VOL: 97, ISSUE: 35, PAGE NO: 30
Jessica Higson, BN, DipHE, RN, is senior staff nurse, Albert day unit, Royal Berkshire Hospital
Rachael Bolland, MSc, BA, RSCN, is senior sister, Island day unit, The Hospital for Children, Great Ormond Street, London
Numerous government and NHS documents over the past few years have hailed the development of standards as a means of ensuring quality in the health service.
With this in mind the Albert day unit at the Royal Berkshire Hospital in Reading and the Island day unit at The Hospital for Children, Great Ormond Street, London, initiated the joint development of a discharge standard for children who have had day surgery. This was done before the units were set up.
The first stage in establishing a discharge standard was to identify the criteria for admission to ensure that delayed discharge and unplanned overnight admission rates were kept within Audit Commission guidelines (1992). Ideally, all children booked into the units should be assessed before admission to ensure that they are suitable for day surgery and inform parents of their responsibilities both before and after the procedure.
The second stage was to draw up criteria for discharge. It is essential that these are evidence-based and not ritualistic. The management of patient problems in surgical day-care units and deciding when a child is ready to go home have become serious quality issues. This is particularly important because more chronically sick children are being selected as suitable for day surgery, which is also becoming increasingly complex (Hitchcock and Ogg, 1997).
Historically, children who have had day surgery and have no obvious anaesthetic or surgical complications have been discharged within a set time (Chung, 1997). One view is that children need to stay in hospital for at least four hours after surgery. This is not a child-centred or evidence-based approach: all children recover at their own pace and not within a specific time.
Ultimately, it is the surgeon’s responsibility to ensure that a child is sufficiently recovered to go home (Marshall and Chung, 1999). But in the UK, in practice this falls to nurses.
Therefore, when establishing the day-care units we felt that it was important to identify criteria to determine when it was safe for children to go home under the care of their parents or carer.
An analysis of day cases nursed on inpatient wards revealed wide differences in when children were being allowed home. The decision to discharge was generally influenced by which nurse was caring for them and how busy the ward was.
If nurses are to take on this responsibility, it is necessary to have a written policy setting out the discharge criteria (Quan and Wieland, 1994). These can be applied in the form of a tick chart, which is practical, easy to use and provides uniform assessment for all children, adding medico-legal value to nurse-led discharge (see box).
Criteria for discharge
The Post-Anaesthetic Discharge Scoring System (PADSS) is an adult scoring system that uses vital signs, activity level, nausea and vomiting, pain and surgical bleeding as measures to assess readiness for discharge (Marshall and Chung, 1999).
In a randomised study of 247 ambulatory surgery patients, Chung (1995a) evaluated the validity and reliability of this scoring system against clinical discharge criteria. The study showed that the PADSS had superior measurement scaling and diagnostic properties. This is the system that was adopted for our units. Chung (1995b) also found that most patients were ready to go home one to two hours after the anaesthetic had worn off.
Checking whether children can tolerate fluids without vomiting or nausea by getting them to drink is commonly used as a criteria for discharge. However, children vomit more frequently after discharge than during their hospital stay, so the fact that a child can keep down clear fluids does not guarantee that vomiting or dehydration will be prevented after discharge (Schreiner et al, 1992). This study involved randomising 989 children into two groups. The mandatory drinkers were required to drink clear liquids without vomiting before discharge and the elective drinkers were allowed, but not required, to drink before discharge.
Only 14% of the elective drinkers vomited compared with 23% of the mandatory drinkers. The mandatory drinkers also had significantly longer stays in hospital. The researchers concluded that it was not necessary to make drinking a prerequisite for the discharging of paediatric day-case patients.
A requirement to pass urine is another common criterion. Fritz et al (1997) audited the discharge of 1,719 patients from an ambulatory surgery unit. Only three (0.17%), who had had procedures involving spinal anaesthetic and a rectal or inguinal procedure, required intervention for retention. The researchers concluded that even patients who were at high risk of urinary retention could be discharged before passing urine if follow-up was available from a community nursing team.
In its first year of operation, the Island day unit saw 1,536 patients. Children are not required to pass urine unless they have had a urological procedure such as cystoscopy or the removal of a urinary catheter. None of the children discharged after a general anaesthetic had problems with urinary retention.
Evidence from the Albert day unit corroborates this: in its first six months of operation there were no such complications.
One of the criteria of the PADSS is that there should be little pain before discharge. However, a study of 500 day-case patients (Chung, 1995b) found that 30% had some pain at the incision site, 25% had a sore throat and 10-15% experienced dizziness, headache or drowsiness after the operation. It is therefore vital to provide families with comprehensive written information to complement the verbal advice given by staff and enable them to care safely for the child at home. The effectiveness of leaflets and verbal instruction can be assessed in a follow-up telephone call.
We agreed that the standard statement for discharging children from both day surgery units would be: each child admitted to the day unit for a procedure under sedation or general anaesthetic would meet the agreed discharge standards before discharge.
The discharge criteria that are now used in both units are based on an adapted PADSS (see box) and the chart is incorporated into each child’s notes.
Audit and feedback have been highlighted as ways to incorporate evidence and research findings into practice (Richardson et al, 2000). We developed an audit tool to enable us to evaluate the process of discharge. This resulted in the following objectives.
- All children and their families are to be seen and assessed by a children’s nurse before discharge;
- All families are to receive written information to enable them to care for their child at home after the procedure: this includes the contact telephone numbers of medical or nursing staff;
- All discharge documentation is to be completed in full.
If the objectives are achieved in 90% of cases, the standard is defined as being successful. The audit, which is completed every six months, involves reviewing the discharge forms of 30 randomly selected patients (about two weeks of consecutive admissions).
For the initial audit, tables were completed to enable the outcomes to be measured and the results were compared with an audit of the follow-up telephone calls. These measures will enable us to monitor the discharge criteria continually.
Parents and children were also asked to fill in a questionnaire about their visit to the unit, including a section on the child’s discharge. So far, none of the parents has expressed any concerns about their child’s readiness for discharge.
Standards can be used as a mechanism to maintain quality in nursing. This work shows how theory can be translated into evidence-based practice. We developed criteria to assess children’s readiness for discharge after day surgery. An initial audit of our practices has shown an improvement in the outcomes of care for paediatric day surgery.