Thisisthepublishedversion:

Phillips, Nicole Margaret, Street, Maryann, Kent, Bridie, Haesler, Emily and Cadeddu, Mary 2013,
Postanaesthetic discharge scoring criteria: key findings from a systematic review, International
Journal of EvidenceBased Healthcare, vol. 11, no. 4, pp. 275284.

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http://hdl.handle.net/10536/DRO/DU:30060448




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doi:10.1111/1744-1609.12044

EVIDENCE

Int J Evid Based Healthc 2013; 11: 275284

SYNTHESIS

Post-anaesthetic discharge scoring criteria: key findings from

a systematic review
Nicole Margaret Phillips PhD MNS GDipAdvNur(Ed) DipAppSc(Nurs) BN RN,1
Maryann Street PhD BSc(Hons) GradDipDrugEval&PharmSci,1,2
Bridie Kent PhD BSc(Hons) RN,3 Emily Haesler BN PGradDipAdvNsg1 and
Mary Cadeddu BSc(Psych)1
1
School of Nursing and Midwifery, Deakin University, and 2Eastern Health-Deakin University Nursing & Midwifery Research Centre,
Melbourne, Victoria, Australia; and 3School of Nursing and Midwifery, Plymouth University, Plymouth, UK

Abstract
Background Patient safety depends on nurses clinical judgment. In post-anaesthetic care, objective scoring
systems are commonly used to help nurses assess when a patient is ready to go back to the ward or be discharged
home after day surgery. Although there are several criteria used to assess patient readiness for discharge from the
post-anaesthetic care unit, evaluation of the validity and reliability of these criteria is scarce.
Aims This article presents key findings from a systematic review conducted to identify the essential components of
an effective and feasible scoring system to assess patients following surgical anaesthesia for discharge from the
post-anaesthetic care unit.

Methods The protocol for the systematic review of quantitative studies investigating assessment criteria for
discharge of adult patients from the post-anaesthetic care unit was approved by the Joanna Briggs Institute and
conducted consistent with the methodology of the Institute. Twelve databases and grey literature, such as conference proceedings, were searched for published studies between 1970 and 2010. Two reviewers independently
assessed study eligibility for inclusion. Reference lists of included studies were appraised.

Results Eight studies met the inclusion criteria; only one was a randomised controlled trial. Variables identified as
essential when assessing a patients readiness for discharge from the post-anaesthetic care unit were conscious state,
blood pressure, nausea and vomiting, and pain. Assessment of psychomotor and cognitive recovery and other vital
signs were also identified as relevant variables to consider.
Conclusions There was limited high-quality research regarding criteria to assess patient readiness for discharge
from the post-anaesthetic unit. The key recommendations, with moderate to high risk of bias, include that
assessment of specific variables (pain, conscious state, blood pressure, and nausea and vomiting) should be made
before patient discharge. These key findings have informed a subsequent study to reach international consensus on
effective assessment criteria and a project to test the clinical reliability of a tool for use by nurses in assessing patient
readiness for discharge from post-anaesthetic care.
Key words: discharge assessment, nursing assessment, post-anaesthetic care unit, systematic review.

Introduction
Failure to recognise deteriorating patients in hospital and
delay in responding to them may lead to avoidable admission to high-level care and longer duration of hospital stay,
Correspondence: Associate Professor Nicole Margaret Phillips, School
of Nursing and Midwifery, Deakin University, 221 Burwood Hwy,
Burwood, Vic. 3125, Australia. Email: [email protected]

as well as increased risk of serious complications or even

death.1 Guidelines for the management of patients have
been developed and implemented internationally.25 In
Australia, the recently introduced National Safety and
Quality Health Service Standards include recognising and
responding to clinical deterioration in acute health care.6 As
a consequence, many health services have implemented
changes to documentation, developed tools to enable more

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International Journal of Evidence-Based Healthcare 2013 The Joanna Briggs Institute

276

NM Phillips et al.

rapid recognition of and response to clinical deterioration,

and conducted staff education, including in perioperative
care. Our team has undertaken research aimed to improve
patient outcomes following surgery through the development of evidence-based nursing assessment criteria for safe
and timely discharge of patients from the post-anaesthetic
care unit (PACU), given the potential for patient risk in this
setting. These risks include excessive bleeding, hypo-/
hypertension, uncontrolled pain, nausea and vomiting,
hypoxia, altered conscious state and death.7
Most PACUs have discharge criteria, and many use a tool to
assess patients, such as the modified Aldrete Score. Although
commonly used, the Aldrete tool has not been validated. This
paper describes the key findings from a systematic review to
establish the evidence for criteria to be included in a discharge
scoring tool for assessing patient readiness for discharge.
Other components of the program of research are (i) a Delphi
consensus study, involving nurses and anaesthetists with
many years experience in post-anaesthetic care, as to which
criteria should be included when assessing readiness for
discharge from the PACU; and (ii) an audit of adverse events
immediately after surgery and anaesthesia in one health
service in Victoria to establish the nature and frequency of
commonly occurring complications.
PACUs (also referred to as recovery rooms) were introduced
in 1923 and since then have been the predominant setting
for patient recovery immediately after surgery.8 Intensive
patient observation immediately following administration of
a general anaesthetic is considered mandatory, as this is a
critical time in patient recovery. Accurate nursing assessment
is important because a patients condition can deteriorate
quickly in PACU, and the time spent in PACU is recognised
internationally as a time of increased risk to patient safety. It
has been common practice to set a minimum duration for the
patient to remain in PACU; however, length of PACU stay is
dependent on a number of factors, including the surgical
procedure, the type of anaesthetic, the patients preoperative
health status and the stability of vital signs postoperatively.9
To assist the identification of deteriorating vital signs, much
work has been conducted to develop universally acceptable
and objective tools to reduce adverse events in ward-based
patients;9,10 however, their relevance to patient assessment in
PACU has not been established.
Although several scoring systems have been proposed for
patient assessment following surgery1115 in the attempt to
define an effective measure of patient readiness for discharge,16 to date no consensus has been reached in regard
to what variables these instruments should include. Aldretes
scoring system has been used internationally since the
1970s, and in 1995, new versions of the scale were proposed
due to the new practice of discharging patients to home
following day procedure surgery.17 Due to its ease of use,
the modified Aldrete Score has been adopted as a standard
postoperative assessment in many PACUs internationally.18
Worldwide, we have seen the development and implementation of guidelines for the management of patients in
perioperative care.24 However, these are focused mainly on
the role of anaesthetists, while the responsibility for the

assessment of patient readiness for discharge from PACU is

often delegated to nurses. Furthermore, the validity and
reliability of the criteria used for assessing a patient for
discharge have not been researched.19 In regard to safe
discharge for patients from PACU, no systematic review of
the literature had been conducted prior to the researchers
systematic review.20
Aims
The aim of this article is to present the key findings of a
systematic review identifying the essential components of an
effective and feasible scoring system to assess patients following surgical anaesthesia. How the findings from the systematic review have informed a subsequent program of
research to enhance patient safety through timely and
appropriate discharge from the PACU is also outlined.

Methods
An initial limited search of CINAHL and MEDLINE was conducted, to identify relevant key words contained in titles and
abstracts. MeSH headings and subject descriptor terms were
used for each database. An extensive search was then conducted using those terms and synonyms in 12 different
databases: AMED, BioMed Central, British Nursing Index,
CINAHL, the Cochrane Central Register of Controlled Trials,
EBM Reviews, EMBASE, MEDLINE, PsycInfo, SCOPUS and
Web of Science. Discharge scores to determine readiness for
discharge from the PACU environment were first introduced
in the early 1970s. The review therefore considered studies
published in English between January 1970 and June 2010.
The reference lists of included studies were also appraised for
titles relevant to the review.
Each study was assessed by the primary reviewer based on
the information contained in the title and the abstract, while
the relevance of references was assessed on title only. Where
a record appeared to be relevant to the review, its full text
was retrieved and appraised for inclusion. Two reviewers
independently screened all abstracts, and each study was
carefully examined for adherence to the inclusion criteria.
Methodological validity was assessed independently by the
two reviewers using the critical appraisal instruments developed by the Joanna Briggs Institute (JBI) (Appendix 1). A
meta-analysis could not be conducted, as there was only one
randomised controlled trial (RCT) included.
Studies evaluating variables suitable for assessment of
adult patient readiness for discharge from the PACU environment were of interest. Studies considered eligible were
those evaluating predetermined discharge criteria (individual or grouped in a discharge tool): vital signs, oxygen
saturation, level of consciousness, blood loss, pain, and existing tools for discharge assessment. Other outcomes of interest were nausea and vomiting, medication administration
(e.g. anti-emetics, analgesics), time spent in PACU, delay in
discharge from PACU and adverse events related to early
discharge from PACU. Of the 2443 abstracts captured by the
search strategy, 2435 were excluded during screening and
eight were included in the systematic review (Fig. 1).

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International Journal of Evidence-Based Healthcare 2013 The Joanna Briggs Institute

Post-anaesthetic discharge scoring criteria

277

Potentially relevant papers identified by literature

search
(duplicates not excluded)
n = 2443

Abstracts retrieved for examination

n = 687
Papers excluded after
evaluation of abstract
n = 624
Papers retrieved for detailed examination
n = 63
Papers excluded after review of full
paper
n = 52
Papers assessed for methodological quality
n = 11

Figure 1 Study identification and selection

process.

Papers included in the systematic review

n=8

Results
Eight studies were included in the systematic review. These
were representative of international perspectives on discharge from PACU. Four were observational studies of moderate to high risk of bias.15,2123 All were conducted using
convenience samples of PACU patients; the assessment tools
were generally not validated, and analysis was often limited.
Only one study was a RCT;24 it focused on the use of a
discharge tool with the aim of defining criteria for bypassing
PACU. Another two observational studies25,26 and one retrospective records analysis27 offered useful data for the development of a PACU assessment tool. The studies included in
the review investigated a wide range of variables. However,
the most common were pain, conscious state, vital signs,
and nausea and vomiting. Details regarding the studies are
given in Table 1.

Studies investigating tools for the assessment of

readiness for discharge from PACU
A Canadian study compared a fast-track group with a
routine recovery group.28 The aim was to determine the time
and cost savings of discharging patients directly from the
operating theatre to a day surgery unit. This unblinded RCT
assessed adult patients scheduled for gynaecologic laparos-

copy, hysteroscopy or arthroscopy. Patients were randomly

allocated to either the fast-track group (n = 110) or usual
PACU care (n = 97). In both groups, patients were assessed
with the fast-track tool once awake in the operating theatre.
If those in the fast-track group met the discharge criteria
within 10 min, they were directly discharged to the day
surgery unit, rather than to PACU. Results showed significant
time savings for patients assessed within the operating
theatre, as the PACU stay could be bypassed. This was
particularly noticeable for those patients undergoing
hysteroscopy (savings of 43 min, P < 0.05) and arthroscopy
(35 min, P < 0.05). However, this time reduction was not
associated with a reduction of adverse events such as pain or
nausea. Also, neither nursing time nor financial costs
improved as a result of the use of the fast-track discharge
system. In terms of assessment of patient readiness for discharge, the fast-track discharge system and the routine
PACU discharge tool were equally effective.
Chung et al.22 conducted a descriptive trial in a Canadian
university teaching hospital. The aim was to validate and
subsequently implement a new objective discharge checklist. The Post-Anaesthetic Discharge Scoring System (PADSS)
was a substitute for the existing clinical discharge criteria
(CDC). The PADSS tool consisted of five categories of discharge criteria: vital signs; activity and mental status; pain,
nausea and/or vomiting; surgical bleeding; and intake and

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International Journal of Evidence-Based Healthcare 2013 The Joanna Briggs Institute

Observational

Discharge by
anaesthetist

N/A

N/A

N/A

Discharge by
anaesthetist

Aldrete criteria

Discharge criteria

Postoperative
urinary retention

Danish Society of
Anaesthesiology
and Intensive
Care Medicine
assessment
Tool with 17
different
subjective
patient
assessments

Medically
appropriate
length of stay

Manual dexterity
test, letter
cancellation test,
critical tracking
test, multichoice
reaction time

Brown et al.,
200821

Feliciano et al.,
200827

Gartner et al.,
201023

Waddle et al.,
199815

Willey et al.,
200226

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International Journal of Evidence-Based Healthcare 2013 The Joanna Briggs Institute
Observational

Observational

Retrospective
record analysis

Observational

Observational

ENT, ear, nose and throat; N/A, not applicable; PACU, post-anaesthetic care unit.

Stephenson,
199025

Observational

Clinical discharge
criteria
(subjective
checklist)

Post-Anaesthetic
Discharge
Scoring System

Chung et al.,
199522

Randomised
controlled trial

Discharge from
operating
theatre to PACU

Fast track
assessment tool
to bypass PACU

Song et al.,
200424

Type of study

Comparison tool

Assessment tool

Study

Table 1 Included studies

31

340

33

116

112

631 (anaesthetist
discharge),
567 (discharge
criteria)

247

110 (fast track

group), 97
(traditional
discharge)

Number of
participants

Day procedure;
endoscopy under
sedation

Procedures excluding
thoracic surgery,
neurosurgery,
ophthalmology and
ENT

Day surgery;
orthopaedic
procedures

Breast cancer surgery

Procedures under spinal

anaesthetic

Day surgery; procedures

under epidural or
spinal anaesthetic

Day surgery;
gynaecologic
laparoscopy,
hysteroscopy or
arthroscopy
Day surgery, short
procedure (dilation
and curettage); day
surgery, long
procedure
(arthroscopy and
laparoscopy)

Type of surgery

N/A; recovery to
preoperative status
was observed for
and not reached

71 37 min

N/A; recovery to
preoperative status
was observed up to
and following
discharge.

40 46 min

N/A; record analysis

Short-procedure
patients: mean
115 min (range 10
to 210 min);
long-procedure
patients, mean
125 min (range 0 to
385 min)
66.3 30 min

N/A; screening tool

administered in
operating theatre

Time to meet criteria

Pain and mental alertness were not at

preoperative levels by 120 min.
Cognitive function, mobility and
educational factors were at or superior to
preoperative levels within 120 min.
Nausea and vomiting peaked at 90 min
following surgery.
8% of patients considered to have delayed
discharge due to anaesthetist assessment.
20% of patients had delayed discharge
when other causes were included (e.g.
awaiting escort).
Anaesthetic, type of surgery, amount
of blood loss and intraoperative fluid
replacement were predictive factors for
length of stay.
Mean time to discharge by Aldrete criteria
was 26 min.
On admission to PACU, 97% of patients
met Aldrete criteria but psychomotor
function was significantly impaired
(P < 0.0001) on all four tests.
Impairment remained significant
(P < 0.0001) on all four tests at discharge
from PACU.

Significant 24% reduction (P = 0.0) in time

spent in PACU.
Significant reduction (P = 0.0) in delayed
discharge due to waiting for nurse escort.
Significant reduction (P = 0.008) in multiple
causes for discharge delay.
Significant decrease (P = 0.042) in arrival at
ward with unstable vital signs.
44% of patients experienced POUR.
Only predictive factor was bladder volume
500 ml on admission to PACU.
Primary cause for delay was inability to
meet criteria for oxygen saturation (at least
90%).

Average time in PACU not significantly

different.
Times may have been shorter if other
causes for delay had been avoided.

97% of patients met fast-track criteria.

Average time saving in recovery was
17 min.

Findings

278
NM Phillips et al.

Post-anaesthetic discharge scoring criteria

output. A total of 247 patients were selected and allocated

to two groups: those who had a dilation and curettage (a
short procedure) and others who had longer minor ambulatory surgical procedures. All patients were assessed to
determine their eligibility for discharge using both tools: the
CDC, used by PACU staff, and the PADSS, used by independent researchers. There was no significant difference in time
to meet the discharge criteria between the two tools for
either group of patients.
An observational study21 conducted in a US tertiary-care
teaching hospital compared a traditional discharge group
(TDG) with a discharge criteria group (DCG) in adults undergoing general anaesthesia who were scheduled for an overnight hospital stay postoperatively. The study involved 631
patients in the TDG being discharged by anaesthetists after
a previous alert by nursing staff on their readiness and 567
patients in the DCG being discharged after assessment using
the discharge criteria tool. The checklist included the following variables: activity, respiration, pulse, blood pressure,
oxygen saturation, consciousness/mental status, pain score,
urine output, nausea or vomiting, and laboratory results. The
discharge of patients in the DCG was characterised by a
substantial and significant (24%, P < 0.001) reduction in
time spent in PACU. In terms of the variables assessed, the
two groups of patients did not report significant differences.
A Danish study23 aimed to understand causes of discharge
delay in patients experiencing surgery for breast cancer. The
discharge tool used was the Danish Society of Anaesthesiology and Intensive Care Medicine (DASAIM) assessment tool.
Forty minutes was the average time for patients to meet the
discharge criteria required by the DASAIM tool, which consisted of assessment of post-anaesthetic nausea and vomiting, sedation levels, vital signs, pain and oxygen saturation.
The mean time to discharge from the PACU was approximately 110 min. The primary reason for discharge delay was
the patients inability to meet the required level of oxygen
saturation (at least 90%). No explanation was found for the
low oxygen saturation levels of patients in this study despite
investigation of the following factors: (i) use of Patent Blue
(an injectable substance for visualisation of the lymph nodes
reported to cause false low oxygen saturation levels); (ii)
respiration rate on arrival at the PACU; and (iii) the use of
intraoperative long-acting opioids.
As a result of their investigation, Gartner and colleagues
concluded that the criteria for oxygen saturation level should
be reconsidered. However, the relationship between discharging patients with low oxygen saturation levels (less
than 90%) and postoperative complications remains uncertain, as adverse events following discharge were not
reported in the study.23
A sample of 340 post-surgical patients was studied by
Waddle et al.15 in a US tertiary-level hospital. The study was
a comparative analysis of a PACU discharge protocol based
on the anaesthetists assessment compared with a medically
appropriate discharge tool based on formal assessment.
Outcomes investigated were the length of PACU stay and
the predictive factors for delayed discharge, including
surgery type, comorbidity and anaesthetic type. In terms of

279

discharge readiness, level of consciousness, vital signs, agitation, arrhythmias, and nausea and vomiting were considered. However, the criteria used in the formal protocol for
determining readiness for discharge were not fully reported
in the study, while those used by the anaesthetists were not
reported at all. In regard to the length of PACU stay, the
study highlighted the significance of implementing a formal
assessment of readiness for discharge. Time to discharge
with the medically appropriate discharge tool was 24 min
less than that determined by the anaesthetists assessment.
In addition, one-fifth of the patients included in the sample
were classified by the researcher as having a delayed discharge, of which a considerable number were due to waiting
for the anaesthetists assessment. These considerations led
the researcher to conclude that to reduce the length of PACU
stay, it would be necessary to adopt a formal discharge
readiness evaluation.
Studies assessing the relevance of specific
variables for determining readiness for discharge
from PACU
A study conducted in the UK addressed recovery of adult
patients after orthopaedic day surgery.25 The study was conducted on a sample of 33 individuals. Seventeen variables
were considered, including nausea and vomiting, appetite,
thirst, alertness, pain, coordination, dizziness, headache,
energy levels, temperature, feeling of wellness, interest
levels, clarity and speed of thought, excitability, feeling of
trouble, and happiness. The study failed to report specific
values for all of the variables investigated. Results showed a
general tendency for the Likert values (010, 0 being
optimal) for mental state (alertness and energy) to increase
at 30 min and then return to baseline at 120 min. By contrast, the mean reported level of pain increased postoperatively at both time intervals, due to a lack of analgesia
administration. Nausea and vomiting peaked at 90 min. The
author reported that values for excitability, feeling of trouble,
and happiness were found to be significantly lower than
those assessed prior to the surgery. The author suggested
the criteria essential for the assessment of patient readiness
for discharge were mental state (alert and responsive),
mobility consistent with preoperative level and type of
surgery, lack of dizziness, pain being under control (analgesia provided), ability to retain orally taken fluids, information
provision, and social support.
In 2002, the use of psychomotor tests in the assessment of
patient recovery from sedation was investigated in an observational study.26 Four different psychomotor tests were
administered on 31 patients undergoing endoscopy: (i) a
manual dexterity test for the assessment of fine motor skills;
(ii) a letter cancellation test (LCT), evaluating concentration
and perception; (iii) a multichoice reaction time test for the
assessment of complex reaction time; and (iv) a critical tracking test, a computer-based assessment of psychomotor
coordination. Patients presented normal functional status
levels and reported comorbidities such as anxiety and
depression. The tests were administered prior to the endoscopy and every 15 min from admission to PACU until

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International Journal of Evidence-Based Healthcare 2013 The Joanna Briggs Institute

280

NM Phillips et al.

discharge. In order to be discharged, patients were also

required to meet modified Aldrete criteria, to independently
ambulate and to hold a simple conversation. Patients recovery level was analysed both at the time of meeting the
discharge criteria and at the time of PACU discharge. Results
showed significant psychomotor impairment even for the
97% of patients who met the discharge criteria on admission
to PACU. At discharge, while recovery was improved, the
psychomotor impairment remained significantly higher than
baseline. The study highlighted limitations for the modified
Aldrete criteria in the assessment of significant psychomotor
impairment and showed that this tool would be more appropriate for discharging to a monitored care ward rather than
directly to home. The researchers emphasised the importance of adding the assessment of ambulation and conversation for an improved recovery for discharge. Also, it was
suggested that the LCT be included in the assessment of
readiness for patient discharge following sedation due to its
simplicity of use and its benefits in terms of patient safety.
The final included study investigating specific variables for
patient discharge from PACU was conducted in Wales in a US
military hospital with a sample of 112 patients undergoing
surgery under spinal anaesthesia.27 This was the only study in
the review that involved spinal anaesthesia. The focus was
exclusively the incidence of postoperative urinary retention
(POUR), defined as a bladder volume of at least 500 mL and
inability to void for at least 30 min.27 Although 44% of the
sample experienced POUR, no significant relationship was
found between this identified adverse event and patient
characteristics such as age, gender, type or duration of
surgery and amount of intraoperative fluids administered.
Based on the assumption that POUR was a common adverse
event for patients undergoing spinal anaesthesia, the aim of
the study was to include POUR in the assessment of readiness for PACU discharge. However, the study was not sufficiently powered to provide evidence on the effectiveness of
considering POUR as a discharge criterion in the PACU environment.27

Discussion
The review20 examined the evidence for the essential variables to be included in an effective scoring system to assess
patient readiness for discharge from PACU. The studies
varied in type of surgery, anaesthesia and destination after
discharge from PACU. The most commonly investigated variables were pain, conscious state, vital signs, and nausea and
vomiting. There was consensus for including pain, nausea
and vomiting, and conscious state. Patients reported that
pain was the worst aspect of the entire operative process,
and thus this variable needs to be carefully assessed.25
Nausea and vomiting have been shown to occur in many
patients despite prophylactic anti-emetic administration,
resulting in longer duration of PACU stay.28 Although one of
the most commonly assessed variables, nausea and vomiting
was shown to peak at 90 min post-surgery25 and was commonly a significant issue after PACU discharge.28 In regard to
conscious state, while this criterion was frequently assessed,

there was no agreement with regard to its specific measurement or the value of including it in assessment criteria.15,2124
Other criteria proposed in the studies were the patients
demonstration of appropriate responsiveness or meeting
preoperative status,21 the patients being orientated and/or
having a steady gait,22 and consciousness based on level of
arousal.23 Psychometric tests were investigated;25,26 however,
their inclusion in the assessment of patient readiness for
discharge from PACU may not justify the additional time and
resources required.29
In regard to vital signs, there was discrepancy between the
studies with regard to the values to be considered when
determining PACU discharge readiness. Five studies15,2124
reported different combinations of vital signs, with blood
pressure the only universally accepted variable. With the
exception of Chung et al.,22 all these studies included
oxygen saturation, which in one study23 was the criterion
that resulted in the most discharge delays. Consequently,
Gartner et al.23 proposed that discharge with oxygen being
administered via nasal prongs may be appropriate. Only one
study15 included temperature in the assessment of patient
readiness, without conclusive evidence of its value. Some of
the assessment tools21,23,24 indicated specific values for each
of the variables to be assessed, but only one study23 reported
values that were independent of baseline measures.
Urinary output and oral fluid intake were included in some
discharge assessments, especially those including ambulatory
surgery patients. In one study,22 patients were required to
have voided and/or to have taken fluids orally before discharge. Brown et al.21 determined patient readiness to
include clear and adequate urine output, and oliguria delayed
discharge. Another study focused on postoperative urinary
retention27 and reported an incidence of 44% following spinal
anaesthesia. However, the impact of including urinary output
and oral fluid retention on PACU discharge and length of stay
is uncertain due to a lack of standard urinary output assessment in discharge criteria tools. For ambulatory surgery
patients, it has been suggested that discharge criteria be
modified so that the abilities to tolerate oral fluid intake and
pass urine are not mandatory for all patients.29
Determining overall readiness for PACU discharge was also
explored. Three of the five studies using a discharge tool
were based on scoring systems,2224 where patients needed
to achieve full recovery in most of the variables assessed.
These systems appeared more flexible than Browns 10-item
tool.21 In regard to patient safety when discharge was determined using assessment tools, patients assessed with the use
of a fast-track scoring system did not report significantly
higher levels of postoperative pain or nausea24 than those
patients who received additional discharge assessments.
Furthermore, there were fewer patients with unstable vital
signs compared with patients assessed without the use of
discharge criteria. It was concluded from the findings of one
study15 that a formalised assessment for discharge readiness
should be implemented by nurses, as there were time
savings compared with waiting for an anaesthetic review.
This has important implications for healthcare settings from
a cost perspective.

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International Journal of Evidence-Based Healthcare 2013 The Joanna Briggs Institute

Post-anaesthetic discharge scoring criteria

The findings of the systematic review informed a subsequent Delphi consensus study conducted by the researchers.
In addition, a retrospective audit of the nature and frequency
of adverse events immediately following surgery has been
undertaken by the team at a Victorian health service. These
studies have informed a current research project that tests the
clinical reliability of a tool for use by nurses in assessing patient
readiness for discharge from post-anaesthetic care, linked to
a costbenefit analysis. It is anticipated that the outcomes will
also contribute to improved documentation and patient
handover practices among PACU nurses. This research
program enables critical evaluation of existing guidelines and
practices, with the potential to enhance nurses clinical
decision-making and thus improve patient safety.

7.
8.
9.

10.
11.

Conclusion

12.

Pain, conscious state, nausea and vomiting should be

assessed for PACU discharge (JBI evidence level 2). While vital
signs were reported to be important to safe patient discharge, there was no agreement on the specific vital signs
included in the tools, apart from blood pressure (JBI evidence level 2). The only validated PACU discharge tool, the
DASAIM assessment,23 considered assessment of blood pressure, pulse, respiration rate and oxygen saturation as essential. Urinary output, oral fluid intake and psychomotor
testing were also investigated; however, the value of including these remains doubtful and requires further investigation. The synthesised evidence suggests there is limited
consensus on criteria for PACU discharge assessment. Further
research should investigate the validity and reliability of
assessment variables in PACU discharge tools, the implementation of validated PACU discharge criteria for assessment
of patient readiness for discharge, and the relationship
between PACU discharge assessment and patient safety.

References

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14.
15.
16.

17.
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19.
20.
21.
22.

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Recommendations for the post-anaesthesia recovery room.
2006 [cited 20 November 2013]; Available from: http://www
.anzca.edu.au/resources/professional-documents/pdfs/ps04
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Appendix I
Joanna Briggs Institute critical appraisal forms

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Post-anaesthetic discharge scoring criteria

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