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 . 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.