PRACTICE CORNER
Length of Stay—Discharge Criteria Theresa Clifford, MSN, RN, CPAN QUESTION: THE CLINICAL PRACTICE COMMITTEE receives a variety of questions related to patient length of stay. Some examples are as follows: Does the American Society of Perianesthesia Nurses (ASPAN) have recommendations regarding the length of stay in the Phase I postanesthesia care unit (PACU)? Is a recommendation of 30 to 60 minutes typical? What are the recommendations for how long a patient with sleep apnea should be monitored? What is the standard recovery time for patients with local anesthesia and no sedation?
and postprocedural sedation periods require high quality, safe nursing care to detect and/or prevent serious complications. Many factors affect the patient’s response to anesthesia and subsequent length of stay in the Phase I and Phase II units. Although the nature of the type and length of surgery or procedure plays a large role in the immediate postanesthesia recovery, the patient’s preanesthesia clinical status and the patient’s unique responses to surgical and pharmacological interventions strongly influence this critical time.
Response
In the past, anecdotally, many PACUs depended on a predetermined minimum length of stay. Gradually, advanced clinical monitoring devices and improved access to these devices have enhanced the objective perianesthesia nursing assessments of patients and have supported early detection of changes in the patient’s condition. As noted by Phillips et al,4 many current practices use criteriabased tools for assessing patient readiness for transfer to another level of care and support bedside decision making. Following a systematic review of literature, Phillips et al4-6 have made the following recommendations for data elements to include in discharge criteria:
There are wide variations in practice across the country with regard to patient assessment and requirements for transfer of care across the perianesthesia continuum. Truong et al1 conducted a cohort analysis in 2004, in which they compared time-based discharge criteria with a modified clinical scoring system that incorporated pain and temperature for Phase I patients having general anesthesia. Preliminary findings suggested that criteria-based assessments significantly reduced the average length of stay for the Phase I patients compared with patients who were discharged according to ‘‘the clock.’’
History Since the first recovery room was designated in 1923 at Johns Hopkins Hospital, the ‘‘recovery room,’’ or postanesthesia care unit, has been valued as ‘‘the most important room in the hospital.’’2,3 Without question, the immediate postanesthesia
Theresa Clifford, MSN, RN, CPAN, is the Interim Nurse Manager for PACU/ACU/Infusion Center at Mercy Hospital, Portland, ME, and a Former President of American Society of PeriAnesthesia Nurses. Conflict of interest: None to report. Address correspondence to Theresa Clifford 54 Ocean House Road, Cape Elizabeth, ME 04107; e-mail address: [email protected]. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.12.005
Journal of PeriAnesthesia Nursing, Vol 29, No 2 (April), 2014: pp 159-160
Assessment of pain, conscious state, blood pressure, and nausea and vomiting should be made before discharging a patient from PACU. Assessment of other vital signs (temperature, respiratory rate, heart rate, and capillary oxygen saturation) should be considered before discharging a patient from PACU.
Sleep Apnea The ASPAN Standards include a practice recommendation created to describe best nursing practice for caring for the adult patient with obstructive sleep apnea (OSA).3 Based on an extensive review of literature, the strategic work team members identified nursing-specific recommendations intended to promote safe care of these patients. In terms of discharging the patient with
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known or suspected OSA from the Phase I PACU, the literature review uncovered very little empirical evidence other than to suggest an anticipated ‘‘extended PACU stay.’’ The literature did reveal evidence to support observing outpatients with OSA an average of 3 hours longer than non-OSA patients, anticipating a minimum observation period of 2 to 6 hours. In the event that the patient demonstrates sustained desaturations or periods of apnea, plan on at least seven additional hours of monitoring for each hypoxemic and/or obstructive event that is witnessed. The only other ‘‘time-based’’ recommendation for the patient with known or suspected OSA is to assure that the patient maintains oxygen saturation greater than 94% or at baseline for at least 2 hours before discharge to home.
Local Anesthesia According to the American Society of Anesthesiologists (ASA), the ultimate responsibility for the medical supervision and discharge of patients lies with a physician.7 The ASA also recommends that patients who receive ‘‘other than unsupplemented local anesthesia’’ should have a responsible individual accompany them home. In a practice guideline published in 2002 by the ASA regarding postanesthesia care, authors reviewed relevant research and expert opinion to develop the guideline intended for improving care and minimizing adverse events. Regarding the concept of ‘‘minimum’’ recovery times they wrote: The literature is insufficient to evaluate the benefits of requiring a minimum mandatory
stay in recovery. The Consultants disagree and the ASA members are equivocal regarding whether a minimum stay in a recovery facility improves patient comfort and satisfaction or should be required. The Consultants and ASA members are equivocal regarding whether a minimum stay reduces adverse outcomes. The Task Force consensus is that a mandatory minimum stay is not necessary and that the length of stay should be determined on a case-by-case basis.7 These Postanesthetic Care Guidelines further state that ‘‘a mandatory minimum stay should not be required’’ and supports the use of objective discharge criteria designed to reduce postanesthesia cardiovascular and cardiopulmonary depression.7
Criteria Summary Current trends in perianesthesia practice lean toward the use of established evidence-based discharge criteria when considering postanesthesia length of stay. General requirements for these criteria suggested for discharge assessments include the development and endorsement of inclusive guiding policies and/or procedures regarding specific data elements for discharge and the provision of staff education regarding the criteria.8 Numerous positive outcomes are associated with the application of discharge criteria assessment tools and include decreased discharge delays and individualized approaches to patient discharge.
References 1. Truong L, Moran JL, Blum P. Post anaesthesia care unit discharge: A clinical scoring system versus traditional timebased criteria. Anaesth Intensive Care. 2004;32:33-42. 2. Odom-Forren J, Clifford T. Evolution of perianesthesia care. In: Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO: Saunders Elsevier; 2009. 3. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012.
4. Phillips NM, Haesler E, Street M, Kent B. Post-anaesthetic discharge scoring criteria: A systematic review. JBI Libr Syst Rev. 2011;9:1679-1713. 5. Joanna Briggs Institute. Best practice: Evidence-based information sheets for health professionals. Post-anesthetic discharge scoring system. JBI. 2011;15:1-4. 6. Moola S. Post-anesthetic discharge: Scoring criteria. JBI 2012;1-3. 7. American Society of Anesthesiologists. Practice guidelines for postanesthetic care. Anesthesiology. 2002;96:742-752. 8. White N. Criteria led discharge. Aust Nurs J. 2013;21:35.
Length of Stay—Discharge Criteria Theresa Clifford, MSN, RN, CPAN QUESTION: THE CLINICAL PRACTICE COMMITTEE receives a variety of questions related to patient length of stay. Some examples are as follows: Does the American Society of Perianesthesia Nurses (ASPAN) have recommendations regarding the length of stay in the Phase I postanesthesia care unit (PACU)? Is a recommendation of 30 to 60 minutes typical? What are the recommendations for how long a patient with sleep apnea should be monitored? What is the standard recovery time for patients with local anesthesia and no sedation?
and postprocedural sedation periods require high quality, safe nursing care to detect and/or prevent serious complications. Many factors affect the patient’s response to anesthesia and subsequent length of stay in the Phase I and Phase II units. Although the nature of the type and length of surgery or procedure plays a large role in the immediate postanesthesia recovery, the patient’s preanesthesia clinical status and the patient’s unique responses to surgical and pharmacological interventions strongly influence this critical time.
Response
In the past, anecdotally, many PACUs depended on a predetermined minimum length of stay. Gradually, advanced clinical monitoring devices and improved access to these devices have enhanced the objective perianesthesia nursing assessments of patients and have supported early detection of changes in the patient’s condition. As noted by Phillips et al,4 many current practices use criteriabased tools for assessing patient readiness for transfer to another level of care and support bedside decision making. Following a systematic review of literature, Phillips et al4-6 have made the following recommendations for data elements to include in discharge criteria:
There are wide variations in practice across the country with regard to patient assessment and requirements for transfer of care across the perianesthesia continuum. Truong et al1 conducted a cohort analysis in 2004, in which they compared time-based discharge criteria with a modified clinical scoring system that incorporated pain and temperature for Phase I patients having general anesthesia. Preliminary findings suggested that criteria-based assessments significantly reduced the average length of stay for the Phase I patients compared with patients who were discharged according to ‘‘the clock.’’
History Since the first recovery room was designated in 1923 at Johns Hopkins Hospital, the ‘‘recovery room,’’ or postanesthesia care unit, has been valued as ‘‘the most important room in the hospital.’’2,3 Without question, the immediate postanesthesia
Theresa Clifford, MSN, RN, CPAN, is the Interim Nurse Manager for PACU/ACU/Infusion Center at Mercy Hospital, Portland, ME, and a Former President of American Society of PeriAnesthesia Nurses. Conflict of interest: None to report. Address correspondence to Theresa Clifford 54 Ocean House Road, Cape Elizabeth, ME 04107; e-mail address: [email protected]. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.12.005
Journal of PeriAnesthesia Nursing, Vol 29, No 2 (April), 2014: pp 159-160
Assessment of pain, conscious state, blood pressure, and nausea and vomiting should be made before discharging a patient from PACU. Assessment of other vital signs (temperature, respiratory rate, heart rate, and capillary oxygen saturation) should be considered before discharging a patient from PACU.
Sleep Apnea The ASPAN Standards include a practice recommendation created to describe best nursing practice for caring for the adult patient with obstructive sleep apnea (OSA).3 Based on an extensive review of literature, the strategic work team members identified nursing-specific recommendations intended to promote safe care of these patients. In terms of discharging the patient with
159
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known or suspected OSA from the Phase I PACU, the literature review uncovered very little empirical evidence other than to suggest an anticipated ‘‘extended PACU stay.’’ The literature did reveal evidence to support observing outpatients with OSA an average of 3 hours longer than non-OSA patients, anticipating a minimum observation period of 2 to 6 hours. In the event that the patient demonstrates sustained desaturations or periods of apnea, plan on at least seven additional hours of monitoring for each hypoxemic and/or obstructive event that is witnessed. The only other ‘‘time-based’’ recommendation for the patient with known or suspected OSA is to assure that the patient maintains oxygen saturation greater than 94% or at baseline for at least 2 hours before discharge to home.
Local Anesthesia According to the American Society of Anesthesiologists (ASA), the ultimate responsibility for the medical supervision and discharge of patients lies with a physician.7 The ASA also recommends that patients who receive ‘‘other than unsupplemented local anesthesia’’ should have a responsible individual accompany them home. In a practice guideline published in 2002 by the ASA regarding postanesthesia care, authors reviewed relevant research and expert opinion to develop the guideline intended for improving care and minimizing adverse events. Regarding the concept of ‘‘minimum’’ recovery times they wrote: The literature is insufficient to evaluate the benefits of requiring a minimum mandatory
stay in recovery. The Consultants disagree and the ASA members are equivocal regarding whether a minimum stay in a recovery facility improves patient comfort and satisfaction or should be required. The Consultants and ASA members are equivocal regarding whether a minimum stay reduces adverse outcomes. The Task Force consensus is that a mandatory minimum stay is not necessary and that the length of stay should be determined on a case-by-case basis.7 These Postanesthetic Care Guidelines further state that ‘‘a mandatory minimum stay should not be required’’ and supports the use of objective discharge criteria designed to reduce postanesthesia cardiovascular and cardiopulmonary depression.7
Criteria Summary Current trends in perianesthesia practice lean toward the use of established evidence-based discharge criteria when considering postanesthesia length of stay. General requirements for these criteria suggested for discharge assessments include the development and endorsement of inclusive guiding policies and/or procedures regarding specific data elements for discharge and the provision of staff education regarding the criteria.8 Numerous positive outcomes are associated with the application of discharge criteria assessment tools and include decreased discharge delays and individualized approaches to patient discharge.
References 1. Truong L, Moran JL, Blum P. Post anaesthesia care unit discharge: A clinical scoring system versus traditional timebased criteria. Anaesth Intensive Care. 2004;32:33-42. 2. Odom-Forren J, Clifford T. Evolution of perianesthesia care. In: Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO: Saunders Elsevier; 2009. 3. American Society of PeriAnesthesia Nurses. 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: ASPAN; 2012.
4. Phillips NM, Haesler E, Street M, Kent B. Post-anaesthetic discharge scoring criteria: A systematic review. JBI Libr Syst Rev. 2011;9:1679-1713. 5. Joanna Briggs Institute. Best practice: Evidence-based information sheets for health professionals. Post-anesthetic discharge scoring system. JBI. 2011;15:1-4. 6. Moola S. Post-anesthetic discharge: Scoring criteria. JBI 2012;1-3. 7. American Society of Anesthesiologists. Practice guidelines for postanesthetic care. Anesthesiology. 2002;96:742-752. 8. White N. Criteria led discharge. Aust Nurs J. 2013;21:35.
