THE PERFECT SCORE Fast tracking through your day surgery unit Wendy Adams MRCNA President Australian Day Surgery Nurses Association Presented by Sarah

THE PERFECT SCOREFast tracking through your

day surgery unit

Wendy AdamsMRCNA

PresidentAustralian Day Surgery Nurses Association

Presented bySarah McDonald

Definitions

• 1st stage recovery– Post Anaesthetic Care Unit (PACU)– Early recovery

• 2nd stage recovery– Intermediate recovery

• 3rd stage– Discharge

• 4th stage– Post discharge follow up

Definitions

• Score based recovery– Patient is moved through the unit

and discharged when they achieve a set of criteria using a scoring system

• Time based recovery– Patient is moved through the unit

and discharged when they achieve a set of criteria and required time length of stay in the unit.

Definitions

• Fast tracking– Clinical pathway that involves

transferring the patient from the operating room to the day surgery ward (2nd Stage recovery) and bypassing PACU (1st stage)

Discharge Scoring systems

• Aldrete scoring system

• White et al scoring system

• PADSS

• Modified PADSS

Aldrete Scoring system

• Requires a patient to reach the criteria of 9 or 10/10 before the can– Move from 1st stage to 2nd stage– By pass 1st stage (by achieving the

score in the operating room)


• Does not address– Pain– Nausea– Vomiting


Discharge Criteria Score

Activity: Able to move voluntarily or on commandFour extremities 2

Two extremities 1

Zero extremities 0

RespirationAble to deep breathe and cough freely 2

Dyspnoea, shallow or limited breathing 1

Apneic 0

CirculationBP +/- 20mm of pre anaesthetic level 2

BP +/- 20-50 mm of pre anaesthetic level 1

BP +/- 50mm of pre anaesthetic level 0



ConsciousnessFully awake 2

Arousable on calling 1

Not responding 0

O2 SaturationAble to maintain O2 saturation >92% room air 2

Needs O2 inhalation to maintain O2 saturation >90% 1

O2 saturation <90% with O2 supplementation 0

Aldrete JA. The post-anaesthesia recovery score revisited J Clin Anesth 1995;7:89-91

White et al scoring system

• Includes pain and emetic scoring symptoms

• Maximum score is 14

• A score of 12 (with no less than 1 in any category) provides criteria for bypassing PACU (1st stage)



Level of consciousnessAwake and orientated 2

Arousable with minimal stimulation 1

Responsive only to tactile stimulation 0

Physical activityAble to move all extremities on command 2

Some weakness in movement of extremities 1

Unable to voluntarily move extremities 0

CirculationBP < 15% of baseline MAP 2

BP 15-30% of baseline MAP 1

BP > 30% of baseline MAP 0



Respiratory stabilityAble to breathe deeply 2

Tachypnoea with good cough 1

Dyspnoeic with weak cough 0

O2 saturation statusMaintains value >90% on room air 2

Requires supplemental oxygen (nasal prongs) 1

Saturation <90% with supplemental oxygen 0



Post operative pain assessmentNone, or mild discomfort 2

Moderate - severe pain controlled with IV analgesics 1

Persistent severe pain 0

Post operative emetic symptomsNone, or mild nausea with no active vomiting 2

Transient vomiting or retching 1

Persistent moderate to severe nausea and vomiting 0

White P, Song D. New criteria for fast-tracking after outpatient anaesthesia: a comparison with the modified Aldrete’s scoring system. Anesth Analg 1999;88:1069-72

Studies

• Randomised study by Francis Chung in 2004– 207 patients GA– 81% bypassed PACU (1st stage)

successfully• 97% arthroscopy• 72% gynaecology

• Randomised controlled trial in a multi-centre– 58% successfully bypassed

Lemos P., Jarret P., Philip B. 2006 Day Surgery-Development and Practice, Chapter 11

My experience

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Post-op LOS in 1st Stage Aug/Sept 2000 (Hours) Post-op LOS in 2nd Stage Aug/Sept 2000 (Hours)

Benefits of fast tracking

• Less intensive nursing staff required

• Less PACU (1st stage) beds required

• Individualised care

• Justifies patients staying longer if required

Discharge criteria

• Francis Chung devised post anaesthetic discharge scoring system (PADSS)

• Later modified to eliminate input and output criteria

• Score of 9 or 10/10 required for discharge home

Modified PADSS


Vital signs: must be stable and consistent with age and pre-operative baseline

BP & PR within 20% pre-operative baseline 2

BP & PR within 20-40% pre-operative baseline 1

BP & PR > 40% pre-operative baseline 0

Activity level: must be able to ambulate at pre-op level

Steady gait, no dizziness, or meets pre-op level 2

Requires assistance 1

Unable to ambulate 0

Modified PADSS


Nausea and vomiting: should have minimal nausea and vomiting before discharge

Minimal: successfully treated without medication 2

Moderate: successfully treated with IM injection 1

Sever: continues after repeated treatment 0

Pain: must have minimal or no pain before discharge , controlled by oral analgesia, location, type and intensity of pain consistent with anticipated post–op discomfort.

Pain acceptable 2

Pain not acceptable 1

Modified PADSS


Surgical bleeding: post operative bleeding should be consistent with expected blood loss for the procedure

Minimal: does not require dressing change 2

Moderate: up to two dressing changes required 1

Severe: more than three dressing changes required 0


Discharge criteria

• In addition, other criteria is necessary– Appropriate carer– Discharge instructions etc given– Patient accepts readiness for

discharge

What about eating & drinking?

• Only necessary on a case by case basis

• Must be well hydrated

• Must understand discharge instructions

• Literature available to support this


• Higher incidence of vomiting and delay in discharge in the ‘mandatory drinkers’ cf. ‘elective drinkers’– Kearney R, Mack C, Entwistle L.

Withholding oral fluids from children undergoing day surgery reduces vomiting. Paediatr Anaesth 1998;8:331-336


• Incidence of vomiting reduced from 73% to 36% when fluids withheld 4-6 hours – Jin FL, Norris A, Chung F. Should

adult patients drink fluids before discharge from ambulatory surgery? Can J Anaesth 1998;87:306-311

Is voiding necessary?

• Risk factors for post operative urinary retention are– Anorectal surgery– Old age– Male sex– Spinal anaesthesia– Hernia surgery

Is voiding necessary?

• Delay in discharge 5-11% of patient who have no risk factors

• Incidence of urinary retention is 1% in low risk patients

• When discharging low risk patients who have not voided– Discharge instructions regarding

medical assistance if not voided 6-8 hours post operatively


My experience

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Post-op LOS pre pathways (Hours)

Post-op LOS Oct-Dec 1999 (Hours)

Post-op LOS Aug/Sept 2000 (Hours)

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Patient satisfied with Pre-op LOS Aug/Sept 2000(%)

Patient satisfied with Post-op LOS Aug/Sept 2000(%)

In summary

• Should we fast track?– Staff competence and experience– Medical staff support it– The use of ultra short acting drugs– Appropriate pain and PONV

management– Collect and analyse data

In summary

• Is it safe to use a scoring system rather than a time based criteria?– Staff competence and experience– Medical staff support it– The use of ultra short acting drugs– Appropriate pain and PONV

management– Collect and analyse data

In summary

• Should we let our patients go home without eating or drinking?– Develop criteria for low risk group– Review fasting times pre operatively– Review intra operative IV hydration

Further information

Further information

www.adsna.info

[email protected]

http://www.adsna.info/

mailto:[email protected]

Documents

THE PERFECT SCORE Fast tracking through your day surgery unit Wendy Adams MRCNA President Australian Day Surgery Nurses Association Presented by Sarah