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How will you determine when the patient is ready to be discharged?
Strong emphasis is placed on early discharge because there is usually limited space available. It is important to identify a set of criteria that helps to determine when a patient can be sent home to finish recovering.
Recovery itself can be divided into several phases that can overlap. Phase I, early recovery, generally begins at the end of an anesthetic and continues until the patient has recovered baseline activity, respiration, circulation, consciousness, and color. The Aldrete scoring system or a modification thereof is widely used in postanesthesia care units (Table 78.1). A score of 9 in the Aldrete system indi-cates that the patient is ready for phase II recovery. It is the physician’s responsibility to determine when a patient is ready for discharge from the facility to complete their recovery at home (phase III). Home readiness criteria include such parameters as stable vital signs, ability to ambulate, control of surgical bleeding, pain control, and minimal nausea and vomiting. Marshall and Chung (1999) developed the Postanesthesia Discharge Scoring System (PADSS) (Table 78.2). When the score is 9 or greater the patient is ready for discharge.
In recent years, the idea of fast-tracking patients after general anesthesia has received much attention. Fast-tracking implies the bypassing of the high-care setting of the postanesthesia care unit and moving the patient directly to an ambulatory surgery unit (ASU). With the newer anesthetic agents and techniques it is possible to complete early recovery in the operating room and transfer a patient directly to an ASU. Proposed fast-track criteria include level of consciousness, physical activity, hemodynamic stability, respiratory stability, oxygen saturation status, postoperative pain assessment, and the absence of postoperative nausea and vomiting. These criteria presented by White incorporate pain and nausea assessment, which previous systems did not include. Much of the impetus is the cost-savings potential, which in a hospital setting or ambulatory surgery center can be significant. It may not be a factor in the office setting where the same personnel are responsible for both phase I and phase II recovery.
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