Adherence to Aldrete Discharge Criteria in Post- Anesthesia Care Unit: A Cross-Sectional Study in Iran: Clinical Determinants of PACU Discharge Readiness: A Descriptive Analysis

The duration of a patient’s stay in the Post-Anesthesia Care Unit (PACU) is crucial for effective operating room management, impacting operational efficiency, hospital costs and staff workload. The timing of patient transitions from the PACU to their post-operative care settings is essential [1]. Extended stays in the PACU can lead to patient dissatisfaction and increased institutional expenses [2]. On the other hand, discharging patients too early can result in complications from anesthesia and surgery, raising mortality and morbidity rates [3]. In Ethiopia, only 73.3% of patients are discharged from the PACU based on established criteria [4], while in the United States, 1.5% of patients leave without proper discharge indications [5]. A study in Iran’s Gilan province found that 17.1% of the American Society of Anesthesiologists’ standards for PACU care are not met [6]. To ensure proper discharge, various checklists are utilized, with the Aldert checklist being the most common [7]. Developed by Dr. Aldert in 1970, this checklist is a modified version of the Apgar scale, assessing five criteria: breathing, blood circulation, consciousness, oxygen saturation, and activity level. Patients scoring 9 or above are considered safe for discharge (Table 1) [8]. Factors such as high patient flow in the PACU, 12-hour shifts, and limited staffing can lead to inadequate calculation of discharge scores, resulting in patients being discharged prematurely. This can lead to issues like altered consciousness, pain and hemodynamic changes, which in turn prolong hospital stays and increase medication needs [9]. Consequently, these issues raise treatment costs for healthcare systems and families [10]. Therefore, the current study aims to investigate adherence to discharge protocols in the PACU to identify related challenges.

Table 1:Modified aldert checklist.

This descriptive cross-sectional was conducted in Firouzgar Medical Education and Research Center between December 2023 and April 2024 with the ethical code IR.IUMS.REC.1402.680 from Iran University of Medical Sciences included a comprehensive examination of 830 patients selected by census method. Informed written consent was obtained from the patients and the objectives of the study were explained to them. The study’s objectives were also communicated to the staff and informed consent was obtained from them as well. any patient who was unwilling to share their demographic and medical information was excluded from the study. Patients were assured that participation in this research would incur no costs for them and that there would be no negative consequences if they chose not to participate in the study. The data analysis was performed anonymously and none of the authors could identify the patients based on their data. Furthermore, this study was conducted following the Helsinki Declaration regarding human subjects. Eligibility criteria for inclusion of participants were defined as individuals between 18 and 60 years of age requiring general anesthesia. Exclusion criteria included any need for intensive care unit admission after surgery. The Aldert checklist was used to assess patients, which was completed by recovery personnel responsible for monitoring the patient’s condition after anesthesia. In addition, the arrival and discharge times of the patients were carefully recorded based on the evaluations made by the recovery staff. The team consisted of four females aged 27, 34, 38 and 40, all with bachelor’s degrees in anesthesiology. They were fully briefed on the aims and methods of the study to ensure a clear understanding of their roles. During the study, the researchers strictly adhered to the ethical guidelines in the Declaration of Helsinki (2018). Furthermore, all patientsˈ information remained confidential and protected by the researchers during the study.

Out of 830 patients examined, 492 were female (59.3%) and 338 were male (40.7%). The average age of the patients was 40.29±12.66 years. 592 patients (71.3%) were ASA I. and 238 patients (28.7%) were ASA II. The underlying diseases of the studied subjects have been listed in Table 2. The findings of the study showed that a significant part of the patients were discharged from the Post-Anesthesia Care Unit (PACU) in a relatively short period. specifically: 476 patients (57.34%), the majority of whom were discharged within the first 15 minutes of admission to the PACU. 263 patients (31.68%) were discharged in the second 15-minute interval. 76 patients (9.15%) were discharged in the third 15 minutes. 14 patients (1.68%), were discharged within 15 minutes of the fourth quarter. Finally, a single patient (0.12%) was discharged at the fifth 15-minute interval. During the initial 15-minute period, 87 patients were prematurely discharged from the PACU. Of these early discharges, 72 patients were discharged with a score of 8 and 17 patients were discharged with a score of 7. Furthermore, 11.49% of patients were discharged with an SPO2 score of 1, and 88.51% of patients had a circulation and consciousness level score of 1. Figure 1 shows the breakdown of patients who were discharged prematurely in the first 15 minutes with a score below 9 according to surgical specialty.

Table 2:PACU: Post Anesthesia Care Unit, ENT: Ear, Neck and Throat, OSA: Obstructive Sleep Apnea, ASA: American Society of Anesthesiologistsˈ Classification.

Figure 1:The breakdown of patients who were discharged prematurely in the first 15 minutes based on surgical specialty.

In the second 15-minute interval, 47 patients were discharged early from the Post Anesthesia Care Unit (PACU). Among these early discharges, 40 patients had a score of 8, 6 patients had a score of 7 and 1 patient was discharged with a score of 6. Additionally, 42.55% of the patients were discharged with an SPO2 score of 1, while 59.57% and 87.23% had circulation and consciousness level scores of 1, respectively. Figure 2 illustrates the distribution of patients who were prematurely discharged in the second 15 minutes with scores below 9, categorized by surgical specialty. During the third 15-minute period, a total of 5 patients were discharged prematurely from the Post Anesthesia Care Unit (PACU). Of these early discharges, 3 patients were assigned a score of 8, while the remaining 2 received a score of 7. Furthermore, 60% of the discharged patients exhibited an SPO2 score of 1, while 100% and 80% were assigned circulation and consciousness level scores of 1, respectively. Figure 3 provides a visual representation of the breakdown of patients discharged early in the third 15 minutes, with scores below 9, categorized according to their respective surgical specialties (Figure 3).

Figure 2:The breakdown of patients who were discharged prematurely in the second 15 minutes based on surgical specialty.

Figure 3:The breakdown of patients who were discharged prematurely in the third 15 minutes based on surgical specialty.

During the fourth 15-minute period and thereafter, a total of 4 patients were discharged early from the Post Anesthesia Care Unit (PACU). Among these early discharges, 3 patients received a score of 8, while 1 patient was assigned a score of 7. Additionally, 20% of the discharged patients had an SPO2 score of 1, with 60% and 80% receiving circulation and consciousness level scores of 1, respectively. Figure 4 illustrates the distribution of patients who were discharged prematurely during the fourth 15-minute interval and beyond, with scores below 9, categorized by their respective surgical specialties.

Figure 4:The breakdown of patients who were discharged prematurely in the fourth 15 minutes and after that based on surgical specialty.

In our study, 17.22% of patients were discharged prematurely from recovery. Among these cases, 33.49% exhibited oxygen saturation levels below the acceptable threshold outlined in the checklist, 77.02% had systolic blood pressure readings higher than preoperative levels and 83.93% of these patients demonstrated lower levels of consciousness than desired. Additionally, all the discharged patients received a score of 2 for the respiration subscale. In a study conducted in 2018 by Bizuneh et al. [4] in Ethiopia found that 73.3% of patients were discharged from recovery according to the Aldrete checklist. In contrast, our study reported a discharge rate of 82.75%, indicating a higher adherence to the Aldrete checklist by recovery staff in our setting. Furthermore, adherence to the systolic blood pressure and respiration criteria was recorded at 73.3% and 75.6%, respectively. The parameters for oxygen saturation and consciousness were adhered to in 84.4% and 91.1% of cases, significantly exceeding our study’s compliance rates. This discrepancy may be attributed to the inclusion of patients undergoing regional and spinal blocks in Bizunehˈs study, while our research exclusively examined patients under general anesthesia. Additionally, in our study, the criterion for limb movement was fully adhered to in all patients, a rate that was lower in Bizunehˈs study, which evaluated a smaller cohort of 45 patients compared to our larger sample size [4].

Additionally, in a study conducted by Waddle et al. [5] involving 340 patients in the United States, it was reported that 1.5% of patients were discharged from recovery without a medical indication. Among these patients, two exhibited decreased levels of consciousness, two experienced pains and one presented with both pain and reduced consciousness. The oxygen saturation levels for all patients in this study were maintained above 92% without the need for supplemental oxygen and blood pressure was preserved within 20% of preoperative values. These findings indicate a superior discharge process in Waddle et al.’s [5] study compared to our own. Although our study included a larger patient population, it exclusively focused on patients undergoing surgeries requiring general anesthesia, excluding those who were candidates for spinal anesthesia and regional blocks. Additionally, in the Waddles study, data were recorded at 30-minute intervals, whereas measurements were done every 15 minutes in our study. This monitoring frequency may have contributed to a more significant reduction in early discharges in their research. In another study conducted by Safavi et al. [11] in Iran, which aimed to assess the level of adherence to anesthesia guidelines among anesthesia residents, it was found that in 35% of discharged cases, the patient’s ability to cough and take deep breaths was not achieved, and in 65% of cases, the patients did not exhibit full consciousness. Similarly, in our study, 83.93% of patients did not have an adequate level of consciousness for safe discharge [11]. However, in the Safavi et al. [11] study, other parameters such as blood pressure were not evaluated.

The discrepancy in the reported rates of inadequate consciousness for discharge between the two studies may be attributed to differences in the study populations, anesthesia techniques, and the specific criteria used to assess consciousness. While both studies highlight the importance of ensuring patients meet all discharge criteria, including adequate consciousness, the Safavi et al. [11] study provides a more limited assessment by focusing solely on the ability to cough and take deep breaths, while our study utilized a more comprehensive evaluation of consciousness. The lack of blood pressure assessment in the Safavi et al. [11] study is a notable limitation, as blood pressure is a crucial vital sign that should be within acceptable ranges before discharging patients from the recovery room. Our study, in contrast, included blood pressure as one of the parameters evaluated, providing a more comprehensive assessment of patient readiness for discharge. Furthermore, in the study conducted by Safavi et al. [11] the patient’s ability to lift their heads was evaluated as a criterion for discharge readiness, which was not specifically assessed in our study due to the use of a structured checklist. The inclusion of head lift as a parameter in the Safavi et al. [11] study provides additional insight into the level of consciousness and neuromuscular function of the patients at the time of discharge from the recovery room.

The discrepancy in the assessment of head lifts between the two studies highlights the importance of considering both standardized tools and individualized criteria when making discharge decisions. While checklists provide a structured and consistent approach, they should not replace clinical judgment and the consideration of specific patient characteristics and recovery patterns.

In another study by Tageza I et al. [12] and colleagues, 24 nurses and 118 discharge processes from the recovery unit were evaluated in Ethiopia. The study revealed a 62.5% adherence rate to checklists during discharge, which was lower than that observed in our study. Furthermore, the Ethiopian study utilized an audit-re-audit methodology, demonstrating a 40% improvement in adherence following implementing strategies like role modeling and guideline presentations [12]. In contrast, our study did not include a re-audit component. Current evidence suggests that the process of patient discharge in developed countries is generally more structured and purposeful than in developing nations [4,12]. However, given the lack of comprehensive studies regarding adherence to patient discharge guidelines from recovery rooms in both developed and developing countries, definitive conclusions cannot yet be drawn but Findings from our study-as well as research conducted in Ethiopia and observations of time-based rather than criteria-based discharges in India [13], indicate that inappropriate discharges are less frequent in developed countries. These observations imply that discharge protocols are implemented more systematically in these settings. Nonetheless, additional studies are required to substantiate and clarify these findings.

In summary, although limited research restricts definitive conclusions, evidence suggests that developed countries have more systematic and effective patient discharge practices than developing nations. Our findings highlight the need for comprehensive discharge protocols, regular staff training using tools like the Aldrete checklist, policy improvements and routine audits to reduce premature discharges. Future studies should also examine how staffing and workload affect discharge decisions to further enhance patient safety and care quality.