Postanesthesia Care Unit Discharge Criteria Research Articles

General anesthesia techniques reducing the time to satisfy phase I post-anesthesia care unit discharge criteria: Narrative review of randomized clinical trials and cohort studies studying unit bypass, supplemented with computer simulation

We performed a narrative review of bypass of the phase I post-anesthesia care unit (PACU) following general anesthesia to gain insight into ways to reduce the time until patients are ready for PACU discharge following general anesthesia. Web of Science and PubMed literature searches were performed. Publications’ references and citations were examined. The Scale for the Assessment of Narrative Review Articles’ six components were satisfied. The 14 articles included 17 studies, with nearly all patients being adults. Most studies’ patients underwent outpatient surgery with an average surgical duration of less than 100 min . The studies applied several different, but similar, criteria to choose if patients bypass the PACU. Notably, 13 of 17 studies and all five with the largest observed bypass rates used some version of the White-Song fast-track bypass criteria. Propofol was used uniformly for induction of general anesthesia. Most studies included at least one antiemetic prophylactically, a local anesthetic administered by the surgeon, and a non-opioid analgesic. The six studies with the largest observed bypass rates used remifentanil or restricted use of intraoperative opioids. We then considered economics. While achievable PACU bypass rates are insufficient to reduce healthcare costs, reducing mean PACU time markedly can lower the nursing labor costs, the total time until the last patient exits the PACU, and the incidence of patients recovering in operating rooms because of unavailable PACU nurses or beds. We examined probability distributions of brief patient recovery times by using Gas Man, an uptake and distribution software program, simulating times until reaching constant incremental reductions (0.1 %) in vessel-rich concentrations of desflurane and sevoflurane once the vaporizer was set to zero. Results showed that simulated recovery from volatile anesthetics can have recovery times appearing log-normal, as seen empirically. Thus, patients already meeting discharge criteria upon PACU arrival can be the far-left fraction of one population of patients. The implication is that the narrative review results for PACU bypass provide insight into how to have more patients with very brief times to recovery. Therefore, future studies should quantify the effectiveness and economic benefits of anesthesia practitioners aiming not for PACU bypass, per se, but rather that the patients meet PACU discharge criteria by the 5–10 min after unit arrival when the practitioner has completed PACU handoff and finished documentation in the anesthesia record.

Nurse Discharge by Criteria Decreases Post Anesthesia Care Unit (PACU) Length of Stay

Background Information The PACU nurses noted that when a patient was ready for discharge, an Anesthesiologist was not always immediately available to evaluate and discharge the patient. This led to both nurse and patient frustration as well as an increased length of stay (LOS) for the patient. Objectives of Project The objective is to facilitate the safe discharge of patients from Phase I PACU while decreasing the LOS. Process of Implementation • Literature review performed to identify best practices supporting this type of initiative. • Visitation to an affiliate hospital who had previously implemented this practice. • Consultation with Department of Anesthesiology to determine support for this initiative: ○ In the electronic medical record the Anesthesiologist orders indicate if the patient is eligible for discharge by criteria or an Anesthesiologist sign out. ○ If a patient is initially ordered for discharge by criteria, but the nurse has concerns, the nurse has the option to call the Anesthesiologist for an evaluation and sign out. • The PACU Nurse Manager and Nurse Educator discussed how to best implement this initiative, scheduled for January 7, 2019. • The Manager introduced this initiative to the nurses at unit staff meetings. • The Educator developed a program focusing on the Aldrete Score and our PACU Discharge Policy. At this session a case study type knowledge test was administered, and once completed, responses were reviewed with each nurse. A competency tool was developed for the Anesthesiologist to document that each nurse demonstrated proficiency in our Phase I PACU Discharge Criteria. Statement of Successful Practice The average length of stay for ambulatory surgery patients (974) in our Phase I PACU prior to this initiative (September- November 2018) was 119.17 minutes. After the implementation of this initiative (May - July 2019) the LOS for this patient population (935) decreased to 112.96 minutes. This reflects a 6.21 minute decrease in PACU LOS. At a cost of approximately $13.33 per minute of recovery time for 935 patients for this period, $77,399.30 was saved. Implications for Advancing the Practice of Perianesthesia Nursing PACU nurses can safely and independently discharge Phase I patients by criteria while demonstrating a decrease in the LOS for the Phase I PACU. The PACU nurses noted that when a patient was ready for discharge, an Anesthesiologist was not always immediately available to evaluate and discharge the patient. This led to both nurse and patient frustration as well as an increased length of stay (LOS) for the patient. The objective is to facilitate the safe discharge of patients from Phase I PACU while decreasing the LOS. • Literature review performed to identify best practices supporting this type of initiative. • Visitation to an affiliate hospital who had previously implemented this practice. • Consultation with Department of Anesthesiology to determine support for this initiative: ○ In the electronic medical record the Anesthesiologist orders indicate if the patient is eligible for discharge by criteria or an Anesthesiologist sign out. ○ If a patient is initially ordered for discharge by criteria, but the nurse has concerns, the nurse has the option to call the Anesthesiologist for an evaluation and sign out. • The PACU Nurse Manager and Nurse Educator discussed how to best implement this initiative, scheduled for January 7, 2019. • The Manager introduced this initiative to the nurses at unit staff meetings. • The Educator developed a program focusing on the Aldrete Score and our PACU Discharge Policy. At this session a case study type knowledge test was administered, and once completed, responses were reviewed with each nurse. A competency tool was developed for the Anesthesiologist to document that each nurse demonstrated proficiency in our Phase I PACU Discharge Criteria. The average length of stay for ambulatory surgery patients (974) in our Phase I PACU prior to this initiative (September- November 2018) was 119.17 minutes. After the implementation of this initiative (May - July 2019) the LOS for this patient population (935) decreased to 112.96 minutes. This reflects a 6.21 minute decrease in PACU LOS. At a cost of approximately $13.33 per minute of recovery time for 935 patients for this period, $77,399.30 was saved. PACU nurses can safely and independently discharge Phase I patients by criteria while demonstrating a decrease in the LOS for the Phase I PACU.

Incidence of Post-Anesthesia Symptoms, Surgical Events and Length of Stay for Surgical Oncology Outpatients

<h3>Introduction</h3> The Main Post Anesthesia Care Unit (PACU) at Memorial Sloan Kettering utilizes a two-step recovery process which provides acute post-operative care during Phase I recovery, and less acute care during Phase II recovery which focuses on preparing the surgical outpatient for discharge. <h3>Identification of the problem</h3> The perianesthesia nursing staff identified several post-operative symptoms including nausea, vomiting, dizziness, somnolence, pain and impaired wound integrity which delayed outpatient discharge and contributed to increased PACU II length of stay (LOS). <h3>Purpose of the Study</h3> This study examined the incidence of post-anesthesia symptoms, post-operative events and length of stay for surgical oncology outpatients during Phase II recovery at three time periods between 4/1/2017 and 8/5/2018. <h3>Methodology</h3> A retrospective analysis of data was used to examine post-surgical records at three time periods: before, one month after, and one-year after PACU I discharge criteria were revised. Records of outpatients receiving regional pain control or pre-operative antiemetics were excluded. Institutional Review Board approval was obtained (19-308). Records (n=1091) were examined for missing and duplicate data. Univariate analysis was conducted to identify relationships between study variables as well as covariant influences on length of stay. Findings were summarized in tables. <h3>Results</h3> Significant decreases in PACU II LOS were found between T-1(30 min), T-2(28 min) and T-3 (27min) (P<0.001). The incidence of dizziness inconsistently decreased from 12% (T-1), 3.8% (T-2) to 5.6% (T-3). Although blood pressure fluctuations decreased between each time — 1.4% (T-1), 0.3% (T-2), and 0.2% (T-3) — post-anesthesia symptoms of dizziness, pain and nausea decreased from T1 to T2, with an anticipated increase in T-3. The use of Fentanyl and continuous IV fluids decreased between all time periods. <h3>Discussion</h3> Although there were some inconsistencies in the incidence of certain post-anesthesia symptoms between time points, the use of measurable clinical criteria can improve patient outcome. <h3>Conclusion</h3> Improving PACU discharge criteria decreased the incidence of post-operative symptoms and overall PACU II LOS. <h3>Implications for perianesthesia nurses and future research</h3> Monitoring key variables related to patient outcomes ensures sustained practice changes and an optimal surgical experience for oncology outpatients.

The Post-Anesthesia Care Unit

This general overview of the postanesthesia care unit (PACU) summarizes the most current standards and guidelines for patient care and monitoring. It also details the causes and treatment of the most common complications observed in PACU, such as postoperative nausea and vomiting, hemodynamic compromise, and respiratory insufficiency. Other relevant topics such as residual neuromuscular blockade and emergence delirium are also addressed. Finally, this chapter concludes with a discussion of the development of commonly used discharge scoring systems, including a discussion of the differences between the ambulatory and inpatient surgery populations. Each of these sections discusses current trends in management as supported by the latest literature and guidelines. This review contains 1 figure, 8 tables, and 53 references. Key Words: Aldrete scoring, delayed awakening, emergence delirium, postanesthesia care unit, postanesthesia care unit discharge criteria, postoperative nausea and vomiting, postoperative respiratory failure, residual neuromuscular blockade, sugammadex

Évaluation des versions pour téléphone intelligent de l’échelle visuelle analogique et de l’échelle d’évaluation numérique en tant qu’outils d’évaluation de la douleur postopératoire : une étude randomisée prospective

The Pain assessment using a novel digital application (Panda) is a smartphone application that contains the digital versions of the visual analogue scale (VAS-100) and numeric rating scale (NRS-11). This study aimed to investigate if the Panda versions of these two pain scales are equivalent to the paper versions in adult patients. This was a prospective, randomized, cross-over-controlled trial of subjects aged 19-75 yr undergoing procedures with anticipated post-surgical pain. Each subject used both the Panda and paper versions of VAS-100 or NRS-11 pain scores after emergence from anesthesia and after meeting postanesthesia care unit (PACU) discharge criteria. Correlations between the two tools were analyzed, and Bland-Altman agreement was calculated. The smartphone and paper versions were considered equivalent at each time point if the differences (and their 95% confidence interval [CI]) between them were less than 20 points for the VAS-100 and 2.1 for NRS-11. The two versions of the VAS-100 correlated strongly after emergence (Pearson's r = 0.93; P < 0.001) and upon meeting discharge criteria (r = 0.94; P < 0.001); the mean (standard deviation [SD]) Panda score after emergence was 35 (27) compared with the paper score of 37 (26) (mean difference, - 2; 95% CI, - 22 to 19). The mean (SD) VAS-100 Panda score upon meeting discharge criteria was 21 (20) compared with the paper score of 23 (21) (mean difference, - 2; 95% CI, - 17 to 13). For the NRS-11, Panda again correlated strongly with the original tool scores after emergence (r = 0.93; P < 0.001) and upon meeting discharge criteria (r = 0.96; P < 0.001); the mean (SD) Panda and paper scores after emergence were both 4 (3) (mean difference, 0.05; 95% CI, - 1.87 to 1.96). The mean (SD) NRS-11 Panda and paper scores upon meeting PACU discharge criteria were both 3 (2) (mean difference, - 0.08; 95% CI, - 1.41 to 1.26). Following emergence from anesthesia in adult patients, the digital Panda version of the NRS-11, but not the VAS-100, is equivalent to the validated paper version. In those who are ready for discharge from the PACU, the digital Panda versions of both the VAS-100 and NRS-11 agreed adequately and can be used in place of the original paper versions.

Implementation of Physiological Scoring to Determine Discharge Readiness for Patients Undergoing Otolaryngology Head and Neck Procedures

This quality improvement project examined whether the use of a validated physiological scoring protocol to determine discharge readiness for surgical procedures proximal to the airway would decrease the time at which discharge criteria were met and postanesthesia care unit (PACU) length of stay. An observational pre-post design compared preimplementation recovery times to postimplementation recovery times. PACU nurses were trained to use two physiological scoring protocols to determine when patients met discharge criteria and to document when discharge criteria were met. During the postimplementation period, there was a significant decrease in the time it took patients to meet PACU discharge criteria when using the physiological scoring protocols compared with the preimplementation group (P < .001). These results suggest that physiological scoring protocols are safe and appropriate to determine discharge readiness for patients who have surgery proximal to the airway.

Comparing low-dose bupivacaine with epidural volume extension to standard bupivacaine dosing for short obstetric procedures: a prospective, randomized study

Intrathecal bupivacaine's long duration of action can unnecessarily increase the time to meet Postanesthesia Care Unit (PACU) discharge criteria for patients undergoing short obstetric procedures. We sought to use a technique known as epidural volume extension (EVE) to determine if we could provide an adequate surgical block while significantly decreasing the time required to meet PACU discharge criteria for patients undergoing short obstetric procedures. Fifty participants were randomized into two groups. The control group received a 10 mg of 0.5% isobaric bupivacaine plus 15 µg of fentanyl injection in the intrathecal space via a combined spinal-epidural technique. The EVE group received a 5 mg of 0.5% isobaric bupivacaine plus 15 µg of fentanyl injection in the intrathecal space followed immediately by a 10 mL injection of sterile saline through the epidural needle for the EVE. Data were analyzed on 45 of the 50 patients. Time to meet PACU discharge criteria was significantly reduced in the EVE group when compared to the control group (50 vs. 135 minutes, P<0.001). The EVE group had a faster time to complete motor recovery when compared to the control group (66 vs. 181 minutes, P<0.001). Peak block height was similar in both groups at the time of surgery start (T5 vs. T5, P=0.44). The use of low-dose isobaric bupivacaine in combination with 10 mL of saline EVE allows for faster motor recovery and time to meet PACU discharge criteria in patients undergoing short obstetric procedures.

Scheduled Intravenous Acetaminophen Improves Patient Satisfaction With Postcraniotomy Pain Management: A Prospective, Randomized, Placebo-controlled, Double-blind Study.

Postcraniotomy pain can be difficult to manage with opioids due to opioid-related side effects, including drowsiness, nausea/vomiting, confusion, and pupillary changes, potentially masking the signs of postoperative neurological deterioration. Intravenous (IV) acetaminophen, a nonopioid analgesic, has been reported to have opioid-sparing effects after abdominal and orthopedic surgeries. This study investigates whether IV acetaminophen has similar effects after craniotomy. In this prospective, randomized, placebo-controlled, double-blind clinical trial, 100 adult patients scheduled to undergo supratentorial craniotomy for excision of a brain mass were randomized to receive either IV acetaminophen or placebo preincision and then every 6 hours for a total of 24 hours after surgery. Total 24-hour opioid consumption, pain scores, satisfaction with overall pain management, time to meet postanesthesia care unit discharge criteria, and incidence of opioid-related side effects were compared. There was no difference in the 24-hour postoperative opioid consumption in morphine equivalents between the IV acetaminophen group (median, 11 mg; n=45) and the placebo group (median, 10.1 mg; n=41). No statistically significant difference of visual analog scale pain score was observed between 2 treatment groups. Patient satisfaction with overall postoperative pain management was significantly higher in the IV acetaminophen group than the placebo group on a 1 to 10 scale (8.1±0.4 vs. 6.9±0.4; P=0.03). There was no significant difference in secondary outcomes, including the incidence of opioid-related side effects. IV acetaminophen, as adjunctive therapy for craniotomy procedures, did not show an opioid-sparing effect in patients for the 24 hours after craniotomy; however, it was associated with improved patient satisfaction regarding overall pain control.

Preemptive analgesia by peritonsillar ketamine versus ropivacaine for post-tonsillectomy pain in children

BackgroundPostoperative pain relief is a desired goal after tonsillectomy. Respiratory depression from opioid, bleeding from nonsteroidal antiinflammatory drugs, and airway edema all these factors make pain control is judges. Peritonsillar infiltration of a local anesthetic has been used for reduction of post-tonsillectomy pain.ObjectiveThis study aims to compare the postoperative analgesic efficacy and side-effects of preincisional peritonsillar infiltration of either ketamine or ropivacaine in children undergoing tonsillectomy.MethodsIn this prospective randomized double blind study, 60 children 7–12 years scheduled to tonsillectomy were divided into three groups: the tonsils were infiltrated by 0.2 ml kg−1 ropivacaine, 0.75% in ropivacaine group R (=21), group 0.5 mg kg−1 ketamine in the ketamine group K (n = 20), and 0.2 ml kg−1 normal saline in the control group S (n = 19). All drugs were prepared in normal saline (3 ml per tonsil) infiltrated 3 min after induction of anesthesia and before surgical incision. Surgery was performed by a single otolaryngology fellow using the same dissection and snare technique. Postoperative pain was compared during 8-h period using a visual analog scale (VAS). The fast-tracking score was used to determine the post-anesthesia care unit discharge criteria. Patients were evaluated for: time of first request and the total analgesic requirement, time of first oral intake, nausea, vomiting, bleeding, and hallucination.ResultsIn the post-anesthesia care unit, groups K and R had comparable pain scores that were significantly lower than S group (P < 0.04). Pain scores in the postoperative ward at 2, 6, and 8 h were significantly higher in group S than in K and R groups (P < 0.05). The time of first analgesic demand was significantly longer in R group (5.52 ± 1.7) h than in K group (3.83 ± 0.16) h p = 0.003. It was the shortest in S group (2.57 ± 0.84) h p = 0.001. The time of first oral intake was significantly longer in S than in R and K groups (5 ± 1.72 versus 3.2 ± 1.97 and 3.65 ± 1.72 h) respectively = 0.006. Total analgesic consumption (mg) was significantly higher in S group than in R and K (12. ± 5.3 versus 8, 2 ± 2.3 and 8.6 ± 3.1) p = 0.004. There were no significant differences between groups regarding nausea, vomiting, or bleeding, and there was no other side-effect recorded.ConclusionPerincisional peritonsillar infiltration of both ropivacaine and ketamine was effective in reduction of post-tonsillectomy pain. Ropivacaine was superior to ketamine in reduction of time to first analgesic demand.

A Clinical Audit of Postoperative Urinary Retention in the Postanesthesia Care Unit

Postoperative urinary retention (PUR) is a common postsurgical complication. Early detection and management of PUR is of particular concern to nurses working in the postanesthesia care unit (PACU) because a single episode of bladder distention may result in permanent bladder damage. A clinical audit (CA) was conducted that examined the risk factors that may contribute to the development of PUR in the PACU. The CA was conducted over a 1-week time period and used a data collection tool that was developed from the current literature. A total of 34 patients met the inclusion criteria for the CA, and a prevalence rate of 20.6% was reported, which was consistent with prevalence rates reported by larger research studies. Despite the small sample size of this CA, results suggested that PUR should be of concern to nurses in the PACU. Recommendations included the development and implementation of a guideline relating to bladder scanning in the PACU and modification of existing PACU discharge criteria to include bladder management.

Office-Based Anesthesia: Dispelling Common Myths

Running parallel with-and perhaps driven by-the huge increase in demand for cosmetic surgery, office-based anesthesia (OBA) is the fastest growing segment of anesthesia practice. Despite this, only 2% of anesthesiology residencies provide exposure to OBA, and many practicing anesthesiologists are not convinced that OBA techniques provide safe, reliable, and effective anesthesia care. To examine OBA techniques and safety records while addressing some of the commonly held beliefs among anesthesiologists regarding OBA. A review of 4800 patients undergoing 5264 cosmetic surgical procedures performed between 1997 and 2007 at Dudley Street Operatory (licensed in Rhode Island as a Physician Office Setting Providing Surgical Treatment and certified by the American Association for Accreditation of Ambulatory Surgery Facilities) was conducted. The primary anesthetic technique was deep sedation with a propofol ketamine infusion, combined with local anesthetic injection. Intercostal nerve blocks were performed before surgery in patients who had breast surgery and/or abdominoplasty. Endotracheal or laryngeal mask airway techniques were not used, nor were paralyzing agents, anesthetic gases, or vapors. There were 16 unanticipated postoperative admissions in 10 years, all but 3 from surgical complications (hematoma, infection, and pneumothorax during dissection for breast implants). One patient had an acute reaction to a small volume of local anesthetic injected into the nasal septum, one patient with a history of panic attacks had an acute anxiety attack manifested as chest pain, and one patient refused discharge from the operatory to home after a face lift, despite meeting postanesthesia care unit discharge criteria, and was admitted overnight to the hospital. There were no hospital admissions because of pain, nausea, or excessive sedation. In experienced hands, OBA techniques deliver an anesthetic for office-based cosmetic surgery superior to the usual general anesthesia performed in hospitals and ambulatory surgical centers. These techniques are safe, do not require expensive equipment other than an infusion pump and vital signs monitor, avoid sore throats and nausea, provide postoperative analgesia, and are well received by patients and surgeons. OBA presents an opportunity for anesthesiologists and aesthetic surgeons to partner for greater patient satisfaction.

Effect of propofol on emergence behavior in children after sevoflurane general anesthesia

Emergence agitation (EA) is a postoperative behavior that may occur in children undergoing general anesthesia with inhaled agents. The aim of the present study was to assess the effect of propofol administered at the end of sevoflurane anesthesia on the incidence and severity of EA in children undergoing magnetic resonance imaging (MRI). Eighty-four children, 2-7 years old, undergoing MRI were enrolled in this randomized double-blind study. No sedative premedication was administered prior to anesthesia induction. Anesthesia was induced and maintained with sevoflurane in N(2)O/O(2). Group P received propofol 1 mg.kg(-1) and group S received saline. Pediatric Anesthesia Emergence Delirium scale (PAEDs) was used to evaluate recovery characteristics upon awakening and during the first 30 min after emergence from anesthesia. Children with PAEDs >16 were considered agitated. EA was analyzed using the Mann-Whitney U-test. Demographic data and other side effects were analyzed using the Student's t-test. Eighty-three children completed the study. There were 42 children in group P. EA was diagnosed in two children in the propofol group (4.8%) and in 11 children in the placebo group (26.8%, P < 0.05). Time to achieving postanesthesia care unit discharge criteria was not different between the two groups. The addition of propofol 1 mg.kg(-1) can significantly decrease the incidence of EA after sevoflurane general anesthesia in children undergoing nonpainful procedures.

Éviter la salle de réveil, l’étude pilote d’un “protocole accéléré” dans un hôpital communautaire

To evaluate the effectiveness of short-acting anesthetic drugs and techniques to achieve recovery room bypass criteria after minor surgery in a community hospital environment. After agreement by a multidisciplinary committee, a pilot project was undertaken to assess the usefulness of ultra- short acting anesthetic drugs and pre-emptive analgesia to facilitate rapid recovery from general anesthesia. A cohort of 100 ASA I-II patients aged 18-65 yr undergoing simple knee arthroscopy or minor peripheral orthopedic procedures was compared to a similar cohort treated in the three months prior to the study period. Outcomes of interest included patient morbidity, success in achieving post-anesthesia care unit (PACU) bypass criteria, impact upon nursing resources, duration of operating room (OR) and hospital stay, and pharmaceutical costs before and after implementation. No patient morbidity was demonstrated prior to discharge home, and successful PACU bypass occurred in 83% of cases. Achievement of PACU discharge criteria while in the OR did not prolong the OR time, and discharge from hospital occurred earlier in the patients who did not require PACU care (P=0.0006 all "fast-track cases" vs all "controls"). Nursing complaints were more numerous when the day surgery personnel did not normally participate in PACU care. The cost of anesthetic care was significantly more using ultra-short acting drugs (CDN $14.17 vs CDN $20.57), but closer adherence to protocol could reduce this differential (CDN $18.84). Not all patients who receive a general anesthetic require admission to a phase I recovery facility. However, the justification for use of more expensive pharmaceuticals to achieve PACU bypass requires extensive changes in operating systems and voluntary professional behaviours.