From Aldrete to PADSS:

Reviewing Discharge Criteria After

Ambulatory Surgery
Heather Ead, BScN, RN
Nurses working in perianesthesia care areas use discharge scoring
criteria to complete patient assessments and ensure patient readiness
for discharge or transfer to the next phase of recovery. However, all
discharge criteria have both advantages and disadvantages. Com-
parative studies on the reliability of the different discharge criteria in
use are extremely limited. As the acuity of our aging population
increases, as well as the number of annual surgeries performed on an
outpatient basis, it is most timely to ensure that we are following
evidence-based discharge criteria.
2006 by American Society of PeriAnesthesia Nurses.
ALMOST A CENTURY has passed since the
surgeon Dr James Nicoll endorsed the benets
of sending patients home to recuperate on the
same day of the operative procedure.
1
Dr Ralph
Waters, an anesthesiologist during this same
time period, also supported this practice.
2
Dr
Waters indicated that, by following certain am-
bulatory procedures, the patient could return
home a fewhours postoperatively to recover.
1,2
Today, patients continue to benet from having
procedures done on an ambulatory basis. The
annual number of ambulatory surgeries per-
formed continues to grow, and growth in am-
bulatory surgery is projected to continue. Fifty
to 70% of all surgeries are performed on an
outpatient basis,
3
and it is anticipated that in a
few years as much as 85% of surgeries will be
performed on an outpatient basis.
4
Many advantages are associated with ambula-
tory surgery. Reduced health careacquired in-
fections, hospital costs, and waits for bed avail-
ability, as well as improved patient comfort are
a few of the reported advantages of ambulatory
surgery.
5
Due to faster-acting anesthetic agents
such as remifentanil and sevourane, improved
options in treating postoperative nausea and
vomiting (PONV)as well as preemptive, mul-
timodal analgesiapatients recover faster.
6
These patients can return home to continue
with late, phase-three recovery in the comfort
of their own homes.
3,7,8
Also facilitating efcient and safe discharge are
clear and concise discharge criteria. The Aldrete
scoring system and the Post Anesthetic Dis-
charge Scoring System (PADSS) have received
widespread acceptance in assessing postanes-
thetic recovery.
1,9
The Aldrete scoring system
originated in 1970 by Dr J. A. Aldrete; the
PADSS originated in 1991 by Dr Frances Chung
(Table 1).
As the popularity of ambulatory surgery grows,
appropriate discharge criteria must be followed
to ensure patient-centered care. With the acuity
Heather Ead, BScN, RN, is a Clinical Educator, PACU and
Day Surgery, Trillium Health Centre, Mississauga, Ontario.
Address correspondence to Heather Ead, BScN, RN, 3735
Densbury Drive, Mississauga ON L5N 6Z2, Canada; e-mail
address: head@thc.on.ca.
2006 by American Society of PeriAnesthesia Nurses.
1089-9472/06/2104-0005$35.00/0
doi:10.1016/j.jopan.2006.05.006
Journal of PeriAnesthesia Nursing, Vol 21, No 4 (August), 2006: pp 259-267 259
of outpatient surgery increasing, the aging pop-
ulation, and expansion of inclusion criteria for
day surgery, it becomes even more signicant
to have clear, evidence-based discharge criteria
in clinical use.
10-12
The following article dis-
cusses the history leading up to current dis-
charge criteria, the modications made to en-
sure continued practicality and accuracy, the
benets and limitations with discharge criteria,
and the resulting implications to the perianes-
thesia nurse.
The History of Aldrete Scoring
and PADSS
How was todays current discharge criteria de-
termined? Reviewing the history of discharge
criteria, postambulatory surgery is of interest to
nurses involved in perianesthesia care. This in-
cludes nurses in PACUs, day surgery/ambula-
tory care areas, ambulatory surgery centers
(ASCs), endoscopy, dental ofces, and plastic
surgeons ofces. Reviewing the history of post-
anesthesia scoring systems identies the im-
provements that have been made over the
years, as well as reinforces the value of abiding
by discharge criteria to maintain high standards
of care.
The Aldrete scoring system, a modication of
the Apgar scoring system used to assess new-
borns, has been used in many PACUs since its
introduction 35 years ago.
13
This system is de-
signed to assess the patients transition from
Phase I recovery to Phase II recovery, from
discontinuation of anesthesia until a return of
protective reexes and motor function.
14
At
most institutions, Phase I recovery occurs in the
PACU. Once Phase I recovery is completed,
Table 1. Discharge Scoring Systems
The Aldrete Scoring System The Post Anesthetic Discharge Scoring System (PADSS)
Respiration Vital signs
Able to take deep breath and cough 2 BP & pulse within 20% preop 2
Dyspnea/shallow breathing 1 BP & pulse within 2040% preop 1
Apnea 0 BP & pulse within 40% preop 0
O
2
saturation Activity
Maintains 92% on room air 2 Steady gait, no dizziness or meets preop level 2
Needs O
2
inhalation to maintain O
2
saturation 90% 1
Requires assistance 1
Unable to ambulate 0
O
2
saturation 90% even with supplemental
oxygen 0
Nausea & vomiting
Minimal/treated with p.o. medication 2
Consciousness Moderate/treated with parenteral medication 1
Fully awake 2 Severe/continues despite treatment 0
Arousable on calling 1 Pain
Not responding 0 Controlled with oral analgesics and acceptable to patient:
Circulation Yes 2
BP 20 mm Hg preop 2 No 1
BP 2050 mm Hg preop 1 Surgical bleeding
BP 50 mm Hg preop 0 Minimal/no dressing changes 2
Activity Moderate/up to two dressing changes required 1
Able to move 4 extremities 2 Severe/more than three dressing changes required 0
Able to move 2 extremities 1
Able to move 0 extremities 0
Information obtained from references
1,9,10,13-16,22-24,29
.
Information obtained from references
1,9,10,13,14,16,19,22-24,29
.
HEATHER EAD 260
homeostasis has been regained. To assess the
patients transition from Phase II to Phase III
recovery, the PADSS is used.
10
Phase II recovery
is judged to be complete when the patient is
ready for discharge home. Phase III recovery
continues at home under the supervision of a
responsible adult and continues until the pa-
tient returns to preoperative psychologic and
physical function.
14
Both the Aldrete system and PADSS evaluate
ve key parameters to ensure safe transfer or
discharge of the patient postoperatively. Pa-
tients achieving a total score of 9 or 10 are
considered t for transfer or discharge to the
next phase of recovery. The individual institu-
tion indicates if such scores are necessary for
transfer or discharge, or if a score of 8 is accept-
able (Table 1).
The original Aldrete scoring system of 1970
used color as an indicator of oxygenation by
assessing the color of the patients mucous
membranes and nail beds. With the advent of
oximetry, the Aldrete scoring system was up-
dated in 1995 to include this technological im-
provement.
15
Although monitoring the patients
mucous membranes and nail beds is still in-
cluded in the nurses assessment, oximetry is
a more reliable indicator of oxygenation.
1
Before the clear objective, numerical scoring of
the Aldrete and PADSS, a number of psychomo-
tor tests were used to assess discharge readiness
postanesthesia.
9
In the late 1960s, a modied
Gestalt test (the Trieger dot test) was proposed
to measure recovery. Patients demonstrated re-
covery by connecting a series of dots on paper
to form a pattern. The more dots the patient
missed, the lower their recovery score.
9
Not
only was this test tedious in nature; it did not
account for the presence of dizziness, hypoten-
sion, pain, bleeding, nausea, vomiting, and
other parameters included in current discharge
scoring systems.
Other psychomotor tests that have been used
are reaction time tests, driving simulator tests,
peg board tests, and a Maddox wing test, which
involves a device to test extraocular balance.
9
These psychomotor tests have limited value in
assessing discharge readiness, but can be useful
tools in conducting research.
6,17
The R.E.A.C.T. assessment tool is another scor-
ing systemthat was developed in Chicago in the
early 1980s. This acronym includes the param-
eters of:
Respiration,
Energy,
Alertness,
Circulation, and
Temperature
18
Several limitations have been observed with the
R.E.A.C.T. assessment tool. Its creators ac-
knowledge that it is not appropriate for moni-
toring acute changes such as the onset of oxy-
gen desaturation, dysrhythmias, or bleeding.
18
This tool is recommended for use after such
problems have been resolved. This is a se-
rious limitation because cardiac and respi-
ratory complications occur more frequently
in the PACU than in ambulatory care ar-
eas.
12,19
The R.E.A.C.T. scoring tool also
lacks a parameter to score oxygenation, a
parameter included in the Aldrete scoring
system.
Before numerical scoring criteria, clinical crite-
ria checklists were used to assess patient dis-
charge readiness. Although these checklists are
used today in conjunction with the Aldrete and
PADSS scoring systems, their use alone does
not permit quantication of discharge readi-
ness. The checklists also do not facilitate
follow-up quality assurance audits.
4
Stan-
dard discharge criteria are listed in Table 2.
Although standard discharge criteria are useful
to assess discharge readiness, the criteria is
broad without specications as to vital sign
ranges or expected pain levels. Therefore, such
guidelines should be used along with the PADSS
to ensure the patient is safe for discharge to
Phase III recovery.
14
DISCHARGE CRITERIA: ALDRETE TO PADSS 261
Drinking and Voiding Before
Home Discharge
Requiring all patients to void and tolerate
oral uids is no longer supported and has
been shown to lead to unnecessary patient
delays.
1,4,9,14,20,22
A patient who has not
voided postoperatively, has no urge to do,
has no bladder distention, or is not at high
risk of urinary retention may be discharged
home if given clear guidelines on when to
seek medical assistance. Patients who are at
high risk of urinary retention are those who
have undergone a procedure involving the
pelvic or genitourinary system, rectal or
urological procedures, hernia repairs, had
urinary catheterization perioperatively,
have a history of urinary retention, or re-
ceived neuroaxial anesthesia.
1,9,14,20,21
This
group of patients has a higher risk of urinary
retention and are generally required to void
before discharge.
22
Current literature remains inconsistent regard-
ing the requirement to void after postneuroaxial
anesthesia. Both neuroaxial and general anes-
thesia can interfere with the detrusor muscle
function and predispose the patient to urinary
retention.
21
If the bladder becomes distended
while anesthesia is blocking the contraction
ability of the detrusor muscles, voiding function
can be impaired.
22
The mechanism of urinary
complications is related to anesthetic agents
blocking parasympathetic bers in the sacral
region of the spine, which control the muscles
of micturition.
23
Gupta and others found that as
many as 17.5% of patients had postspinal uri-
nary retention.
21
Kang and others found that
urinary complications occur in less than 1% of
spinal anesthetics.
23
Urinary retention may
occur with elderly men, whereas urinary
incontinence can occur with female pa-
tients. Even with the low occurrence of
urinary complications, these problems usu-
ally subside in the PACU, and intermittent
urinary catheterization is rarely needed.
23
The choice of opioid used with spinal anes-
thesia is a factor in postoperative urinary re-
tention. Hydrophilic opioids, such as mor-
phine, may cause urinary retention, whereas
lipophilic opioids, such as fentanyl are less
likely to cause this side effect.
20
A suggested practice is for the patient to remain
in the ambulatory care area for another hour if
the patient is at risk of urinary retention and has
more than 400 mL of urine in the bladder
(determined by an ultrasonic bladder scanner),
or if bladder distention is present. If after one
hour the patient still has not voided, an inter-
mittent catheterization can be done.
22
If the
patient is not at increased risk of urinary reten-
tion, discharge should not be delayed if postop-
erative voiding does not occur in the hospital.
Such patients are given clear discharge instruc-
tions on when to seek medical assistance, eg, if
they are not able to void at home eight hours
after discharge.
14
Patients are no longer required to drink uids
before discharge home. Current recommenda-
tions are that postoperative hydration status is
Table 2. Clinical Discharge Criteria
Stable vital signs for at least one hour
Alert and oriented to time, place, and person
No excessive pain, bleeding, or nausea
Ability to dress and walk with assistance
Discharged home with a vested adult who will remain
with the patient overnight
Written and verbal instructions outlining diet,
activity, medications, and follow-up appointments
provided
A contact person and circumstances that warrant
seeking the assistance of a health care professional
clearly outlined
Voiding before discharge not mandatory, unless
specically noted by physician (ie, urological
procedure, rectal surgery, history of urinary
retention)
Tolerating oral uids not mandatory, unless
specied by physician (ie, patient is diabetic, frail,
and/or elderly; not able to tolerate an extended
period of NPO status)
Abbreviation: NPO, nothing by mouth.
Data from references
1,2,10,14
.
HEATHER EAD 262
assessed and managed in the PACU.
6
Current
practice guidelines set out by the American
Society of Anesthesiologists Task Force on Post-
Anesthetic Care recommend that drinking clear
uids should not be a part of a discharge pro-
tocol, but may only be necessary for selected
patients, such as diabetics.
6
Not abiding by such
recommendations will unnecessarily delay dis-
charges, reduce patient satisfaction, and in-
crease the incidence of nausea and vomiting
when patients are encouraged to drink to be
discharged.
1,4,9,14,16
Although the initial PADSS
of 1991 did include voiding and drinking in the
discharge criteria, the revised PADSS of 1993
removed these criteria to avoid unnecessary
delays and support patient-focused care.
24
Clinical practice and some clinical studies sup-
port using the Aldrete scoring criteria to ensure
discharge readiness from Phase I recovery, and
PADSS to ensure discharge readiness from
Phase II recovery.
4,9,14,15,19,24
Institutions
should also have clear guidelines on dis-
charge criteria, and requirement for all pa-
tients to void or tolerate oral uids should
not be part of such a protocol.
1,4,6,9,14,22,24
Fast-Tracking/Bypassing the PACU
The practice of fast-tracking patients to the am-
bulatory care areabypassing the PACUhas
been practiced in some institutions since the
late 1990s.
25
With fast-tracking, patients must
meet discharge criteria to illustrate comple-
tion of Phase I recovery before transfer
from the operating room to the ambulatory
care area.
26,27
The fast-tracking criteria sug-
gested by White
26
appear to be a union of the
Aldrete scoring system and the PADSS. To
meet fast-tracking criteria, the patient must
score a minimum of 12 (maximum score is
14), with no score 1 in any parameter.
26
As
mentioned previously, this scoring criterion
may vary slightly according to the facilities
individual protocols (Table 3).
Although fast-tracking is possible due to
factors such as minimally invasive tech-
niques and short-duration anesthetics, there
is inconsistent support in the literature sup-
porting its use.
14,28
Not all patients are ap-
propriate for fast-tracking. In one study,
only 31% of patients were eligible for fast-
tracking.
14
Thus, a large number of patients
still required traditional postanesthesia care
in the PACU. The PACU needs to be staffed
appropriately to receive patients who are
not eligible for fast-tracking; therefore cost
savings by reducing stafng in the PACU
could not be guaranteed.
27
The Ontario
Perianesthesia Nurses Association (OPANA)
Practice Standards indicate there is cur-
rently very little data addressing patient out-
comes related to fast-tracking.
28
Another
concern regarding fast-tracking is that there
Table 3. Criteria for Fast-Tracking After
Ambulatory Anesthesia
Level of Consciousness:
Awake and oriented 2
Arousable with minimal stimulation 1
Responsive only to tactile stimulation 0
Physical Activity:
Able to move all extremities on command 2
Some weakness in movement of extremities 1
Unable to voluntarily move extremities 0
Hemodynamic Stability:
BP 15% of baseline 2
BP 30% of baseline 1
BP 50% of baseline 0
Oxygen Saturation:
Maintains value 90% on room air 2
Requires supplemental oxygen to maintain
oxygen saturation 90% 1
Saturation 90% with supplemental oxygen 0
Pain:
None/mild discomfort 2
Moderate to severe, controlled with IV analgesics 1
Persistent to severe 0
Emetic Symptoms:
None/mild nausea with no active vomiting 2
Transient vomiting controlled with IV
antiemetics 1
Persistent moderate to severe nausea & vomiting 0
Abbreviation: IV, intravenous.
Data from references
2,3,7,14,25,26
.
DISCHARGE CRITERIA: ALDRETE TO PADSS 263
is no one agreed-upon practice guideline or
denition of the factors involved in fast-
tracking.
28
Further clinical studies are re-
quired for its validation and benets.
9
It is
clear that there is a need for caution in
implementing fast-tracking, and that a learn-
ing curve exists with this practice.
Advantages and Limitations
of Discharge Scoring Criteria
Although working in the perianesthesia area is
often demanding and hectic, it is important to
regularly review current processes to ensure
that up-to-date standards of care are in place.
There are many benets for both the patient
and nurse in consistently using evidenced-based
discharge scoring criteria. However, with all
discharge criteria, there are limitations. Table 4
illustrates how the benets of using numer-
ical discharge criteria are more numerous
than the limitations. Using criteria such as
the Aldrete scoring system and the PADSS is
supported by the Joint Commission for Ac-
creditation of Healthcare Organizations
(JCAHO), the Canadian Anesthetists Society
(CAS), and OPANA.
1,14,28
Using numerical
scoring is also user-friendly and easily re-
peated during the patients stay to monitor
Table 4. Advantages and Limitations of Discharge Scoring Criteria
Advantages of Discharge Scoring Criteria Limitations of Discharge Scoring Criteria
1. A well designed clinical scoring system provides a
reliable guide for nursing assessment.
2. Using scoring criteria follows standards set out by the
JCAHO and OPANA.
3. The reliability of scoring criteria is superior to clinical
discharge criteria.
4. Scoring systems are efcient and user friendly for
varying age groups.
5. Individualized scoring promotes patient-focused care.
6. Scoring criteria (Aldrete and PADSS) are widespread
in acceptance, providing consistency among health care
providers.
7. Unnecessary delays related to lack of voiding or uid
intake can be avoided.
8. Using scoring criteria follows the recommendations
of the CAS.
9. Scoring systems are practical, easy to retain and repeat
throughout the patients stay.
10. Progress is quantied, and the scores can be tracked
or used in patients stay.
11. Progress is quantied, and the scores can be tracked
or used in follow-up chart audits/studies.
12. The scoring criteria assess all parameters of recovery
to ensure patient safety and readiness to be transferred
to the next phase of recovery.
1. A denitive tool that is sensitive to the patient,
surgical procedure, and anesthetic technique has
yet to be nalized.
2. Scoring systems do not include criteria for specic
requirements, eg, a required increased length of
stay if M.H. susceptible, patient at high risk of
urinary retention has not voided. In these cases,
additional guidelines need to be established and
followed.
3. The postoperative vital sign parameter may be
inaccurate if preoperative values were abnormally
high for the patient. (eg, elevated blood pressure
preoperatively, related to anxiety).
Abbreviations: JCAHO, Joint Commission on Accreditation of Health Care Organizations; OPANA, Ontario Perian-
esthesia Nurses Association; CAS, Canadian Anesthetists Society; MH, malignant hyperthermia.
Information obtained from references
1,4,5,9-11,13-16,19,22-24,28
.
Information obtained from references
1,2,14,29
.
HEATHER EAD 264
improvement. Tracking improvements in clin-
ical status allows a patient-focused approach,
and conrms when the patient is ready to be
transferred to the next phase of recovery.
Limitations exist that have important implica-
tions for nursing with any discharge criteria.
Although scoring criteria are reliable tools, they
do not replace the critical thinking or profes-
sional judgment of the nurse. For example, the
patient may t all discharge criteria, yet the
surgeon indicates that the patient must stay a
minimum of four hours postoperatively be-
cause of susceptibility to malignant hyperther-
mia.
12
Another example of a limitation is the
elderly postoperative patient who is frail, dia-
betic, has some renal insufciency, and resides
a long distance from a medical facility. In this
case it is better to err on the side of caution, and
ensure the patient can tolerate oral uids before
discharge because the preoperative health sta-
tus indicates that this patient may not tolerate
an extended period of nothing-by-mouth sta-
tus if unable to tolerate uids at home. Long
distances to accessing medical assistance and
age are relative factors that the critical-thinking
nurse keeps in mind when using scoring sys-
tems to assess discharge readiness. Scoring sys-
tems focus on discharge goals; however, such
systems can still fail patients if we blindly look at
the scoring criteria.
1
Other limitations to keep in mind are the occur-
rence of postoperative complications requiring
re-admission to the hospital. The complication
rate after ambulatory procedures remains low.
Most complications are transient, such as pain,
sore throat, and nausea. Some complications
can be managed before discharge. The rates of
unanticipated admissions after day surgical pro-
cedures range between 0.3 to 1.4%.
29,30
Dis-
charge teaching is key to the patient and family
understanding which situations will warrant re-
turn to the hospital or further medical assistance.
Calculating scores on the vital sign parameters
of both the Aldrete scoring system and the
PADSS can be an area of uncertainty. Although
the patients vital signs may be within normal
range for age, the blood pressure should be
compared with that of preoperative value to
ensure the patients return to homeostasis.
However, if the preoperative value was abnor-
mally elevated because of anxiety or pain, ex-
pecting the postoperative blood pressure to be
within 20% of an elevated blood pressure may
not be appropriate. Again, an individualized pa-
tient assessment by the nurse and consultation
with the surgeon or anesthesiologist, as needed,
will conrm that the patient is suitable for dis-
charge in such situations. Discharge readiness
does not assume street tness.
14
If the patient
does not understand the activity restrictions
required as they continue Phase III recovery at
home, there is risk for overexertion and adverse
reactions occurring. Again, it is recognized that
scoring criteria are an important part of assess-
ing discharge readiness, but they must be used
with approved discharge criteria, health teach-
ing, and follow-up telephone calls. Using dis-
charge criteria as well as appropriate patient
selection for ambulatory surgery are key factors
to ensure the patients ability to meet discharge
criteria.
28,29
Common Complications After
Ambulatory Surgery
Ambulatory surgery is safe, with adverse events
occurring at low rates, less than 2%.
31
Cardio-
vascular events (such as hypotension, hyperten-
sion, and dysrhythmias) occur most frequently,
followed by respiratory events (such as laryngo-
spasm, bronchospasm, and oxygen desatura-
tion).
31
Cardiac or respiratory comorbidities are
strongly associated with such postoperative
complications.
5,28
Pain, PONV, and minor se-
quela such as sore throat and shivering, are
other concerns that arise after surgery.
5
Follow-up telephone calls to the patients home
have an large role in ensuring safety throughout
late recovery
5,28
; concerns such as continued
PONV, pain, and bleeding can be addressed.
These phone calls can also conrmthe patients
DISCHARGE CRITERIA: ALDRETE TO PADSS 265
understanding and compliance to the verbal
and written discharge instructions provided.
1,28
Follow-up phone calls can also be used in qual-
ity assurance studies.
Conclusion
The pillars of efcient, safe ambulatory surgery
include appropriate patient selection and timely
discharge.
12,14
Assessment of the patient
with the aid of scoring criteria such as the
Aldrete scoring system and the PADSS can
facilitate safe transition of care throughout
the three phases of recovery. Chung, Chan,
and Ong demonstrated increased reliability
using PADSS versus a criteria checklist.
10
The requirement to void and tolerate uids
is no longer considered part of standard
discharge criteria.
1,4,6,9,14,20,24
However, because the scoring criteria is only
part of the discharge assessment, patients at
higher risk of complications such as dehydra-
tion and urinary retention can be assessed on a
case-by-case basis.
6,14,22
Patients with such risks
would be instructed to return to the hospital if
postoperative concerns continue at home. Fol-
low-up phone calls are of particular importance
for high-risk patients to ensure patient-focused
care.
Once discharge protocols are established
and approved, it is mandatory that they are
consistently followed. By including dis-
charge scoring criteria, such as those out-
lined in this article, patients can continue to
benet from ambulatory surgery and home
recovery with the comfort of their familys
supervision.
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ASPAN 2008 National Conference
CALL FOR PROPOSALS
Proposals are now being accepted for presentations at the
ASPAN National Conference
May 4 8, 2008 Dallas, Texas
Lecture topics will be selected for the following categories:
Clinical Research Education
Geriatrics Pediatrics Preoperative Assessment
Leadership/Management Legal/Ethical Alternative/Integrative Therapies
To obtain a proposal packet,
please contact Carol Hyman at the ASPAN National Office:
877-737-9696 ext. 19 or chyman@aspan.org
Proposals must be postmarked by May 15, 2007.
DISCHARGE CRITERIA: ALDRETE TO PADSS 267