Introduction

This guideline details the discharge of patients from the PACU, including the transfer of patients to the in-Patient wards, Day of Surgery (DOS) and Paediatric Intensive Care Unit (PICU). This guideline also outlines the discharge recommendations for patients being discharged home from PACU, Medical Imaging and Peter MacCallum Cancer Centre.

To provide clear and comprehensive guidance for staff at the Royal Children’s Hospital on the safe and effective discharge of patients who have undergone anaesthesia, ensuring that all necessary criteria for safe discharge are met.

Definition of Terms

• ASA: American Society of Anaesthesiologist is a physical status classification system. It provides grading from I (one) through to V (five) to identify the health of a patient prior to a surgical procedure requiring anaesthesia.
• Clinical indicators:  data collection of PACU events.
  

PACU Discharge Criteria

• Clinical Observations within age-appropriate limits or previous baseline. 
• Observations which fall within shaded areas of clinical observation chart should be managed following the Medical Emergency Response Procedure, please note appendix 4 specifically refers to transfer of patients from PACU to ward. 
• Temperature ≥ 36 degrees C or ≥36.6 degrees C for neonates.
• If the temperature is <36 C and>35.5 degrees C, the patient is rousable and all other observations are within normal range, patient can be transferred to the ward.
• Sedation score 1 or 2 (UMSS). The patient is rousable; they may be asleep but can be easily awakened or at baseline cognitive state
• No active vomiting.
• Pain management controlled
• Surgical bleeding from wounds/drains are assessed, within expected parameters and escalated if required. 
• Clinical indicators completed. 
• Parental concerns addressed
  

Note: Patients who have received Naloxone or Flumazenil require a greater length of stay in PACU, see flowchartNaloxone_Flumazenil CPG reversal flowchart.pdf. Receiving nurses should remain vigilant for changes in conscious state or level of sedation.

Discharge from PACU directly to HOME

Direct discharge from PACU to home should only occur when it is safe to do so and there are no other appropriate locations for the patient to be discharged from. Every effort must be made to ensure that patients are transferred to Day of Surgery unit or an in-patient unit prior to discharge.

The decision regarding suitability for discharge directly home from PACU should only be made by the in-charge or treating anaesthetist, surgical team in consultation with the PACU AUM/Nurse In Charge or PACU nurse.

If the patient has received a sedative premedication, they may require an extended stay in the PACU and may not be suitable for direct discharge home.

In the event that parents/carers do not want to or are reluctant be discharged home from PACU, the PACU AUM/Nurse In Charge must escalate to the hospital bed manager in consultation with the anaesthesia and medical or surgical team.

Patients who may be suitable for discharge directly from PACU to home include:

• Patients must have undergone only minor procedures or imaging (MRI/ CT) and are appropriate for same day discharge.
• ASA 1 & ASA 2 patients can be discharged home from PACU once they meet Day Of Surgery discharge home criteria; anaesthesia review is not required but considered if requested from PACU.
• ASA 3 patients may be considered suitable for discharge only if deemed appropriate by anaesthesia and medical or surgical teams. Day Of Surgery criteria must be met and the patient reviewed by an anaesthetist prior to transfer.

Timing of Discharge

•  Patients who have had a General Anaesthetic GA must stay for a minimum of 30 minutes from emergence of anaesthesia.
• Patients in whom a muscle relaxant is used during anaesthesia must stay for a minimum of 1 hour from emergence of anaesthesia.
•  Any patient who has received any opioid (oral or IV) cannot be discharged home until 30 minutes after the last opioid dose.

It is the responsibility of the PACU RN who is caring for the patient and/or PACU AUM/Nurse In-charge to provide discharge education and post-operative instructions. It is recommended that the PACU nurse documents the discharge process using the Day Of Surgery discharge checklist on EMR. 

Discharge information should include any relevant Kids Fact Information sheets, follow up appointments and instructions. Parents and caregivers must be informed of the appropriate escalation pathways for concerns including calling RCH, presenting to the nearest emergency department or contacting emergency services.

For more information please see the Post Operative Discharge Criteria following General Anaesthesia for Minor Surgical Procedures

Day Of Surgery Discharge Criteria for HOME

• Discharge from the Day of Surgery Unit to home should be completed in line with the Post Operative Discharge Criteria following General Anaesthesia for Minor Surgical ProceduresPost Operative Discharge Criteria following General Anaesthesia for Minor Surgical Procedures as well as the following:
• Observations are at baseline (including procedure specific observations)
• IV cannula removed
• Surgical site clean, dry and intact
• Pain management controlled
• Nausea and vomiting controlled
• Tolerating fluids without any vomiting
• Diet as per surgical team requirement
• Parental concerns addressed and parent/carer is satisfied/comfortable with discharge plan
• Follow up appointment arranged, if required
• Other criteria as per surgical requirement/post-op orders i.e. voiding for urology patients

Discharge Checklist

• Discharge criteria met
• Post procedure plan, action and contact details provided, Kids health information fact sheet provided as appropriate.
• Prescriptions provided
• Phone follow up offered
• Patient discharge on IBA
• After Visit Summary AVS given to parents/carer

Patients with Dysregulated or High-Risk Behaviours

• Every effort should be made in the pre-operative phase to identify patients with dysregulated or high- risk behaviour who would benefit from a PACU discharge to home.
• PACU to home discharge of these patients should be planned in consultation with parent/carer and all care providers, including but not limited to PARC, PACU, Code Grey team and Child Life Therapy as well as surgical and anaesthetic teams.
• Special consideration may need to  be given to these patients, as it may not be feasible to discharge them according to the Day Of Surgery criteria. For example, a patient may need to be discharged from anaesthesia room or early in the PACU phase.
• For these patients, the PACU nurse must document the discharge process on the EMR and offer the parent/carer a follow up phone call made by the discharging nurse.
• Discharge information should include any relevant Kids Fact Information sheets, follow up appointments and instructions. Parents and caregivers must be informed of the appropriate escalation pathways for concerns including calling RCH, presenting to the nearest emergency department or contacting emergency services.

Discharge from PACU, transfer to Day of Surgery or Inpatient Units:

Once the patient has reached PACU discharge criteria, the PACU nurse or PACU AUM/Nurse In-Charge will contact the receiving inpatient unit or Day of Surgery.

DOS/Possum:

• PACU RN/AUM to ask for the bay/bed number to facilitate patient transfer. Delays should be communicated with PACU immediately to minimise impact to patient flow.
• The PACU nurse will transfer the patient to DOS/Possum unless otherwise communicated.
• It is recommended that DOS/Possum are provided with the opportunity to review the patient prior to transfer if there has been a clinical issue or critical event intraoperatively or in the PACU.

All other inpatient units:

• Patients should be collected from the PACU within 20 minutes of the call, unless otherwise arranged through the AUM or Nurse in-charge. This is done to provide the receiving ward with the opportunity to assess the patient prior to transfer.

All areas:

• Delays in collecting the patient from PACU, should be communicated to the PACU AUM/Nurse In-Charge  as soon as possible to prevent issues with patient flow.
• Monitoring by the PACU nurse will continue until patient is discharged from the unit.
• PACU nurse will provide a comprehensive handover as per the Clinical Handover Guideline between Post Anaesthetic Care Unit and Ward Teams, Nursing Clinical Handover guideline and Clinical Handover procedure.
• It is the responsibility of the proceduralist or surgeon to ensure that all post-operative orders for the patient are added to the EMR. If post operative orders are not documented the PACU nurse will escalate to the treating team.
• Prior to transfer from PACU, the oneTeam question must be asked to parent/carer

Refusal of Patients

Refusal of transfer of patients by the receiving nurse, cannot occur without visual and physical assessment of the patient. 

Refusal maybe considered if:

• The patient’s clinical observations are breaching MET criteria and their condition has not been appropriately escalated (Deteriorating Patient Escalation of Care)

• MET modification is required but has not been documented

• The patient’s care requirements cannot be met by the receiving unit

The process for patient refusal

• Patient must be assessed in PACU by the inpatient RN and refusal deemed appropriate. The inpatient RN should escalate/inform the inpatient AUM of their concerns and refusal.
• Refusal documented on patient notes.
• PACU RN notifies PACU AUM/Nurse in-charge .
• Escalation to both Proceduralist and treating anaesthetist/(in charge anaesthetist if treating anaesthetist unavailable) for clinical review, optimisation or alteration of MET criteria.

If continued refusal post clinical review by proceduralist/anaesthetist:

• The refusal should be escalated to the bed manager by PACU or inpatient AUM.
• VHIMS completed if appropriate
  

Patient Reviews & MET Modification

If PACU nurses have concerns regarding the clinical condition of the patient in PACU, they should: 

• Escalate to PACU AUM/Nurse In-charge
• Notify the treating anaesthetist or In-charge anaesthetist, if treating anaesthetist is unavailable
• Notify Surgical team
• Contact the PICU outreach for further support and review as needed
• PACU RN to document review process

If MET modification is deemed necessary, PACU MET modifications are valid for two hours.

Please see Medical Emergency Response, MET modification and PICU outreach for further information.

Discharge from PACU to PICU

• Patients identified as requiring PICU admission postoperatively, prior to their operation, will be directly transferred from operating suite to PICU if intubated or otherwise deemed necessary by the treating anaesthesia and surgical team.
• If the patient recovered in PACU, once discharge criteria has been met or patient has been deemed ready for transfer thePACU AUM/Nurse In charge will notify PICU AUM that patient is ready for transfer.
• 30-minute notice will be given to PICU by anaesthesia team or PACU, notifying them of the transfer.
• Delays in transfer must be communicated as soon as possible to prevent impact on patient flow.
• Once ready for transfer, the patient will be transferred by the PACU nurse to PICU. Anaesthesia may escort the patient depending on the clinical complexity of the patient or if requested by PACU AUM/In-Charge Nurse or PACU nurse.
• If anaesthesia team is not escorting the patient to PICU, the anaesthesia team must provide a clinical handover to the PICU medical team via phone.   
• Prior to transfer from PACU the oneTeam question must be asked if Parents/Carers are present.

Discharge from PACU Medical Imaging to Home

• PACU will be responsible for the provision of care in a stage 1 recovery capacity in medical imaging.
• The PACU nurse will ensure that the patient has met PACU discharge criteria and will handover care to the Day of Surgery nurse.
• Day Of Surgery will provide stage 2 care for the patient in medical imaging.
• The Day of Surgery nurse will follow the Day of Surgery discharge criteria and checklist.
• Discharge information should include any relevant Kids Fact Information sheets, follow up appointments and instructions. Parents and caregivers must be informed of the appropriate escalation pathways for concerns including calling RCH, presenting to the nearest emergency department or contacting emergency services.
  

Discharge from PACU Peter MacCallum Cancer Centre (PMAC) 

• The provision of PACU care for paediatric patients requiring anaesthesia at PMAC is delegated to the attending RCH Anaesthesia team and RCH PACU nurse. The RCH PACU nurse will be responsible for PACU care and discharge home from PMAC.
• For escalation of patient concerns, the first point of call is the treating anaesthetist from RCH.
• For clinical concerns which may be related to underlying diagnosis, escalate to the paediatric Clinical Nurse Consultants at PMAC.
• Documentation of observations, clinical notes and discharge will via PMAC EMR.
• Prior to discharge the oneTeam question must be asked
• Discharge information should include any relevant Kids Fact Information sheets, follow up appointments and instructions. Parents and caregivers must be informed of the appropriate escalation pathways for concerns including calling Paediatric Clinical Nurse Consultants, RCH or Monash medical team, presenting to the nearest emergency department or contacting emergency services.
• In the event that the patient is not deemed to be ready for discharge home or to treating hospital (RCH/Monash) due to clinical concerns, escalation of care should be initiated by the treating anaesthetist.
• Treating anaesthetist will escalate to RCH or Monash and contact PIPER or ambulance service for transfer.
  

Family Centred Care

• Provide clear information
• Ensure concers or parents and carers are listened and escalated
• Consider family/caregiver discharge education
•  Oneteam
  

Companion Documents

RCH Nursing Guidelines

• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Routine_post_anaesthetic_observation/
  
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_assessment/
  
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Temperature_management/
  
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Assisted_thermoregulation/
  
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Observation_and_continuous_monitoring/
  
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Management_of_the_paediatric_patient_receiving_opioids/
  
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Adrenaline_and_fluid_bolus_administration_in_resuscitation/
  
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_clinical_handover/
  
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Oxygen_delivery/
  
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Premedication_for_anaesthesia/

RCH Clinical Practice Guidelines & Prompt

• https://www.rch.org.au/clinicalguide/guideline_index/Resuscitation/
  
• https://www.rch.org.au/uploadedFiles/Main/Content/policy/Appendix%204%20-%20Modifying%20Emergency%20Response%20Criteria%20in%20Recovery%20prior%20to%20Transfer%20to%20a%20Ward%20-%20April%202017.pdf
  
• Medical Emergency Response
  
• PICU Outreach Service
  
• Criteria Led Discharge
  
• Post Operative Discharge Criteria following General Anaesthesia for Minor Surgical Procedures
  
• Pre-Op Hold - Criteria for Transferring Ward Inpatients to Pre-Op Hold

Kids Health Information Sheet

• https://www.rch.org.au/oneteam/
  
• https://www.rch.org.au/kidsinfo/fact_sheets/Preparing_your_child_for_surgery_general_anaesthesia/
  
• https://www.rch.org.au/kidsinfo/fact_sheets/Day_surgery_General_surgery_discharge_care/
  
• https://www.rch.org.au/kidsinfo/fact_sheets/Emergence_delirium/
  
• https://www.rch.org.au/kidsinfo/fact_sheets/Pain_relief_for_children/