Transcript Slide 1
THE PERFECT SCORE Fast tracking through your day surgery unit
Wendy Adams
MRCNA President Australian Day Surgery Nurses Association Presented by
Sarah McDonald
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
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 (2 nd Stage recovery) and bypassing PACU (1 st 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 1 st stage to 2 nd stage – By pass 1 st stage (by achieving the score in the operating room)
Aldrete Scoring system
• Does not address – Pain – Nausea – Vomiting
Aldrete Scoring system
Discharge Criteria Activity: Able to move voluntarily or on command Four extremities Two extremities Zero extremities Respiration Able to deep breathe and cough freely Dyspnoea, shallow or limited breathing Apneic Circulation BP +/- 20mm of pre anaesthetic level BP +/- 20-50 mm of pre anaesthetic level BP +/- 50mm of pre anaesthetic level Score 2 1 0 2 1 0 2 1 0
Aldrete Scoring system
Discharge Criteria Consciousness Fully awake Arousable on calling Not responding O 2 Saturation Able to maintain O 2 saturation >92% room air Needs O 2 inhalation to maintain O 2 saturation >90% O 2 saturation <90% with O2 supplementation Score 2 1 0 2 1 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 (1 st stage)
White et al scoring system
Discharge Criteria Level of consciousness Awake and orientated Arousable with minimal stimulation Responsive only to tactile stimulation Physical activity Able to move all extremities on command Some weakness in movement of extremities Unable to voluntarily move extremities Circulation BP < 15% of baseline MAP BP 15-30% of baseline MAP BP > 30% of baseline MAP Score 2 1 0 2 1 0 2 1 0
White et al scoring system
Discharge Criteria Respiratory stability Able to breathe deeply Tachypnoea with good cough Dyspnoeic with weak cough O 2 saturation status Maintains value >90% on room air Requires supplemental oxygen (nasal prongs) Saturation <90% with supplemental oxygen Score 2 1 0 2 1 0
White et al scoring system
Discharge Criteria Post operative pain assessment None, or mild discomfort Moderate - severe pain controlled with IV analgesics Persistent severe pain Post operative emetic symptoms None, or mild nausea with no active vomiting Transient vomiting or retching Persistent moderate to severe nausea and vomiting Score 2 1 0 2 1 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 (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
My experience
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1.00
General Gynae Scopes Ortho Opthal Oral Plastics Urology ENT/paeds 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 (1 st 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
Discharge Criteria Vital signs:
must be stable and consistent with age and pre operative baseline
BP & PR within 20% pre-operative baseline BP & PR within 20-40% pre-operative baseline BP & PR > 40% pre-operative baseline Activity level:
must be able to ambulate at pre-op level
Steady gait, no dizziness, or meets pre-op level Requires assistance Unable to ambulate Score 2 1 0 2 1 0
Modified PADSS
Discharge Criteria Nausea and vomiting:
should have minimal nausea and vomiting before discharge
Minimal: successfully treated without medication Moderate: successfully treated with IM injection Sever: continues after repeated treatment 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 Pain not acceptable Score 2 1 0 2 1
Modified PADSS
Discharge Criteria Surgical bleeding:
post operative bleeding should be consistent with expected blood loss for the procedure
Minimal: does not require dressing change Moderate: up to two dressing changes required Severe: more than three dressing changes required Score 2 1 0 Lemos P., Jarret P., Philip B. 2006
Day Surgery-Development and Practice, Chapter 11
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
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
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
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 Lemos P., Jarret P., Philip B. 2006
Day Surgery-Development and Practice, Chapter 11
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My experience
Post-op LOS pre pathways (Hours) Post-op LOS Oct-Dec 1999 (Hours) Post-op LOS Aug/Sept 2000 (Hours)
100.00
90.00
80.00
70.00
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40.00
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10.00
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My experience
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