Discharge Readiness

Locate ExpertsByJane Shufro September, 2014                      

Part 2.

In last month’s Blog I outlined a popular current discharge scoring system, the modified Aldrete, and the use of established safe discharge criteria in the PACU setting.   The scoring system evaluates 5 key parameters to ensure the safe transfer or discharge of the patient post operatively.

The clinical scoring system provides a reliable guide for nursing assessment, has been widely supported by The Joint Commission and proven to be efficient to use over the years. A well documented standardized discharge scoring system can prove to be a valuable asset, if you know what it means and where to find it in the medical record review.  Both paper PACU records and EHR integrate the scoring system into the nurses’ assessments area.  You will also find the information on the discharge nursing note.  In performing a medical record review, it’s prudent to compare the numerical scores with what else is documented in the same time frame.  For example, does the patient have a score of “2” for awake and alert but the nurse’s notes state the patient is sedated?   Validate that the scoring reflects what was really going on.

Not just a number…..

Now that you have a good basic idea of how numerical scores for discharge are used, let’s put it together the way you would when doing a case review.  Say, for example, a PACU nurse documents at 2 pm that the patient is responsive but sleepy on supplemental O2, unlabored resps, moving well with a blood pressure of 98/68. The patient’s baseline BP was 130/70 so he should have an Aldrete score of “7”. (Sleepy=1, activity=2, resps=2, O2 sat=1, and hemodynamic=1) You note a discrepancy because a score of “8” is documented instead.   Does it matter?  The answer is:  that depends.

The use of discharge criteria reinforces the value of having a system to maintain high standards of care, but there are limitations.  First, the criteria are broad and miss certain parameters that need to be assessed before readiness can be determined.   For example, vital sign ranges and expected pain or nausea levels and whether the patient needs to void are not included. Post- operative vital sign parameters may be inaccurate if preoperative values were abnormally high for the patient due to anxiety or other causes. Expecting the postoperative blood pressure to be within 20% of an elevated blood pressure may not be appropriate.

In the example above, it’s clear one needs to look beyond the numerical scoring data when analyzing a medical record review of a surgical patient.  The data alone does not replace the critical thinking or professional judgments of the nurse.  A patient may seem to fit all of the discharge criteria, yet a safe discharge requires an assessment on a case-by-case basis.  There are times when it’s reasonable to err on the side of caution as discharge goals can fail patients when used as a stand -alone measure.

Safe ambulatory surgery includes appropriate patient selection and timely discharge.  Discharge protocols must be established and consistently followed using scoring criteria and individualized assessments.

Hospital and unit based discharge policies should be requested and reviewed. Obtain copies of the scoring systems used as each facility has their own way of documenting these and they vary.  Pain, Sedation and Discharge are common types of scales that can be requested.   Websites such as American Society of Anesthesiologists (ASA) and American Society of Perianesthesia Nurses (ASPAN) are a good source of current practices.

Reviewing postoperative records can be a challenge.   It’s necessary to have an understanding of current discharge practices and protocols because limitations exist that have important implications for nursing.  Guidelines are evolving and are sometimes inconsistent, adding to the burden of finding literature to support the standards of care in this area.

If you need more information or have a question, contact me anytime.

Is Your Day Surgery Patient Ready for Discharge?

To reflect current technology and anesthesia practice, the American Society of Anesthesiologists have standards of care that require that a physician accept responsibility for discharge of patients from the unit. This is the case even when the decision to discharge the patient is made by the bedside nurse in accordance with the hospital-sanctioned discharge criteria or scoring system. If discharge scoring systems are to be used in this way, they must first be approved by the department of anesthesia and the hospital medical staff.  A responsible physician’s name must be noted on the record.

PADSS photoThe American Society of Perianesthesia Nurses (ASPAN) neither requires or endorses any particular scoring system, and leaves the frequency or interval between scores to the individual facility policy. Typically, the minimum assessment would be done on admission to the PACU and on discharge for each level of post anesthesia care. Perianesthesia nurses everywhere, however, recognize the use of  post-op scoring as an integral part of their discharge criteria.  Written discharge criteria should be developed by the department of Anesthesia.  The criteria states a certain acceptable post-op score be achieved prior to discharge.  There are several widely accepted post-anesthetic discharge scoring systems, the most common being the modified Aldrete.

Consciousness Awake and oriented
Arousable with minimum stimuli
Non responsive to tactile stimuli
2
1
0
Activity Able to move extremities
Mild to moderate weakness in extremities
Unable to move extremities
2
1
0
Respiration Able to deep breathe and cough, with no tachypnea
Tachypnea, but able to cough adequately
Dyspnea and unable to cough
2
1
0
Hemodynamics Blood pressure ±15% from pre-procedure level
Blood pressure ±30% from pre-procedure level
Blood pressure ±50% from pre-procedure level
2
1
0
O2 saturation Maintains saturation >92% on room air
Needs to inhale oxygen to maintain saturation ≥90%
Saturation <90% in spite of oxygen therapy
2
1
0

The numerical scores of each category are added up at each assessment and a total patient score of “8” or above must be reached to be able to go home.  There is of course some variability to each facility.  There are also some disadvantages to using the scoring system and many situations rely on good clinical nursing judgement.

In order to be able to determine whether a patient was appropriately discharged, a discharge ” score” system provides a tool- but that’s only a piece of what determines a patient’s overall readiness.  You must know how to interpret the anesthesia and PACU medical records, and know where to focus.

Learn more about how to better evaluate whether discharge criteria was met and where to locate this information in the medical record in my next Blog……part 2