Post anaesthetic care units in the Republic of Ireland: a survey of discharge criteria.
KEY WORDS Discharge criteria, Post anaesthetic care unit, Recovery
As the volume and complexity of surgeries continues to grow and develop, nurses are challenged to provide patients with an optimal perioperative experience. The PACU, or recovery room, is the environment in which patients are cared for in the initial period post anaesthesia and surgery (Muller-Smith 1999). The care provided in the PACU aims to:
* support patients in the removal of the pharmacological effect of anaesthesia
* attain haemodynamic stabilisation of patients
* monitor for and treat potential complications
* ensure patient's comfort
* discharge patients who meet a certain minimum standard of fitness to appropriate environments (Leykin et al 2001).
Nursing care in the PACU needs to be planned in a manner that not only identifies reports and treats complications in their early stages but also reduces the risk of unpleasant complications that would delay the patient's discharge from the PACU (Burden 2003).
Discharge of patients from the PACU The safe and expeditious discharge of patients from the PACU can be achieved if appropriate discharge criteria are utilised to assist the nurse or anaesthetist in assessing the patient's fitness for discharge. Recovery following anaesthesia takes time. In the early recovery period patients awaken and recover their vital reflexes. This is the phase that generally occurs in the PACU. No specific duration of stay in the PACU can be specified with certainty for patients undergoing specific procedures or types of anaesthetic as a patient's condition may vary in response to the surgical procedure, type of anaesthetic or medications given. Patients also leave the PACU for a number of destinations: some may be discharged home, others go to day case units, surgical inpatient units, high dependency units or even intensive care units. The choice of destination will depend on the type of procedure the patient has had, the patient's physical status, the patient's needs, and the availability of appropriate resources to meet those needs.
Patients generally remain in the PACU until they meet a certain number of outcome indicators. Outcome indicators are usually based on the patient's level of consciousness, maintenance of airway, breathing and circulation, patient's comfort and absence of complications. The variety of indicators assessed and appropriateness of the patient scores on these indicators varies depending on the ultimate destination of the patient when they leave the PACU and the policies and procedures adopted by the PACU staff. Discharge protocols, developed by a multidisciplinary team should be in place in all PACUs (Swatton 2004).
There are many and varied criteria used to discharge patients post general anaesthetic (Table 1). However evaluation of the validity and reliability of these criteria needs further work. The factors which influence the duration of time spent by patients in the PACU are varied and have been studied by a number of researchers citing the need to contain costs as a rationale for the need to study this topic. Seago et al (1998) sought to identify the factors, which lead to prolonged lengths of patient stay in the PACU for 1,067 patients using prospective observational analysis. Variations in prolonged length of stay (LOS) can be predicted by age, pain medication at the time of admission to the PACU and postoperative cardiovascular, pulmonary and pain symptoms. Interestingly, it was noted that organisational factors might be a more important indicator of prolonged PACU stay (Seago et al 1998).
In an observational study by Waddle et al (1998) of 340 PACU patients, mean actual LOS (SD) was 95mins (43). LOS predictors were anaesthetic time and technique, and amount of intraoperative fluids (Waddle et al 1998). Frequent causes of excessive LOS were cited as waiting for physician release or laboratory or radiographic results (Waddle et al 1998).
Using prospective cohort analysis, Truong et al (2004) demonstrated that a clinical scoring system based on Aldrete's scoring system (Aldrete & Kroulik 1970) was associated with a significantly reduced PACU LOS post general anaesthesia in comparison with time-based criteria. Anaesthetic technique has been shown to influence the length of stay in the PACU (Marshall & Chung 1997). However some PACUs delay discharge of patients, post spinal anaesthesia, from recovery units until full or partial (sensory levels of Lumbar spine one or less) return of sensation, or until a specific time has elapsed (Knoerl et al 2001), citing the potential effect of the sympathetic blockade on the cardiovascular system as the rationale.
Researchers using a prospective descriptive design and a convenience sample of 109 same day surgery patients demonstrated that orthostatic blood pressure testing as a discharge criterion is a safe and effective alternative to sensory/motor/time-based criterion in assessing haemodynamic stability and reducing the amount of time patients spend in the PACU post spinal anaesthesia (Knoerl et al 2001).
The post anaesthesia patient trajectory (Prowse & Lynne 2000) describes the journey of patients from a state of unconsciousness and potential cardiovascular instability to consciousness, cardiovascular stability, maintenance of airway and pain control. Indeed this trajectory is the basis on which discharge criteria have been developed. A large variety of criteria exist to assist nurses and anaesthetists when discharging patients from the PACU. In the UK, a pilot study sought to describe the use of such criteria by nurses. The majority of respondents utilised a criteria that encompassed the airway, breathing and circulation algorithm (Oakley 2004). From an Irish perspective, this descriptive study sought to examine the use of discharge criteria within PACUs within all public hospitals in the Republic of Ireland.
The study objectives were to:
* find out if documented discharge criteria were used to assess patient fitness for discharge from the PACU
* describe the types of written criteria being used to discharge patients within PACUs
* ascertain the means by which discharge criteria were developed within PACUs
* identify the healthcare professional who most frequently makes the decision to discharge a patient from the PACU.
The method used was a descriptive survey design of all the public PACUs in the Republic of Ireland. We designed a self-report questionnaire to collect information about discharge criteria used in PACUs.
A literature review assisted in identifying possible criteria used to discharge patients. The questionnaire consisted of nine questions, which could be answered by ticking the most appropriate options listed. The questionnaire was piloted with a clinical nurse manager of a PACU and a lecturer in nursing with expert knowledge in the area. The choice of responses provided for most questions were taken from the findings of the literature review. Each question had an 'other' option to allow for any responses that had not been anticipated. The identity of the healthcare professionals who made the decision to discharge the patient from the PACU was obtained by use of a scale (a range of responses from: 'almost always' to 'hardly ever' were provided).
The sample hospitals were selected based on a computer search of the Health Service Executive, Ireland (management structure for healthcare provision in Ireland) website (www.hse.ie), which listed all public hospitals with operating theatre departments. The final questionnaire was then mailed to all PACUs of public hospitals (n=45) in the Republic of Ireland marked for the attention of the clinical nurse manager in charge of the unit. One reminder was sent seven weeks later. The final response rate was 77.8% (n=35).
An information letter accompanied the questionnaire, which assured respondents that participation in the study was optional, respondents would remain anonymous and publications resulting from this study would not identify any individual PACUs. Completion and return of the anonymous questionnaire was taken as inferred consent. The research protocol was exempt from review by the appropriate ethics review board because according to its policies and procedures manual it exempts studies from review that involve the collection of existing data, documents and records if they are publicly available or if the data is recorded in a manner that subjects cannot be identified, directly or through identifiers linked to the subjects.
A statistical expert was consulted regarding the appropriateness of the questionnaire and the statistical tests used. Responses to the questionnaire were entered into a database and analysed using Statistical Package for Social Sciences (v 12.0.1). Descriptive and inferential statistics (percentages, [chi square] and t-tests) were carried out.
Completed questionnaires were received from 35 PACUs (Figure 2). The average number of recovery bays (patient care spaces in the PACU) was 5.14 (SD 3.46) and the range was from one to 15 recovery bays. The average patient throughput in the PACU on a normal weekday was 24.81 (SD 23.68) and the range was from three to 115 patients per day. A total of 77% of the respondents utilise discharge criteria in their units.
Of the 35 PACUs included in the study 26 covered general surgery, 15 vascular, 10 plastics, 30 gynaecology, five renal, three cardiac, 16 urology, three neurosurgery, two ophthalmology, 14 ear, nose and throat, 18 orthopedic, 15 obstetrics and 11 other specialties.
Discharge criteria documentation methods used included: tick boxes (n=5, 14.2%), numerical scoring (n=4, 11.4%) and comment boxes (n=9, 25.7%).
Discharge criteria used in particular units (outlined in Table 1 and Figure 2) were developed utilising PACU staff's clinical experience (n=18, 51.4%), sourced from colleagues in other hospitals (n=7, 20%) or from the literature (n=8, 22.9%), developed in conjunction with anaesthetic colleagues (n=24, 68.6%) or through practice development initiatives (n= 4, 11.4%).
The decision to discharge patients from the PACU was made by the: nurse (almost always n= 23, 65.7%), nurse and anaesthetist (almost always n=9, 25.7% and the anaesthetist alone (almost always n=2, 5.7%).
A [chi square] test was conducted in order to investigate the possible relationship between the type/size of hospital and the utilisation of discharge criteria. There was not a significant relationship between the variables ([chi square] = 1.72, p=ns). A t-test was conducted in order to compare the number of recovery bays and the average patient throughput for PACUs that utilised discharge criteria and PACUs that did not. There was no significant difference (t(33) = 0.098, p=ns) in the number of recovery bays for PACUs that utilised discharge criteria and PACUs that did not. There was no significant difference (t(30)= -1.272, p=ns) in the average patient throughput for PACUs that utilised discharge criteria and PACUs that did not.
Patient fitness for discharge from the PACU needs to be approached in a structured but simple and clear manner that meets international standards of appropriate nursing, medical and anaesthesia patient care. The majority (71.4%) of the respondent PACUs confirmed that they utilised discharge criteria to evaluate patient's fitness for discharge from the PACU. Time-based discharge criteria were used in n=8 PACUs (22.9%), Aldrete (1970) scoring system (n=4, 11.4%) and PADSS (n=4, 11.4%) (Table 1). The effectiveness of these discharge criteria in terms of appropriate patient outcomes, time management as well as resource management needs to be researched in a global as well as an Irish context.
The question of how long patients should remain in PACU following surgery and anaesthesia is crucial as it has safety, cost and resource implications. Therefore, the most appropriate discharge criteria should be chosen carefully for each individual patient as well as each PACU. The discharge criteria chosen (see Tables 1 and Figure 2) will depend on the type of surgery/anaesthesia as well as the ultimate discharge destination of the patient. The variables included in the discharge criteria used within the Republic of Ireland vary considerably (Table 1). The majority of criteria include airway, breathing and circulation as the major indicators. Other criteria include nausea and vomiting, pain and surgical bleeding. However, most of the discharge criteria utilised do not seem to incorporate temperature as a major variable. Estimates of the incidence of inadvertent perioperative hypothermia range from 60% to 90% of all surgical cases when this condition is defined as a body temperature below 36[degrees]C/97[degrees]F (Bernthal 1999, Kenley 1999).
A study of clinical indicators and complications in the PACU (n=13,266) found that the incidence of hypothermia (tympanic temperature < 35[degrees]C/95[degrees]F) equalled the incidence of respiratory complications in the PACU (Peskett 1999). A minority (22.9%) of the surveyed PACUs in the Republic of Ireland utilised a discharge criterion that was based on the time spent in recovery, the unit having predetermined the minimum amount of time a patient should spend in recovery. Hatfield and Tronson (2004) in The Complete Recovery Room Book recommended that adult patients should spend a minimum of at least an hour after general anaesthesia and a half an hour after local anaesthesia. However this practice is not evidence-based (Troung et al 2004). Evaluation of orthostatic blood pressure (BP) testing as a discharge criterion from PACU after spinal anaesthesia was used by 20% of PACUs. However, 22.9% of PACUs utilised motor/sensory discharge criteria, and 28.6% of PACUs used time spent in recovery as a discharge criterion post spinal anaesthesia. This is interesting, as orthostatic BP criterion has been shown to be a safe and effective alternative to motor/sensory criteria in assessing haemodynamic stability and reducing the amount of time the patient spends in the PACU after spinal anaesthesia (Knoerl et al 2001).
Development of discharge criteria in Irish PACUs
Different methods were used to develop the PACU discharge criteria chosen for each unit. Slightly over half of the units (51.8%) indicated that they utilised the clinical experience of their PACU staff to determine the most appropriate discharge criteria for their individual PACUs. Thus, PACU staff need to have the appropriate clinical experience to undertake this role. Retention of experienced PACU staff within recovery units in Ireland in recent years has been a major issue for perioperative nursing managers, particularly in the large urban centres. An in-depth literature review was undertaken in 22.9% of the units in order to decide on a chosen PACU discharge criteria. Perceived barriers to the utilisation of evidence-based practice in the PACU have been shown to include organisational factors such as lack of time and poor access to research literature (LaPierre et al 2004). For well over half a century, educators and health policy leaders have written about and promoted interdisciplinary approaches as an ideal way to provide optimum care for patients (Huff & Garrola 1995). Interdisciplinary care delivery is evident in the PACU as 68.6% of discharge criteria were developed by nurses in conjunction with their anaesthetic colleagues. This could, however, also be seen as an area where PACU nurses have chosen not to become leaders/experts in their own clinical area(s).
The Commission on Nursing recognised the necessity for promotional opportunities for experienced nurses wishing to remain in clinical practice (Government of Ireland 1998). Accordingly they recommended a clinical career pathway leading from registration to clinical specialisation to advanced practice (Government of Ireland 1998). The PACU is an area which could benefit significantly from having advanced nurse practitioners. The core concepts of an advanced nurse practitioner include autonomy in practice and expert practice as well as professional and clinical leadership (National Council for the Professional Development of Nursing and Midwifery 2004).
Decision making and the discharge of the patient from the PACU
Nurses made 65.7% of the decisions to discharge patients. This highlights the specialist knowledge and skill required by nurses working in the PACU. The Association of Anaesthetists of Great Britain and Ireland (2002) notes that the decision to discharge patients from the PACU is the responsibility of the anaesthetist, but the adoption of precise discharge criteria allows this decision to be delegated to a PACU nurse. To ensure a high standard of care and appropriate decision making, an investment in education and training of PACU nurses is essential.
The majority of decisions to discharge patients from the PACU are made by recovery nurses. This highlights that nurses working in this area are autonomous in their practice in the PACU and are free to make discretionary and binding decisions consistent with their scope of practice and using their personal clinical judgment. Woods (1999) noted that nurses made the final decision to discharge patients from the PACU in 70% of cases. An Bord Altranais (The Irish Nursing Board) (2000) published a Code of Professional Conduct that provides guidance to the nursing profession. It states that all nurses are accountable for their own practice but for this to happen nurses need to have the autonomy to practice according to their professional judgment. Stephenson (1990) noted that the majority of nurses consider discharge criteria to be a minimum standard, and that most would be very cautious about discharging a patient if there was any doubt regarding the patients wellbeing.
This study provides information regarding the use of discharge criteria in Irish PACUs. Discharge criteria assist the perioperative nurse who cares for the patient post anaesthesia and surgery to make the decision to discharge the patient from their care. However, from an Irish as well as an international context further research needs to be undertaken to assess the reliability, validity and appropriateness of discharge protocols being used. Factors such as patient safety and resource management would need to be considered in such research. Discharge criteria provide nurses with guidance to assist their decision making thus ensuring patient safety when discharging patients from the PACU.
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About the authors
Dr Josephine Hegarty PhD, MSc, BSc, RGN
Senior Lecturer, Catherine McAuley School of Nursing & Midwifery, Brookfield Health Sciences Complex, University College Cork, Ireland
Aileen Burton MSc, BNS, RGN
College Lecturer, Catherine McAuley School of Nursing & Midwifery, Brookfield Health Sciences Complex, University College Cork, Ireland
Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk. Access is also available to non-members who pay a small fee for each article download.
Table 1 Discharge criteria, variables assessed and the number of PACUs which utilise the discharge criterion Discharge criterion Variables assessed within Scoring system the criterion Time-based Specific time frame as Based on a discharge criteria decided by PACU minimum (PACU specific policy specified period protocols usually) of time the patient is required to spend in recovery prior to discharge Clinical discharge Varied clinical criteria type criteria (see list below) (CDC) or clinical scoring systems or a criteria based solely on airway, breathing, circulation (see breakdown below) Aldrete (1970) Activity, respiration, Numerical scoring system circulation, scoring system, consciousness, colour maximum score (Or oxygen (02)) of 10 saturation included in modified Aldrete (1995) Post anaesthesia Vital signs, Numerical Discharge Scoring activity/ambulation and scoring system, System (Chung mental status, pain, maximum score 1993),(PADSS) nausea and/or vomiting, of 10 surgical bleeding and fluid intake and output Modified post Vital signs, Numerical anaesthesia ambulation/activity scoring system, discharge scoring level, nausea and maximum score system (Chung vomiting, pain, surgical of 10 1995) (Modified bleeding PADSS) Salim's coma score Airway, behaviour Numerical (movement), scoring system, consciousness maximum score of 9 White and Song Level of consciousness, Numerical discharge criteria physical activity, haemo- scoring system, (also used to fast- dynamic stability, maximum score track patients from respiratory stability, 02 14 the operating room saturation status, to Phase II area for postoperative pain recovery, assessment, post- White & operative emetic Song 1999) symptoms Association of Consciousness, Anaesthetists respiration/oxygenation, discharge criteria cardiovascular system, (2002) pain, emesis, temperature, prescription of 02 and intravenous therapy Other PACUs using this criterion (%) Discharge criterion Time-based n=8 (22.9%) discharge criteria (PACU specific protocols usually) Clinical discharge n=15 (42.9%) type criteria (CDC) or clinical scoring systems or a criteria based solely on airway, breathing, circulation (see breakdown below) Aldrete (1970) n=4 (11.4%) scoring system Post anaesthesia n=4 (11.4%) Discharge Scoring System (Chung 1993),(PADSS) Modified post 0 anaesthesia discharge scoring system (Chung 1995) (Modified PADSS) Salim's coma score n=1 (2.9%) White and Song n=0 discharge criteria (also used to fast- track patients from the operating room to Phase II area for recovery, White & Song 1999) Association of n=5 (14.3%) Anaesthetists discharge criteria (2002) Other n=6 (17.1%) Figure 1 Discharge criteria used after specific procedures or types of anaesthesia, and the number (%) of PACUs, which utilise the discharge criterion Other (s) n=3 (8.6%) Following ambulatory (day) surgery n=3 (8.6%) Following neurosurgery (e.g. Glasgow Coma Scale) n=2 (5.7%) Based on a specific time spent in the recovery unit n=10 (28.6%) Based on motorsensory discharge criteria (e.g. The n=8 (22.9%) Bromage Scale Based on orthostatic blood pressure n=7 (20%) Following spinal anaesthesia n=15 (42.9%) Following epidural anaesthesia n=12 (32.3%) Following nerver blocks (s) n=5 (14.3%) Following local anaesthesia n=8 (22.9%) Following intravenous sedation n=11 (31.4%) Note: Table made from pie chart Figure 2 Hospital category and questionnaire completion rate Other Hospitals 3% Maternity Hospitals 12.1% Band 3 Hospitals 18.2% Band 2 Hospitals 39.4% Band 1 Hospitals 27.3% Note: Table made from pie chart.
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|Title Annotation:||CLINICAL FEATURE|
|Author:||Hegarty, Josephine; Burton, Aileen|
|Publication:||Journal of Perioperative Practice|
|Date:||Feb 1, 2007|
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