Do you need these discharge criteria?
Drinking and voiding may not be needed
Some anesthesiologists question the necessity of the common requirement for patients to drink and/or void before discharge. Waiting for a patient to void may lead to unnecessary delays, and asking patients to drink can actually provoke nausea and vomiting, some anesthesiologists say.
Mark S. Schreiner, MD, and his colleagues found that requiring pediatric outpatients to drink before discharge increased the incidence of vomiting by more than 50%.1,2
"A lot of people believe that if a child tolerates a drink in the hospital, they’ll go home, and they won’t get dehydrated," says Schreiner, associate professor of anesthesia at the Children’s Hospital of Philadelphia and the University of Pennsylvania. In fact, dehydration is not a high risk for those children, who often have had intravenous fluids, he says.
"When we require children to drink, they are more likely to vomit in the hospital and stay longer," Schreiner says. "When we don’t require children to drink, they do just as well at home, and they have a lower incidence of vomiting in the hospital."1, 2
Children’s Hospital also does not require patients to void before discharge. In the case of some procedures, such as inguinal hernia repair, the children might not void for 200 to 300 minutes after surgery while they might be otherwise ready for discharge within 45 minutes, Schreiner says.
Patients who had spinal anesthesia may be more comfortable if they are catheterized during recovery, but they may be discharged without voiding as long as they have clear discharge instructions about when to contact a nurse or doctor if they have not voided, says Frances F. Chung, MD, FRCPC, deputy anaesthetist-in-chief at the Toronto Hospital.
"Most of the time, voiding is not an issue except in certain patients," she says. For example, such patients include those undergoing urological or gynecological procedures in which damage to the urinary tract is possible or elderly patients who have prostate problems and could have urinary retention, Chung says.
References
1. Schreiner MS, Nicolson SC, Martin T, Whitney L. Should children drink before discharge from day surgery? Anesthesiology 1992; 76:528-533.
2. Schreiner MS, Nicolson SC. Pediatric ambulatory anesthesia: NPO before or after surgery? J Clin Anesth 1995; 7:589-596.
Discharge Criteria
• Awake, alert, oriented, responsive (or return to baseline)
• Minimal pain
• No active bleeding
• Vital signs stable (not likely to require pharmacologic intervention)
• Minimal nausea
• No vomiting
• If nondepolarizing neuromuscular blocking agent used, patient can perform 5-second head lift
• Oxygen saturation of 94% on room air (three minutes or longer) OR return of oxygen saturation to baseline or higher
In order to be eligible to bypass phase one recovery (PACU), the patient must meet all of the above criteria, and in the judgment of the anesthesiologist, be capable of transfer to the step-down unit, with appropriate care and facility for patient management at the location.
Source: Jeffrey Apfelbaum, MD, University of Chicago Hospitals.
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