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Patient discharge from the ambulatory setting
Patient Discharge from the Ambulatory Setting REX A. MARLEY, MS, CRNA, RRT BEVERLY M. MOLINE, MSN, RN, CPAN Ambulatory surgical care is an integral part of the health care spectrum. The advantages of such care are well documented. One benefit of outpatient care is the potential for cost savings for the patient, medical facility, and third party payers by dismissing the patient to a remote recovery location following surgery and interlnediate anesthetic recovery. To realize this goal an essential component of patient management must be the safe and expedient postoperative care of the patient until they are discharged from the ambulatory facility. This article will review considerations for discharging the surgical patient from the ambulatory setting. 9 1996 by American Society of Post Anesthesia Nurses.
After operation its the out-patient room, such yotmg children with their wounds closed by collodion or rubber plaster, are easily carried home ht their mothers' a/Tns, and rest there more quietly, on the whole, than anywhere else. --NICOLL
l
HAS BEEN nearly 90 years since James I TNicoll, a pioneer of outpatient surgery, touted the attributes of sending postsurgical patients home to recuperate. Since that time, the popularity of ambulatory surgical care has grown to the extent that following surgery and after intermediate recovery from the anesthetic effects, 50% to 60% of all patients are discharged to either their home or an extended care facility. An important aspect of this process involves managing patients to a point where they can be weaned from the immediate postoperative care offered by the medical facility staff and where they can continue to recuperate with the assistance of a responsible adult. Paramount to this care is patient safety and efficiency of the discharge process. From a medicolegal perspective, it is imperative the patient be clinically stable and able to
be cared for at home. This concern was discussed in Nicoll's first description of ambulatory surgical care when stated that once discharged if "that child died from sepsis or other cause, a little awkwardness might arise with a jury . . . . ,,t A valid, organized discharge plan for each patient, which includes individual patient considerations, the type and duration of surgery and anesthesia, and the required postdischarge care, is imperative to achieve this end. DISCHARGE PLANNING GOALS
While caring for the ambulatory surgical patient in preparation for their discharge from the facility and their continued care remote from the
Rex A. Marley, MS, CRNA, RRT, is bz the Department of Anesthesia and Beverly M. Molhze, MSN, RN, CPAN, is Staff Development Coordinator for Surgical Services at Poudre Valley Itosp#al, Fort Collins, CO. Address correspondence to Rex A. Marie); MS, CRNA, RRT, Department of Anesthesia, Poudre Valley Itospital, 1024 Lemay Ave, Fort Collins, CO 80524. 9 1996 by American Society of Post Anesthesia Nurses. 0883-9433/96/1101-0008503.00/0
Journal of Post Anesthesia Nursing, Vol 11, No 1 (February), 1996: pp 39-49
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MARLEY AND MOLINE Table 1. Goals of Discharging Patients Following Ambulatory Surgery and Anesthesia
To promote patient satisfaction by minimizing disruptive influences associated with the patient's perioperative care. To optimize quality patient care such that patients can be safely discharged from the facility. To proficiently manage patients to minimize costs to the patient, medical facility, and third party payers.
ambulatory center, certain objectives are used (Table I). These objectives promote consistency, efficiency, and cost-effectiveness while preserving quality care. REGULATORY DISCHARGE GUIDELINES
General guidelines for discharging the patient from the ambulatory facility have been established by two national accrediting organizations, the Joint Commission for Accreditation of Health Organizations Ambulatory Care Accreditation Services 2 and the Accreditation Association of Ambulatory Health Care, 3'4 plus anesthesia 5"6and postanesthesia7 provider associations. The recommendations offered by these groups are designed to establish standards to maintain quality care for ambulatory facilities (Table 2).
hlstitutional Discharge Policy Each facility must establish a written protocol for patient discharge. The process should include specific discharge criteria to determine whether the patient is ready to be discharged, to promote quality care, and to provide a foundation for practice decisions. It is important that the institutional
Table 2. Guidelines for Discharging the Ambulatory Patient Institutional guidelines are developed and approved by the anesthesia department and the medical staff for patient discharge. Patient evaluation prior to discharge is the responsibility of a licensed independent practitioner. A responsible adult must accompany any patient who has received other than tJnsupplemented local anesthesia. Written postoperative and follow-up care instructions are provided the patient and responsible adult." A written transfer agreement must exist between a freestanding facility and a nearby hospital in the event that hospitalization for more definitive or prolonged care becomes necessary. Data from references 2-7.
discharge policy be well documented and uniformly employed.
Patient Evaluation A licensed independent practitioner* is responsible for making the final decision to discharge a patient. 2 Depending on state law or institutional policy, this responsibility may fall within the role of the operating surgeon, dentist, or anesthesiology staff. In the event the primary licensed independent practitioner is not personally present to evaluate the patient, (1) a specifically detailed protocol for discharge shall be followed and documented by the phase II recovery nurse, and (2) the responsible practitioner's name will be recorded in the patient's medical record]
Responsible Aduh A responsible adult is considered to be any willing individual who is physically and intellectually capable of caring for the patient. 8 The role of the responsible adult is to (1) assist with activities of daily living as needed, (2) assure compliance with postoperative instructions, and (3) monitor the patient's progress toward recovery. The third stage of recovery, known as the late stage, occurs after the patient is released from the surgical facility. A responsible adult is required to assist the patient during this recovery period, which may last hours to days. The duration and extent of adult assistance will depend on the patient's age, general health status, operative procedure, and length and type of anesthesia. Nearly 40% of ambulatory surgical patients report return to normal activities the day after surgery.9 Assistance may be necessary for up to 48 hours, especially in elderly patients. I~
Written hzstructions Written discharge instructions are verbally reviewed and given to each patient and the responsible adult before discharge. 2 To the extent possible, postoperative instructions, along with the appropriate rationale, are reviewed before surgery because pain, anxiety, and drug influence can negatively impact attention and recall in the * A licensed independent practitioner is any individual who is permitted by law and by the organization to provide patient care sen'ices without direction or super~'ision, within the scope of the individual's license and in accordance with hldividually granted clhlical privileges. 2
AMBULATORY PATIENT DISCHARGE
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Table 3. Postoperative Discharge Instructions Medications
Possible complications and symptoms
1. Detail the name, purpose, and dosage schedule for each medication. Emphasize th e importance of following the directions on the label. 2. The patient should resume medications taken before surgery perphysician's order. 3. If pain medication is not prescribed, nonprescription, nonaspirin analgesics, eg, acetaminophen, ibuprofen, may be effective on mild aches and pains. 4. Additional pain medication may be ordered by the physician following surgery. The patient should take these medications as directed, preferably with food to prevent gastrointestinal upset.
Instruct the patient and responsible adult in pertinent signs and symptoms which could be indicative of postoperative complications. 2. The patient should call the responsible physician if they develop: Fever >38.3~ (101~ orally Atypical pain Pain not relieved by pain medication Bleeding or unexpected drainage from the wound that does not stop Extreme redness/swelling around the incision or drainage of pus Urinary retention Continual nausea or vomiting
Activity restriction 1. Caution patient to take it easy for the rest of the day 9following surgery. Dizziness or drowsiness is not unusual following su'rgery and anesthesia. 2. For the next 24 h, the patient should not: Drive a vehicle, operate machinery or power tgols Consume alcohol, including beer Make important personal or business decisions or sig'n important papers 3. Activity level: In specific behavioral terms (eg, do not lift objects greater than 20 Ibs), describe any limitation of activities.
Treatments and tests 1. Any procedures which the patient or responsible adult are expected to perform, such as dressing changes or the application of warm moist compresses, should be described in detail. 2. A complete list of necessary supplies should be included. 3. If any postoperative tests are to be conducted, instructions as to the date, time, test location, and any preparation should be listed. Access to postdischarge care
Diet 1. Explain any dietary restrictions or instructions. 2. If no dietary restriction, instruct the patient to progress slowly as tolerated without nausea and vomiting to a regular diet.
1. The telephone number of the responsible and available physician. 2. The telephone number of the ambulatory center and the hours of operation. 3. The name, address, and telephone number of the appropriate emergency care facility.
Surgical side effects 1. Anticipated sequelae of surgery and anesthesia, such as bleeding, should be delineated. 2. Common side effects incltJde dizziness, drowsiness, myalgia, nausea and vomiting, pain, or sore throat. 9
Follow-up care Identify the date, time, and location, of the patient's scheduled return visit to the clinic or surgeon.
Data from references 11-13.
postoperative period. The instructions should be written clearly and comprehensively so that the needs of the patient will be met as effectively as possible (Table 3). Ij13 It is important to validate patient understanding and ability to comply with the instructions. For example, psychomotor skills, such as emptying a surgical drain, should be demonstrated by the 9 or caregiver to verify ability to perform the activity.
Transfer Policy Unanticipated hospital admission.
With today's standard of anesthesia care, major morbid-
ity and mortality following ambulatory surgery is quite low. A review of ambulatory surgical care encompassing 45,090 patients during a 3year period at a rural-based referral center found most major postoperative morbidities (1:1,455) to occur within the first 48 hours, whereas no deaths occurred during the first week of postsurgery. ~4 However, factors exist that lead to unexpected hospitalization following ambulatory surgery; the causes are multifactorial, ranging from medical or surgical emergencies to failure to secure adequate support personnel once discharged. The more common reasons that patients
MARLEY AND MOLINE
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require admission to the hospital are surgery-related (eg, more extensive surgery, hemorrhage), persistent pain, and unrelenting nausea and vomiting. 152~ Recent publications have cited overall unanticipated hospital admissions following ambulatory surgery to range between 0.2% and 33%. 18'19'21"27 Certain procedures (eg, laparoscopic sterilization, laparoscopic inguinal herniorrhaphy, head and neck procedures) are associated with a higher incidence of hospital admissions; otherwise, the hospital admission rate following ambulatory surgery approaches 0.5% to 1%. Admission plan and implementation. For the patient requiring a higher level of care than the ambulatory facility can offer, a written protocol is necessary to facilitate patient transport to the nearby hospital offering a full range of services. Ongoing review of this policy and procedure with the ambulatory staff is necessary so the staff will be proficient in (1) responding to activation of the transport team (eg, paramedics and ambulance), (2) patient stabilization, and (3) use of emergency equipment. To assure patient access to the full-service hospital, either (1) a written transfer agreement between the ambulatory facility and hospital is present or (2) the ambulatory facility grants privileges only to physicians who have admission privileges at the nearby hospital. 4 CRITERIA-BASED SCORING SYSTEMS
A means of patient evaluation that has consistent, discriminative attributes is useful to evaluate the "home readiness" of the patient. Select patient scoring systems are in use or have been proposed for phase I and II recovery locations.
The Aldrete phase I PAR scoring system is not specific for evaluating the ambulatory patient's readiness for home discharge. Limitations of this scoring system for discharging ambulatory patients include no mention of the patient's (1) ability to ambulate, (2) hydration status, (3) comfort level, (4) ability to void, and (5) whether persistent nausea or vomiting is present. These are important issues that require consideration before patient discharge.
Aldrete's Phase H Postanesthetic Recovery Score A criteria-based scoring system specific to the ambulatory setting was recently offered by Dr Aldrete. 3~ In addition to the categories found in his phase I discharge criteria (activity, respiration, circulation, consciousness, and oxygen saturation) this scoring system includes five additional criteria (dressing, pain, ambulation, fasting-feeding, and urine output) specific to ambulatory patients (Table 5). Modified Post Anesthesia Discharge Scoring System In 1991, Dr Chung first proposed using a discriminative discharge scoring system for ambulaTable 4. Aldrete's Modified Phase I Postanesthetic Recovery Score Patient Sign Activity
Respiration
Circulation
Aldrete's Phase I Postanesthetic Recovery Score The patient scoring system that has received nearly universal acceptance for discharge readiness from phase I is the Aldrete and Krovlik postanesthetic recovery score (PAR). 2s For years we have been cognizant that observation of the patient's skin or mucous membranes to determine their oxygenation level was an imprecise science. 29 Dr Aldrete has recently updated his original phase I PAR score to reflect the contemporary ability to monitor oxygenation in a more exact fashion with the use of pulse oximetry (Table 4). 3~
Consciousness
Oxygen saturation
Criterion
Score
Able to move 4 extremities* Able to move 2 extremities* Able to move 0 extremities* Able to deep-breathe and cough Dyspnea or limited breathing Apneic, obstructed airway BP + / - 20% of preanes value BP + / - 20%-49% of preanes value BP +1- 50% of preanes value Fully awake Arousable (by name) Nonresponsive SpOz > 92% on room air
2 1 O 2 1 0 2 1 0 2 I 0 2
Requires supplemental Oz to maintain SpO2 > 90% SpO2 < 90% even with 02 supplement
1 0
Reprinted with permission? ~ ABBREVIATIONS: BP, blood pressure; SpOz, oxyhemoglobin saturation determination via pulse oximetry. Preans, preanesthesia. * Voluntarily or on command.
AMBULATORY PATIENT DISCHARGE
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Table 5. Aldrete's Phase II Postanesthetic Recovery Score Patient Sign Activity
Respiration
Circulation
Consciousness
Oxygen. saturation
Dressing
Pain
Ambulation
Fasting-feeding
Urine output
Criterion
Score
Able to move 4 extremities* Able to move 2 extremities* Able to move 0 extremities* Able to breathe deeply and cough Dyspnea, limited breathing or tachypnea Apneic or on mechanical ventilator BP + / - 20% of preanes level BP + / - 20%-49% of preanes level BP + / - 50% of preanes level Fully awake Arousable on calling Not responding SpO= > 92% on room air
2 1 0 2 1
Requires supplemental Oz to maintain SpO2 > 90% SpOz < 90% even with 02 supplement Dry and clean Wet but stationary or marked Growing area of wetness Pain free Mild pain handled by oral meds Severe pain requiring IV or IM reeds Can stand up and walk straightt Vertigo when erect Dizziness when supine Able to drink fluids Nauseated Nauseated and vomiting Has voided Unable to void but comfortable Unable to void and uncomfortable
1
0 2 1 0 2 1 0 2
0 2 1 0 2 1 0 2 1 0 2 1 O 2 1 0
Reprinted with permission. 3~ NOTE. The total possible score is 20. A score of ~18 is required before patient discharge. ABBREVIATIONS: Preans, preanesthesia. IV, intravenously. IM, intramuscular. * Voluntarily or on command. f May be substituted by Romberg's test, or picking up 12 clips in one hand.
These two criteria-based discharge scoring systems offer easy and objective methods of assessing " h o m e readiness"; however, they should not replace critical and individualized patient assessment. These scoring systems are focusing our discharge goals in the right direction, yet the systems can still fail patients if we blindly look at the present criteria. For example, we might consider the patient presenting in phase II (I) who has a blood pressure of 114/62 (preoperative baseline was 148/74; Aldrete phase II PAR score = 1), (2) who expresses mild nausea (Aldrete phase II PAR score = 1), (3) who has some discomfort (oral medication is adequate for pain control; AIdrete phase II PAR score = 1), and (4) who has not voided but denies bladder discomfort (Aldrete phase II PAR score = 1). This patient's Aldrete's phase II PAR Score would be 16 and the patient would not meet discharge criteria. Critical and individualized patient assessment reveals a history of (1) mild nausea following all previous surgeries, which generally resolves later that day or the next, (2) nothing by mouth 7 hours before surgery, (3) adequate hydration, and (4) no preexisting health problems. The surgical procedure did not involve the pelvic region or genitourinary system. The patient denies any urge to void and the bladder region is not distended. Pain con-
Table 6. Modified Post Anesthesia Discharge Scoring System Patient Sign Vital signs
Ambulation
Nausea/vomiting
tory patients, termed the Post Anesthesia Discharge Scoring System (PADSS). 3] Refinements in the original PADSS (such as removing the criteria of whether or not the patient took oral fluids or could void) led to a more clinically practical discharge criteria "known as the modified PADSS (Table 6). 32 This scoring system identifies five points of evaluation (vital signs, ambulation, nausea/vomiting, pain, and surgical bleeding).
Pain
Surgical bleeding
Criterion
Score
Within 20% of preop value 20% to 40% of preop value >40% of preop value Steady gait; no dizziness With assistance None; dizziness Minimal Moderate Severe Minimal Moderate Severe Minimal Moderate Severe
2 1 0 2 1 0 2 1 0 2 1 0 2 1 0
Reprinted with permission. 32 NOTE. The total possible score is 10. Patients scoring ~9 are considered fit for discharge.
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MARLEY AND MOLINE
trol is reported by the patient to be satisfactory and the patient is enjoying conversation with a friend. The current blood pressure is compatible with intraoperative and postoperative values. This patient appears to be a viable candidate for discharge even though the patient failed to meet the required score of 18 or higher. Retaining the patient in the phase II recovery area until an adequate score of 18 is reached may not be the most efficient approach. The cost of prolonging phase II recovery until the patient has voided or nausea has resolved is a relevant concern in the changing health care arena. Nausea and voiding are problems that can be managed at home with clear directions on when to contact appropriate resources should symptoms persist. Pain is not expected to decrease in the immediate future, and the blood pressure may not reach preoperative levels considering the patient's recent surgical experience. Although significant progress has been made in attempts to develop a meaningful discharge scoring system for the ambulatory surgical population, a definitive tool that is sensitive to the patient, surgical procedure, and anesthetic technique, as well as compatible with today's economic concerns, has yet to be finalized. DISCHARGE CRITERIA MANAGEMENT
When evaluating whether the patient is ready to be discharged, certain objective discharge requirements must be addressed.
Orientation Appropriate mentation. The patient should be oriented to person, time, and place or at a level appropriate to the patient's developmental age and preoperative status. hzappropriate mentation. Further patient observation, evaluation, and workup may become necessary if the patient does not return to their normal preoperative mental state. Pah~ Preemptive analgesia. Preemptive analgesia, 33 consisting of measures such as local wound infiltration,3) peripheral nerve block, 35 regional anesthesia, or narcotic and nonnarcotic analgesic administration, whether administered intraarticularly, intravenously, intramuscularly, or orally,
should be assured when postoperative discomfort is anticipated. Pahl management. Postoperative pain should be recognized and appropriately treated with analgesics without causing somnolence. 3~ Initially, this may be accomplished by administering pain medication intravenously or intramuscularly to help smooth the transition to the patient's home analgesic medication. Pain should be controllable by oral analgesics, and the home analgesic therapy should be initiated before discharge to evaluate its effectiveness. It is essential to address pain management through the patient's perspective. Eliciting the therapy that worked well for the patient in the past is desirable. Atypical discomfort. The location, type, and intensity of pain should be consistent with anticipated postoperative discomfort. Atypical pain (eg, abdominal pain following a diagnostic dilation and curettage) would require further patient observation. 36
Nausea and Vomiting Etiology. Postoperative nausea and vomiting is one of the more disconcerting side effects faced by the patient following ambulatory surgery and anesthesia. The anesthetic-related and nonanesthetic-related factors contributing to nausea and vomiting are many; they include the individual patient, type and duration of surgery, anesthesia technique, and postoperative factors (eg, pain, dizziness, ambulation, oral intake, narcotics). 37 Patient evahtation. Discharge evaluation of a patient experiencing nausea and vomiting is multifaceted as well. It is essential to evaluate the patient from a comprehensive perspective. Parameters include the patient's general health status, age, hydration status, and the probability of the nausea and vomiting resolving, continuing, or progressing. It seems obvious that the effects of nausea and vomiting on a healthy adult have less impact than they would on a diabetic patient. Hydration status is an important variable, and includes fasting interval, intravenous fluids infused and oral fluids retained, fluids lost in surgery or through emesis, and the amount and concentration of urinary output. Naasea and vomiting management. Although the routine prophylactic administration of antiemetics is not advocated, 3s preventive antiemetic therapy in high-risk situations will help
AMBULATORY PATIENT DISCHARGE minimize patient annoyance and dissatisfaction, shorten time until discharge, and reduce unanticipated hospital admissions. "Rescue" antiemetic therapy with agents relatively free of side effects, (eg, ondansetron, 4 mg, intravenously in the adult patient) should be considered for patients developing nausea and vomiting in the phase I or II areas. The patient should have no more than minimal nausea or vomiting before discharge. 36
Surgical Bleedhzg The expertise of the phase II recovery nurse is crucial in evaluating appropriate surgical bleeding. With some procedures no bleeding is anticipated, whereas with others it is expected that dressing changes will be required. Communication with the surgeon is important to establish permissible levels of drainage (eg, blood, urine, or other fluids) from the surgical site. The patient must have a clear understanding of what is acceptable bleeding or drainage, and when to contact the responsible and available physician.
Vital Signs It is often difficult to ascertain the patient's normal vital signs in the preoperative environment of today's ambulatory setting. One set of vital signs in the preoperative setting is the norm; however, these can be influenced by a rushed admission, pain, anxiety, or the activity of changing clothes and getting onto the gurney. Discharge evaluation of vital signs should reflect age appropriateness, general health status, anesthetic technique, a comparison with not only preoperative values but also intraoperative and postoperative values, and the patient's position when blood pressure and heart rate were observed. Vital signs should be stable for at least 30 minutes 36 and be consistent with the patient's age. Blood pressure and pulse rate. Ideally, the criteria established by Aldrete 3~ and Chung 3z of being within +20% of preanesthesia value should be observed. Occasionally, the physician must depend on the entire clinical picture to make an informed decision to discharge in instances when the established criteria cannot be met. 39 Clinical signs of orthostatic hypotension (eg, dizziness, tachycardia, nausea, syncope) should be monitored especially while the patient is sitting uptight. Temperature. Postoperative hypothermia and the associated clinical consequences have been
45 well illustrated.4~Among the complications associated with hypothermia are coagulopathy,4~ negative nitrogen balance, 42 prolonged drug action, 43 and shiveringY Ambulatory surgery may predispose the patient to temperature drops approximating 2~ to 3~ which are well endured.4s A patient temperature of less than 35~ should be aggressively treated with active skin-surface warming devices (eg, forced air warmers). The usefulness of establishing a minimum temperature criteria before patient discharge has yet to be demonstrated. 46
Ambulation The upright position alone may challenge the body's ability to maintain hemodynamic stability, as reflected by minimal changes in blood pressure and pulse rate. The patient's ability to ambulate can be impacted by the surgical procedure, the patient's developmental level, and the typical preoperative movement patterns. If assistance to ambulate is required, the home caregiver must be capable of meeting this need. It must be determined that the patient can safely move from the vehicle to their resting location at home. They must also be able to perform basic functions such as dressing themselves and walking to the bathroom. Dizzhzess. There should be minimal dizziness after changing into street clothes and sitting for at least 10 minutes. 36 Postural hypotension. Assuring sufficient hydration will help prevent dizziness and postural hypotension. 37 Healthy adult outpatients, given at least 20 mL/kg lactated Ringers 47 or Plasmalyte48 perioperatively, exhibited less dizziness. Ephedrine, a sympathomimetic drug, given intramuscularly (0.5 mg/kg) during surgery49 or 10 mg to 25 mg intravenously in phase II5~may be beneficial in attenuating the dizziness and nausea and vomiting associated with postural hypotension.
Oral hltake The ability to swallow fluids and to gag or cough should be demonstrated. 5~ It is important to establish that a protective airway reflex is present. The capacity to tolerate oral fluids should be confirmed if this is crucial to the patient's continued convalescence at home. If oral medications (eg, analgesics) are necessary for the patient to remain comfortably at home,
46 then it is essential to confirm their ability to tolerate such intake. The patient with diabetes mellitus should be able to resume caloric intake as soon as possible. It is unnecessary to force oral fluids in the otherwise healthy outpatient who is adequately hydrated (eg, minimal fasting time, generous intravenous hydration, and minimal vomiting). The incidence of vomiting in patients required to take oral fluids was found to be approximately 75% greater than in those who resumed oral intake voluntarily.52
Voiding Patient evaluation. Patient evaluation relative to postoperative voiding should include the patient's age, state of hydration, and psychomotor state of arousal. The patient who (l) has fasted extensively (eg, nothing by mouth since the evening before surgery), (2) has voided just before surgery, (3) is not provided an understanding, relaxed atmosphere (a particular consideration with children),53 or (4) has received minimal intravenous hydration in the perioperative setting may not demonstrate the need to void. Conversely, the older patient (>53 years of age) who received sufficient intravenous hydration (> 1.2 L) for inguinal herniorrhaphy may be expected to show more urinary retention. 54 High risk procedures. Certain procedures (eg, urological, gynecological, inguinal herniorrhaphy) are associated with a high incidence of urinary retention. Patients having these procedures should show the ability to void before discharge. Following cystoscopy procedures, the urine should be observed to assure that hematuria, if present, is within clinically acceptable limits. Consideration for central axial blocks. Patients receiving spinal or epidural anesthesia should demonstrate the ability to void before discharge because intact functioning of the autonomic nerve supply to the bladder and urethra is essential for micturition. In select patients who are unable to void, bladder catheterization along with explicit instructions (eg, how to recognize signs of urinary retention and the timeframe in which to contact the physician if unable to void) may allow patient discharge. 55 Postdischarge urinary retention. When voiding is not a criteria for discharge, the patient should be advised at what point following dis-
MARLEY AND MOLINE charge (eg, after 6 to 8 hours) they should contact the responsible and available physician if they can not void. ~3
Respiratory Status The patient with significant respiratory impairment is not a candidate for discharge. Adequate oxyhemoglobin saturations via pulse oximetry (SpO2), respiratory rates consistent with age and preoperative health status, and an uncompromised airway permit further evaluation of the patient to meet other discharge criteria. The patient should be free of respiratory distress as shown by absence of croupy (barky) cough, dyspnea, nasal flaring, obstructed respiration, retractions, stridor, or wheezing. 5L56 SPECIAL CARE ISSUES
Regional Anesthesia Criteria specific to regional anesthesia must be followed before patient discharge. These criteria are in addition to those applied to the patient following general anesthesia. Subarachnoid and epidural block. Patients may recuperate in the phase II recovery area when their block has receded to LI or lower because hemodynamic aberrations secondary to sympathetic block will be minimal.55 The patient may transfer with assistance to a chair once full sensation has returned and if the blood pressure remains stable when the head of the bed is elevatedY Total resolution of sensory blockade could be assessed by skinprick sensation to the perianal region ($4_5).5s To show recovery from the motor blockade, the patient should be able to take each heel and move it contralaterally from the big toe to the knee and back) 3 If the patient tolerates the sitting position without postural hypotension, they may then ambulate with assistance. 57 It is important that the patient show total recovery from sympathetic, motor, and sensory blockade to assure that steady gait, and bowel and bladder control are present. This might best be shown by the patient's ability to walk to the bathroom and urinate without significant orthostatic blood pressure changes. Premature discharge may predispose the patient to urinary retention, bladder overdistension, and signs and symptoms of hypotonic bladder. 55 Caudal block. The patient should not be permitted to ambulate without assistance for :>6 to 8
AMBULATORY
PATIENT DISCHARGE
47
hours following surgery with caudal analgesia. 38 Urinary retention is not usually a p r o b l e m following caudal block; 59 however, the patient and responsible party should be instructed to contact the responsible physician if the patient is unable to v o i d after 6 to 8 hours. $5 Axillary block. F o l l o w i n g axillary b l o c k a d e , the patient m a y be discharged with residual sensory or m o t o r b l o c k with the arm supported in a sling, The patient should be cautioned to protect the e x t r e m i t y from injury (eg, no s m o k i n g or cooking) until normal sensation and reflexes have returnedY Foot block. T h e foot should be protected with a b u l k y dressing and the patient instructed on the proper use o f crutches. T h e patient should be monitored to assure proper crutch operation, and if technically difficult for the patient to master, the responsible adult must be p h y s i c a l l y able to assist the patientP 7
Malignant Hyperthermia Susceptible A malignant h y p e r t h e r m i a ( M H ) - s u s c e p t i b l e patient is defined as having (1) a previous e p i s o d e
o f MH, (2) masseter m u s c l e rigidity with previous anesthesia, or (3) a first degree relative with history o f an M H e p i s o d e or positive muscle biopsy. 6~ T h e M H susceptible patient w h o has received a routine, trigger-free anesthetic does not require hospital a d m i s s i o n based exclusively on being M H susceptible. 6~ The patient should be scheduled as early in the day as possible to facilitate extended patient observation for 4 to 6 hours. 62 H o w e v e r , any concerns about discharging the patient should lead to overnight patient monitoring.
SUMMARY T e c h n o l o g i c a l and p h a r m a c o l o g i c a l advances will increase the scope o f outpatient procedures. Financial efficiency and cost containment will also drive the e x p a n d i n g role o f outpatient facilities in the surgical arena. Patient m a n a g e m e n t related to discharge must include safety, quality care, and e c o n o m i c viability. A thoughtful, organized approach to patient care in regards to planning for their eventual discharge from the facility impacts greatly on these issues.
REFERENCES 1. Nicoll JH: The surgery of infancy. Br Med J 2:753754, 1909 2. Joint Commission on Accreditation of llealthcare Organizations: Surgical and anesthesia services, in 1994 Accreditation Manual for Ambulatory Health Care. I. Standards. Oakbrook Terrace, IL, 1993, pp 37-41 3. Accreditation Association for Ambulatory Health Care: Anesthesia Services, in 1994/1995 Accreditation Handbook for Ambulatory Health Care. Sknkie, IL, 1993, p 37 4. Accreditation Association for Ambulatory tlealth Care: Overnight Care and Services, in 1994/1995 Accreditation ttandbook for Ambulatory tlealth Care. Skokie, IL, 1993, p 40 5. American Association of Nurse Anesthetists: Postanesthesia Care Standards for the Certified Registered Nurse Anesthetist, in Professional Practice Manual for the Certified Registered Nurse Anesthetist. Park Ridge, IL, 1992, p2 6. American Society of Anesthesiologists: Guidelines for ambulatory surgical facilities, in ASA Standards, Guidelines and Statements. Park Ridge, IL, 1994, p 9 7. American Society of Post Anesthesia Nurses: Preanesthesia, postanesthesia-data required for initial, ongoing and discharge assessment, in Standards of Perianesthesia Nursing Practice. Thorofare, NJ, 1995, pp 42-45 8. Griffith JL, McLaughlin Sit: Legal implications, in Wetchler BV (ed): Anesthesia for Ambulatory Surgery (ed 2). Philadelphia, PA, Lippincon, 1991, pp 61-62 9. Philip BK: Patients' assessment of ambulatory anesthesia and surgery. J Clin Anesth 4:355-358, 1992
10. Weintraub tlD: Anesthetic management of the geriatric outpatient, in Barash PG (ed): ASA Refresher Courses in Anesthesiology. Philadelphia, PA, Lippincott, 1986, pp 237246 11. Sehremp PS: Discharge instruction: Providing continuity of care for ophthalmic patients. J Ophthalmic Nurs and Technology 4:30-33, 1985 12. American Society of Anesthesiologists: Home care instructions, in Peer Review in Anesthesiology. Park Ridge, IL, 1993, p 101 13. Chung F: Discharge process, in Twersky RS (ed): The Ambulatory Anesthesia ttandbook. St. Louis, MO, MosbyYear Book, 1995, pp 431-449 14. Warner MA, Shields SE, Chute CG: Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA 270:1437-1441, 1993 15. Patel RI, Hannallah RS: Anesthetic complications following pediatric ambulatory surgery: A 3-yr study. Anesthesiology 69:1009-1012, 1988 16. Gold BS, Kitz DS, Lecky JH, et al: Unanticipated admission to the hospital following ambulatory surgery. JAMA 262:3008-3010, 1989 17. Duncan PG, Cohen MM, Tweed WA, et al: The Canadian four-centre study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice? Can J Anaesth 39:440-448, 1992 18. Osborne GA, Rudkin GE: Outcome after day-care surgery in a major teaching hospital. Anaesth Intensive Care 21:822-827, 1993 19. Rudkin GE, Osborne GA, Doyle CE: Assessment and
48 selection of patients for day surgery in a public hospital. Med J Aust 158:308-312, 1993 20. Meeks GR, Meydrech EF, Bradford TH, et al: Comparison of unscheduled hospital admission following ambulatory operative laparoscopy at a teaching hospital and a community hospi!al. J Laparoendosc Surg 5:7-13, 1995 21. Chung F: Recovery pattern and home-readiness after ambulatory surgery. Anesth Analg 80:896-902, 1995 22. Cardosa M, Rudkin GE, Osborne GA: Outcome from day-case knee arthroscopy in a major teaching hospital. Arthroscopy 10:624-629, 1994 23. Cade L, Kakulas P: Ketorolac or pethidine for analgesia after elective laparoscopic sterilization. Anaesth Intensive Care 23:158-161, 1995 24. Brooks DC: A prospective comparison of lapar0scopic and tension-free open hemiorrhaphy. Arch Surg 129:361366, 1994 25. ttelmus C~ Grin M, Westfall R: Same-day-stay head and neck surgery. Laryngoscope 102:1331-1334, 1992 26. Biswas TK, Leafy C: Postoperative hospital admission from a day surgery unit: A seven-year retrospective survey. Anaesth Intensive Care 20:147-150, 1992 27. Meeks GR, Waller GA, Meydrech EF, et al: Unscheduled hospital admission following ambulatory gynecologic surgery. Obstet Gynecol 80:446-450, 1992 28. Aldrete JA, Kroulik D: A postanesthetic recovery score. Anesth Analg 49:924-933, 1970 29. Comroe Jr Jtt, Botelho S: The unreliability of cyanosis in the recognition of arterial anoxemia. Am J Med Sci 214:16, 1947 30. Aldrete JA: Discharge criteria, in Thomson D, Frost E (eds): Baillieres Clin Anaesthesiol-Postanaesthesia Care. London, Bailliere Tindall, 1994, pp 763-773 31. Chung F, Ong D, Sey0ne C, et al: PADS-A discriminative discharge index for ambulatory surgery. Anesthesiology 75:A1105, 1991 32. Theodorou-Michaloliakou C, Chung FF, Chua JG: Does a modified postanaesthetic discharge scoring system determine home-readiness sooner? Can J Anaesth 40:A32, 1993 33. Dahl JB, Kehlet H: The value of preemptive analgesia in the treatment of postoperative pain. Br J Anaesth 70:434439, 1993 34. Dalai JB, Moiniche S, Kehlet tl: Wound infiltration with local anaesthetics for postoperative pain relief9 Acta Anaesthesiol Scand 38:7-14, 1994 935. Ding Y, White PF: Post-hemiorrh.aphy pain in outpatients after pre-incision ilioinguinal-hypogastric nerve block during monitored anaesthesia care. Can J Anaesth 42:12-15, 1995 36. Reed WA: Recovery from anesthesia and discharge, in Shultz R (ed): Outpatient Surgery. Philadelphia, PA, Lea & Febiger, 1979, p 45 37. Watcha MF, White PF: Postoperative nausea and vomiting: It s etiology, treatment, and prevention. Anesthesiology 77:162-184, 1992 38. Kapur PA: Postanesthesia care recovery and management, in Twersky RS (ed): The Ambulatory Anesthesia Handbook. St. Louis, Mosby-Year Book, 1995, pp 399-430
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39. McMullen JNB, Jahr JS: Discharge criteria for ambulatory surgery: A review of the current literature. J Louisiana St Med Soc 145:101-105, 1993 40. Slotman GJ, Jed Ell, Burchard KW: Adverse effects of hy.pothermia in postoperative patients. Am J Surg 149:495501, 1985 41. Valeri RC, Feingold H, Cassidy G, et al: ttypothermiainduced reversible platelet dysfunction. Ann Surg 205:175181, 1987 42. Carli F, Emery PW, Freemantle CAJ: Effect of preoperative normothermia on postoperative protein metabolism in elderly patients undergoing hip arthroplasty. Br J Anaesth 63:276-282, 1989 43. Heier T, Caldwell JE, Sessler DI, et al: Mild intraoperative hypothermia increases duration of action and spontaneous recovery of vecuronium blockade during nitrous oxideisoflurane anesthesia in humans. Anesthesiology 74:815-819, 1991 44. Sessler DI, Ruhinstein Ett, Moayeri A: Physiologic responses to mild perianesthetic.,hypothermia in humans. Anesthesiology 75:594-610, 1991 45. Mecca RS, Sharnick SV: Common postanesthesia care unit problems, in McGoldrick KE (ed): Ambulatory Anesthesiology: A Problem-Oriented Approach. Baltimore, MD, Williams & Wilkins, 1995, pp 582-618 46. Fetzer-Fowler SJ, Huot S: The use of temperature as a discharge criterion for ambulatory surgery patients. J Post Anesth Nurs 7:398-403, 1992 47. Cook R, Anderson S, Riseborough M, et al: Intravenous fluid load and recovery. A double-blind comparison in gynaecological patients who had day-case laparoscopy. Anaesthesia 45:826-830, 1990 48. Yogendran S, Asokumar B, Cheng DCH, et al: A prospective randomized double-blinded siudy of the effect of intravenous fluid therapy on adverse outcomes on outpatient surgeryJ Anesth Analg 80:682-686, 1995 49. Rothenberg DM, Pamass SM, Litwack K, et al: Efficacy of ephedrine in the prevention of postoperative nausea and vomiting. Anesth Analg 72:58-61, 1991 50. Wetchler BV: Management of nausea and vomiting in the ambulatory surgical patient9 Society for Ambulatory Anesthesia Newsletter 3:2-3, 1988 51. WetchlerBV: Problem solving in the p0stanesthesia care unit, in Wetchler BV (ed): Anesthesia for Ambulatory Surgery (ed 2). Philadelphia, PA, Lippincott, 1991, pp 375436 52. Schreiner MS, Nicolson SC, Martin T, et al: Should children drink before discharge from day surgery? 9 ology 76:528-533, 1992 53. ttjalmas K: Urodynamics in normal infants and children. Stand J Urol Nephrol 114(suppl):20-27, 1988 54. Petros JG, Rimm EB, Robillard RJ, et al: Factors influencing postopemti,/'e urinary retention in patients undergoing elective inguinal hemiorrhaphy. Am J Surg 161:431-433, 1991 55. Pavlin DJ: Regional anesthesia, in Twersky RS (ed): The Ambulatory Anesthesia Handbook. St. Louis, MO, Mosby-Year Book, 1995, pp 239-300 56. Patel RI: D~scharge criteria and postanesthetic complications following pediatric ambulatory surgery. J Post Anesth Nuts 3:114-117, 1988 57. Mulroy MR: Regional anesthetic techniques, in White
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PF (ed): International Anesthesiology Clinics: Anesthesia for Ambulatory Surgery. Boston, MA, Little, Brown and Co, 1994, pp 81-98 58. Pflug AE, Aasheim GM, Foster C: Sequence of return of neurological function and criteria for safe ambulation following subarachnoid block (spinal anaesthetic). Can Anaesth Soc J 25:133-139, 1978 59. Fisher QA, McComiskey CM, Hill JL, et al: Postoperative voiding interval and duration of analgesia following peripheral or caudal nerve blocks in children. Anesth Analg 76:173-177, 1993
49 60. McGoldrick K: Is malignant hyperthermia a contraindication for outpatient surgery? Society for Ambulatory Anesthesia Newsletter 7:11, 1992 61. Spieker M: Patients susceptible to malignant hyperthermia, in McGoldrick KE (ed): Ambulatory Anesthesiology: A Problem-Oriented Approach. Baltimore, MD, Williams & Wilkins, 1995, pp 318-331 62. Yentis SM, Levine MF, Hartley EJ: Should all children with suspected or confirmed malignant hyperthermia susceptibility be admitted after surgery? A 10-year review. Anesth Analg 75:345-350, 1992
After operation its the out-patient room, such yotmg children with their wounds closed by collodion or rubber plaster, are easily carried home ht their mothers' a/Tns, and rest there more quietly, on the whole, than anywhere else. --NICOLL
l
HAS BEEN nearly 90 years since James I TNicoll, a pioneer of outpatient surgery, touted the attributes of sending postsurgical patients home to recuperate. Since that time, the popularity of ambulatory surgical care has grown to the extent that following surgery and after intermediate recovery from the anesthetic effects, 50% to 60% of all patients are discharged to either their home or an extended care facility. An important aspect of this process involves managing patients to a point where they can be weaned from the immediate postoperative care offered by the medical facility staff and where they can continue to recuperate with the assistance of a responsible adult. Paramount to this care is patient safety and efficiency of the discharge process. From a medicolegal perspective, it is imperative the patient be clinically stable and able to
be cared for at home. This concern was discussed in Nicoll's first description of ambulatory surgical care when stated that once discharged if "that child died from sepsis or other cause, a little awkwardness might arise with a jury . . . . ,,t A valid, organized discharge plan for each patient, which includes individual patient considerations, the type and duration of surgery and anesthesia, and the required postdischarge care, is imperative to achieve this end. DISCHARGE PLANNING GOALS
While caring for the ambulatory surgical patient in preparation for their discharge from the facility and their continued care remote from the
Rex A. Marley, MS, CRNA, RRT, is bz the Department of Anesthesia and Beverly M. Molhze, MSN, RN, CPAN, is Staff Development Coordinator for Surgical Services at Poudre Valley Itosp#al, Fort Collins, CO. Address correspondence to Rex A. Marie); MS, CRNA, RRT, Department of Anesthesia, Poudre Valley Itospital, 1024 Lemay Ave, Fort Collins, CO 80524. 9 1996 by American Society of Post Anesthesia Nurses. 0883-9433/96/1101-0008503.00/0
Journal of Post Anesthesia Nursing, Vol 11, No 1 (February), 1996: pp 39-49
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4o
MARLEY AND MOLINE Table 1. Goals of Discharging Patients Following Ambulatory Surgery and Anesthesia
To promote patient satisfaction by minimizing disruptive influences associated with the patient's perioperative care. To optimize quality patient care such that patients can be safely discharged from the facility. To proficiently manage patients to minimize costs to the patient, medical facility, and third party payers.
ambulatory center, certain objectives are used (Table I). These objectives promote consistency, efficiency, and cost-effectiveness while preserving quality care. REGULATORY DISCHARGE GUIDELINES
General guidelines for discharging the patient from the ambulatory facility have been established by two national accrediting organizations, the Joint Commission for Accreditation of Health Organizations Ambulatory Care Accreditation Services 2 and the Accreditation Association of Ambulatory Health Care, 3'4 plus anesthesia 5"6and postanesthesia7 provider associations. The recommendations offered by these groups are designed to establish standards to maintain quality care for ambulatory facilities (Table 2).
hlstitutional Discharge Policy Each facility must establish a written protocol for patient discharge. The process should include specific discharge criteria to determine whether the patient is ready to be discharged, to promote quality care, and to provide a foundation for practice decisions. It is important that the institutional
Table 2. Guidelines for Discharging the Ambulatory Patient Institutional guidelines are developed and approved by the anesthesia department and the medical staff for patient discharge. Patient evaluation prior to discharge is the responsibility of a licensed independent practitioner. A responsible adult must accompany any patient who has received other than tJnsupplemented local anesthesia. Written postoperative and follow-up care instructions are provided the patient and responsible adult." A written transfer agreement must exist between a freestanding facility and a nearby hospital in the event that hospitalization for more definitive or prolonged care becomes necessary. Data from references 2-7.
discharge policy be well documented and uniformly employed.
Patient Evaluation A licensed independent practitioner* is responsible for making the final decision to discharge a patient. 2 Depending on state law or institutional policy, this responsibility may fall within the role of the operating surgeon, dentist, or anesthesiology staff. In the event the primary licensed independent practitioner is not personally present to evaluate the patient, (1) a specifically detailed protocol for discharge shall be followed and documented by the phase II recovery nurse, and (2) the responsible practitioner's name will be recorded in the patient's medical record]
Responsible Aduh A responsible adult is considered to be any willing individual who is physically and intellectually capable of caring for the patient. 8 The role of the responsible adult is to (1) assist with activities of daily living as needed, (2) assure compliance with postoperative instructions, and (3) monitor the patient's progress toward recovery. The third stage of recovery, known as the late stage, occurs after the patient is released from the surgical facility. A responsible adult is required to assist the patient during this recovery period, which may last hours to days. The duration and extent of adult assistance will depend on the patient's age, general health status, operative procedure, and length and type of anesthesia. Nearly 40% of ambulatory surgical patients report return to normal activities the day after surgery.9 Assistance may be necessary for up to 48 hours, especially in elderly patients. I~
Written hzstructions Written discharge instructions are verbally reviewed and given to each patient and the responsible adult before discharge. 2 To the extent possible, postoperative instructions, along with the appropriate rationale, are reviewed before surgery because pain, anxiety, and drug influence can negatively impact attention and recall in the * A licensed independent practitioner is any individual who is permitted by law and by the organization to provide patient care sen'ices without direction or super~'ision, within the scope of the individual's license and in accordance with hldividually granted clhlical privileges. 2
AMBULATORY PATIENT DISCHARGE
41
Table 3. Postoperative Discharge Instructions Medications
Possible complications and symptoms
1. Detail the name, purpose, and dosage schedule for each medication. Emphasize th e importance of following the directions on the label. 2. The patient should resume medications taken before surgery perphysician's order. 3. If pain medication is not prescribed, nonprescription, nonaspirin analgesics, eg, acetaminophen, ibuprofen, may be effective on mild aches and pains. 4. Additional pain medication may be ordered by the physician following surgery. The patient should take these medications as directed, preferably with food to prevent gastrointestinal upset.
Instruct the patient and responsible adult in pertinent signs and symptoms which could be indicative of postoperative complications. 2. The patient should call the responsible physician if they develop: Fever >38.3~ (101~ orally Atypical pain Pain not relieved by pain medication Bleeding or unexpected drainage from the wound that does not stop Extreme redness/swelling around the incision or drainage of pus Urinary retention Continual nausea or vomiting
Activity restriction 1. Caution patient to take it easy for the rest of the day 9following surgery. Dizziness or drowsiness is not unusual following su'rgery and anesthesia. 2. For the next 24 h, the patient should not: Drive a vehicle, operate machinery or power tgols Consume alcohol, including beer Make important personal or business decisions or sig'n important papers 3. Activity level: In specific behavioral terms (eg, do not lift objects greater than 20 Ibs), describe any limitation of activities.
Treatments and tests 1. Any procedures which the patient or responsible adult are expected to perform, such as dressing changes or the application of warm moist compresses, should be described in detail. 2. A complete list of necessary supplies should be included. 3. If any postoperative tests are to be conducted, instructions as to the date, time, test location, and any preparation should be listed. Access to postdischarge care
Diet 1. Explain any dietary restrictions or instructions. 2. If no dietary restriction, instruct the patient to progress slowly as tolerated without nausea and vomiting to a regular diet.
1. The telephone number of the responsible and available physician. 2. The telephone number of the ambulatory center and the hours of operation. 3. The name, address, and telephone number of the appropriate emergency care facility.
Surgical side effects 1. Anticipated sequelae of surgery and anesthesia, such as bleeding, should be delineated. 2. Common side effects incltJde dizziness, drowsiness, myalgia, nausea and vomiting, pain, or sore throat. 9
Follow-up care Identify the date, time, and location, of the patient's scheduled return visit to the clinic or surgeon.
Data from references 11-13.
postoperative period. The instructions should be written clearly and comprehensively so that the needs of the patient will be met as effectively as possible (Table 3). Ij13 It is important to validate patient understanding and ability to comply with the instructions. For example, psychomotor skills, such as emptying a surgical drain, should be demonstrated by the 9 or caregiver to verify ability to perform the activity.
Transfer Policy Unanticipated hospital admission.
With today's standard of anesthesia care, major morbid-
ity and mortality following ambulatory surgery is quite low. A review of ambulatory surgical care encompassing 45,090 patients during a 3year period at a rural-based referral center found most major postoperative morbidities (1:1,455) to occur within the first 48 hours, whereas no deaths occurred during the first week of postsurgery. ~4 However, factors exist that lead to unexpected hospitalization following ambulatory surgery; the causes are multifactorial, ranging from medical or surgical emergencies to failure to secure adequate support personnel once discharged. The more common reasons that patients
MARLEY AND MOLINE
42
require admission to the hospital are surgery-related (eg, more extensive surgery, hemorrhage), persistent pain, and unrelenting nausea and vomiting. 152~ Recent publications have cited overall unanticipated hospital admissions following ambulatory surgery to range between 0.2% and 33%. 18'19'21"27 Certain procedures (eg, laparoscopic sterilization, laparoscopic inguinal herniorrhaphy, head and neck procedures) are associated with a higher incidence of hospital admissions; otherwise, the hospital admission rate following ambulatory surgery approaches 0.5% to 1%. Admission plan and implementation. For the patient requiring a higher level of care than the ambulatory facility can offer, a written protocol is necessary to facilitate patient transport to the nearby hospital offering a full range of services. Ongoing review of this policy and procedure with the ambulatory staff is necessary so the staff will be proficient in (1) responding to activation of the transport team (eg, paramedics and ambulance), (2) patient stabilization, and (3) use of emergency equipment. To assure patient access to the full-service hospital, either (1) a written transfer agreement between the ambulatory facility and hospital is present or (2) the ambulatory facility grants privileges only to physicians who have admission privileges at the nearby hospital. 4 CRITERIA-BASED SCORING SYSTEMS
A means of patient evaluation that has consistent, discriminative attributes is useful to evaluate the "home readiness" of the patient. Select patient scoring systems are in use or have been proposed for phase I and II recovery locations.
The Aldrete phase I PAR scoring system is not specific for evaluating the ambulatory patient's readiness for home discharge. Limitations of this scoring system for discharging ambulatory patients include no mention of the patient's (1) ability to ambulate, (2) hydration status, (3) comfort level, (4) ability to void, and (5) whether persistent nausea or vomiting is present. These are important issues that require consideration before patient discharge.
Aldrete's Phase H Postanesthetic Recovery Score A criteria-based scoring system specific to the ambulatory setting was recently offered by Dr Aldrete. 3~ In addition to the categories found in his phase I discharge criteria (activity, respiration, circulation, consciousness, and oxygen saturation) this scoring system includes five additional criteria (dressing, pain, ambulation, fasting-feeding, and urine output) specific to ambulatory patients (Table 5). Modified Post Anesthesia Discharge Scoring System In 1991, Dr Chung first proposed using a discriminative discharge scoring system for ambulaTable 4. Aldrete's Modified Phase I Postanesthetic Recovery Score Patient Sign Activity
Respiration
Circulation
Aldrete's Phase I Postanesthetic Recovery Score The patient scoring system that has received nearly universal acceptance for discharge readiness from phase I is the Aldrete and Krovlik postanesthetic recovery score (PAR). 2s For years we have been cognizant that observation of the patient's skin or mucous membranes to determine their oxygenation level was an imprecise science. 29 Dr Aldrete has recently updated his original phase I PAR score to reflect the contemporary ability to monitor oxygenation in a more exact fashion with the use of pulse oximetry (Table 4). 3~
Consciousness
Oxygen saturation
Criterion
Score
Able to move 4 extremities* Able to move 2 extremities* Able to move 0 extremities* Able to deep-breathe and cough Dyspnea or limited breathing Apneic, obstructed airway BP + / - 20% of preanes value BP + / - 20%-49% of preanes value BP +1- 50% of preanes value Fully awake Arousable (by name) Nonresponsive SpOz > 92% on room air
2 1 O 2 1 0 2 1 0 2 I 0 2
Requires supplemental Oz to maintain SpO2 > 90% SpO2 < 90% even with 02 supplement
1 0
Reprinted with permission? ~ ABBREVIATIONS: BP, blood pressure; SpOz, oxyhemoglobin saturation determination via pulse oximetry. Preans, preanesthesia. * Voluntarily or on command.
AMBULATORY PATIENT DISCHARGE
43
Table 5. Aldrete's Phase II Postanesthetic Recovery Score Patient Sign Activity
Respiration
Circulation
Consciousness
Oxygen. saturation
Dressing
Pain
Ambulation
Fasting-feeding
Urine output
Criterion
Score
Able to move 4 extremities* Able to move 2 extremities* Able to move 0 extremities* Able to breathe deeply and cough Dyspnea, limited breathing or tachypnea Apneic or on mechanical ventilator BP + / - 20% of preanes level BP + / - 20%-49% of preanes level BP + / - 50% of preanes level Fully awake Arousable on calling Not responding SpO= > 92% on room air
2 1 0 2 1
Requires supplemental Oz to maintain SpO2 > 90% SpOz < 90% even with 02 supplement Dry and clean Wet but stationary or marked Growing area of wetness Pain free Mild pain handled by oral meds Severe pain requiring IV or IM reeds Can stand up and walk straightt Vertigo when erect Dizziness when supine Able to drink fluids Nauseated Nauseated and vomiting Has voided Unable to void but comfortable Unable to void and uncomfortable
1
0 2 1 0 2 1 0 2
0 2 1 0 2 1 0 2 1 0 2 1 O 2 1 0
Reprinted with permission. 3~ NOTE. The total possible score is 20. A score of ~18 is required before patient discharge. ABBREVIATIONS: Preans, preanesthesia. IV, intravenously. IM, intramuscular. * Voluntarily or on command. f May be substituted by Romberg's test, or picking up 12 clips in one hand.
These two criteria-based discharge scoring systems offer easy and objective methods of assessing " h o m e readiness"; however, they should not replace critical and individualized patient assessment. These scoring systems are focusing our discharge goals in the right direction, yet the systems can still fail patients if we blindly look at the present criteria. For example, we might consider the patient presenting in phase II (I) who has a blood pressure of 114/62 (preoperative baseline was 148/74; Aldrete phase II PAR score = 1), (2) who expresses mild nausea (Aldrete phase II PAR score = 1), (3) who has some discomfort (oral medication is adequate for pain control; AIdrete phase II PAR score = 1), and (4) who has not voided but denies bladder discomfort (Aldrete phase II PAR score = 1). This patient's Aldrete's phase II PAR Score would be 16 and the patient would not meet discharge criteria. Critical and individualized patient assessment reveals a history of (1) mild nausea following all previous surgeries, which generally resolves later that day or the next, (2) nothing by mouth 7 hours before surgery, (3) adequate hydration, and (4) no preexisting health problems. The surgical procedure did not involve the pelvic region or genitourinary system. The patient denies any urge to void and the bladder region is not distended. Pain con-
Table 6. Modified Post Anesthesia Discharge Scoring System Patient Sign Vital signs
Ambulation
Nausea/vomiting
tory patients, termed the Post Anesthesia Discharge Scoring System (PADSS). 3] Refinements in the original PADSS (such as removing the criteria of whether or not the patient took oral fluids or could void) led to a more clinically practical discharge criteria "known as the modified PADSS (Table 6). 32 This scoring system identifies five points of evaluation (vital signs, ambulation, nausea/vomiting, pain, and surgical bleeding).
Pain
Surgical bleeding
Criterion
Score
Within 20% of preop value 20% to 40% of preop value >40% of preop value Steady gait; no dizziness With assistance None; dizziness Minimal Moderate Severe Minimal Moderate Severe Minimal Moderate Severe
2 1 0 2 1 0 2 1 0 2 1 0 2 1 0
Reprinted with permission. 32 NOTE. The total possible score is 10. Patients scoring ~9 are considered fit for discharge.
44
MARLEY AND MOLINE
trol is reported by the patient to be satisfactory and the patient is enjoying conversation with a friend. The current blood pressure is compatible with intraoperative and postoperative values. This patient appears to be a viable candidate for discharge even though the patient failed to meet the required score of 18 or higher. Retaining the patient in the phase II recovery area until an adequate score of 18 is reached may not be the most efficient approach. The cost of prolonging phase II recovery until the patient has voided or nausea has resolved is a relevant concern in the changing health care arena. Nausea and voiding are problems that can be managed at home with clear directions on when to contact appropriate resources should symptoms persist. Pain is not expected to decrease in the immediate future, and the blood pressure may not reach preoperative levels considering the patient's recent surgical experience. Although significant progress has been made in attempts to develop a meaningful discharge scoring system for the ambulatory surgical population, a definitive tool that is sensitive to the patient, surgical procedure, and anesthetic technique, as well as compatible with today's economic concerns, has yet to be finalized. DISCHARGE CRITERIA MANAGEMENT
When evaluating whether the patient is ready to be discharged, certain objective discharge requirements must be addressed.
Orientation Appropriate mentation. The patient should be oriented to person, time, and place or at a level appropriate to the patient's developmental age and preoperative status. hzappropriate mentation. Further patient observation, evaluation, and workup may become necessary if the patient does not return to their normal preoperative mental state. Pah~ Preemptive analgesia. Preemptive analgesia, 33 consisting of measures such as local wound infiltration,3) peripheral nerve block, 35 regional anesthesia, or narcotic and nonnarcotic analgesic administration, whether administered intraarticularly, intravenously, intramuscularly, or orally,
should be assured when postoperative discomfort is anticipated. Pahl management. Postoperative pain should be recognized and appropriately treated with analgesics without causing somnolence. 3~ Initially, this may be accomplished by administering pain medication intravenously or intramuscularly to help smooth the transition to the patient's home analgesic medication. Pain should be controllable by oral analgesics, and the home analgesic therapy should be initiated before discharge to evaluate its effectiveness. It is essential to address pain management through the patient's perspective. Eliciting the therapy that worked well for the patient in the past is desirable. Atypical discomfort. The location, type, and intensity of pain should be consistent with anticipated postoperative discomfort. Atypical pain (eg, abdominal pain following a diagnostic dilation and curettage) would require further patient observation. 36
Nausea and Vomiting Etiology. Postoperative nausea and vomiting is one of the more disconcerting side effects faced by the patient following ambulatory surgery and anesthesia. The anesthetic-related and nonanesthetic-related factors contributing to nausea and vomiting are many; they include the individual patient, type and duration of surgery, anesthesia technique, and postoperative factors (eg, pain, dizziness, ambulation, oral intake, narcotics). 37 Patient evahtation. Discharge evaluation of a patient experiencing nausea and vomiting is multifaceted as well. It is essential to evaluate the patient from a comprehensive perspective. Parameters include the patient's general health status, age, hydration status, and the probability of the nausea and vomiting resolving, continuing, or progressing. It seems obvious that the effects of nausea and vomiting on a healthy adult have less impact than they would on a diabetic patient. Hydration status is an important variable, and includes fasting interval, intravenous fluids infused and oral fluids retained, fluids lost in surgery or through emesis, and the amount and concentration of urinary output. Naasea and vomiting management. Although the routine prophylactic administration of antiemetics is not advocated, 3s preventive antiemetic therapy in high-risk situations will help
AMBULATORY PATIENT DISCHARGE minimize patient annoyance and dissatisfaction, shorten time until discharge, and reduce unanticipated hospital admissions. "Rescue" antiemetic therapy with agents relatively free of side effects, (eg, ondansetron, 4 mg, intravenously in the adult patient) should be considered for patients developing nausea and vomiting in the phase I or II areas. The patient should have no more than minimal nausea or vomiting before discharge. 36
Surgical Bleedhzg The expertise of the phase II recovery nurse is crucial in evaluating appropriate surgical bleeding. With some procedures no bleeding is anticipated, whereas with others it is expected that dressing changes will be required. Communication with the surgeon is important to establish permissible levels of drainage (eg, blood, urine, or other fluids) from the surgical site. The patient must have a clear understanding of what is acceptable bleeding or drainage, and when to contact the responsible and available physician.
Vital Signs It is often difficult to ascertain the patient's normal vital signs in the preoperative environment of today's ambulatory setting. One set of vital signs in the preoperative setting is the norm; however, these can be influenced by a rushed admission, pain, anxiety, or the activity of changing clothes and getting onto the gurney. Discharge evaluation of vital signs should reflect age appropriateness, general health status, anesthetic technique, a comparison with not only preoperative values but also intraoperative and postoperative values, and the patient's position when blood pressure and heart rate were observed. Vital signs should be stable for at least 30 minutes 36 and be consistent with the patient's age. Blood pressure and pulse rate. Ideally, the criteria established by Aldrete 3~ and Chung 3z of being within +20% of preanesthesia value should be observed. Occasionally, the physician must depend on the entire clinical picture to make an informed decision to discharge in instances when the established criteria cannot be met. 39 Clinical signs of orthostatic hypotension (eg, dizziness, tachycardia, nausea, syncope) should be monitored especially while the patient is sitting uptight. Temperature. Postoperative hypothermia and the associated clinical consequences have been
45 well illustrated.4~Among the complications associated with hypothermia are coagulopathy,4~ negative nitrogen balance, 42 prolonged drug action, 43 and shiveringY Ambulatory surgery may predispose the patient to temperature drops approximating 2~ to 3~ which are well endured.4s A patient temperature of less than 35~ should be aggressively treated with active skin-surface warming devices (eg, forced air warmers). The usefulness of establishing a minimum temperature criteria before patient discharge has yet to be demonstrated. 46
Ambulation The upright position alone may challenge the body's ability to maintain hemodynamic stability, as reflected by minimal changes in blood pressure and pulse rate. The patient's ability to ambulate can be impacted by the surgical procedure, the patient's developmental level, and the typical preoperative movement patterns. If assistance to ambulate is required, the home caregiver must be capable of meeting this need. It must be determined that the patient can safely move from the vehicle to their resting location at home. They must also be able to perform basic functions such as dressing themselves and walking to the bathroom. Dizzhzess. There should be minimal dizziness after changing into street clothes and sitting for at least 10 minutes. 36 Postural hypotension. Assuring sufficient hydration will help prevent dizziness and postural hypotension. 37 Healthy adult outpatients, given at least 20 mL/kg lactated Ringers 47 or Plasmalyte48 perioperatively, exhibited less dizziness. Ephedrine, a sympathomimetic drug, given intramuscularly (0.5 mg/kg) during surgery49 or 10 mg to 25 mg intravenously in phase II5~may be beneficial in attenuating the dizziness and nausea and vomiting associated with postural hypotension.
Oral hltake The ability to swallow fluids and to gag or cough should be demonstrated. 5~ It is important to establish that a protective airway reflex is present. The capacity to tolerate oral fluids should be confirmed if this is crucial to the patient's continued convalescence at home. If oral medications (eg, analgesics) are necessary for the patient to remain comfortably at home,
46 then it is essential to confirm their ability to tolerate such intake. The patient with diabetes mellitus should be able to resume caloric intake as soon as possible. It is unnecessary to force oral fluids in the otherwise healthy outpatient who is adequately hydrated (eg, minimal fasting time, generous intravenous hydration, and minimal vomiting). The incidence of vomiting in patients required to take oral fluids was found to be approximately 75% greater than in those who resumed oral intake voluntarily.52
Voiding Patient evaluation. Patient evaluation relative to postoperative voiding should include the patient's age, state of hydration, and psychomotor state of arousal. The patient who (l) has fasted extensively (eg, nothing by mouth since the evening before surgery), (2) has voided just before surgery, (3) is not provided an understanding, relaxed atmosphere (a particular consideration with children),53 or (4) has received minimal intravenous hydration in the perioperative setting may not demonstrate the need to void. Conversely, the older patient (>53 years of age) who received sufficient intravenous hydration (> 1.2 L) for inguinal herniorrhaphy may be expected to show more urinary retention. 54 High risk procedures. Certain procedures (eg, urological, gynecological, inguinal herniorrhaphy) are associated with a high incidence of urinary retention. Patients having these procedures should show the ability to void before discharge. Following cystoscopy procedures, the urine should be observed to assure that hematuria, if present, is within clinically acceptable limits. Consideration for central axial blocks. Patients receiving spinal or epidural anesthesia should demonstrate the ability to void before discharge because intact functioning of the autonomic nerve supply to the bladder and urethra is essential for micturition. In select patients who are unable to void, bladder catheterization along with explicit instructions (eg, how to recognize signs of urinary retention and the timeframe in which to contact the physician if unable to void) may allow patient discharge. 55 Postdischarge urinary retention. When voiding is not a criteria for discharge, the patient should be advised at what point following dis-
MARLEY AND MOLINE charge (eg, after 6 to 8 hours) they should contact the responsible and available physician if they can not void. ~3
Respiratory Status The patient with significant respiratory impairment is not a candidate for discharge. Adequate oxyhemoglobin saturations via pulse oximetry (SpO2), respiratory rates consistent with age and preoperative health status, and an uncompromised airway permit further evaluation of the patient to meet other discharge criteria. The patient should be free of respiratory distress as shown by absence of croupy (barky) cough, dyspnea, nasal flaring, obstructed respiration, retractions, stridor, or wheezing. 5L56 SPECIAL CARE ISSUES
Regional Anesthesia Criteria specific to regional anesthesia must be followed before patient discharge. These criteria are in addition to those applied to the patient following general anesthesia. Subarachnoid and epidural block. Patients may recuperate in the phase II recovery area when their block has receded to LI or lower because hemodynamic aberrations secondary to sympathetic block will be minimal.55 The patient may transfer with assistance to a chair once full sensation has returned and if the blood pressure remains stable when the head of the bed is elevatedY Total resolution of sensory blockade could be assessed by skinprick sensation to the perianal region ($4_5).5s To show recovery from the motor blockade, the patient should be able to take each heel and move it contralaterally from the big toe to the knee and back) 3 If the patient tolerates the sitting position without postural hypotension, they may then ambulate with assistance. 57 It is important that the patient show total recovery from sympathetic, motor, and sensory blockade to assure that steady gait, and bowel and bladder control are present. This might best be shown by the patient's ability to walk to the bathroom and urinate without significant orthostatic blood pressure changes. Premature discharge may predispose the patient to urinary retention, bladder overdistension, and signs and symptoms of hypotonic bladder. 55 Caudal block. The patient should not be permitted to ambulate without assistance for :>6 to 8
AMBULATORY
PATIENT DISCHARGE
47
hours following surgery with caudal analgesia. 38 Urinary retention is not usually a p r o b l e m following caudal block; 59 however, the patient and responsible party should be instructed to contact the responsible physician if the patient is unable to v o i d after 6 to 8 hours. $5 Axillary block. F o l l o w i n g axillary b l o c k a d e , the patient m a y be discharged with residual sensory or m o t o r b l o c k with the arm supported in a sling, The patient should be cautioned to protect the e x t r e m i t y from injury (eg, no s m o k i n g or cooking) until normal sensation and reflexes have returnedY Foot block. T h e foot should be protected with a b u l k y dressing and the patient instructed on the proper use o f crutches. T h e patient should be monitored to assure proper crutch operation, and if technically difficult for the patient to master, the responsible adult must be p h y s i c a l l y able to assist the patientP 7
Malignant Hyperthermia Susceptible A malignant h y p e r t h e r m i a ( M H ) - s u s c e p t i b l e patient is defined as having (1) a previous e p i s o d e
o f MH, (2) masseter m u s c l e rigidity with previous anesthesia, or (3) a first degree relative with history o f an M H e p i s o d e or positive muscle biopsy. 6~ T h e M H susceptible patient w h o has received a routine, trigger-free anesthetic does not require hospital a d m i s s i o n based exclusively on being M H susceptible. 6~ The patient should be scheduled as early in the day as possible to facilitate extended patient observation for 4 to 6 hours. 62 H o w e v e r , any concerns about discharging the patient should lead to overnight patient monitoring.
SUMMARY T e c h n o l o g i c a l and p h a r m a c o l o g i c a l advances will increase the scope o f outpatient procedures. Financial efficiency and cost containment will also drive the e x p a n d i n g role o f outpatient facilities in the surgical arena. Patient m a n a g e m e n t related to discharge must include safety, quality care, and e c o n o m i c viability. A thoughtful, organized approach to patient care in regards to planning for their eventual discharge from the facility impacts greatly on these issues.
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39. McMullen JNB, Jahr JS: Discharge criteria for ambulatory surgery: A review of the current literature. J Louisiana St Med Soc 145:101-105, 1993 40. Slotman GJ, Jed Ell, Burchard KW: Adverse effects of hy.pothermia in postoperative patients. Am J Surg 149:495501, 1985 41. Valeri RC, Feingold H, Cassidy G, et al: ttypothermiainduced reversible platelet dysfunction. Ann Surg 205:175181, 1987 42. Carli F, Emery PW, Freemantle CAJ: Effect of preoperative normothermia on postoperative protein metabolism in elderly patients undergoing hip arthroplasty. Br J Anaesth 63:276-282, 1989 43. Heier T, Caldwell JE, Sessler DI, et al: Mild intraoperative hypothermia increases duration of action and spontaneous recovery of vecuronium blockade during nitrous oxideisoflurane anesthesia in humans. Anesthesiology 74:815-819, 1991 44. Sessler DI, Ruhinstein Ett, Moayeri A: Physiologic responses to mild perianesthetic.,hypothermia in humans. Anesthesiology 75:594-610, 1991 45. Mecca RS, Sharnick SV: Common postanesthesia care unit problems, in McGoldrick KE (ed): Ambulatory Anesthesiology: A Problem-Oriented Approach. Baltimore, MD, Williams & Wilkins, 1995, pp 582-618 46. Fetzer-Fowler SJ, Huot S: The use of temperature as a discharge criterion for ambulatory surgery patients. J Post Anesth Nurs 7:398-403, 1992 47. Cook R, Anderson S, Riseborough M, et al: Intravenous fluid load and recovery. A double-blind comparison in gynaecological patients who had day-case laparoscopy. Anaesthesia 45:826-830, 1990 48. Yogendran S, Asokumar B, Cheng DCH, et al: A prospective randomized double-blinded siudy of the effect of intravenous fluid therapy on adverse outcomes on outpatient surgeryJ Anesth Analg 80:682-686, 1995 49. Rothenberg DM, Pamass SM, Litwack K, et al: Efficacy of ephedrine in the prevention of postoperative nausea and vomiting. Anesth Analg 72:58-61, 1991 50. Wetchler BV: Management of nausea and vomiting in the ambulatory surgical patient9 Society for Ambulatory Anesthesia Newsletter 3:2-3, 1988 51. WetchlerBV: Problem solving in the p0stanesthesia care unit, in Wetchler BV (ed): Anesthesia for Ambulatory Surgery (ed 2). Philadelphia, PA, Lippincott, 1991, pp 375436 52. Schreiner MS, Nicolson SC, Martin T, et al: Should children drink before discharge from day surgery? 9 ology 76:528-533, 1992 53. ttjalmas K: Urodynamics in normal infants and children. Stand J Urol Nephrol 114(suppl):20-27, 1988 54. Petros JG, Rimm EB, Robillard RJ, et al: Factors influencing postopemti,/'e urinary retention in patients undergoing elective inguinal hemiorrhaphy. Am J Surg 161:431-433, 1991 55. Pavlin DJ: Regional anesthesia, in Twersky RS (ed): The Ambulatory Anesthesia Handbook. St. Louis, MO, Mosby-Year Book, 1995, pp 239-300 56. Patel RI: D~scharge criteria and postanesthetic complications following pediatric ambulatory surgery. J Post Anesth Nuts 3:114-117, 1988 57. Mulroy MR: Regional anesthetic techniques, in White
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PF (ed): International Anesthesiology Clinics: Anesthesia for Ambulatory Surgery. Boston, MA, Little, Brown and Co, 1994, pp 81-98 58. Pflug AE, Aasheim GM, Foster C: Sequence of return of neurological function and criteria for safe ambulation following subarachnoid block (spinal anaesthetic). Can Anaesth Soc J 25:133-139, 1978 59. Fisher QA, McComiskey CM, Hill JL, et al: Postoperative voiding interval and duration of analgesia following peripheral or caudal nerve blocks in children. Anesth Analg 76:173-177, 1993
49 60. McGoldrick K: Is malignant hyperthermia a contraindication for outpatient surgery? Society for Ambulatory Anesthesia Newsletter 7:11, 1992 61. Spieker M: Patients susceptible to malignant hyperthermia, in McGoldrick KE (ed): Ambulatory Anesthesiology: A Problem-Oriented Approach. Baltimore, MD, Williams & Wilkins, 1995, pp 318-331 62. Yentis SM, Levine MF, Hartley EJ: Should all children with suspected or confirmed malignant hyperthermia susceptibility be admitted after surgery? A 10-year review. Anesth Analg 75:345-350, 1992