DISCHARGE CRITERIA

Discharge after General Anesthesia and Monitored Anesthesia Care

The three stages of recovery after ambulatory surgery are the early, intermediate, and late recovery periods (see Chapter 71 ). The early and intermediate recovery stages occur in the ambulatory surgical facility, whereas late recovery refers to the resumption of normal daily activities and occurs after discharge home. Early recovery is the time interval during which patients emerge from anesthesia, recover control of their protective reflexes, and resume early motor activity. During this phase of recovery, patients are cared for in the PACU, where their vital signs and oxygen saturation are carefully monitored and supplemental oxygen, analgesics, or antiemetics can be readily administered. The modified Aldrete score is commonly used to assess the fitness of patients to be transferred to the phase II day-surgery recovery area.^[579] Ideally, most outpatients would complete the early recovery criteria in the operating room.

During the intermediate recovery period, patients are usually cared for in a reclining chair and progressively begin to ambulate, drink fluids, void, and prepare for discharge. Most ambulatory surgical facilities have a separate area for the intermediate recovery of outpatients to a home-ready state (see Fig. 68-1 ). The choice of anesthetic technique, as well as the choice of postoperative analgesic and antiemetic drugs, has an impact on the duration of the intermediate recovery period. A prolonged early and intermediate recovery will significantly increase the overall cost of the patient's operation.^[278] Factors that predict a more prolonged stay in the day-surgery unit include female gender, advanced age, longer operations, large fluid or blood loss and opioid use, nondepolarizing muscle relaxants, postoperative pain and PONV, and spinal anesthesia. ^{[30] [580]}

The late recovery period starts when the patient is discharged home and continues until functional recovery is achieved and the patient is able to resume normal activities of daily living. The anesthetics, analgesics, and antiemetics can also have an effect on the patient's recovery during the postdischarge period. However, the surgical procedure itself has the highest impact on the patient's full functional recovery. Guidelines for safe discharge from an ambulatory surgical facility include stable vital signs, return to baseline orientation, ambulation without dizziness, minimal pain and PONV, and minimal bleeding at the surgical site.^[52] The major accreditation bodies in the United States and Canada require that all ambulatory surgical patients have an escort to transport them home, and they must receive written postoperative instructions, including advice on whom to contact if a problem develops.

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A more objective discharge scoring system has been developed to evaluate and document the patient's readiness for discharge.^{[580] [581]} The so-called postanesthetic discharge scoring (PADS) system is a simple cumulative index that measures the patient's home readiness; it is based on five major criteria: (1) vital signs, including blood pressure, heart rate, respiratory rate, and temperature; (2) ambulation and mental status; (3) pain and PONV; (4) surgical bleeding; and (5) fluid intake/output.^[579] Patients who achieve a score of 9 or greater and have an adult escort are considered fit for discharge (or home ready). The requirement for patients to drink and void before discharge is no longer considered mandatory. A modified postanesthetic discharge scoring system was developed that eliminated input and output as discharge criteria and resulted in earlier discharge for up to 20% of patients ( Table 68-18 ).^[52]

Delays in discharge are typically related to persistent symptoms such as pain, PONV, hypotension, dizziness, unsteady gait, or the lack of an escort. ^[581] Excessive postoperative pain is a common surgery-related cause of delayed discharge from ambulatory surgical facilities and a cause of unexpected hospital admissions.^[260] The highest incidence of moderate to severe pain occurred in patients undergoing orthopedic, general, and plastic surgery procedures.^[582] Outpatients with severe postoperative pain often had more prolonged surgical procedures, a longer stay in the PACU and step-down unit, and a longer time to discharge.