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201611313

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Policies,Clinical,UWHC Clinical,Department Specific,Surgical Services,Clinical

Use of PACU Discharge Scoring Criteria – Pediatric (2.36P)

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

2.36P

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 2016
 ORIGINAL
REVISION

MAY 2016
PAGE 1
OF 3
POLICY #

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



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 EMR. 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 EMR.

II. PROCEDURE

A. Assessment of Respiration
1. Score 2 if breathes deeply and freely, coughs freely, or crying or on home Bipap or Cpap settings.
2. Score 1 if dyspneic, no voluntary cough, oral or nasal airway present or on Bipap/Cpap set up by
RT.
3. Score 0 if airway open only with artificial airway, chin lift, oral and nasal airway.
B. Assessment of Circulation
1. Score 2 if BP within 10% - 15% of baseline BP;

TABLE 10-1. Heart Rate
According to Age
Age Heart Rate
(Beats/Min)
Preterm 150 ± 20
Term 133 ± 18
6 Months 120 ± 20
12 Months 120 ± 20
2 Years 105 ± 25
5 Years 90 ± 10
12 Years 70 ± 17
23 Years 77 ± 5

2. Score 1 if BP within 20% of baseline BP.
3. Score 0 if BP not within 20% of baseline or MAP <45.


UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 2016
 ORIGINAL
REVISION

MAY 2016
PAGE 2
OF 3
POLICY #

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



C. Assessment of Consciousness
1. Score 2 if awake or awakes to verbal stimuli, alert, and oriented or oriented to pre-sedation level.
2. Score 1 if awakes to verbal/tactile stimuli and not oriented to pre-sedation level of orientation.
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 or only moves extremities to painful stimuli.
E. Assessment of Oxygen Saturation
1. Score 2 if O2 saturation 93-100% on oxygen 4 L or less, or equal to pre-operative saturation, or
following standardized orders per service or PACU orders.
2. Score 1 if supplemental oxygen greater than 4L needed to maintain saturation above 92%
3. Score 0 if oxygen saturation under 88 % or intubated.
F. Add together scores of airway, circulation, consciousness, activity, and oxygen saturation.
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
B. Pediatric Surgical Services Bladder Scan Guidelines








UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 2016
 ORIGINAL
REVISION

MAY 2016
PAGE 3
OF 3
POLICY #

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




REVIEWED BY

Sandy Schoenmann, Interim Director Surgical Services, 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 4/2016
Bethany Steindl, Surgical Services Supervisor, AFCH 4/2016

SIGNED BY

Cathy Madsen, MSN, RN
Director, Surgical Services Department – AFCH