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the perfect score fast tracking through your day surgery unit

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the perfect score fast tracking through your day surgery unit

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    1: THE PERFECT SCORE Fast tracking through your day surgery unit Wendy Adams MRCNA President Australian Day Surgery Nurses Association Presented by Sarah McDonald

    3: Definitions Score based recovery Patient is moved through the unit and discharged when they achieve a set of criteria using a scoring system Time based recovery Patient is moved through the unit and discharged when they achieve a set of criteria and required time length of stay in the unit.

    4: Definitions Fast tracking Clinical pathway that involves transferring the patient from the operating room to the day surgery ward (2nd Stage recovery) and bypassing PACU (1st stage)

    5: Discharge Scoring systems Aldrete scoring system White et al scoring system PADSS Modified PADSS I have been using scored based criteria for 8 years Have introduced it in 2 centres as manager Introduce it in centres where I am quality consultant I have been using scored based criteria for 8 years Have introduced it in 2 centres as manager Introduce it in centres where I am quality consultant

    6: Aldrete Scoring system Requires a patient to reach the criteria of 9 or 10/10 before the can Move from 1st stage to 2nd stage By pass 1st stage (by achieving the score in the operating room)

    7: Aldrete Scoring system Does not address Pain Nausea Vomiting

    8: Aldrete Scoring system

    9: Aldrete Scoring system

    10: White et al scoring system Includes pain and emetic scoring symptoms Maximum score is 14 A score of 12 (with no less than 1 in any category) provides criteria for bypassing PACU (1st stage)

    11: White et al scoring system

    12: White et al scoring system

    13: White et al scoring system

    14: Studies Randomised study by Francis Chung in 2004 207 patients GA 81% bypassed PACU (1st stage) successfully 97% arthroscopy 72% gynaecology Randomised controlled trial in a multi-centre 58% successfully bypassed

    15: My experience

    16: Benefits of fast tracking Less intensive nursing staff required Less PACU (1st stage) beds required Individualised care Justifies patients staying longer if required Refer to other presentation for more details on this one.Refer to other presentation for more details on this one.

    17: Discharge criteria Francis Chung devised post anaesthetic discharge scoring system (PADSS) Later modified to eliminate input and output criteria Score of 9 or 10/10 required for discharge home

    18: Modified PADSS

    19: Modified PADSS

    20: Modified PADSS

    21: Discharge criteria In addition, other criteria is necessary Appropriate carer Discharge instructions etc given Patient accepts readiness for discharge

    22: What about eating & drinking? Only necessary on a case by case basis Must be well hydrated Must understand discharge instructions Literature available to support this

    23: What about eating & drinking? Higher incidence of vomiting and delay in discharge in the ‘mandatory drinkers’ cf. ‘elective drinkers’ Kearney R, Mack C, Entwistle L. Withholding oral fluids from children undergoing day surgery reduces vomiting. Paediatr Anaesth 1998;8:331-336

    24: What about eating & drinking? Incidence of vomiting reduced from 73% to 36% when fluids withheld 4-6 hours Jin FL, Norris A, Chung F. Should adult patients drink fluids before discharge from ambulatory surgery? Can J Anaesth 1998;87:306-311

    25: Is voiding necessary? Risk factors for post operative urinary retention are Anorectal surgery Old age Male sex Spinal anaesthesia Hernia surgery

    26: Is voiding necessary? Delay in discharge 5-11% of patient who have no risk factors Incidence of urinary retention is 1% in low risk patients When discharging low risk patients who have not voided Discharge instructions regarding medical assistance if not voided 6-8 hours post operatively

    27: My experience

    28: My experience

    29: In summary Should we fast track? Staff competence and experience Medical staff support it The use of ultra short acting drugs Appropriate pain and PONV management Collect and analyse data

    30: In summary Is it safe to use a scoring system rather than a time based criteria? Staff competence and experience Medical staff support it The use of ultra short acting drugs Appropriate pain and PONV management Collect and analyse data

    31: In summary Should we let our patients go home without eating or drinking? Develop criteria for low risk group Review fasting times pre operatively Review intra operative IV hydration

    32: Further information

    33: Further information www.adsna.info president@adsna.info

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