CHAPTER 30. Phase I Discharge Criteria
Susan Jane Fetzer
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Define terminology describing discharge definitions.
2. Describe commonly used post anesthesia care unit (PACU) discharge criteria.
3. Describe the function of discharge criteria.
I. OVERVIEW
A. Standard: PACU nurses must assess and evaluate the patient’s readiness for discharge. Using a criteria-based scoring system ensures patients are adequately prepared for transfer to PACU phase II extended observation or a nursing unit.
B. Definitions
1. Discharge ready: a multifaceted concept that describes a patient’s functional and cognitive state as sufficiently recovered from anesthesia and able to leave the PACU and be safely cared for in a less intensive nursing environment
2. Discharge readiness: the state of being ready to leave the PACU and be cared for in a less intensive nursing environment
3. Discharge criterion: a standard or test by which to judge or decide whether a PACU patient is discharge ready
4. Discharge score: a quantitative measurement applied to one or more discharge criteria that have been assigned numerical values to categories of achievement; a discharge score is a summation of criteria ratings into a total score.
5. Ready for transfer: a description of the patient who is discharge ready
6. Fast-tracking: an action bypassing PACU phase I recovery when phase I criteria have been met before leaving the operating room (OR)
7. Evidence of discharge readiness includes:
a. An assessment by the attending anesthesia personnel
b. Meeting established criterion or criteria
c. Achieving an acceptable score on an established discharge scoring system
d. Documentation of nursing assessment that reflects that the patient is:
(1) Physiologically stable
(2) Responsive to external stimuli
(3) Free from anesthetic and surgical complications
(4) Adequately recovered from the major effects of anesthesia
8. Ready for transfer criteria may extend to include patient characteristics that are not included under discharge criteria but fall within the jurisdiction of nursing judgment such as:
a. Attaining an acceptable level of pain
b. Attaining an acceptable level of nausea
c. Need for ongoing pharmacological or technological treatments
(1) Completed blood transfusion
(2) Chest x-ray
(3) Respiratory treatment
d. Need for ongoing collaboration with other health care providers
(1) Respiratory therapy
(2) Surgeon
9. Ready-for-transfer criteria may extend to include institutional characteristics that affect the patient’s ability to leave the PACU environment such as:
a. Ability of receiving unit to accept transfer due to bed availability
b. Ability of receiving unit to accept transfer due to personnel availability
C. Function of discharge criteria
1. Ensure standard of care is met for all patients.
2. Guide practice decisions without dictating practice.
3. Promote efficient use of fiscal and personnel resources.
a. Use of discharge criteria shown to reduce PACU time by 24%.
b. Use of discharge criteria shown to decrease discharge delays.
c. Use of discharge criteria had no significant differences in adverse events.
4. Allow nurses to act on behalf of anesthesia personnel.
a. American Society of Anesthesiologists (ASA) states in their Standards for Postanesthesia Care that “in the absence of the physician responsible for the discharge, the PACU nurse shall determine that the patient meets the discharge criteria.”
5. Meet Joint Commission requirements.
a. Relevant discharge criteria rigorously applied to determine the readiness of the patient for discharge
b. Discharge criteria approved by the medical staff
6. Meet American Society of PeriAnesthesia Nurses (ASPAN) Standards of Perianesthesia Nursing Practice 2008-2010.
7. Nurse Practice Act: determining discharge readiness is a delegated act (refer to specific practice act of each state).
D. Requirements for determining discharge readiness
1. ASA Standards for Postanesthesia Care
a. Standard V: Physician is responsible for the discharge of the patient from the post anesthesia care unit.
b. Standard V.1. When discharge criteria are used, they must be approved by the Department of Anesthesiology and the medical staff. They may vary depending upon whether the patient is discharged to a hospital room, to the intensive care unit (ICU), to a short stay unit, or home.
2. Discharge criteria must be applied consistently.
3. Discharge criteria must be enforced.
4. Compliance to discharge criteria must be monitored.
E. Application of discharge criteria
1. Applied when patient is about to leave the OR to determine eligibility for fast-tracking
2. Applied when patient is admitted to PACU as part of nursing assessment
3. Applied routinely (every 15 or 30 minutes depending on institutional policy) as part of a nursing assessment
4. Used to monitor intraoperative and postanesthesia interventions for effectiveness during quality assurance activities
5. Used in nursing research to monitor the effect of interventions on patient outcomes
6. Supports physician and nursing critical judgment of discharge readiness
F. Variations of discharge readiness
1. PACU to ICU
a. Achievement of discharge criteria reflects need for ongoing critical care nursing to monitor and intervene.
b. All discharge criteria may not be met.
c. Discharge score defining discharge readiness may not be achieved.
d. Physician evaluation is used in place of discharge criteria or discharge score.
e. Discharge readiness and ready to transfer should occur concurrently.
2. PACU to acute care
a. Discharge criteria met with one or two exceptions.
b. Discharge score attained within acceptable range set by policy.
c. Reasons for exceptions included in nursing documentation.
d. Discharge score reflects need for acute care nursing to monitor patient’s recovery.
e. Institutional policies identify exceptions that must be reported to the physician before transfer.
f. Discharge readiness may be attained before ready to transfer.
3. PACU to phase II/extended observation
a. Achievement of most discharge criteria with the likelihood that all discharge criteria will be attained shortly after discharge to phase II
b. Discharge criteria are met, but occasionally other patient characteristics (e.g., pain control, nausea) may restrict the patient from phase II discharge to home.
c. Discharge score attained within acceptable range set by institutional policy.
d. Discharge readiness may be attained before ready to transfer.
4. PACU to home
a. Achievement of all PACU discharge criteria and all phase II discharge criteria met
b. Any discharge criteria exceptions documented and reported to the physician
c. Order to discharge home documented
d. Appropriate for patients receiving monitored anesthesia care
II. STANDARDS FOR DISCHARGE CRITERIA
A. Discharge criteria are:
1. Objective
2. Measurable
3. Understandable
4. Able to be applied by knowledgeable health care providers
B. Discharge criteria are valid.
1. Criterion reflects the concept being measured (e.g., arterial oxygen saturation [Sa o2] is a more valid measurement of oxygenation than patient color).
2. Criterion acknowledged as appropriate by content experts
3. Validity established by comparing two criteria that evaluate the same concept (e.g., level of sensory block and extremity movement)
4. Reflect the ability of the criterion to be sensitive to changes in patient status and able to measure change in patient status appropriately
5. Can be supported by testing the criterion against future predictions
6. Validity evaluated on a continuum
7. A discharge criterion may be valid for one population of patients but not for another (e.g., discharge criterion of Sa o2 >92% is not valid for a patient with chronic obstructive pulmonary disease who has baseline Sa o2 of 89%).
C. Discharge criteria are reliable.
1. Criterion applied the same way regardless of health care provider (interrater reliability)
2. Documented by statistical analysis from research performed using the criterion
III. COMMONLY USED DESCRIPTORS FOR PACU DISCHARGE CRITERIA
A. Respiratory criteria
1. Respiratory stability
a. Able to breathe deeply
b. Able to breathe deeply and cough freely
c. Coughs on commands or cries
d. Tachypnea with a good cough
e. Maintains good airway
f. Dyspnea or limited breathing
g. Dyspnea, limited breathing, or tachypnea
h. Dyspnea with a weak cough
i. Apneic
j. Apneic or on mechanical ventilator
k. Requires airway maintenance
2. Oxygen saturation
a. Maintains value >92% on room air
b. Needs O 2 inhalation to maintain saturation >90%
c. Requires supplemental oxygen
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