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THE PERFECT SCORE Fast tracking through your day surgery unit

THE PERFECT SCORE Fast tracking through your day surgery unit. Wendy Adams MRCNA President Australian Day Surgery Nurses Association Presented by Sarah McDonald. Definitions. 1 st stage recovery Post Anaesthetic Care Unit (PACU) Early recovery 2 nd stage recovery

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THE PERFECT SCORE Fast tracking through your day surgery unit

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  1. THE PERFECT SCOREFast tracking through your day surgery unit Wendy Adams MRCNA President Australian Day Surgery Nurses Association Presented by Sarah McDonald

  2. Definitions • 1st stage recovery • Post Anaesthetic Care Unit (PACU) • Early recovery • 2nd stage recovery • Intermediate recovery • 3rd stage • Discharge • 4th stage • Post discharge follow up

  3. Definitions • Score based recovery • Patient is moved through the unit and discharged when they achieve a set of criteria using a scoring system • Time based recovery • Patient is moved through the unit and discharged when they achieve a set of criteria and required time length of stay in the unit.

  4. Definitions • Fast tracking • Clinical pathway that involves transferring the patient from the operating room to the day surgery ward (2nd Stage recovery) and bypassing PACU (1st stage)

  5. Discharge Scoring systems • Aldrete scoring system • White et al scoring system • PADSS • Modified PADSS

  6. Aldrete Scoring system • Requires a patient to reach the criteria of 9 or 10/10 before the can • Move from 1st stage to 2nd stage • By pass 1st stage (by achieving the score in the operating room)

  7. Aldrete Scoring system • Does not address • Pain • Nausea • Vomiting

  8. Aldrete Scoring system

  9. Aldrete Scoring system Aldrete JA. The post-anaesthesia recovery score revisited J Clin Anesth 1995;7:89-91

  10. White et al scoring system • Includes pain and emetic scoring symptoms • Maximum score is 14 • A score of 12 (with no less than 1 in any category) provides criteria for bypassing PACU (1st stage)

  11. White et al scoring system

  12. White et al scoring system

  13. White et al scoring system White P, Song D. New criteria for fast-tracking after outpatient anaesthesia: a comparison with the modified Aldrete’s scoring system. Anesth Analg 1999;88:1069-72

  14. Studies • Randomised study by Francis Chung in 2004 • 207 patients GA • 81% bypassed PACU (1st stage) successfully • 97% arthroscopy • 72% gynaecology • Randomised controlled trial in a multi-centre • 58% successfully bypassed Lemos P., Jarret P., Philip B. 2006 Day Surgery-Development and Practice, Chapter 11

  15. My experience

  16. Benefits of fast tracking • Less intensive nursing staff required • Less PACU (1st stage) beds required • Individualised care • Justifies patients staying longer if required

  17. Discharge criteria • Francis Chung devised post anaesthetic discharge scoring system (PADSS) • Later modified to eliminate input and output criteria • Score of 9 or 10/10 required for discharge home

  18. Modified PADSS

  19. Modified PADSS

  20. Modified PADSS Lemos P., Jarret P., Philip B. 2006 Day Surgery-Development and Practice, Chapter 11

  21. Discharge criteria • In addition, other criteria is necessary • Appropriate carer • Discharge instructions etc given • Patient accepts readiness for discharge

  22. What about eating & drinking? • Only necessary on a case by case basis • Must be well hydrated • Must understand discharge instructions • Literature available to support this

  23. What about eating & drinking? • Higher incidence of vomiting and delay in discharge in the ‘mandatory drinkers’ cf. ‘elective drinkers’ • Kearney R, Mack C, Entwistle L. Withholding oral fluids from children undergoing day surgery reduces vomiting. Paediatr Anaesth 1998;8:331-336

  24. What about eating & drinking? • Incidence of vomiting reduced from 73% to 36% when fluids withheld 4-6 hours • Jin FL, Norris A, Chung F. Should adult patients drink fluids before discharge from ambulatory surgery? Can J Anaesth 1998;87:306-311

  25. Is voiding necessary? • Risk factors for post operative urinary retention are • Anorectal surgery • Old age • Male sex • Spinal anaesthesia • Hernia surgery

  26. Is voiding necessary? • Delay in discharge 5-11% of patient who have no risk factors • Incidence of urinary retention is 1% in low risk patients • When discharging low risk patients who have not voided • Discharge instructions regarding medical assistance if not voided 6-8 hours post operatively Lemos P., Jarret P., Philip B. 2006 Day Surgery-Development and Practice, Chapter 11

  27. My experience

  28. My experience

  29. In summary • Should we fast track? • Staff competence and experience • Medical staff support it • The use of ultra short acting drugs • Appropriate pain and PONV management • Collect and analyse data

  30. In summary • Is it safe to use a scoring system rather than a time based criteria? • Staff competence and experience • Medical staff support it • The use of ultra short acting drugs • Appropriate pain and PONV management • Collect and analyse data

  31. In summary • Should we let our patients go home without eating or drinking? • Develop criteria for low risk group • Review fasting times pre operatively • Review intra operative IV hydration

  32. Further information

  33. Further information www.adsna.info president@adsna.info

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