Optimal Discharge Strategy

INTRODUCTION

The concept of the ambulatory procedure with admission, operation, and discharge on the same day has evolved considerably over the last several decades. Both the types and volume of surgical procedures performed on an outpatient basis have expanded tremendously over that period. The reason ambulatory surgical care has rapidly grown is multifaceted and related to changes in both surgical and anesthesia fields. Some of the advantages include but are not limited to earlier return to preoperative physiologic state with reduced physical and mental disturbance, fewer complications, earlier resumption of normal activities, and reduced hospital costs. The increasing use of regional anesthesia as a primary anesthetic has played a significant role in facilitating same-day surgeries. Because of these advances, it is expected that the number, diversity, and complexity of procedures performed in the outpatient setting will continue to increase.

Time to discharge from a postanesthesia care unit (PACU) is considered to be a measure of the efficiency of the unit. Nonetheless, patient safety should not be sacrificed at the expense of optimizing efficiency. Therefore having evidence-based guidelines for safe discharge from the PACU is crucial. This chapter outlines the current literature and guidelines on discharge criteria and management and treatment recommendations for factors affecting PACU discharge.

PHASES OF POSTANESTHETIC CARE

The American Society of Anesthesiologists (ASA) refers to postanesthetic care as activities involved in managing a patient after completion of a procedure and its respective anesthetic. This is done until it is determined that the patient is safe to proceed home. PACU care is divided into two stages: Phase I and Phase II. Phase I focuses on recovery from anesthesia and on a return to baseline vital signs. Here consideration is given to the specific procedure, anesthetic, and patient comorbidities to minimize complications and facilitate their management. PACU providers are assessing vital signs, managing respiratory and hemodynamic changes, and treating any postoperative pain or nausea/vomiting (PONV). Phase II pivots attention to the patient's transition to home or extended care facility. This includes ensuring the patient's ability to ambulate and their understanding of their home care instructions.

Most patients are transferred from the operating room to the PACU and are transitioned through sequential phases of PACU care before they are discharged home. Nevertheless, some facilities will have a process known as “fast tracking,” which entails bypassing Phase I of PACU care. Criteria for this group of patients will be institution and facility specific. Most commonly, this is used for procedures done with local anesthesia. Patient and procedure selection is imperative to maintaining patient safety in this abridged monitoring process.

OPTIONS: DISCHARGE CRITERIA

There are several scoring systems that have been used as a part of the complete clinical evaluation to determine safe discharge criteria from the PACU. These are outlined in Box 56.1 . The most used system has been the postanesthetic recovery scoring system (PAS), also known as the modified Aldrete score. The metrics quantified in this assessment can be found in Table 56.1 . The postanesthesia discharge score was devised by Chung and colleagues in 1993 and further honed to eliminate the requirements for oral fluid intake and urinary output prior to discharge. ^, These same authors outlined a less refined but more blanketed set of safe discharge criteria, which can be found in Box 56.2 . PADS is a cumulative index that measures the home-readiness of patients based on five major criteria: (1) vital signs, (2) activity and mental status, (3) pain, (4) postoperative nausea and vomiting, and (5) surgical bleeding. The pain criteria have been further refined to score pain with a visual analog scale ranging from 1 to 10. Patients who achieve a score of 9 or greater are considered fit for discharge with an adult escort. The full scale of this system can be seen in Table 56.2 .

BOX 56.1

Common Discharge Criteria

Discharge Criteria Applied at Different Phases of Recovery

Discharge criteria at postanesthesia care unit (phase 1 recovery)
Aldrete score
Discharge criteria at ambulatory surgical unit (phase 2 recovery)
Postanesthesia discharge score
Outcome-based discharge criteria
Discharge criteria for fast-tracking
White fast-tracking score

Discharge Criteria Used for Research Purposes

Psychomotor test of recovery (phase 3 recovery)

Discharge Criteria Used Under Specific Circumstances

Discharge home criteria after neuraxial blockade
Discharge home criteria after peripheral nerve block
Discharge home criteria for suspected malignant hyperthermia

TABLE 56.1

Modified Aldrete Scoring System ^a

	Discharge Criteria from Postanesthesia Care Unit	Score
Activity	Able to move voluntarily or on command
	Four extremities	2
	Two extremities	1
	Zero extremities	0
Respiration	Able to breathe and cough freely	2
	Dyspnea, shallow or limited breathing	1
	Apneic	0
Circulation	Blood pressure 20 mm of preanesthetic level	2
	Blood pressure 20–50 mm of preanesthesia level	1
	Blood pressure −50 mm of preanesthesia level	0
Consciousness	Fully awake	2
	Arousable on calling	1
	Not responding	0
O ₂ saturation	Able to maintain O ₂ saturation >92% on room air	2
	Needs O ₂ inhalation to maintain O ₂ saturation >90%	1
	O ₂ saturation <90% even with O ₂ supplementation	0

a To determine readiness for discharge from postanesthesia care unit. A score greater than 9 is required for discharge. From Aldrete JA. The postanesthesia recovery score revisited. J Clin Anesth. 1995;7:89–91.

BOX 56.2

“Safe Discharge” Criteria ^a

Patient alert and oriented to time, place, and person
Stable vital signs
Pain controlled by oral analgesics
Nausea and emesis controlled
Able to walk without dizziness
No unexpected bleeding from the operating sites
Discharge instruction and prescription received
Patient accepts readiness for discharge
Responsible escort

a A set of typical discharge criteria to determine readiness for discharge from a postanesthesia care unit. All parameters of safe discharge criteria need to be met before discharge. (From Awad IT, Chung F. Factors affecting recovery and discharge following ambulatory surgery. Can J Anaesth. 2006;53:858–872.)

TABLE 56.2

Postanesthetic Discharge Scoring System

	Vital Signs
	Within 20% of preoperative baseline	2
	20%–40% of preoperative baseline	1
	40% of preoperative baseline	0
	Activity Level
	Steady gait, no dizziness, consistent with preoperative level	2
	Requires assistance	1
	Unable to ambulate/assess	0
	Nausea and Vomiting
	Minimal: mild, no treatment required	2
	Moderate: treatment effective	1
	Severe: treatment not effective	0
	Pain
	VAS = 0–3: the patient has minimal or no pain before discharge	2
	VAS = 4–6: the patient has moderate pain	1
	VAS = 7–10: the patient has severe pain	0
	Surgical Bleeding
	Minimal: does not require dressing change	2
	Moderate: required up to two dressing changes with no further bleeding	1
	Severe: required three or more dressing changes and continues to bleed	0

VAS, visual analog scale.

Maximum score = 10: patients scoring greater than 9 are fit for discharge.

From Awad IT, Chung F. Factors affecting recovery and discharge following ambulatory surgery. Can J Anaesth. 2006;53:858–872.

In 2002, the ASA published updated guidelines for postanesthetic care with three main areas of emphasis: perioperative assessment and monitoring, treatment during emergence and recovery, and protocol for discharge. These have now become more foundational to facility-specific discharge guidelines, whereas the previous scoring systems are used as adjuncts to supplement safe discharge.

PERIOPERATIVE ASSESSMENT AND MONITORING

This phase of postanesthetic care involves monitoring and assessment of different clinical criteria, some of which apply to all patients and others to selected patients. The functions that are followed for all-comers are: respiratory and cardiovascular function (respiratory rate, oxygen saturation, pulse, blood pressure), neuromuscular function, mental status, pain, temperature, and nausea/vomiting. Additional parameters that are specific to patients meeting certain criteria are: electrocardiogram (ECG), urine output and voiding, and drainage and bleeding of the surgical site. The ASA has agreed that monitoring of these measures will identify complications and reduce adverse outcomes.

Previous literature has suggested that assessment of pulse oximetry has facilitated earlier detection of hypoxemia. Therefore it is recommended that periodic assessment of airway patency, respiratory rate, and oxygen saturation occur during emergence and recovery. There is insufficient literature to note the significance of cardiac monitoring in the perioperative setting. Despite this, all patients should have their pulse oximetry and blood pressure monitored during emergence and recovery. ECG monitoring should be available but is not a recommended routine practice. If a patient received neuromuscular blockade, their neuromuscular function should be assessed via physical examination. Mental status, temperature, nausea/vomiting, and pain should be periodically examined during emergence and recovery. Fluid status also requires assessment; fluid management, with respect to fluid and blood loss and resuscitation, is specific to the procedure and the patient. Finally, both urine output/voiding and surgical site drainage and bleeding are assessed for selected patients and procedures.

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