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

2. Definitions 1 st stage recovery –Post Anaesthetic Care Unit (PACU) –Early recovery 2 nd stage recovery –Intermediate recovery 3 rd stage –Discharge 4 th stage –Post discharge follow up

3. 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.

4. Definitions Fast tracking –Clinical pathway that involves transferring the patient from the operating room to the day surgery ward (2 nd Stage recovery) and bypassing PACU (1 st stage)

5. Discharge Scoring systems Aldrete scoring system White et al scoring system PADSS Modified PADSS

6. Aldrete Scoring system Requires a patient to reach the criteria of 9 or 10/10 before the can –Move from 1 st stage to 2 nd stage –By pass 1 st stage (by achieving the score in the operating room)

7. Aldrete Scoring system Does not address –Pain –Nausea –Vomiting

8. Aldrete Scoring system Discharge Criteria Score Activity: Able to move voluntarily or on command Four extremities 2 Two extremities1 Zero extremities0 Respiration Able to deep breathe and cough freely 2 Dyspnoea, shallow or limited breathing1 Apneic0 Circulation BP +/- 20mm of pre anaesthetic level 2 BP +/- 20-50 mm of pre anaesthetic level1 BP +/- 50mm of pre anaesthetic level0

9. Aldrete Scoring system Discharge Criteria Score Consciousness Fully awake 2 Arousable on calling1 Not responding0 O 2 Saturation Able to maintain O 2 saturation >92% room air 2 Needs O 2 inhalation to maintain O 2 saturation >90%1 O 2 saturation <90% with O2 supplementation0 Aldrete JA. The post-anaesthesia recovery score revisited J Clin Anesth 1995;7:89-91

10. 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 (1 st stage)

11. White et al scoring system Discharge Criteria Score Level of consciousness Awake and orientated 2 Arousable with minimal stimulation1 Responsive only to tactile stimulation0 Physical activity Able to move all extremities on command 2 Some weakness in movement of extremities1 Unable to voluntarily move extremities0 Circulation BP < 15% of baseline MAP 2 BP 15-30% of baseline MAP1 BP > 30% of baseline MAP0

12. White et al scoring system Discharge Criteria Score Respiratory stability Able to breathe deeply 2 Tachypnoea with good cough1 Dyspnoeic with weak cough0 O 2 saturation status Maintains value >90% on room air 2 Requires supplemental oxygen (nasal prongs)1 Saturation <90% with supplemental oxygen0

13. White et al scoring system Discharge Criteria Score Post operative pain assessment None, or mild discomfort 2 Moderate - severe pain controlled with IV analgesics1 Persistent severe pain0 Post operative emetic symptoms None, or mild nausea with no active vomiting 2 Transient vomiting or retching1 Persistent moderate to severe nausea and vomiting0 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

14. Studies Randomised study by Francis Chung in 2004 – 207 patients GA –81% bypassed PACU (1 st 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

15. My experience

16. Benefits of fast tracking Less intensive nursing staff required Less PACU (1 st stage) beds required Individualised care Justifies patients staying longer if required

17. 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

18. Modified PADSS Discharge Criteria Score 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 baseline1 BP & PR > 40% pre-operative baseline0 Activity level: must be able to ambulate at pre-op level Steady gait, no dizziness, or meets pre-op level 2 Requires assistance1 Unable to ambulate0

19. Modified PADSS Discharge Criteria Score Nausea and vomiting: should have minimal nausea and vomiting before discharge Minimal: successfully treated without medication 2 Moderate: successfully treated with IM injection1 Sever: continues after repeated treatment0 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 acceptable1

20. Modified PADSS Discharge Criteria Score 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 required1 Severe: more than three dressing changes required0 Lemos P., Jarret P., Philip B. 2006 Day Surgery-Development and Practice, Chapter 11

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

22. 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

23. What about eating & drinking? 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

24. What about eating & drinking? 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

25. Is voiding necessary? Risk factors for post operative urinary retention are –Anorectal surgery –Old age –Male sex –Spinal anaesthesia –Hernia surgery

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

27. My experience

29. 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

30. 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

31. 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

32. Further information

33. www.adsna.info president@adsna.info