Post-anaesthetic discharge scoring criteria: A comprehensive systematic review

Commencement Date: May 2010 Completion Date: December 2010 Background The time immediately following a general anaesthetic is a critical period for patient recovery, requiring intensive observation to enable early detection of complications from the surgical episode. Since its introduction in 1923, the Post Anaesthesia Care Unit (PACU) is the preferred location for the immediate recovery of the post-operative patient 1. A patient's length of stay in PACU is dependent upon a number of factors, including pre-operative health status, surgical procedure, type of anaesthetic administered and the stability of vital signs. It has been common practice for PACU discharge policies to stipulate a minimum length of stay and traditionally a patient's readiness for discharge has relied on nursing assessment of normality and stability of physiological parameters. A patient's condition can deteriorate quickly and much work has been carried out to develop tools to assist the identification of deteriorating vital signs. These have been associated with a reduction in adverse events in ward-based patients 2. Increasingly, particularly since the advent of day procedure surgical units, there has been a trend towards the use of similar objective scoring systems to aid decision-making and quantify patient readiness for discharge from PACU. Several different scoring systems have been developed and tested 3-6. A study by Riley et al. 7 highlighted the methodological problems in developing a valid measurement tool for post-anaesthetic discharge scoring. Currently there is no consensus regarding the variables that should be used and a particular need has been identified to establish criteria to assess a patient's “home readiness” given the increasing frequency of day surgery procedures 1. The impetus for this systematic review has been concern about anecdotal reports of a growing number of patient safety issues relating to post-anaesthetic care at different metropolitan hospitals 8. While reporting of adverse events is mandatory for all Australian hospitals, the indicators of patient safety which are collated do not allow the incidence of events relating to post-anaesthetic care to be determined. Substantial research attention is now being paid to generating and synthesising findings in ways that are designed to have immediate applicability to healthcare practitioners 9-11. Nurses manage patients in the PACU and evaluate discharge suitability. The Association of Anaesthetists of Great Britain and Ireland (cited in 12) have recommended discharge criteria and the Australian and New Zealand College of Anaesthetists 13 have recommendations for post-anaesthetic care. However anaesthetists often delegate the responsibility for patient discharge to the PACU nurse 14. Basing nursing practice on evidence is fundamental to optimal and effective care 15. Even experienced nurses can face a dilemma about the right time to transfer patients to general wards 14. Many and varied criteria are used to assess a patient for discharge from PACU, however evaluation of the validity and reliability of these criteria requires further work 16. To date a systematic review of the literature relating to safe discharge for patients from PACU to either transfer to the ward or to discharge directly to the home environment has not been conducted. Review question and objectives This review will systematically examine the evidence to answer the question: • What are the essential components of an effective scoring system to assess patients, following anaesthesia and surgery, thereby enhancing patient safety through timely and appropriate discharge? The key objectives to be addressed are: To identify the most commonly used predetermined PACU discharge criteria, which can be used, predominantly but not exclusively, by nurses to assess patient readiness for discharge from PACU. To investigate whether some variables have greater relevance than others in terms of determining readiness for discharge. To develop, from the evidence synthesis, a draft of a discharge tool that can be later submitted for review by a panel of experts to establish content validity Inclusion criteria Types of participants The review will consider studies that include adult patients (over 18 years of age), male and female, who have received care in the PACU for any type of surgery, planned or unplanned. Types of Interventions The review will consider studies that evaluate variables suitable for assessment of patient readiness for discharge from the PACU. This will include studies evaluating both individual and grouped predetermined discharge criteria; for example, measure of vital signs (temperature, respiratory rate, heart rate, blood pressure) and /or return to pre-operative baseline, capillary oxygen saturation, assessing level of consciousness, blood loss, pain assessment, and existing tools for discharge. Type of Outcomes This review will consider studies that include variables for patient assessment, examples of which are the following outcome measures: stable vital signs and/ or stable capillary oxygen saturation presence or absence of nausea and/ vomiting pain score medication administration (such as anti-emetics and analgesics) PACU time PACU discharge delay adverse events related to early discharge from PACU, e.g: complications that may have been avoided (eg. medical emergency team (MET) calls) unexpected admissions to intensive care, critical care or high dependency units readmission rates (to theatre or hospital) increased length of hospital stay Types of Studies This review will consider any randomised controlled trials (RCTs) and quasi-randomised controlled trials that compare sets of variables or discharge tools to identify patients who are ready to be discharged from PACU. In the absence of RCTs, other research designs such as nonrandomised controlled trials, before and after studies and descriptive studies will be considered for inclusion in a narrative summary to enable the identification of current best evidence for the essential components of an effective scoring system to assess patients following surgery and anaesthesia, which will enhance patient safety through timely and appropriate discharge. Search Strategy In the early 1970's discharge scores were first introduced to determine discharge from the PACU environment. The review will therefore consider studies published in the English language between 1970 and 2010. The search strategy aims to find both published and unpublished studies. An initial scoping phase will be undertaken to identify any relevant MeSH terms and keywords. During the development of the search strategy consideration will be given to the diverse terminology used and the spelling of keywords as this may influence identification of relevant trials. A three step search strategy will be utilised for each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: AMED BioMedCentral British Nursing Index CINAHL Cochrane Library EBM reviews EMBASE JBI library of systematic reviews MEDLINE Psyc Info SCOPUS TRIP Web of Science The search will also be conducted in the Grey Literature including: Conference proceedings Directory of open access journals Dissertations international Google Scholar Networked digital library of theses In addition broader strategies will include: hand searching of journals, contact with key individuals who have researched and written on any relevant aspects, and government health department websites. All of the identified materials will be assessed for relevance to the review and a full report retrieved where studies meet the inclusion criteria. Studies identified from the reference list searches will be assessed for relevance on the study title. Wherever possible, personal contact will be made with relevant individuals and organisations for recommendation of literature e.g. Australian College of Operating Room Nurses (ACORN), Australian and New Zealand College of Anaesthetists (ANZCA) and the Australian Commission on Safety and Quality in Healthcare. Initial keywords to be used will be: Post-operati* OR post-surg* Post-operative care OR post-operative complication* Post-anaesth OR post-anesth* Nurs* assessment Surgical/ adverse effect* Adverse event* PACU Recovery Discharge scor* Criteria Length of stay Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review. The two reviewers will use the standardised critical appraisal instruments from Joanna Briggs Institute JBI-MAStARI (Meta Analysis of Statistics Assessment and Review Instrument; Appendix I) for quantitative evidence. Any disagreements that arise between the two reviewers will be resolved through discussion, or by a third reviewer. Data Collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from the JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data Synthesis Quantitative papers will, where possible, be pooled in statistical meta-analysis using the JBIMAStARI. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square test. Where statistical pooling is not possible, the findings will be presented in narrative form. Conflicts of interest No conflicts of interest noted. Acknowledgements The reviewer's would like to acknowledge Deakin University's Clinical Care, Quality and Risk Management (CCQRM) Strategic Research Centre for funding this systematic review through the CCQRM- Research Grants Scheme.