Original contribution
Use of postanesthesia discharge criteria to reduce discharge delays for inpatients in the postanesthesia care unit

https://doi.org/10.1016/j.jclinane.2007.09.014Get rights and content

Abstract

Study objective

To determine whether a set of predetermined discharge criteria, used by nurses, shortens the length of patient stay in the postanesthesia care unit (PACU) without compromising safety.

Study design

Prospective clinical study.

Setting

Postoperative recovery area of a large, tertiary-care, academic hospital.

Patients

1,198 adult, ASA physical status I, II, and III patients, 18 years or older, requiring general anesthesia.

Interventions

Two groups of inpatients were followed. In the first group, over a 90 day period, all inpatients meeting study inclusion criteria were discharged by a physician (traditional discharge group [TDG]). This period was followed by a subsequent 90 day period in which a second group of patients were discharged by a PACU nurse using predetermined discharge criteria (discharge criteria group [DCG]).

Measurements

Demographic and discharge variables, including the time when the physician was called for an order, the time a discharge order was written, and the actual discharge time, were recorded. Other comparisons of various discharge variables included the time that discharge criteria were met, the actual discharge time, and the difference between these times. The frequency of PACU stays longer than 60 minutes, PACU discharge delays, and the time discharge criteria were met longer than 60 minutes were also compared between groups. Floor nurse satisfaction with patient status and any related morbidities noted were also measured.

Main results

Length of PACU stay was significantly shorter (133.1 ± 91.4 vs 101.7 ± 53.7 min; P < 0.05) for inpatients in the DCG group. Discharge delays were higher with physician discharge. The DCG had a lower number of patients with multiple delays. There was no significant difference in the occurrence of adverse events between the two groups.

Conclusions

Predetermined discharge criteria resulted in a 24% decrease in PACU time.

Introduction

Numerous studies have analyzed postanesthesia care unit (PACU) discharge procedures, focusing on factors that might or might not decrease PACU time [1], [2], [3], [4], [5], [6], [7], [8], [9], [10]. Some of this work evaluated how the choice of anesthetic management could influence PACU time. Several studies showed that the use of insoluble anesthetic agents and/or rapidly acting intravenous drugs such as propofol or remifentanil could significantly reduce PACU length of stay [1], [2], [3], [4].

We believe that patient stays in PACU are often unnecessarily prolonged because of delays in receiving discharge orders. These discharge delays may reduce PACU resources and may create an operating room backlog. We speculate that using predetermined, criteria-based discharge as opposed to traditional discharge after contemporaneous physician evaluation may decrease PACU length of stay.

Currently, there are practice standards available permitting the autonomy of nurses to discharge inpatients without a physician at the bedside [6]. However, only a few studies that compared physician discharge with nurse discharge using predetermined criteria have also evaluated differences in discharge times and complications. The primary aim of this study was to determine if inpatients discharged by a nurse following predetermined discharge criteria reduces PACU length-of-stay and increases efficiency compared with the standard anesthesia practice of contemporaneous physician discharge. A secondary aim of the study was to compare the condition of inpatients, discharged via criteria versus the traditional physician discharge evaluation, on arrival to the floor.

Section snippets

Materials and methods

After obtaining permission from the Loyola University Medical Center Institutional Review Board to conduct this study, we then followed two groups of patients. Group 1 consisted of patients who were discharged from the PACU by the anesthesiologist after PACU nurse notification and physician evaluation of discharge readiness (traditional discharge group [TDG]). Each physician used individual evaluation criteria and judgment for patient discharge from PACU. Group 2 individuals were discharged

Results

The demographic data of both groups were comparable (Table 2). Discharge times were shorter in the DCG group when compared with those from the TDG group (Table 3). The difference in time that discharge criteria were met to actual time leaving the PACU was also shorter in the DCG group (Table 3). The number of patients whose PACU stay exceeded 60 and 75 minutes was higher in the TDG than in the DCG. The PACU discharge delays for the TDG group were more than double that of the DCG group (Table 3

Discussion

We have shown that implementing a set of predetermined discharge criteria reduces PACU length of stay by 24% when compared with traditional physician discharge. This difference occurred primarily because of the extra time that it takes to obtain a physician's order. (Discharge delay was defined as an excess of 15 minutes after the PACU nurse believed the patient was ready for discharge.) One fifth of the overall rate for PACU discharge delay was due to inability to obtain a physician's order in

Conclusion

Our study shows that predetermined discharge criteria resulted in a 24% decrease in PACU time when compared with patients discharged by physician evaluation. The use of predetermined discharge criteria resulted in no apparent increase of adverse events. Patients were stable, and nurse-evaluated discharge resulted in improved discharge times without apparent compromise of patient status.

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