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Also facilitating efficient and safe discharge are clear and concise
discharge criteria. The Aldrete scoring system and the Post Anesthetic
Discharge Scoring System (PADSS) have received widespread
acceptance in assessing postanesthetic recovery. The Aldrete scoring
system originated in 1970 by Dr J. A. Aldrete; the PADSS originated in
1991 by Dr Frances Chung (Table 1).
As the popularity of ambulatory surgery grows, appropriate discharge
criteria must be followed to ensure patient-centered care. With the
acuity of outpatient surgery increasing, the aging population, and
expansion of inclusion criteria for day surgery, it becomes even more
significant to have clear, evidence-based discharge criteria in clinical
use. The following article discusses the history leading up to current
discharge criteria, the modifications made to ensure continued
practicality and accuracy, the benefits and limitations with discharge
criteria, and the resulting implications to the perianesthesia nurse.
R espiration,
E nergy,
A lertness,
C irculation, and
T emperature
Several limitations have been observed with the R.E.A.C.T. assessment
tool. Its creators acknowledge that it is not appropriate for monitoring
acute changes such as the onset of oxygen desaturation, dysrhythmias,
or bleeding.
This tool is recommended for use after such problems have been
resolved. This is a serious limitation because cardiac and respiratory
complications occur more frequently in the PACU than in ambulatory
care areas. The R.E.A.C.T. scoring tool also lacks a parameter to score
oxygenation, a parameter included in the Aldrete scoring system.
Although standard discharge criteria are useful to assess discharge
readiness, the criteria is broad without specifications as to vital sign
ranges or expected pain levels. Therefore, such guidelines should be used
along with the PADSS to ensure the patient is safe for discharge to
Phase III recovery.
medical assistance and age are relative factors that the critical-thinking
nurse keeps in mind when using scoring systems to assess discharge
readiness. Scoring systems focus on discharge goals; however, such
systems can still fail patients if we blindly look at the scoring criteria.
Other limitations to keep in mind are the occurrence of postoperative
complications requiring re-admission to the hospital. The complication
rate after ambulatory procedures remains low. Most complications are
transient, such as pain, sore throat, and nausea. Some complications can
be managed before discharge. The rates of unanticipated admissions
after day surgical procedures range between 0.3 to 1.4%. Discharge
teaching is key to the patient and family understanding which situations
will warrant return to the hospital or further medical assistance.
Calculating scores on the vital sign parameters of both the Aldrete
scoring system and the PADSS can be an area of uncertainty. Although
the patients vital signs may be within normal range for age, the blood
pressure should be compared with that of preoperative value to ensure
the patients return to homeostasis. However, if the preoperative value
was abnormally elevated because of anxiety or pain, expecting the
postoperative blood pressure to be within 20% of an elevated blood
pressure may not be appropriate. Again, an individualized patient
assessment by the nurse and consultation with the surgeon or
anesthesiologist, as needed, will confirm that the patient is suitable for
discharge in such situations. Discharge readiness does not assume street
fitness. If the patient does not understand the activity restrictions
required as they continue Phase III recovery at home, there is risk for
overexertion and adverse reactions occurring. Again, it is recognized that
scoring criteria are an important part of assessing discharge readiness,
but they must be used with approved discharge criteria, health teaching,
and follow-up telephone calls. Using discharge criteria as well as
appropriate patient selection for ambulatory surgery are key factors to
ensure the patients ability to meet discharge criteria.
Common Complications After Ambulatory Surgery
Ambulatory surgery is safe, with adverse events occurring at low rates,
less than 2%. Cardiovascular events (such as hypotension, hypertension,
and dysrhythmias) occur most frequently, followed by respiratory events
(such as laryngospasm, bronchospasm, and oxygen desaturation).
Cardiac or respiratory comorbidities are strongly associated with such
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References
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