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  benefits 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  few  hours  postoperatively  to 
recover.1,2  Today,  patients  continue  to  benefit 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  care–acquired  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 sevoflurane, improved options in treating postoperative nausea and 
vomiting  (PONV)—as  well  as  preemptive,  mul-  timodal  analgesia—patients  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  efficient  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  significant  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 
modifications  made  to  en-  sure  continued  practicality  and  accuracy,  the  benefits  and  limitations  with 
discharge criteria, and the resulting implications to the perianes- thesia nurse. 
The History of Aldrete Scoring and PADSS 
How  was  today’s  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- 
HEATHER EAD 
260 
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 20–40% 
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 20–50 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. 

tory  care  areas,  ambulatory  surgery  centers  (ASCs),  endoscopy,  dental  offices,  and  plastic  surgeons’ 
offices.  Reviewing  the  history  of post- anesthesia scoring systems identifies 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  modification  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 
patient’s  transition  from  Phase  I  recovery  to  Phase  II  recovery, from discontinuation of anesthesia until a 
return  of  protective  reflexes  and  motor  function.14  At  most  institutions,  Phase  I  recovery  occurs  in  the 
PACU. Once Phase I recovery is completed, 
 
homeostasis  has  been  regained.  To  assess  the  patient’s  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  five  key  parameters  to  ensure safe transfer or discharge of 
the  patient  postoperatively.  Pa-  tients  achieving  a  total  score  of  9  or  10  are  considered  fit  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  patient’s  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 
patient’s  mucous membranes and nail beds is still in- cluded in the nurse’s 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  modified  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, 
DISCHARGE CRITERIA: ALDRETE TO PADSS 
261 

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  system  that  was  developed  in  Chicago  in  the  early 
1980s. This acronym includes the param- eters of: 
Respiration, Energy, Alertness, Circulation, and Temperature18 
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 quantification 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 
specifications  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 
 
Drinking and Voiding Before Home Discharge 
Requiring  all  patients  to void and tolerate oral fluids 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 
HEATHER EAD 
262 
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 specifically noted by physician (ie, urological procedure, rectal surgery, 
history of urinary retention) 
● Tolerating oral fluids not mandatory, unless specified 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. 

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 fibers 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 fluids before discharge home. Current recommenda- tions are that 
postoperative hydration status is 
 
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  fluids  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  fluids  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  area—bypassing  the  PACU—has  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  White26  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- 
DISCHARGE CRITERIA: ALDRETE TO PADSS 
263 
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. 
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  staffing  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 
 
is  no  one  agreed-upon  practice  guideline  or  definition  of  the  factors  involved in fast- tracking.28 Further 
clinical  studies  are  re-  quired  for  its  validation  and  benefits.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. 
HEATHER EAD 
264 
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 efficient 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 fluid 
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 patient’s stay. 10. Progress is quantified, and the scores can be tracked 
or used in patient’s stay. 11. Progress is quantified, 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 definitive tool that is sensitive to the patient, 
surgical procedure, and anesthetic technique has yet to be finalized. 2. Scoring systems do not include criteria for specific 
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. 

There  are  many  benefits  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 
benefits  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  patient’s 
stay to monitor 
 
improvement.  Tracking  improvements in clin- ical status allows a patient-focused approach, and confirms 
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  fit  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  insufficiency,  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  fluids  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  fluids  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 
DISCHARGE CRITERIA: ALDRETE TO PADSS 
265 

PADSS  can  be  an  area  of  uncertainty.  Although  the  patient’s  vital  signs  may  be  within normal range for 
age,  the  blood  pressure  should  be  compared  with  that  of  preoperative  value  to ensure the patient’s 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  confirm  that  the  patient  is  suitable  for  dis-  charge  in  such  situations. 
Discharge  readiness  does  not  assume  street  fitness.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 patient’s 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  patient’s  home  have  an  large  role  in  ensuring  safety  throughout  late 
recovery5,28;  concerns  such  as  continued  PONV, pain, and bleeding can be addressed. These phone calls 
can also confirm the patient’s 
 
However, understanding and compliance to the verbal 
because the scoring criteria is only and 
written discharge instructions provided.1,28 
part of the discharge assessment, patients at 
Follow-up phone calls can also be used in qual- 
higher risk of complications such as dehydra- ity 
assurance studies. 
tion and urinary retention can be assessed on a case-by-case basis.6,14,22 Patients with such risks 
Conclusion 
would be instructed to return to the hospital if 
The  pillars  of  efficient,  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 
postoperative  concerns  continue  at  home.  Fol-  low-up  phone  calls  are  of  particular  importance  for 
high-risk patients to ensure patient-focused care. 
Aldrete scoring system and the PADSS can 
Once discharge protocols are established facilitate 
safe transition of care throughout 
and approved, it is mandatory that they are the three 
phases of recovery. Chung, Chan, 
consistently followed. By including dis- and Ong 
demonstrated increased reliability 
charge scoring criteria, such as those out- using 
PADSS versus a criteria checklist.10 
lined in this article, patients can continue to The 
requirement to void and tolerate fluids 
benefit from ambulatory surgery and home is no 
longer considered part of standard 
recovery with the comfort of their family’s 
discharge criteria.1,4,6,9,14,20,24 
supervision. 
References 
1. Marley RA, Moline BM. Patient discharge from the ambu- latory setting. J Post Anesth Nurs. 1996;11:39-49. 
2. Fessey E. Implementing nurse-led discharge from day surgery. Nurs Times. 2005;101:32-33. 
3. Apfelbaum J, Walawander C, Thaddeus M, et al. Eliminat- ing intensive postoperative care in same-day surgery patients using 
short-acting anesthetics. Anesthesiology. 2002;97:66-74. 4. Beatty A, Martin D, Couch M, et al. Relevance of oral intake and 
necessity to void as ambulatory surgical discharge criteria. J Post Anesth Nurs. 1997;12:413-421. 
 5.  The  Joanna  Briggs  Institute.  Management  of  the  day  sur-  gery  patient.  Best Practice Supplement 1. 2003;1-4. Available at: 
http://www.joannabriggs.edu.au/pdf/BPISSup2004.pdf. Ac- cessed January 2006. 
6. Silverstein J, Apfelbaum J, Barlow J, et al. Practice guidelines for postanesthetic care. Anesthesiology. 2002;96: 742-752. 
7.  White  P,  Song  D.  New  criteria  for  fast-tracking  after  outpa-  tient  anesthesia:  A  comparison  with  the  modified  Aldrete’s 
scoring system. Anesth Analg. 1999;88:1069-1072. 
8.  Casati  A, Cappelleri G, Berti M, et al. Randomized com- parison of remifentanil-propofol with a sciatic-femoral nerve block 
for out-patient knee arthroscopy. Eur J Anesthesiol. 2002;19:109-114. 
9. Marshall S, Chung F. Discharge criteria and complica- tions after ambulatory surgery. Ambulat Anesth. 1999;88: 508-517. 
10.  Chung  F,  Chan  V, Ong D. A post anaesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin 
Anesth. 1995;7:500-506. 
11.  Friedman  Z,  Chung  F,  Wong  D.  Ambulatory  surgery  adult  patient  selection  criteria—A  survey  of  Canadian  anesthe- 
siologists. Can J Anesth. 2004;51:437-443. 
12.  Bryson  G,  Chung  F,  Cox  R. Patient selection in ambula- tory anesthesia—An evidence-base review: Part II. Can J Anesth. 
2004;51:782-794. 
13. Suddarth B. Textbook of Medical-Surgical Nursing. Phil- adelphia: Lippincott, William & Wilkins; 2004:303-306. 
14.  Kamming  D,  Chung  F.  What  criteria  should  be  used  for  discharge  after  outpatient  surgery?  In  Fleisher  L,  ed.  Evidence- 
Based Practice of Anesthesiology. Philadelphia: Saunders; 2004:247-252. 
15. Aldrete JA. The post-anesthetic recovery score revisited. J Clin Anesth. 1995;7:89-91. 
16. Chung F. Discharge criteria—A new trend. Can J Anesth. 1995;42:1056-1058. 
17. Saunders LD. Recovery of psychological function after anaesthesia. Int Anesth Clin. 1991;29:105-115. 
18. Fraulini K, Murphy P. R.E.A.C.T.—A new system for measuring postanesthesia recovery. Nursing. 1984;14:12-13. 
19.  Ang  P,  Pagan  A,  Lewis  M.  Determining  patients’  readi-  ness  for  release  from  the  postanesthesia  recovery unit. AORN J. 
2002;76:664-666. 
20.  Korhonen  A,  Valanne  J,  Jokela  R,  et  al.  Intrathecal  hy-  perbaric  Bupivacaine  3  mg  Fentanyl  10  μg,  for  outpatient  knee 
arthroscopy with tourniquet. Acta Anaesthesiol Scand. 2003;47:342-346. 
21.  Gupta  A,  Axelsson  K,  Thorn  S,  et  al.  Low-dose  Bupiv-  acaine  plus  Fentanyl  for  spinal  anesthesia  during  ambulatory 
inguinal herniorrhaphy: A comparison between 6 mg and 7.5 mg of bupivacaine. Acta Anaesthesiol Scand. 2003;47: 13-19. 
22.  Mulroy  M,  Salinas  F,  Larkin  K,  et  al.  Ambulatory  surgery  patients  may  be  discharged  before  voiding  after  short-acting 
spinal and epidural anesthesia. Anesthesiology. 2002;97:315- 319. 
HEATHER EAD 
266 
 
 23.  Kang  S,  Rudrud  L,  Nelson  W,  et  al. Postanesthesia nurs- ing care for ambulatory surgery patients post-spinal anesthesia. J 
Post Anesth Nurs. 1994;9:101-106. 
24. Chung F. Recovery pattern and home readiness after ambulatory surgery. Anesth Analg. 1995;80:896-902. 
25.  Song  D,  Joshi  G, White P. Fast track eligibility after ambulatory anesthesia: A comparison of desflurane, sevoflu- rane and 
propofol. Anesth Analg. 1998;86:267-273. 
26. White P. Criteria for fast-tracking outpatients after am- bulatory surgery. J Clin Anesth. 1999;11:78-79. 
27.  Dexter  F.  Computer  simulation  to  determine  how  rapid  anesthetic  recovery  protocols  decrease  the  time  of  emergence  or 
increase the phase one postanesthesia care unit bypass rate 
DISCHARGE CRITERIA: ALDRETE TO PADSS 
267 
affect staffing of an ambulatory surgical centre. Anesth Analg. 1999;88:1053-1063. 
28.  Casey  V,  Kitowski  T,  Nahorney  S,  et  al.  Standards  of  Perianesthesia  Nursing  Practice,  5th  ed.  Ontario,  Canada:  Ontario 
PeriAnesthesia Nurses Association; 2005:5–31. 
29. Chari P, Sen I. Paediatric ambulatory surgery-periopera- tive concerns. Indian J Anaesth. 2004;48:387-394. 
30.  Fortier  D,  Chung  F,  Su  J.  Unanticipated  admission  after  ambulatory  surgery—A  prospective  study.  Can  J  Anesth.  1998; 
45:612-619. 
31.  Chung  F,  Mezei  G,  Tong  D.  Adverse  events  in ambula- tory surgery: A comparison between younger and older pa- tients. 
Can J Anesth. 1999;99:309-321. 

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.