Background

Outpatient or same-day surgery is surgery that does not require an overnight stay in a hospital facility.1 These surgeries can be performed in a hospital surgical suite or in an ambulatory surgical facility. Children undergoing outpatient surgery are a special surgical population requiring unique care. Internationally, up to 85% of surgical cases performed on pediatric patients are outpatient procedures.2 Most pediatric patients undergoing outpatient surgery are aged six months to 18 years and qualify as American Society of Anesthesiologists (ASA) Physical Status Classification System I (normal, healthy patient) or II (mild, systemic disease).3 The ASA Physical Status Classification System is used internationally to predict patient risk in the perioperative setting.4 Postoperatively, pediatric outpatients typically go to a post-anesthesia care unit (PACU), also known as Phase I of recovery. Patients in the PACU are continuously monitored by a member of the nursing staff. The nurse monitors vital signs, pain control, nausea and vomiting, and attempts to recover the patient. Recovery is considered a return to baseline physiologic status.2 The time necessary for recovery is unique to the patient, as recovery requires vital signs to be at or close to baseline, the patient must not have active nausea and vomiting, and the pain must be manageable with oral pain medicine.2 Once a patient is deemed ready for discharge from the PACU, he/she is transferred to a Phase II unit where he/she will subsequently be discharged from the facility. Specific criteria for discharge after outpatient surgery vary from facility to facility, but the overall goal is to safely discharge the patient from the facility.

Minimizing postoperative physical symptoms is coupled with the psychosocial needs of pediatric patients. In the pediatric population, there is a desire to reunite the patient with parents or caregivers in an attempt to decrease anxiety.5 Balancing the need for return to physiologic baseline with the desire to reunite patients with parents in an expeditious manner presents a problem in the immediate postoperative recovery period. Determining ways to meet all the needs of the patients is desirable for the patient's wellbeing.6

Internationally, outpatient surgery is widely used in the pediatric population, with multiple tools currently used to assess discharge readiness from PACU.2 The Aldrete score, developed in the 1970s for use in the adult surgical population, was the first official discharge criteria and was based on the Apgar scoring system.7 The Apgar score is the system utilized to assess the clinical status of the newborn.7 The Aldrete system has an individual score for activity, respiration, circulation, consciousness and oxygen saturation. Each of these areas are scored then added together for a total score. The maximum score achievable is 10. As outpatient surgery became popular, the Modified Aldrete score was developed. This system is more in depth and includes factors such as activity, respiration, circulation, consciousness, oxygenation, surgical wound site and dressing, pain, ambulation, feeding and urine output.8 The Modified Aldrete has a total possible score of 20. The Post-Anesthetic Discharge Scoring System (PADSS) is another tool used for discharge from PACU. The PADSS includes vital signs, activity, nausea and vomiting, pain and surgical bleeding, and has a maximum score of 10.8 Other physiologic based systems are available where hospitals predetermine the standards that outpatients must meet prior to discharge.9,10 The PACU discharge criteria can vary greatly from facility to facility with best practice remaining unclear.

The currently used PACU discharge practices were created specifically for use with the adult surgical population and have not been validated for use in the pediatric surgical population.2 The pediatric outpatient surgical population is unique and ranges in age from zero to age 10 and spans a multitude of developmental milestones. The patients qualifying for outpatient surgery typically have no pre-existing conditions, and if present, they are well controlled and managed. Although the goal is to return the patient to as close to baseline as possible prior to discharge, children react and respond differently than adults to postoperative occurrences, such as pain, anxiety or emergence from anesthesia.2 Often times children exhibit separation anxiety from their caregivers, but may not be old enough to verbalize their insecurity about being separated from their loved ones. Developmental milestones vary greatly between ages, and knowing each patient's current developmental level is critical for the nurse to properly assess the patient's discharge readiness.8 Utilization of an adult-based scoring system does not address all the unique needs of the pediatric population. Criteria that may be appropriate for an adult, who is able to follow commands, may be completely irrelevant for an infant or toddler.8 Reactions in smaller children may be mischaracterized and inappropriately treated or left untreated, depending on how the child behaves. Without age specific discharge criteria, it is impossible to know whether a pediatric patient is truly ready for discharge. The applicability of a system made for adult patients should be evaluated in the pediatric population. Inappropriate discharge criteria can lead to patients being discharged precipitously, which, in turn, can lead to adverse outcomes such as unexpected hospital admissions or, though rare, death.9,10

After reviewing the literature, the authors have determined that a scoping review on this topic is necessary in order to determine discharge criteria currently in use in pediatric PACUs around the world. The Joanna Briggs Institute methodology will be used to undertake this scoping review.11 The purpose of this scoping review is to identify and describe the discharge criteria, tools and strategies used in the pediatric postoperative outpatient surgical population. The review will also map the determinants of readiness for discharge beyond formalized tools by reviewing the literature and case studies available, identifying any discharge tools used internationally in the pediatric setting, and ascertaining the specific measurements of the tools identified. Although outpatient surgery is ideal for the pediatric population, having appropriate discharge criteria is crucial to ensuring that the patient is discharged from the facility safely. With the age variation that exists in the pediatric surgical setting, having the best evidence available to serve the differing needs of the patients is important. An initial search of PubMed, Cochrane, CINAHL, JBI Database of Systematic Reviews and Implementation Reports, Campbell and PROSPERO in November of 2016 showed that no scoping reviews or systematic reviews currently exist on this topic or are currently underway.

Inclusion criteria

Types of participants

The current scoping review will consider studies that include patients aged six months to 18 years who have undergone outpatient surgery, with an ASA classification of I or II, and are being discharged from the PACU. Patients who are being admitted to an inpatient area will be excluded.

Concept

The current review will consider studies that examine various discharge criteria, tools and strategies being used in pediatric PACUs for use in discharging patients after outpatient surgery. Objective and subjective criteria will be considered. The criteria may measure, but will not be limited to, vital signs, pain, nausea and vomiting and bleeding. This review will consider studies that use various instruments to measure subjective and objective criteria for discharge readiness. These instruments may include, but will not be limited to, the Aldrete Score, Modified Aldrete Score and PADSS.

Some discharge guidelines may utilize more subjective approaches due to the unique nature of the pediatric population. This could include nurse observation of patient behavior in terms of developmental expectations. Nurses may observe patient age appropriate behaviors and utilize those behaviors as part of the discharge criteria.

Context

The current scoping review will consider studies that have been conducted in any pediatric PACU.

Types of studies

The current scoping review will consider both experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies, including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies, will be considered for inclusion. This review will also consider descriptive observational study designs, including case series, individual case reports and descriptive cross-sectional studies for inclusion.

Qualitative studies will also be considered that focus on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research.

Text and opinion papers will also be considered for inclusion in this scoping review.

Studies published in English will be included. Studies published from 1970 to the present will be included, as 1970 is considered the year the first PACU discharge criteria were recognized. This was done through formalization of a scoring system that ranged from 0 to 10 and measured respiration, oxygen saturation, consciousness, circulation and activity. A total score of 8 was considered acceptable for discharge. Prior to this, discharge readiness was not formalized.8

Search strategy

The search strategy will aim to find both published and unpublished studies. An initial limited search of CINAHL and MEDLINE, via PubMed as a platform, has been undertaken to identify articles on this topic, followed by analysis of the text words contained in the titles and abstracts, and of the index terms used to describe these articles. This informed the development of a search strategy, including identified keywords and index terms, which will be tailored for each information source. A proposed search strategy for each database is detailed in Appendix I. The reference list of all included studies will be screened for additional studies.

The databases to be searched will include: CINAHL Plus with Full Text, PubMed, SCOPUS and Cochrane Central Register of Controlled Trials.

The search for gray literature and unpublished studies will include: MedNar, ProQuest Dissertations and Theses.

Data extraction

Data will be extracted from papers included in the scoping review using the draft data extraction tool listed in Appendix II by two independent reviewers. The data extracted will include specific details about the populations, concept, context and study methods of significance to the scoping review question and specific objective. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data where required. The draft data extraction tool will be piloted and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report.

Data mapping

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns to the objective and scope of this scoping review. Figures, tables and charts will be used wherever appropriate. The tables and charts will report on: distribution of studies by year or period of publication, countries of origin, area of practice (clinical, policy, educational etc.), research methods, criteria used for discharge, tools used for discharge, age of patients and any reported outcomes. A qualitative thematic analysis will be undertaken to provide an overview of the literature. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the review objective and question. The findings will be discussed as they relate to practice and research.

Acknowledgements

Special thanks to the faculty of the University of Mississippi Medical Center School of Nursing, especially Dr. Janet Harris and Dr. Robin Christian. This protocol will contribute toward a Doctor of Nursing Practice (DNP) degree.

Appendix I: Search strategy

CINAHL

* "Pediatric" OR "Pediatrics" OR "Child" OR "Children" OR "Baby" OR "Babies OR "Adolescents" OR "Adolescent" OR "Teenager" OR "Young Person"

* "Post-Anesthesia Care Unit" OR "PACU"

* "Discharge criteria" OR "Discharge tools" OR "Dishcarge Instruments"

* "Outpatient surgery" OR "Outpatient procedure" OR "Same-day surgery" OR "Ambulatory surgery"

* #1 AND #2 AND #3 AND #4

PubMed

* "Pediatric" OR "Pediatrics" OR "Child" OR "Children" OR "Baby" OR "Babies OR "Adolescents" OR "Adolescent" OR "Teenager" OR "Young Person"

* "Post-Anesthesia Care Unit" OR "PACU"

* "Discharge criteria" OR "Discharge tools" OR "Dishcarge Instruments"

* "Outpatient surgery" OR "Outpatient procedure" OR "Same-day surgery" OR "Ambulatory surgery"

* #1 AND #2 AND #3 AND #4

SCOPUS

* "Pediatric" OR "Pediatrics" OR "Children" OR "Child" OR "Baby" OR "Babies" OR "Adolescent" OR "Adolescents"

* "Post-Anesthesia Care Unit" OR "PACU"

* "Discharge" OR "Discharge Criteria" OR Discharge Tools"

* "Outpatient Surgery" OR "Same-day surgery" OR "same day surgery" OR "ambulatory surgery" OR "Outpatient Procedure"

* #1 AND #2 AND #3 AND #4

Cochrane Central Register of Controlled Trials

* "Pediatric" OR "Pediatrics" OR "Children" OR "Child" OR "Baby" OR "Babies" OR "Adolescents" OR "Adolescent" OR "Teenager" OR "Young person"

* "Post-Anesthesia Care Unit" OR "PACU"

* "Discharge criteria" OR "Discharge tools" OR "Dishcarge Instruments"

* "Outpatient surgery" OR "Same-day surgery" OR "Ambulatory surgery"

* #1 AND #2 AND #3 AND #4

JBI Database of Systematic Reviews and Implementation Reports

* "Scoping Review"

* "Pediatrics" OR "Pediatric"

* "Post-Anesthesia Care Unit" OR "PACU"

* "Discharge" OR "Discharge Tool" OR "Discharge Instrument" OR "Discharge Criteria"

* "Outpatient surgery" OR "Same-day surgery" OR "same day surgery" OR "ambulatory surgery"

* #1 AND #2 AND #3 AND #4 AND #5

MedNar

* "Pediatrics"

* "Pediatric"

* "Children"

* "Child"

* "Baby"

* "Adolescent"

* "Post-anesthesia care unit"

* "PACU"

* "Discharge Criteria"

* "Discharge Tools"

* "Discharge Instruments"

* "Outpatient Surgery"

* "Outpatient Procedure"

* "Same day surgery"

* "Ambulatory Surgery"

ProQuest

* "Pediatric" OR "Pediatrics" OR "Children" OR "Child" OR "Baby" OR "Babies" OR "Adolescents" OR "Adolescent" OR "Teenager" OR "Young person"

* "Post-Anesthesia Care Unit" OR "PACU"

* "Discharge criteria" OR "Discharge tools" OR "Dishcarge Instruments"

* "Outpatient surgery" OR "Same-day surgery" OR "Ambulatory surgery"

* #1 AND #2 AND #3 AND #4

Appendix II: Data extraction tool

References