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Adapted from

FROM ALDRETE TO PADSS:


REVIEWING DISCHARGE CRITERIA
AFTER AMBULATORY SURGERY
(2006 American Society of PeriAnesthesia)
Objectives
1. Describe Aldrete Scoring System & Post Anesthetic Discharge
Scoring System (PADSS).
2. Identify advantages and limitation of discharge scoring criteria.
Pre Test (True or False)
1.

Both Aldrete system and PADSS evaluate five key


parameters in assessing postanesthetic recovery.

2.

Patients achieving a total score of 12 are considered fit for


transfer or discharge to the next phase of recovery.

3.

Cardiovascular events, e.g. hypotension, hypertension, and


dysrhthmias are the most frequent complications after
ambulatory surgery.

4.

Voiding before discharge is mandatory in all postanesthetic


patients.

5.

Scoring criteria are reliable tools that replace the critical


thinking or professional judgment of the nurse.

6.

Discharge teaching is the key to the patient and family


understanding which situations will warrant return to the
hospital or further medical assistance.

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.

The History of Aldrete Scoring and PADSS


The Aldrete scoring system, a modification of the Apgar scoring system
used to assess newborns, has been used in many PACUs since its
introduction 35 years ago. This system is designed to assess the patients
transition from Phase I recovery to Phase II recovery, from
discontinuation of anesthesia until a return of protective reflexes and
motor function. At most institutions, Phase I recovery occurs in the
PACU. Once Phase I recovery is completed, homeostasis has been
regained. To assess the patients transition from Phase II to Phase III
recovery, the PADSS is used. Phase II recovery is judged to be complete
when the patient is ready for discharge home. Phase III recovery
continues at home under the supervision of a responsible adult and
continues until the patient returns to preoperative psychologic and
physical function.
Both the Aldrete system and PADSS evaluate five key parameters to
ensure safe transfer or discharge of the patient postoperatively. Patients
achieving a total score of 9 or 10 are considered fit for transfer or
discharge to the next phase of recovery. The individual institution
indicates if such scores are necessary for transfer or discharge, or if a
score of 8 is acceptable (Table 1).
The original Aldrete scoring system of 1970 used color as an indicator of
oxygenation by assessing the color of the patients mucous membranes
and nail beds. With the advent of oximetry, the Aldrete scoring system
was updated in 1995 to include this technological improvement.
Although monitoring the patients mucous membranes and nail beds is
still includedin the nurses assessment, oximetry is a more reliable
indicator of oxygenation.
Before the clear objective, numerical scoring of the Aldrete and PADSS,
a number of psychomotor tests were used to assess discharge readiness
postanesthesia. In the late 1960s, a modified Gestalt test (the Trieger
dot test) was proposed to measure recovery. Patients demonstrated
recovery by connecting a series of dots on paper to form a pattern. The
more dots the patient missed, the lower their recovery score. Not only
was this test tedious in nature; it did not account for the presence of
dizziness, hypotension, pain, bleeding, nausea, vomiting, andother
parameters included in current discharge scoring systems.

The R.E.A.C.T. assessment tool is another scoring system that was


developed in Chicago in the early 1980s. This acronym includes the
parameters of:

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.

Drinking and Voiding Before Home Discharge


Requiring all patients to void and tolerate oral fluids is no longer
supported and has been shown to lead to unnecessary patient delays. A
patient who has not voided postoperatively, has no urge to do, has no
bladder distention, or is not at high risk of urinary retention may be
discharged home if given clear guidelines on when to seek medical
assistance. Patients who are at high risk of urinary retention are those
who have undergone a procedure involving the pelvic or genitourinary
system, rectal or urological procedures, hernia repairs, had urinary
catheterization perioperatively, have a history of urinary retention, or
received neuroaxial anesthesia. This group of patients has a higher risk
of urinary retention and is generally required to void before discharge.
Current literature remains inconsistent regarding the requirement to
void after postneuroaxial anesthesia. Both neuroaxial and general
anesthesia can interfere with the detrusor muscle function and
predispose the patient to urinary retention. If the bladder becomes
distended while anesthesia is blocking the contraction ability of the
detrusor muscles, voiding function can be impaired. The mechanism of
urinary complications is related to anesthetic agents blocking
parasympathetic fibers in the sacral region of the spine, which control

the muscles of micturition. Gupta and others found that as many as


17.5% of patients had postspinal urinary retention. Kang and others
found that urinary complications occur in less than 1% of spinal
anesthetics. Urinary retention may occur with elderly men, whereas
urinary incontinence can occur with female patients. Even with the low
occurrence of urinary complications, these problems usually subside in
the PACU, and intermittent urinary catheterization is rarely needed.
The choice of opioid used with spinal anesthesia is a factor in
postoperative urinary retention. Hydrophilic opioids, such as morphine,
may cause urinary retention, whereas lipophilic opioids, such as fentanyl
are less likely to cause this side effect.
A suggested practice is for the patient to remain in the ambulatory care
area for another hour if the patient is at risk of urinary retention and
has more than 400 mL of urine in the bladder (determined by an
ultrasonic bladder scanner), or if bladder distention is present. If after
one hour the patient still has not voided, an intermittent catheterization
can be done. If the patient is not at increased risk of urinary retention,
discharge should not be delayed if postoperative voiding does not occur
in the hospital. Such patients are given clear discharge instructions on
when to seek medical assistance, eg, if they are not able to void at home
eight hours after discharge.
Patients are no longer required to drink fluids before discharge home.
Current recommendations are that postoperative hydration status is
assessed and managed in the PACU. Current practice guidelines set out
by the American Society of Anesthesiologists Task Force on
PostAnesthetic Care recommend that drinking clear fluids should not be
a part of a discharge protocol, but may only be necessary for selected
patients, such as diabetics. Not abiding by such recommendations will
unnecessarily delay discharges, reduce patient satisfaction, and increase
the incidence of nausea and vomiting when patients are encouraged to
drink to be discharged.
Clinical practice and some clinical studies support using the Aldrete
scoring criteria to ensure discharge readiness from Phase I recovery, and
PADSS to ensure discharge readiness from Phase II recovery.
Institutions should also have clear guidelines on discharge criteria, and
requirement for all patients to void or tolerate oral fluids should not be
part of such a protocol.

Fast-Tracking/Bypassing the PACU


The practice of fast-tracking patients to the ambulatory care area
bypassing the PACUhas been practiced in some institutions since the
late 1990s. With fast tracking, patients must meet discharge criteria to
illustrate completion of Phase I recovery before transfer from the
operating room to the ambulatory care area. The fast-tracking criteria
suggested by White appear to be a union of the Aldrete scoring system
and the PADSS. To meet fast-tracking criteria, the patient must score a
minimum of 12 (maximum score is 14), with no score <1 in any
parameter. As mentioned previously, this scoring criterion may vary
slightly according to the facilities individual protocols (Table 3).

Although fast tracking is possible due to factors such as minimally


invasive techniques and short-duration anesthetics, there is inconsistent
support in the literature supporting its use. Not all patients are
appropriate for fast-tracking. In one study, only 31% of patients were
eligible for fast tracking. Thus, a large number of patients still required

traditional postanesthesia care in the PACU. The PACU needs to be


staffed appropriately to receive patients who are not eligible for fast
tracking; therefore cost savings by reducing staffing in the PACU could
not be guaranteed. The Ontario Perianesthesia Nurses Association
(OPANA) Practice Standards indicate there is currently very little data
addressing patient outcomes related to fast tracking. Another concern
regarding fast tracking is that there is no one agreed-upon practice
guideline or definition of the factors involved in fast tracking. Further
clinical studies are required for its validation and benefits. It is clear
that there is a need for caution in implementing fast tracking, and that a
learning curve exists with this practice.
Advantages and Limitations of Discharge Scoring Criteria
Although working in the perianesthesia area is often demanding and
hectic, it is important to regularly review current processes to ensure
that up-to-date standards of care are in place. There are many benefits
for both the patient and nurse in consistently using evidenced-based
discharge scoring criteria. However, with all discharge criteria, there are
limitations. Table 4 illustrates how the benefits of using numerical
discharge criteria are more numerous than the limitations. Using
criteria such as the Aldrete scoring system and the PADSS is supported
by the Joint Commission for Accreditation of Healthcare Organizations
(JCAHO), the Canadian Anesthetists Society (CAS), and OPANA. Using
numerical scoring is also user-friendly and easily repeated during the
patients stay to monitor improvement. Tracking improvements in
clinical status allows a patient-focused approach, and confirms when the
patient is ready to be transferred to the next phase of recovery.
Limitations exist that have important implications for nursing with any
discharge criteria. Although scoring criteria are reliable tools, they do
not replace the critical thinking or professional judgment of the nurse.
For example, the patient may fit all discharge criteria, yet the surgeon
indicates that the patient must stay a minimum of four hours
postoperatively because of susceptibility to malignant hyperthermia.
Another example of a limitation is the elderly postoperative patient who
is frail, diabetic, has some renal insufficiency, and resides a long
distance from a medical facility. In this case it is better to err on the side
of caution, and ensure the patient can tolerate oral fluids before
discharge because the preoperative health status indicates that this
patient may not tolerate an extended period of nothing-by-mouth
status if unable to tolerate fluids at home. Long distances to accessing

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

postoperative complications. Pain, PONV, and minor sequela such as


sore throat and shivering, are other concerns that arise after surgery.
Follow-up telephone calls to the patients home have a large role in
ensuring safety throughout late recovery; concerns such as continued
PONV, pain, and bleeding can be addressed. These phone calls can also
confirm the patients understanding and compliance to the verbal and
written discharge instructions provided. Follow-up phone calls can also
be used in quality assurance studies.
Conclusion
The pillars of efficient, safe ambulatory surgery include appropriate
patient selection and timely discharge. Assessment of the patient with
the aid of scoring criteria such as the Aldrete scoring system and the
PADSS can facilitate safe transition of care throughout the three phases
of recovery. The requirement to void and tolerate fluids is no longer
considered part of standard discharge criteria.
However, because the scoring criteria is only part of the discharge
assessment, patients at higher risk of complications such as dehydration
and urinary retention can be assessed on a case-by-case basis. Patients
with such risks would be instructed to return to the hospital if
postoperative concerns continue at home. Follow-up phone calls are of
particular importance for high-risk patients to ensure patient-focused
care.
Once discharge protocols are established and approved, it is mandatory
that they are consistently followed. By including discharge scoring
criteria, such as those outlined in this article, patients can continue to
benefit from ambulatory surgery and home recovery with the comfort of
their familys supervision.

Pre Test Answers (True or False)


1.

Both Aldrete system and PADSS evaluate five key parameters


in assessing postanesthetic recovery.

2.

Patients achieving a total score of 12 are considered fit for


transfer or discharge to the next phase of recovery.

3.

Cardiovascular events, e.g. hypotension, hypertension, and


T dysrhthmias are the most frequent complications after
ambulatory surgery.

4.

Voiding before discharge is mandatory in all postanesthetic


patients.

5.

Scoring criteria are reliable tools that replace the critical


thinking or professional judgment of the nurse.

6.

Discharge teaching is the key to the patient and family


T understanding which situations will warrant return to the
hospital or further medical assistance.

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