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.