A prospective observational study comparing the pediatric post anesthesia discharge scoring system with clinical discharge criteria in pediatric day surgical patients in Western China

doi:10.21203/rs.3.rs-1636379/v1

Objective: To evaluate the safety and efficacy of the pediatric post-anesthesia discharge scoring system (Ped-PADSS), and compared with the existing clinical discharge criteria (CDC) in the day surgery ward of our hospital.

Methods: After the patient completed the operation and returned to the day surgery ward, the initial assessment was conducted by an independent observer using the Ped-PADSS and CDC. This process was repeated at 1 hour intervals until the patient achieved a Ped-PADSS score of 9 and met the CDC.

Results: From July to December 2021, 721 pediatric patients. One hour after returning from PACU to the day surgery ward, 92.65% of pediatric patients were dischargeable based on the Ped-PADSS scores. Two hour after returning from PACU to the day surgery ward, 100.00% of pediatric patients were dischargeable. The median length of stay in the day surgery ward (n=720) was reduced by 1 hour after surgery compared with the median length of stay in the day surgery ward before the use of the output score (P<0.05); and there were 9 (1.25%) adverse events occurred in the interval between Ped-PADSS and CDC time.

Conclusion: This prospective study reveals that the Ped-PADSS-based discharge decision greatly speeds the transit of pediatric patients through the day surgery ward, thus improving day surgery ward efficiency and medical resource utilization.

Day surgery

Pediatric

Patient discharge

Postoperative complications

The concept of day surgery was first proposed by Dr. James Nicoll in England. It is defined by the International Association for Ambulatory Surgery (IAAS) as an operation completed within one working day of a patient’s admission, operation and discharge, excluding ambulatory surgery [1]. Day surgery is safer than outpatient surgery [2, 3]. Several studies have reported that the day surgery has the advantages of reducing the length of hospital stay, reducing nosocomial infection rate and hospitalization costs, accelerating bed turnover rate and optimizing the allocation of health-care resources[4–6]. This procedure has been rapidly promoted at home and abroad in recent years. In China, day surgery has been proposed for indirect inguinal hernia in children since 1960^[7]. With the technological advancements in anesthesia technology, the annual number of day surgeries performed for pediatric patients have increased dramatically [8]. Day surgery has been conducted at the Children’s Hospital of Chongqing Medical University, China since 2014.

Day surgery is expanding in China. The pediatric population is well suited for day surgery because most children have a good health status and no medical history. Therefore, pediatric day surgery will become more popular in the near future. As the popularity of day surgery expands, appropriate discharge criteria should be provided to facilitate patient-centered care. The length of hospitalization after day surgery is critical to ensure the safety of hospital discharge and promote future development in patient care.

Since 1995, the postanesthetic discharge scoring system (PADSS) is considered the gold standard for assessing home readiness after day surgery in adults [9, 10]. In 2014, Biederman and co-workers developed a pediatric adaptation of the PADSS called Ped-PADSS ^[11]. The items are adapted to pediatrics, and it consists of 5 main criteria: level of consciousness, hemodynamic status, nausea and vomiting, pain, and surgical site bleeding. Each of the main criteria is graded from 0 to 2, and a total score of 9–10 indicates that patient is fit for discharge. The home discharge requirements include a post-operative discharge score of at least 9 and the presence of a responsible adult to accompany the patient at home. Studies have suggested that Ped-PADSS can promote a fast-tracking recovery process after day surgery ^[11,12]. Whilst, a number of pediatric institutions have adopted Pre-PADSS as the day surgery unit discharge criteria. However, in China, some medical institutions still employ self-made clinical discharge criteria (CDC) as the discharge criteria for day surgery. Moreover, there is lack of reports about the application of Ped-PADSS in children undergoing day surgery in China.

This prospective observational study aimed to assess the safety and efficacy of Ped-PADSS, and compared with CDC in pediatric day surgical patients. Moreover, descriptive statistics were used to evaluate the criteria for day surgery ward discharge in this patient population.

The research project was approved by the Ethics Committee of Children’s Hospital Affiliated to Chongqing Medical University (ethical approval number: 293). An observational, prospective, monocentric study was performed. American Society of Anesthesiologists (ASA) physical status I-III patients aged 1–18 years who were admitted to the day surgery ward after undergoing day surgery were recruited at a tertiary hospital in Western China from July to December 2021. The management of patients was in accordance with the current guidelines in China, including a preanesthetic assessment conducted prior to the procedure, and fasting 2 h for clear liquids, 4 h for breast milk and 6–8 h for solid food. At our hospital, Phase I recovery was initiated in the postanesthesia care unit (PACU). After the completion of Phase I recovery, the patient was returned from the PACU to the day surgery ward. To evaluate the patient’s transition from Phase II to Phase III recovery, the CDC was employed. Phase II recovery was considered complete when the patient was ready for discharge. Phase III recovery was performed at home under the supervision of an adult and continued until the patient returned to preoperative physical and psychological functions.

The study included 721 patients who had received general anesthesia for various surgical procedures. After the surgery, they were transferred to the PACU firstly, the data were obtained at 1 hour intervals after returning from the PACU to the day surgery ward. The Ped-PADSS (Table 1) and CDC (Table 2) assessments were conducted by an independent investigator who not directly involved in the patient care one hour after the operation. This process was repeated at 1 hour intervals until the patient achieved the Ped-PADSS of 9 and met the CDC. The CDC had been used in our institution on the basis of clinical experiences spanning several decades (Table 2). The decision to discharge the patients was made independently by a hospital personnel who directly involved in the patient care but unaware of the scores obtained according to the Ped-PADSS. Time zero was the time of admission to the day surgery ward. Adverse events that required medical or nursing intervention in the time interval between the two hospital discharges were recorded. All children’s parents were followed-up with phone calls the day after the operation to inquire about their health status.

Table 1

Ped-PADSS scores.
Hemodynamics
< 20% of preoperative values	2
20–40% of preoperative values	1
> 40% of preoperative values	0
State of awakening
Consistent with the preoperative state	2
Decreased compared to the preoperative state	1
Unconscious state	0
Nausea/vomiting
Minimal	2
Moderate, might require treatment	1
Severe, required treatment	0
Pain
Minimal	2
Moderate, might require treatment	1
Severe, required treatment	0
Bleeding
Minor	2
Moderate	1
Excessive	0
Note: Total pad score is 10, score ≥ 9 is deemed fit for discharge.

Table 2

CDC statement.
1	The child is fully awake, and protective reflexes such as swallowing and coughing have recovered.
2	In the case of no oxygen inhalation, the blood oxygen saturation is 98% and above.
3	The vital signs are stable.
4	No nausea and vomiting after eating.
5	Self-resolve urination.
6	There is no obvious bleeding or exudate in the wound dressing.
Note: The pediatric patients met all of the above criteria and obtained consent from the doctor and nurse before leaving the hospital.

Statistical Analysis

Statistical tests were conducted with SPSS v25.0. Measurement data that conformed to normal distribution were presented as mean ± standard deviation, and independent samples t-test was used to compare the differences between groups. Meanwhile, those that did not conform to the normal distribution were presented as median and interquartile range, and the rank sum test was employed to compare the differences between groups. The enumeration data were presented as rate and percentage, and the chi-square test or Fisher’s exact test was applied to compare the differences between groups. P < 0.05 indicates that the differences are statistically significant.

A total of 721 day surgery patients admitted to the day surgery ward who met the inclusion criteria were consecutively observed from July to December 2021. The clinical and demographic characteristics of the patients are presented in Table 3.

Table 3

Demographic data.
Total number of patients, n	721
Sex (n, %)
Male	546 (75.73)
Female	175 (24.27)
Age (years)	4.00 (2.00, 6.00)
Weight (kg)	16.00 (13.00, 21.00)
ASA physical status (n, %)
I	171 (23.72)
II	528 (73.23)
III	22 (3.05)
Diagnosis (n, %)
Indirect inguinal hernia	329 (45.63)
Hydrocele	189 (26.21)
Trigger thumb	118 (16.37)
Superficial skin mass	53 (7.35)
Cryptorchidism	12 (1.66)
Preauricular fistula	10 (1.39)
Hypospadias	10 (1.39)
Type of anesthesia (n, %)
General anesthesia	550 (76.28)
General anesthesia combined with locoregional anesthesia	171 (23.72)
Length of operation (h)	0.17 (0.17, 0.025)
Length of PACU (h)	0.83 (0.58, 1.08)

After the children returned from PACU to the day surgery ward, 668 (92.65%) and 721 (100%) of these children achieved Ped-PADSS ≥ 9 after the first and second assessments, respectively; while only 231 (32.04%) and 571 (79.20%) met the CDC. After the third evaluation, 716 children (99.31%) met the CDC. After the fourth evaluation, there was still 1 patient who failed to meet the CDC. No children were readmitted within 2 days after discharge, and all parents were successfully contacted the day after the surgery.

Among the 721 children underwent day surgery, 720 children met both discharge criteria, but 1 patient failed to meet the CDC. The child underwent hypospadias surgery, but did not urinate after surgery and was finally discharged with the consent of the urologist. Therefore, we excluded this patient. If the Ped-PADSS scoring system was used for the 720 patients, the patients could be discharged within an average of 1.00 (1.00, 1.00) hour after returning to the day surgery ward, but based on the CDC, the patients could be discharged within an average of 2.00 (1.00, 2.00) hours after returning to the day surgery ward. Notably, the difference between the two time intervals was statistically significant (P < 0.05).

In the interval between Ped-PADSS and CDC time, adverse events occurred in 9 (1.25%) children, including 4 with vomiting, 3 with pain and 2 with fever.

This prospective observational study compared the Ped-PADSS with a traditional CDC-based day surgery ward discharge system in children who underwent day surgery. The CDC-based protocol was employed at our institution since day surgery was performed (Table 2). With the development of the enhanced recovery after surgery (ERAS) in China and new approaches for the treatment and prevention of postoperative complications, it is obvious that the CDC-based discharge criteria should be revised. This study indicated that Ped-PADSS-based discharge criteria could speed the transit of pediatric patients through the day surgery ward without compromising patient safety. These results are consistent with those from previously reported studies [11, 12].

Using the Ped-PADSS scoring system, 92.65% of children who underwent day surgery could be discharged within 1 hour after returning to the day surgery ward, and 100% of patients who underwent day surgery could be discharged from the hospital within 2 hours. However, using the CDC, only 32.04% of the children could reach the discharge standard within 1 hour, and only 79.20% of the children could reach the discharge standard within 2 hours. At 4 hours after returning to the day surgery ward, 1 of the 721 children still failed to meet the CDC. The child underwent hypospadias surgery, but did not urinate after the operation, and was finally discharged with the consent of the urologist. After excluding the patient who did not meet CDC, 720 patients in this study experienced a delay in discharge time for CDC assessment compared with Ped-PADSS assessment. The average time to discharge based on the Ped-PADSS was 1 hour, while the average time to discharge based on the CDC was 2 hours (P < 0.05). These results demonstrate that the Ped-PADSS has potential to reduce time spent in the day surgery ward and improve utilization of day surgery services.

In this study, adverse events occurred in 9 (1.25%) children in the interval between Ped-PADSS and CDC time, including 4 with vomiting, 3 with pain and 2 with fever. After performing laparoscopic surgery, 4 cases of vomiting occurred after drinking. However, the children were not treated with drugs, and the symptoms of vomiting were relieved spontaneously after the feeding was suspended. Numerous studies have pointed out that drinking clear liquids should not be part of a discharge protocol, but may only be needed for some patients (e.g., diabetes), and these studies have confirmed that encouraging patients to drink before discharge may increase the risk of nausea and vomiting, thereby delaying discharge [13–15]. In this study, 3 children had mild pain without drug treatment, and after diverting attention from children, the pain was relieved. Vomiting, nausea and pain have been identified as the main sources of morbidity after day surgery, which account for a high rate of unplanned admission [16, 17]. Therefore, medical staff should correctly identify high-risk patients during the perioperative period, and take preventive and therapeutic measures in a timely manner. In the other 2 children with fever, the highest temperature in one case rose to 37.8°C, and the body temperature returned to normal after physical cooling, and the highest temperature in the other case reached 38.7°C, and the body temperature returned to normal after physical cooling and drug treatment. Through medical history, it was found that the two febrile children had been hospitalized for upper respiratory tract infection 1 week before surgery. Therefore, we speculate that the postoperative fever may be related to the preoperative upper respiratory tract infection. However, whether the body temperature is one of the discharge criteria has not been mentioned in previous literature. This study highlights that, as a day surgery, the child is discharged home after a short period of observation after surgery. It is necessary for medical staff to strictly grasp the admission guidelines for children who underwent day surgery, and it is of great importance to identify and effectively prevent children at high risk of fever before surgery. In this study, no children required readmission after surgery. If the Ped-PADSS discharge system was in place, these nine adverse events could occur after discharge, leading to hospital readmission. This rate is in line with the range reported in the literature for unplanned readmission (0.15–1.5%) [16, 18, 19], which is considered to be acceptable.

There is controversy about whether to urinate before discharge. In this study, 1 patient was delayed discharge from the hospital because he did not urinate, and was finally discharged with the consent of the urologist. The child was followed up by telephone on the next day after the operation. The parents complained that the child had urinated spontaneously after returning home, but no other complications occurred. Postoperative dysuria is one of the most common symptoms after hypospadias surgery [20]. In this study, we speculate that that lack of urination in this child may be due to a change in the urination environment (the child had a urinary catheter and the child was in an unfamiliar environment such as a hospital). After all, the child can urinate on his own after returning home. Therefore, we recommend that urination before discharge may not be one of the discharge criteria, but it is necessary to consider the type of operation and route of anesthesia before day surgery.

This study has several limitations. First, Ped-PADSS is a subjective scoring system, which may lead to a potential bias. Second, 1-hour testing intervals was employed for patient assessment. Differences in recovery parameters between Ped-PADSS and CDC may be neglected due to the length of the study intervals. More frequent testing intervals can lead to earlier and shorter discharge times. Nonetheless, our study confirms that Ped-PADSS can enhance the transit of pediatric patients through the day surgery ward. Third, the sample size of this single-center observational study is relatively small. Hence, the efficacy and safety of Ped-PADSS in children undergoing day surgery in China need to be verified with a larger sample-size study.

In conclusion, the introduction of Ped-PADSS markedly reduces the time spent in the day surgery ward, thus improving day surgery ward efficiency and medical resource utilization.

Funding

This work was supported by the Chongqing Science and Technology Bureau and Chongqing Municipal Health Commission (2021MSXM230).

Conflict of interest

The authors have no conflict of interest to declare.

Acknowledgment

We thank the nurses of the pediatric day surgery ward for their valuable work.

Jarrett PEM. The International Association for Ambulatory Surgery (IAAS) [J]. Ambul Surg, 2003, 10: 113.
Castoro C. Ambulatory surgery: current status and future trends. East Centr Afric J Surg. (2006) 11:67–8.
Marij Z, Aurangzeb Q, Rizwan HR, Haroon R, Pervaiz MH. Outpatient percutaneous release of trigger finger: a cost effective and safe procedure. Malays Orthop J. (2017) 11:52–6. doi: 10.5704/MOJ.1703.021
Hoggett L, Anderton MJ, Khatri M. 30-day complication rates and patient-reported outcomes following day case primary lumbar microdiscectomy in a regional NHS spinal centre [J]. Ann R Coll Surg Engl, 2018, 101: 50-54.
Solodkyy A, Feretis M, Fedotovs A, et al. Elective “ True Day Case” Laparoscopic Inguinal Hernia Repair in a District General Hospital: Lessons Learned from 1000 Consecutive Cases [J]. Minim Invasive Surg, 2018, 2018: 7123754.
Wang L, Baser O, Wells P, et al. Benefit of early discharge among patients with low-risk pulmonary embolism [J]. PLoS One, 2017, 12: e0185022.
Endoscopic Surgery Group, Chinese Society of Pediatric Surgery, Chinses Medical Association. Expert consensus on pediatric ambulatory surgery. Chin J Pediatric Surg. (2020). 41:676–82. doi: 10.3760/cma.j.cn421158-20200221-00106
Ma J, Bian H, Duan X, Wang J, Liu X. Safety analysis of pediatric day surgery. Chin J Pediatr Surg. (2020) 41:704–9.doi: 10.3760/cma.j.cn421158-20200330-00222
Chung F. Are discharge criteria changing? J Clin Anesth 1993; 5(6 Suppl 1): 64S-68S.
Chung F. Discharge criteria - a new trend. Can J Anaesth 1995; 42: 1056-1058.
Biedermann S, Wodey E, De La Briere F et al. Paediatric discharge score in ambulatory surgery. Ann Fr Anesth Reanim 2014;33: 330-334.
Moncel JB, Nardi N, Wodey E, Pouvreau A, Ecoffey C. Evaluation of the pediatric post anesthesia discharge scoring system in an ambulatory surgery unit. Paediatr Anaesth. 2015;25(6):636-641. doi:10.1111/pan.12612
Kamming D, Chung F. What criteria should be used for discharge after outpatient surgery? In Fleisher L, ed. Evidence-Based Practice of Anesthesiology. Philadelphia: Saunders; 2004:247-252.
Korhonen A, Valanne J, Jokela R, et al. Intrathecal hyperbaric Bupivacaine 3 mg + Fentanyl 10ug, for outpatient knee arthroscopy with tourniquet. Acta Anaesthesiol Scand. 2003;47:342-346.
Mulroy M, Salinas F, Larkin K, et al. Ambulatory surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia. Anesthesiology. 2002;97:315-319.
Coley KC, Williams BA, DaPos SV, Chen C, Smith RB. Retrospective evaluation of unanticipated admissions and readmissions after same day surgery and associated costs. J Clin Anesth 2002; 14: 349-53.
Awad IT, Moore M, Rushe C, Elburki A, O’Brien K, Warde D. Unplanned hospital admission in children undergoing day-case surgery. Eur J Anaesthesiol 2004; 21: 379-83.
Mezei G, Chung F. Return hospital visits and hospital readmissions after ambulatory surgery. Ann Surg 1999; 230:721-7.
Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg 1997; 84: 319-24.
Springer A. Assessment of outcome in hypospadias surgery-areview. Front Pediatr 2014; 2: 2

No competing interests reported.

A prospective observational study comparing the pediatric post anesthesia discharge scoring system with clinical discharge criteria in pediatric day surgical patients in Western China

Status:

Version 1

Abstract

Introduction

Materials And Methods

Statistical Analysis

Results

Discussion

Declarations

References

Additional Declarations

Status:

Version 1