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
d. Saturation <92% with supplemental oxygen
e. O 2 saturation <90% with supplemental oxygen
3. Color
a. Pink
b. Pink and warm
c. Pale, dusky, blotchy, jaundice, others
d. Cyanotic
B. Cardiovascular criteria: hemodynamic stability
1. Blood pressure within 15%, 30%, 50% of preoperative baseline
2. Blood pressure >90 mm systolic and within 30 mm Hg of preoperative baseline
3. Blood pressure within 20%, 20% to 50%, 50% of preanesthetic level
4. Blood pressure within 20%, 20% to 49%, 50% of preanesthetic level
5. Exception: children who are crying
C. Musculoskeletal criteria: physical activity
1. Able to stand up and walk straight
2. Able to move all extremities on command
3. Able to move all extremities voluntarily or on command
4. Active motion, voluntary or on command
5. Head lift with closed mouth for 5 seconds
6. Moving limbs purposefully
7. Vertigo when erect
8. Some weakness in movement of extremities
9. Dizziness when supine
10. Weak motion, voluntary or on command
11. Able to move two extremities on command
12. Able to move two extremities voluntarily or on command
13. Nonpurposeful movements; unable to move extremities voluntarily
14. Unable to move extremities voluntarily or on command
15. No motion
D. Neurological criteria: level of consciousness
1. Fully awake
2. Awake and oriented
3. Fully awake or easily aroused when called
4. Verbal response to spoken command
5. Arousable with minimal stimulation
6. Responding to stimuli
7. Responds to stimuli and exhibits presence of protective reflexes
8. Arousable on calling
9. Responsive to only tactile stimulation
10. Not responding
11. No response or absence of protective reflexes
E. Temperature
1. Core temperature at least 36° C (96.8° F)
2. Patient describes feeling acceptable level of warmth.
3. No signs and symptoms of hypothermia
4. Exception: can be discharged to critical care with temperature less than 36° C
F. Presence of pain
1. Pain free
2. No pain or mild pain
3. Moderate to severe, controlled with analgesics
4. Mild pain handled by oral medication
5. Persistent severe pain
6. Severe pain requiring parenteral medication
7. Comfortable with regard to pain
G. Additional criteria considered concurrently with discharge criteria
1. Emetic symptoms
a. Able to drink fluids
b. None or mild nausea with no vomiting
c. Nauseated
d. Transient vomiting or retching
e. Nausea and vomiting
f. Persistent moderate or severe nausea and vomiting
2. Urinary symptoms
a. Has voided
b. Unable to void but comfortable
c. Unable to void and uncomfortable
d. Bladder ultrasound less than 400 mL
3. Surgical site
a. Dry and clean
b. Wet but stationary or marked
c. Growing area of wetness
H. Additional regional anesthesia (epidural/spinal) discharge criteria
1. Orthostatic blood pressure challenges
a. Intervals of 30 minutes
b. Less than 10% decrease in mean arterial pressure
2. Sensory level
a. Less than or equal to T10
3. Block has started and continues to recede.
4. Two segment regression of sensory block
5. Receding block to L1 or lower
I. Additional regional anesthesia (shoulder/ankle) discharge criteria
1. No sensory or motor criteria required for discharge from PACU
J. Minimum mandatory stay as a discharge requirement
1. Insufficient research literature to support minimum 1-hour stay in PACU
2. Length of stay should be determined on case-by-case basis.
K. Sources of discharge criteria descriptors as noted in preceding sections
1. Postanesthesia Recovery Score (PARS)—Aldrete and Kroulik (1970)
6. Postanesthesia Recovery Score for Ambulatory Patients (PARSAP)—modified Aldrete (1995)
8. White (1999)
10. ASPAN (2008)
IV. OVERVIEW OF DISCHARGE SCORING MEASURES
A. Quantitatively summarizes clinical observations and judgments
B. Composed of discharge criteria that best reflect the patient’s overall status
C. Discharge criteria used for discharge score may be patient specific
1. Criteria and scoring system for general anesthesia patient
2. Criteria and scoring system for obstetric patient
3. Criteria and scoring system for regional anesthesia patient
D. Each criteria has two or more levels on which patient can be described.
1. Point for each level of criterion attained
2. Greater total score reflects:
a. Increased patient stability
b. Lower risk of complications upon transfer
c. Progress toward discharge readiness
E. Requirements for discharge scoring measures
1. Simple to administer
2. Easy to remember
3. Applicable to all situations
4. Able to discriminate among patients at different levels of recovery (validity)
5. Able to be scored similarly by two different providers simultaneously (reliability)
V. EXAMPLES OF DISCHARGE CRITERIA SCORING SYSTEMS
A. Aldrete (also known as PARS)
1. Developed in 1970
2. Five criteria rated from 0 to 2
a. Activity
b. Respiration
c. Circulation
d. Consciousness
e. Color
3. Maximum score of 10
4. Scores 8 and 9 reflect discharge readiness.
5. Scores less than 7 are dangerous.
6. Recommended assessment every 30 minutes
7. Evidence of validity and reliability
a. Aldrete (1970)
(1) Studied 352 patients undergoing general anesthesia
(2) Seventy-eight percent of patients scored 8 or higher upon PACU admission.
b. Figueroa (1972)
(1) Studied 500 cases with 89% having general anesthesia
(2) Fifty-six percent of patients scored lower than 7 upon PACU admission.
(3) Eleven percent of patients scored 10 upon PACU admission.
(4) Age, sex and surgical procedure did not influence scores.
c. Holzgrafe (1972)
(1) Studied 456 patients
(2) Twenty-four percent of patients scored 8 or higher upon PACU admission.
(3) Circulation criteria were likely to have higher score on admission.
(4) Level of consciousness and activity had lowest scores on admission to PACU.
d. Soliman et al. (1988)
(1) Studied 81 children undergoing general anesthesia
(2) Used PARS with additional oxygen saturation criterion
(3) No significant association with PARS score and oxygen saturation was identified.
(4) Twelve children had PARS scores higher than 8 with Sa o2 less than 95%.
B. Steward
1. Proposed in 1975
2. Three criteria rated from 0 to 2
a. Consciousness
b. Airway
c. Movement
3. Maximum score of 6
4. Excluded color because deemed color was not objective and difficult to interpret
5. Excluded blood pressure because of little constant relation to recovery from general anesthesia
6. Minimum score for discharge not recommended
7. Evidence of validity and reliability not published
C. Thomas and Davis
1. Proposed in 1984
2. Five criteria rated either 0 or 1
a. Systolic blood pressure above 90 mm Hg, but not 30 mm Hg above or below the preoperative reading
b. Pink and warm
c. Verbal response to spoken command
d. Head lift with closed mouth for 5 seconds
e. Comfortable with regard to pain
3. Minimum score of 5 required for discharge
4. Evidence of validity and reliability not published
D. Modified Aldrete (also known as PARSAP)
1. Reported in 1995 in response to trends in ambulatory surgery for ambulatory surgery patients
2. Modified one criterion of original PARS by replacing color index with Sa o2
3. Ten criteria rated from 0 to 2
a. Activity
b. Respiration
c. Circulation
d. Consciousness
e. Oxygenation
f. Dressing
g. Pain
h. Ambulation
i. Fast feeding
j. Urine output
4. Maximum score of 20
a. PACU phase I discharge requires minimum score of 8 to 10 using original PARS criteria.
b. Home discharge requires minimum score of 18.
5. Addition of five criteria to original PARS when determining discharge from phase II
a. Dressing appearance
b. Pain severity
c. Ability to ambulate
d. Tolerance of oral fluids
e. Ability to urinate
6. Useful for combined PACU phase I and phase II units
7. Evidence of validity and reliability
a. Aldrete (1998)
(1) Studied 740 adult patients
(2) Sixty-two percent of patients scored 18 and higher within an hour of arrival in PACU.
E. White
1. Developed in 1999
2. Used for fast-tracking
3. More sensitive and selective than Modified Aldrete Scale
4. Seven criteria rated from 0 to 2
a. Level of consciousness
b. Physical activity
c. Hemodynamic stability
d. Respiratory stability
e. Oxygen saturation status
f. Postoperative pain assessment
g. Postoperative emetic symptoms
5. Maximum score of 14
6. Requirements for discharge to phase II
a. Minimum score of 12
b. All criteria with scores of 1 or above
7. Evidence for validity and reliability not published
F. Cohen et al.
1. Reported in 1998
2. Proposed specific PACU discharge criteria for obstetric patients after regional anesthesia
3. Criteria
a. Stable cardiorespiratory status
b. Block started to recede
c. Block continuing to recede
4. Evidence for validity and reliability
a. Retrospective review of 6-month data from 358 patients
b. All patients kept 1 hour in PACU and monitored for events.
c. Patients who received epidurals were discharged sooner than those who received spinals.
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