the PADSS originated in 1991 by Dr Frances Chung (Table 1). As the popularity of ambulatory surgery grows, appropriate discharge criteria must be followed to ensure patient-centered care. With the acuity
Heather Ead, BScN, RN, is a Clinical Educator, PACU and Day Surgery, Trillium Health Centre, Mississauga, Ontario. Address correspondence to Heather Ead, BScN, RN, 3735 Densbury Drive, Mississauga ON L5N 6Z2, Canada; e-mail address: [email protected]. © 2006 by American Society of PeriAnesthesia Nurses. 1089-9472/06/2104-0005$35.00/0 doi:10.1016/j.jopan.2006.05.006 259
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Table 1. Discharge Scoring Systems The Aldrete Scoring Systemⴱ
The Post Anesthetic Discharge Scoring System (PADSS)†
Respiration Able to take deep breath and cough ⫽ 2 Dyspnea/shallow breathing ⫽ 1 Apnea ⫽ 0 O2 saturation Maintains ⬎92% on room air ⫽ 2 Needs O2 inhalation to maintain O2 saturation ⬎90% ⫽ 1 O2 saturation ⬎90% even with supplemental oxygen ⫽ 0 Consciousness Fully awake ⫽ 2 Arousable on calling ⫽ 1 Not responding ⫽ 0 Circulation BP ⫾ 20 mm Hg preop ⫽ 2 BP ⫾ 20–50 mm Hg preop ⫽ 1 BP ⫾ 50 mm Hg preop ⫽ 0 Activity Able to move 4 extremities ⫽ 2 Able to move 2 extremities ⫽ 1 Able to move 0 extremities ⫽ 0
Vital signs BP & pulse within 20% preop ⫽ 2 BP & pulse within 20–40% preop ⫽ 1 BP & pulse within ⬎40% preop ⫽ 0 Activity Steady gait, no dizziness or meets preop level ⫽ 2 Requires assistance ⫽ 1 Unable to ambulate ⫽ 0 Nausea & vomiting Minimal/treated with p.o. medication ⫽ 2 Moderate/treated with parenteral medication ⫽ 1 Severe/continues despite treatment ⫽ 0 Pain Controlled with oral analgesics and acceptable to patient: Yes ⫽ 2 No ⫽ 1 Surgical bleeding Minimal/no dressing changes ⫽ 2 Moderate/up to two dressing changes required ⫽ 1 Severe/more than three dressing changes required ⫽ 0
ⴱInformation obtained from references †Information obtained from references
1,9,10,13-16,22-24,29
.
1,9,10,13,14,16,19,22-24,29
of outpatient surgery increasing, the aging population, and expansion of inclusion criteria for day surgery, it becomes even more significant to have clear, evidence-based discharge criteria in clinical use.10-12 The following article discusses the history leading up to current discharge criteria, the modifications made to ensure continued practicality and accuracy, the benefits and limitations with discharge criteria, and the resulting implications to the perianesthesia nurse.
The History of Aldrete Scoring and PADSS How was today’s current discharge criteria determined? Reviewing the history of discharge criteria, postambulatory surgery is of interest to nurses involved in perianesthesia care. This includes nurses in PACUs, day surgery/ambula-
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tory care areas, ambulatory surgery centers (ASCs), endoscopy, dental offices, and plastic surgeons’ offices. Reviewing the history of postanesthesia scoring systems identifies the improvements that have been made over the years, as well as reinforces the value of abiding by discharge criteria to maintain high standards of care. The Aldrete scoring system, a modification of the Apgar scoring system used to assess newborns, has been used in many PACUs since its introduction 35 years ago.13 This system is designed to assess the patient’s transition from Phase I recovery to Phase II recovery, from discontinuation of anesthesia until a return of protective reflexes and motor function.14 At most institutions, Phase I recovery occurs in the PACU. Once Phase I recovery is completed,
DISCHARGE CRITERIA: ALDRETE TO PADSS
homeostasis has been regained. To assess the patient’s transition from Phase II to Phase III recovery, the PADSS is used.10 Phase II recovery is judged to be complete when the patient is ready for discharge home. Phase III recovery continues at home under the supervision of a responsible adult and continues until the patient returns to preoperative psychologic and physical function.14 Both the Aldrete system and PADSS evaluate five key parameters to ensure safe transfer or discharge of the patient postoperatively. Patients achieving a total score of 9 or 10 are considered fit for transfer or discharge to the next phase of recovery. The individual institution indicates if such scores are necessary for transfer or discharge, or if a score of 8 is acceptable (Table 1). The original Aldrete scoring system of 1970 used color as an indicator of oxygenation by assessing the color of the patient’s mucous membranes and nail beds. With the advent of oximetry, the Aldrete scoring system was updated in 1995 to include this technological improvement.15 Although monitoring the patient’s mucous membranes and nail beds is still included in the nurse’s assessment, oximetry is a more reliable indicator of oxygenation.1 Before the clear objective, numerical scoring of the Aldrete and PADSS, a number of psychomotor tests were used to assess discharge readiness postanesthesia.9 In the late 1960s, a modified Gestalt test (the Trieger dot test) was proposed to measure recovery. Patients demonstrated recovery by connecting a series of dots on paper to form a pattern. The more dots the patient missed, the lower their recovery score.9 Not only was this test tedious in nature; it did not account for the presence of dizziness, hypotension, pain, bleeding, nausea, vomiting, and other parameters included in current discharge scoring systems. Other psychomotor tests that have been used are reaction time tests, driving simulator tests,
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peg board tests, and a Maddox wing test, which involves a device to test extraocular balance.9 These psychomotor tests have limited value in assessing discharge readiness, but can be useful tools in conducting research.6,17 The R.E.A.C.T. assessment tool is another scoring system that was developed in Chicago in the early 1980s. This acronym includes the parameters of: Respiration, Energy, Alertness, Circulation, and Temperature18 Several limitations have been observed with the R.E.A.C.T. assessment tool. Its creators acknowledge that it is not appropriate for monitoring acute changes such as the onset of oxygen desaturation, dysrhythmias, or bleeding.18 This tool is recommended for use after such problems have been resolved. This is a serious limitation because cardiac and respiratory complications occur more frequently in the PACU than in ambulatory care areas.12,19 The R.E.A.C.T. scoring tool also lacks a parameter to score oxygenation, a parameter included in the Aldrete scoring system. Before numerical scoring criteria, clinical criteria checklists were used to assess patient discharge readiness. Although these checklists are used today in conjunction with the Aldrete and PADSS scoring systems, their use alone does not permit quantification of discharge readiness. The checklists also do not facilitate follow-up quality assurance audits.4 Standard discharge criteria are listed in Table 2. Although standard discharge criteria are useful to assess discharge readiness, the criteria is broad without specifications as to vital sign ranges or expected pain levels. Therefore, such guidelines should be used along with the PADSS to ensure the patient is safe for discharge to Phase III recovery.14
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Table 2. Clinical Discharge Criteriaⴱ ● ● ● ● ● ● ● ●
●
Stable vital signs for at least one hour Alert and oriented to time, place, and person No excessive pain, bleeding, or nausea Ability to dress and walk with assistance Discharged home with a vested adult who will remain with the patient overnight Written and verbal instructions outlining diet, activity, medications, and follow-up appointments provided A contact person and circumstances that warrant seeking the assistance of a health care professional clearly outlined Voiding before discharge not mandatory, unless specifically noted by physician (ie, urological procedure, rectal surgery, history of urinary retention) Tolerating oral fluids not mandatory, unless specified by physician (ie, patient is diabetic, frail, and/or elderly; not able to tolerate an extended period of NPO status) Abbreviation: NPO, nothing by mouth. ⴱData from references 1,2,10,14.
Drinking and Voiding Before Home Discharge Requiring all patients to void and tolerate oral fluids is no longer supported and has been shown to lead to unnecessary patient delays.1,4,9,14,20,22 A patient who has not voided postoperatively, has no urge to do, has no bladder distention, or is not at high risk of urinary retention may be discharged home if given clear guidelines on when to seek medical assistance. Patients who are at high risk of urinary retention are those who have undergone a procedure involving the pelvic or genitourinary system, rectal or urological procedures, hernia repairs, had urinary catheterization perioperatively, have a history of urinary retention, or received neuroaxial anesthesia.1,9,14,20,21 This group of patients has a higher risk of urinary retention and are generally required to void before discharge.22 Current literature remains inconsistent regarding the requirement to void after postneuroaxial
anesthesia. Both neuroaxial and general anesthesia can interfere with the detrusor muscle function and predispose the patient to urinary retention.21 If the bladder becomes distended while anesthesia is blocking the contraction ability of the detrusor muscles, voiding function can be impaired.22 The mechanism of urinary complications is related to anesthetic agents blocking parasympathetic fibers in the sacral region of the spine, which control the muscles of micturition.23 Gupta and others found that as many as 17.5% of patients had postspinal urinary retention.21 Kang and others found that urinary complications occur in less than 1% of spinal anesthetics.23 Urinary retention may occur with elderly men, whereas urinary incontinence can occur with female patients. Even with the low occurrence of urinary complications, these problems usually subside in the PACU, and intermittent urinary catheterization is rarely needed.23 The choice of opioid used with spinal anesthesia is a factor in postoperative urinary retention. Hydrophilic opioids, such as morphine, may cause urinary retention, whereas lipophilic opioids, such as fentanyl are less likely to cause this side effect.20 A suggested practice is for the patient to remain in the ambulatory care area for another hour if the patient is at risk of urinary retention and has more than 400 mL of urine in the bladder (determined by an ultrasonic bladder scanner), or if bladder distention is present. If after one hour the patient still has not voided, an intermittent catheterization can be done.22 If the patient is not at increased risk of urinary retention, discharge should not be delayed if postoperative voiding does not occur in the hospital. Such patients are given clear discharge instructions on when to seek medical assistance, eg, if they are not able to void at home eight hours after discharge.14 Patients are no longer required to drink fluids before discharge home. Current recommendations are that postoperative hydration status is
DISCHARGE CRITERIA: ALDRETE TO PADSS
assessed and managed in the PACU.6 Current practice guidelines set out by the American Society of Anesthesiologists Task Force on PostAnesthetic Care recommend that drinking clear fluids should not be a part of a discharge protocol, but may only be necessary for selected patients, such as diabetics.6 Not abiding by such recommendations will unnecessarily delay discharges, reduce patient satisfaction, and increase the incidence of nausea and vomiting when patients are encouraged to drink to be discharged.1,4,9,14,16 Although the initial PADSS of 1991 did include voiding and drinking in the discharge criteria, the revised PADSS of 1993 removed these criteria to avoid unnecessary delays and support patient-focused care.24 Clinical practice and some clinical studies support using the Aldrete scoring criteria to ensure discharge readiness from Phase I recovery, and PADSS to ensure discharge readiness from Phase II recovery.4,9,14,15,19,24 Institutions should also have clear guidelines on discharge criteria, and requirement for all patients to void or tolerate oral fluids should not be part of such a protocol.1,4,6,9,14,22,24
Fast-Tracking/Bypassing the PACU The practice of fast-tracking patients to the ambulatory care area— bypassing the PACU— has been practiced in some institutions since the late 1990s.25 With fast-tracking, patients must meet discharge criteria to illustrate completion of Phase I recovery before transfer from the operating room to the ambulatory care area.26,27 The fast-tracking criteria suggested by White26 appear to be a union of the Aldrete scoring system and the PADSS. To meet fast-tracking criteria, the patient must score a minimum of 12 (maximum score is 14), with no score ⬍1 in any parameter.26 As mentioned previously, this scoring criterion may vary slightly according to the facilities’ individual protocols (Table 3). Although fast-tracking is possible due to factors such as minimally invasive tech-
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Table 3. Criteria for Fast-Tracking After Ambulatory Anesthesiaⴱ Level of Consciousness: Awake and oriented Arousable with minimal stimulation Responsive only to tactile stimulation Physical Activity: Able to move all extremities on command Some weakness in movement of extremities Unable to voluntarily move extremities Hemodynamic Stability: BP ⫾ 15% of baseline BP ⫾ 30% of baseline BP ⫾ 50% of baseline Oxygen Saturation: Maintains value ⬎90% on room air Requires supplemental oxygen to maintain oxygen saturation ⬎90% Saturation ⬍90% with supplemental oxygen Pain: None/mild discomfort Moderate to severe, controlled with IV analgesics Persistent to severe Emetic Symptoms: None/mild nausea with no active vomiting Transient vomiting controlled with IV antiemetics Persistent moderate to severe nausea & vomiting
2 1 0 2 1 0 2 1 0 2 1 0 2 1 0 2 1 0
Abbreviation: IV, intravenous. ⴱData from references 2,3,7,14,25,26.
niques and short-duration anesthetics, there is inconsistent support in the literature supporting its use.14,28 Not all patients are appropriate for fast-tracking. In one study, only 31% of patients were eligible for fasttracking.14 Thus, a large number of patients still required traditional postanesthesia care in the PACU. The PACU needs to be staffed appropriately to receive patients who are not eligible for fast-tracking; therefore cost savings by reducing staffing in the PACU could not be guaranteed.27 The Ontario Perianesthesia Nurses Association (OPANA) Practice Standards indicate there is currently very little data addressing patient outcomes related to fast-tracking.28 Another concern regarding fast-tracking is that there
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Table 4. Advantages and Limitations of Discharge Scoring Criteria Advantages of Discharge Scoring Criteriaⴱ
Limitations of Discharge Scoring Criteria†
1. A well designed clinical scoring system provides a reliable guide for nursing assessment. 2. Using scoring criteria follows standards set out by the JCAHO and OPANA. 3. The reliability of scoring criteria is superior to clinical discharge criteria. 4. Scoring systems are efficient and user friendly for varying age groups. 5. Individualized scoring promotes patient-focused care. 6. Scoring criteria (Aldrete and PADSS) are widespread in acceptance, providing consistency among health care providers. 7. Unnecessary delays related to lack of voiding or fluid intake can be avoided. 8. Using scoring criteria follows the recommendations of the CAS. 9. Scoring systems are practical, easy to retain and repeat throughout the patient’s stay. 10. Progress is quantified, and the scores can be tracked or used in patient’s stay. 11. Progress is quantified, and the scores can be tracked or used in follow-up chart audits/studies. 12. The scoring criteria assess all parameters of recovery to ensure patient safety and readiness to be transferred to the next phase of recovery.
1. A definitive tool that is sensitive to the patient, surgical procedure, and anesthetic technique has yet to be finalized. 2. Scoring systems do not include criteria for specific requirements, eg, a required increased length of stay if M.H. susceptible, patient at high risk of urinary retention has not voided. In these cases, additional guidelines need to be established and followed. 3. The postoperative vital sign parameter may be inaccurate if preoperative values were abnormally high for the patient. (eg, elevated blood pressure preoperatively, related to anxiety).
Abbreviations: JCAHO, Joint Commission on Accreditation of Health Care Organizations; OPANA, Ontario Perianesthesia Nurses Association; CAS, Canadian Anesthetists Society; MH, malignant hyperthermia. ⴱInformation obtained from references 1,4,5,9-11,13-16,19,22-24,28. †Information obtained from references 1,2,14,29.
is no one agreed-upon practice guideline or definition of the factors involved in fasttracking.28 Further clinical studies are required for its validation and benefits.9 It is clear that there is a need for caution in implementing fast-tracking, and that a learning curve exists with this practice.
Advantages and Limitations of Discharge Scoring Criteria Although working in the perianesthesia area is often demanding and hectic, it is important to regularly review current processes to ensure that up-to-date standards of care are in place.
There are many benefits for both the patient and nurse in consistently using evidenced-based discharge scoring criteria. However, with all discharge criteria, there are limitations. Table 4 illustrates how the benefits of using numerical discharge criteria are more numerous than the limitations. Using criteria such as the Aldrete scoring system and the PADSS is supported by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), the Canadian Anesthetists Society (CAS), and OPANA.1,14,28 Using numerical scoring is also user-friendly and easily repeated during the patient’s stay to monitor
DISCHARGE CRITERIA: ALDRETE TO PADSS
improvement. Tracking improvements in clinical status allows a patient-focused approach, and confirms when the patient is ready to be transferred to the next phase of recovery. Limitations exist that have important implications for nursing with any discharge criteria. Although scoring criteria are reliable tools, they do not replace the critical thinking or professional judgment of the nurse. For example, the patient may fit all discharge criteria, yet the surgeon indicates that the patient must stay a minimum of four hours postoperatively because of susceptibility to malignant hyperthermia.12 Another example of a limitation is the elderly postoperative patient who is frail, diabetic, has some renal insufficiency, and resides a long distance from a medical facility. In this case it is better to err on the side of caution, and ensure the patient can tolerate oral fluids before discharge because the preoperative health status indicates that this patient may not tolerate an extended period of “nothing-by-mouth” status if unable to tolerate fluids at home. Long distances to accessing medical assistance and age are relative factors that the critical-thinking nurse keeps in mind when using scoring systems to assess discharge readiness. Scoring systems focus on discharge goals; however, such systems can still fail patients if we blindly look at the scoring criteria.1 Other limitations to keep in mind are the occurrence of postoperative complications requiring re-admission to the hospital. The complication rate after ambulatory procedures remains low. Most complications are transient, such as pain, sore throat, and nausea. Some complications can be managed before discharge. The rates of unanticipated admissions after day surgical procedures range between 0.3 to 1.4%.29,30 Discharge teaching is key to the patient and family understanding which situations will warrant return to the hospital or further medical assistance. Calculating scores on the vital sign parameters of both the Aldrete scoring system and the
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PADSS can be an area of uncertainty. Although the patient’s vital signs may be within normal range for age, the blood pressure should be compared with that of preoperative value to ensure the patient’s return to homeostasis. However, if the preoperative value was abnormally elevated because of anxiety or pain, expecting the postoperative blood pressure to be within 20% of an elevated blood pressure may not be appropriate. Again, an individualized patient assessment by the nurse and consultation with the surgeon or anesthesiologist, as needed, will confirm that the patient is suitable for discharge in such situations. Discharge readiness does not assume street fitness.14 If the patient does not understand the activity restrictions required as they continue Phase III recovery at home, there is risk for overexertion and adverse reactions occurring. Again, it is recognized that scoring criteria are an important part of assessing discharge readiness, but they must be used with approved discharge criteria, health teaching, and follow-up telephone calls. Using discharge criteria as well as appropriate patient selection for ambulatory surgery are key factors to ensure the patient’s ability to meet discharge criteria.28,29
Common Complications After Ambulatory Surgery Ambulatory surgery is safe, with adverse events occurring at low rates, less than 2%.31 Cardiovascular events (such as hypotension, hypertension, and dysrhythmias) occur most frequently, followed by respiratory events (such as laryngospasm, bronchospasm, and oxygen desaturation).31 Cardiac or respiratory comorbidities are strongly associated with such postoperative complications.5,28 Pain, PONV, and minor sequela such as sore throat and shivering, are other concerns that arise after surgery.5 Follow-up telephone calls to the patient’s home have an large role in ensuring safety throughout late recovery5,28; concerns such as continued PONV, pain, and bleeding can be addressed. These phone calls can also confirm the patient’s
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understanding and compliance to the verbal and written discharge instructions provided.1,28 Follow-up phone calls can also be used in quality assurance studies.
Conclusion The pillars of efficient, safe ambulatory surgery include appropriate patient selection and timely discharge.12,14 Assessment of the patient with the aid of scoring criteria such as the Aldrete scoring system and the PADSS can facilitate safe transition of care throughout the three phases of recovery. Chung, Chan, and Ong demonstrated increased reliability using PADSS versus a criteria checklist.10 The requirement to void and tolerate fluids is no longer considered part of standard discharge criteria.1,4,6,9,14,20,24
However, because the scoring criteria is only part of the discharge assessment, patients at higher risk of complications such as dehydration and urinary retention can be assessed on a case-by-case basis.6,14,22 Patients with such risks would be instructed to return to the hospital if postoperative concerns continue at home. Follow-up phone calls are of particular importance for high-risk patients to ensure patient-focused care. Once discharge protocols are established and approved, it is mandatory that they are consistently followed. By including discharge scoring criteria, such as those outlined in this article, patients can continue to benefit from ambulatory surgery and home recovery with the comfort of their family’s supervision.
References 1. Marley RA, Moline BM. Patient discharge from the ambulatory setting. J Post Anesth Nurs. 1996;11:39-49. 2. Fessey E. Implementing nurse-led discharge from day surgery. Nurs Times. 2005;101:32-33. 3. Apfelbaum J, Walawander C, Thaddeus M, et al. Eliminating intensive postoperative care in same-day surgery patients using short-acting anesthetics. Anesthesiology. 2002;97:66-74. 4. Beatty A, Martin D, Couch M, et al. Relevance of oral intake and necessity to void as ambulatory surgical discharge criteria. J Post Anesth Nurs. 1997;12:413-421. 5. The Joanna Briggs Institute. Management of the day surgery patient. Best Practice Supplement 1. 2003;1-4. Available at: http://www.joannabriggs.edu.au/pdf/BPISSup2004.pdf. Accessed January 2006. 6. Silverstein J, Apfelbaum J, Barlow J, et al. Practice guidelines for postanesthetic care. Anesthesiology. 2002;96: 742-752. 7. White P, Song D. New criteria for fast-tracking after outpatient anesthesia: A comparison with the modified Aldrete’s scoring system. Anesth Analg. 1999;88:1069-1072. 8. Casati A, Cappelleri G, Berti M, et al. Randomized comparison of remifentanil-propofol with a sciatic-femoral nerve block for out-patient knee arthroscopy. Eur J Anesthesiol. 2002;19:109-114. 9. Marshall S, Chung F. Discharge criteria and complications after ambulatory surgery. Ambulat Anesth. 1999;88: 508-517. 10. Chung F, Chan V, Ong D. A post anaesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth. 1995;7:500-506. 11. Friedman Z, Chung F, Wong D. Ambulatory surgery adult patient selection criteria—A survey of Canadian anesthesiologists. Can J Anesth. 2004;51:437-443.
12. Bryson G, Chung F, Cox R. Patient selection in ambulatory anesthesia—An evidence-base review: Part II. Can J Anesth. 2004;51:782-794. 13. Suddarth B. Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott, William & Wilkins; 2004:303-306. 14. Kamming D, Chung F. What criteria should be used for discharge after outpatient surgery? In Fleisher L, ed. EvidenceBased Practice of Anesthesiology. Philadelphia: Saunders; 2004:247-252. 15. Aldrete JA. The post-anesthetic recovery score revisited. J Clin Anesth. 1995;7:89-91. 16. Chung F. Discharge criteria—A new trend. Can J Anesth. 1995;42:1056-1058. 17. Saunders LD. Recovery of psychological function after anaesthesia. Int Anesth Clin. 1991;29:105-115. 18. Fraulini K, Murphy P. R.E.A.C.T.—A new system for measuring postanesthesia recovery. Nursing. 1984;14:12-13. 19. Ang P, Pagan A, Lewis M. Determining patients’ readiness for release from the postanesthesia recovery unit. AORN J. 2002;76:664-666. 20. Korhonen A, Valanne J, Jokela R, et al. Intrathecal hyperbaric Bupivacaine 3 mg ⫹ Fentanyl 10 g, for outpatient knee arthroscopy with tourniquet. Acta Anaesthesiol Scand. 2003;47:342-346. 21. Gupta A, Axelsson K, Thorn S, et al. Low-dose Bupivacaine plus Fentanyl for spinal anesthesia during ambulatory inguinal herniorrhaphy: A comparison between 6 mg and 7.5 mg of bupivacaine. Acta Anaesthesiol Scand. 2003;47: 13-19. 22. Mulroy M, Salinas F, Larkin K, et al. Ambulatory surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia. Anesthesiology. 2002;97:315319.
DISCHARGE CRITERIA: ALDRETE TO PADSS 23. Kang S, Rudrud L, Nelson W, et al. Postanesthesia nursing care for ambulatory surgery patients post-spinal anesthesia. J Post Anesth Nurs. 1994;9:101-106. 24. Chung F. Recovery pattern and home readiness after ambulatory surgery. Anesth Analg. 1995;80:896-902. 25. Song D, Joshi G, White P. Fast track eligibility after ambulatory anesthesia: A comparison of desflurane, sevoflurane and propofol. Anesth Analg. 1998;86:267-273. 26. White P. Criteria for fast-tracking outpatients after ambulatory surgery. J Clin Anesth. 1999;11:78-79. 27. Dexter F. Computer simulation to determine how rapid anesthetic recovery protocols decrease the time of emergence or increase the phase one postanesthesia care unit bypass rate
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affect staffing of an ambulatory surgical centre. Anesth Analg. 1999;88:1053-1063. 28. Casey V, Kitowski T, Nahorney S, et al. Standards of Perianesthesia Nursing Practice, 5th ed. Ontario, Canada: Ontario PeriAnesthesia Nurses Association; 2005:5–31. 29. Chari P, Sen I. Paediatric ambulatory surgery-perioperative concerns. Indian J Anaesth. 2004;48:387-394. 30. Fortier D, Chung F, Su J. Unanticipated admission after ambulatory surgery—A prospective study. Can J Anesth. 1998; 45:612-619. 31. Chung F, Mezei G, Tong D. Adverse events in ambulatory surgery: A comparison between younger and older patients. Can J Anesth. 1999;99:309-321.
ASPAN 2008 National Conference
CALL FOR PROPOSALS Proposals are now being accepted for presentations at the
ASPAN National Conference Dallas, Texas May 4 – 8, 2008 Lecture topics will be selected for the following categories: Clinical Research Education Geriatrics Pediatrics Preoperative Assessment Leadership/Management Legal/Ethical Alternative/Integrative Therapies To obtain a proposal packet, please contact Carol Hyman at the ASPAN National Office: 877-737-9696 ext. 19 or [email protected]
Proposals must be postmarked by May 15, 2007.