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Use of PACU Discharge Scoring Criteria – Adult (2.36A)

Use of PACU Discharge Scoring Criteria – Adult (2.36A) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Clinical

2.36A

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 1999
ORIGINAL
 REVISION

MAY 2016
PAGE 1
OF 3
POLICY #

2.36A
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
USE OF PACU DISCHARGE SCORING CRITERIA - ADULT


I. PURPOSE

To develop guidelines/criteria for the discharge of patients from the Post Anesthesia Care Unit. The patient’s
post-procedure status is assessed on admission, at regular intervals, and before discharge from the Post
Anesthesia Care Unit. If the patient has met discharge criteria and in need of being "held" due to inpatient
bed unavailability or staffing issues, vital signs/other assessments will be done according to post-op orders
which are written for inpatient use. The hold start and stop times along with the reason for the hold will be
reflected in the PACU flow sheet in the patient care record. Discharge criteria will be repeated before
discharge. This criteria indicates the patient’s condition at regular intervals in the acute recovery process.
Documentation is done in the PACU charting navigator within the patient care record.

II. PROCEDURE

A. Assessment of Respiration
1. Score 2 if breathes deeply and freely, coughs freely, or crying.
2. Score 1 if dyspneic, no voluntary cough, artificial airway may be present.
3. Score 0 if airway open only with support, or artificial airway.
B. Assessment of Circulation
1. Score 2 if BP within 10% of baseline ; BP within 10-15% of baseline, peripheral pulse strength
normal, skin pink, warm and dry.
2. Score 1 if BP within 20% of baseline.
3. Score 0 if BP not within 20% of baseline or MAP <55
C. Assessment of Consciousness
1. Score 2 if awake or awakes to verbal stimuli, alert, and oriented, or at pre-sedation level of
consciousness.
2. Score 1 if awakes to verbal/tactile stimuli.
3. Score 0 if no response to verbal/tactile stimuli.
D. Assessment of Activity
1. Score 2 if moves all extremities voluntarily, or on command, or consistent with pre-op status, age,
and procedure.
2. Score 1 if non-purposeful extremity movement.
3. Score 0 if non-spontaneous movement.
E. Assessment of Oxygen Saturation
1. Score 2 if O2 saturation 93-100% on room air, or equal to pre-operative saturation, or following
standardized orders per service, or PACU orders.
2. Score 1 if supplemental O2 required to maintain saturation between 86-93%.
3. Score 0 if O2 saturation under 85%.
F. Add together scores of airway, circulation, consciousness, activity, and oxygen saturation.

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 1999
ORIGINAL
 REVISION

MAY 2016
PAGE 2
OF 3
POLICY #

2.36A
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
USE OF PACU DISCHARGE SCORING CRITERIA - ADULT


1. A score of 9 or greater indicates patient may be discharged from the PACU. Patients who score
less than 9 will need the order of an MD, preferably the attending, for discharge.
ADDITIONAL DISCHARGE CRITERIA:
a. No unusual bleeding and/or discharge.
b. Patient receiving spinal or epidural anesthesia will have discharge parameters communicated
by the attending anesthesiologist.
c. If pain is still present at time of discharge from PACU, document in the EMR and report to
transferring unit.
d. If urinary catheter is present, urine output is 1/2 mL/kg/per hour.
e. If urinary catheter is not present, scan per Adult and Pediatric Bladder Scan Guidelines to
ensure bladder not distended.

III. REFERENCE

A. Adult Surgical Services Bladder Scan Guidelines







REVIEWED BY

Lisa Koeppel, Surgical Services Supervisor, IP PACU 4/2016
Dr. Kenneth Van Dyke, Medical Director, Inpatient PACU 4/2016
Dr. Jeffrey Lee, Medical Director, Outpatient Surgical Services 4/2016
Dr. Deborah Rusy, Director of Perioperative Services - AFCH-OR 4/2016

SIGNED BY

Sandy Schoenmann, Interim Director, BSN, RN
Director, Surgical Services Department