ACCREDITATION STANDA RDS DISCHARGE Facility processes ensure safe and appropriate discharge of patients to home Facility written policy and procedures are in place for appropriate patient discharge home Readiness for discharge is based upon an objective discharge scoring system and not on a specific period of time (see Appendix A) The patient meets minimum discharge score requirements Other discharge criteria specific to the patient are met (e.g. difficult intubation, obstructive sleep apnea, voiding) (see Appendix B) The most responsible physician (e.g. anesthesiologist, surgeon) is responsible for writing the discharge order The decision to discharge, using an objective discharge scoring system, may be delegated to the PACU RN Facility written policy and procedures are in place for transfer to hospital if patients do not meet discharge criteria Transfer processes ensure safe and appropriate discharge of patients to overnight stay Facility has written policies and procedures in place for appropriate patient transfer to overnight stay The most responsible physician (e.g. anesthesiologist, surgeon) remains at the facility until the patient meets documented predetermined discharge criteria for transfer to overnight stay Readiness for transfer to overnight stay is based upon an objective discharge scoring system and not on a specific period of time (see Appendix A) The patient meets minimum discharge score requirements December 3, 7 Page of 5
Other discharge criteria specific to the patient are met (e.g. difficult intubation, obstructive sleep apnea, voiding) (see Appendix B) The most responsible physician (e.g. anesthesiologist, surgeon) is responsible for writing the transfer to overnight stay order; the decision to transfer to overnight stay, using an objective discharge scoring system, may be delegated to the PACU RN Facility has written policies and procedures in place for transfer to hospital if patient status changes Discharge processes ensure all patients are appropriately prepared for discharge from PACU and/or overnight stay Facility has written policies and procedures in place for post-operative teaching related to the surgery and discharge The teaching plan includes: education specific to the surgery and anesthesia type management of post-operative pain, nausea and vomiting awareness of potential complications and steps to take (e.g. bleeding, fever, urinary retention) review of post-operative instructions Verbal and written discharge instructions are provided to the patient and the accompanying adult and include but are not limited to: general instructions (e.g. pain, fever, driving restrictions) patient specific instructions (e.g. type of surgery and anesthesia) medication instructions (e.g. resuming medications) follow-up care (e.g. appointments, telephone calls) accessing emergency care (e.g. surgeon, facility, other) notifying the facility of any reportable incidents as per the College Bylaws Patients are accompanied from the facility by a responsible adult Additional measures are taken in circumstances where patients are unable or unwilling to arrange accompaniment from the facility by a responsible adult the additional measures include but are not limited to: patients are advised of the importance of an accompanying adult the most responsible physician (e.g. anesthesiologist, surgeon) determines that the patient s cognitive and physical parameters exceed minimum discharge requirements and that the patient can function independently the most responsible physician (e.g. anesthesiologist, surgeon) determines whether the transportation method reported by the patient is acceptable the most responsible physician (e.g. anesthesiologist, surgeon) is responsible for writing the discharge order which includes that the patient may be discharged without a responsible December 3, 7 Page of 5
adult; the decision to discharge without a responsible adult may not be delegated to the PACU RN arrangements for ongoing care are made for patients who do not exceed minimum cognitive and physical parameters for discharge Discharge records ensure consistent and informed care A unified medical record is maintained for every patient in which all components (e.g. medical history, laboratory and imaging reports, surgical reports, consultations etc.) are gathered into one file, in one location The medical record is complete, up to date and includes documentation of all discharge readiness assessments, teaching, instructions, prescriptions and status upon discharge Appendix A: Discharge scoring system examples Modified Aldrete scoring system (NAPAN, 4) Category Description of status Aldrete score Respirations O Saturation Circulation Level of Consciousness Movement Able to deep breathe and cough freely Dyspnea or limited breathing Apneic Able to maintain O saturation > 9% on room air Requires supplemental O to maintain SpO > 9% O saturation < 9% even with supplemental O BP +/- % pre-op value BP +/- 5% pre-op value BP +/- > 5% pre-op value Awake and oriented Wakens with stimulation Not responding Moves 4 limbs on own Moves limbs on own Moves limbs on own December 3, 7 Page 3 of 5
Post-anesthetic discharge scoring system (PADSS) (NAPAN, ) Category Description of status PADSS score Vital Signs Ambulation Nausea & Vomiting Pain Surgical Bleeding Within % range of pre-op value 4% range of pre-op value > 4% range of pre-op value Steady gait/no dizziness Ambulates with assistance Not ambulating/dizziness Minimal, treated with PO medications Moderate, treated with parenteral medications Continues after repeated treatments Acceptable to patient (PO medications) Acceptable to patient (parenteral medications) Pain not controlled/not acceptable to patient Minimal/no dressing changes required Moderate bleeding Severe bleeding Appendix B: Post-operative voiding Patients who possess one or more at-risk criteria, as outlined below, must void post-operatively prior to discharge. Patients who do not possess any of the at-risk criteria are not required to void prior to discharge. At-risk criteria includes: History of urinary retention Following a gynecological, spinal, rectal or urological procedure Post spinal/epidural anesthesia Older male patients December 3, 7 Page 4 of 5
References Apfelbaum JL, Silverstein JH, Chung FF, Connis RT, Fillmore RB, Hunt SE, Nickinovich DG, Schreiner MS, Barlow JC, Joas TA, American Society of Anesthesiologists Task Force on Postanesthetic Care. Practice guidelines for postanesthetic care: an updated report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology. 3 Feb;8():9-37. College of Physician & Surgeons of Alberta, Non-Hospital Surgical Facility Task Force. Non-hospital surgical facility [Internet]. Edmonton: College of Physician & Surgeons of Alberta; 997 [revised 4 Jun v; cited 5 Feb 9]. 6 p. (Standards & guidelines). Available from: http://www.cpsa.ab.ca/libraries/pro_qofc_non_hospital/nhsf_standards.pdf?sfvrsn= College of Physicians and Surgeons of Ontario. Out-of-hospital premises inspection program (OHPIP): program standards [Internet]. Toronto: College of Physicians and Surgeons of Ontario; 3 [cited 5 Feb 9]. 4 p. Available from: http://www.cpso.on.ca/uploadedfiles/policies/guidelines/office/ohp_standards.pdf Ead H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery. Journal of PeriAnesthesia Nursing. 6 Aug;(4):59-67. Merchant R, Chartrand D, Dain S, Dobson G, Kurrek MM, Lagace A, Stacey S, Thiessen B. Guidelines to the practice of anesthesia--revised edition 4. Can J Anaesth [Internet]. 4 Jan [cited 5 Feb 9];6():46-59. Available from: http://www.cas.ca/english/page/files/97_guidelines_4_web.pdf National Association of PeriAnesthesia Nurses of Canada. Standards for practice. 3rd ed. Oakville, ON: National Association of PeriAnesthesia Nurses of Canada; 4. Stanford Hospital and Clinics. Discharge criteria for phase I and II-post anesthesia care [Internet]. Stanford, CA: Stanford Hospital and Clinics; Oct [updated Apr; cited 5 Feb 9]. 7 p. Available from: http://ether.stanford.edu/pacu/documents/discharge%criteria%for%phase%i%and%ii% Post%Anesthesia%Care%D%4%5%.pdf December 3, 7 Page 5 of 5