Aldrete Scoring System

Issues of Concern

The Aldrete scoring system is valuable for measuring physiological recovery from anesthesia. However, the emphasis on physiological factors may not be enough to address certain postoperative complications that do not cause significant deviations in the scoring system but still require extended PACU care or additional medical attention, such as arrhythmias not yet resulting in hemodynamic compromises, hypothermia or hyperthermia, uncontrolled pain, or severe nausea and vomiting.[8] Therefore, consideration of the overall clinical picture and factors beyond the Aldrete scoring system is necessary to ensure proper patient care. Additionally, concerns have been raised regarding the applicability and efficacy of the Aldrete scoring system as a clinical assessment tool in ambulatory surgical settings.

Advancements in surgical and anesthetic techniques and the rise in healthcare expenses have led to more diagnostic and therapeutic procedures being performed in the outpatient setting. Recent studies indicate that increasingly diverse and complex procedures are being performed on less healthy patients discharged home on the day of the procedure.[10][11][12][13][14] Physiologic recovery from anesthesia is a complex process that extends over several days; ambulatory surgical patients' discharge criteria should assess readiness for PACU discharge and ensure safe discharge home.[12][15][8]

Although the original Aldrete scoring system has proven valuable in determining suitability for discharge from the PACU, the scoring system does not address common postprocedural issues such as pain, nausea and vomiting, and surgical site bleeding. Assessing and managing these issues before patients are discharged home is imperative to ensure their safety, reduce unexpected hospital readmissions, and promote patient satisfaction.[16][17][18] The Aldrete scoring system was expanded in 1995 to include 5 additional criteria specific to the outpatient surgical setting; this expansion is the Modified Aldrete Score for ambulatory surgeries. These criteria, which include dressing appearance, severity of pain, ability to walk, ability to tolerate oral fluids, and ability to urinate, are each assigned a score between 0 and 2 (Table 2. The Modified Aldrete Scoring System for Ambulatory Surgeries). A cumulative score of 18 or more indicates that the patient is fit for discharge and can safely return home.[9]

Another major discharge scoring tool for ambulatory surgery patients was developed during this period. The initial Post Anesthetic Discharge Scoring System (PADSS) included five criteria: vital signs; activity and mental status; pain, nausea, or vomiting; surgical bleeding; and intake and output.[15] However, subsequent revisions of PADSS removed the oral fluid intake and voiding before discharge criteria; there was a lack of clinical evidence supporting their impact on reducing adverse outcomes.[16][18] PADSS has proven effective and reliable in facilitating the early discharge of average-risk surgical outpatients from the PACU without compromising their safety (Table 3. The Postanesthetic Discharge Scoring System). High-risk patients still require individualized assessment.[19][20][21]

Table 2. The Modified Aldrete Scoring System for Ambulatory Surgeries

Table 3. The Postanesthetic Discharge Scoring System (PADSS)

Abbreviations: VAS, visual analog scale

The modified Aldrete scoring system and the PADSS are frequently used in the PACU to assist decision-making for Phase I discharge and discharge from Phase II to home, respectively. However, the use of modern anesthetic techniques and agents with short-lasting effects coupled with further cost-saving incentives have promoted the emergence and acceptance of fast-track recovery for clinically suitable patients undergoing select types of surgeries such as ophthalmology or orthopedic procedures.[22] In this fast-track recovery pathway, a postsurgical outpatient is evaluated by an anesthesia provider against a set of well-defined criteria before leaving the operating room. If deemed eligible, the patient will bypass the traditional Phase I care and move directly to Phase II recovery.

Given its niche in early postoperative recovery assessment, the Aldrete scoring system was examined for its potential use in the fast-track pathways; concerns remained due to its primary focus on vital signs and wakefulness. Therefore, the Aldrete scoring system was expanded to include factors commonly delaying ambulatory discharge, such as pain and emetic symptoms, creating the Ambulatory Surgery Fast Track Discharge Criteria (Table 4 - The Ambulatory Surgery Fast-Track Discharge Criteria).[14][22] A score of 12 or higher, with each category scoring a minimum of 1 point, indicates eligibility for the fast-track program to bypass Phase I recovery.[22]Further studies suggest that when applied to carefully selected patients having undergone a particular type of surgery, the fast-track criteria can safely triage patients directly to Phase II recovery with a reduced hospital stay.[23][24]

Table 4. The Ambulatory Surgery Fast-Track Discharge Criteria

Abbreviations: MAP, mean arterial pressure

Clinical Significance

The Aldrete scoring system has significantly contributed to the safety and quality of care for postoperative patients over the past 40 years by revolutionizing the approach to gauging postoperative recovery in a simple, reliable, and reproducible way based on common physiological parameters. Together with its numerically scaled evaluation mechanism, the Aldrete scoring system employs a uniform quantitative assessment of the recovery process and discharge readiness regardless of anesthetic and surgical types, which has been shown to improve patient outcomes.[25]

Before the origination of the Aldrete scoring system, there were many inconsistencies and practice variations in the process of deciding when to transfer a patient through different phases of postoperative care and eventually to discharge to home or a step-down unit. The Aldrete scoring system facilitated decision-making on appropriate levels of postoperative care and resources available while ensuring patient safety.

Despite its limitations in the ambulatory surgery setting and the fast-track recovery pathway, the Aldrete scoring system undoubtedly played an essential role in promoting the establishment of a standard of care to ensure safe patient discharge or transfer of care after surgery while balancing the need for efficient utilization of healthcare resources. Currently, the Aldrete scoring system often serves as the core basis for developing institution-specific discharge guidelines or protocols to assist decision-making and improve patient outcomes in the PACU in many hospitals worldwide.

Although an effective discharge tool such as the Aldrete scoring system or PADSS provides consistent quality care and more efficient use of resources, the discharge criteria are integral but insufficient for a complete final evaluation; the criteria should not substitute for common sense and the clinical judgment of a healthcare professional. Careful consideration must still be given in unique circumstances, such as those characterized by postoperative complications, neurological injuries, temperature disturbances, and neuraxial anesthesia complications.[21] Additionally, safe, high-quality postanesthetic care must be individualized, accounting for the medical history and comorbidities, surgical- and anesthesia-related factors, and socioeconomic circumstances that directly or indirectly impact postoperative recovery.

Nursing, Allied Health, and Interprofessional Team Interventions

The PACU plays a crucial role in providing monitoring, support, and interventions to minimize complications for postoperative patients. The postoperative period is characterized by rapid changes in patient status, making it essential to adopt a multidisciplinary approach that leverages the unique skills and perspectives of each healthcare professional involved in postanesthetic care.

For instance, PACU nurses are responsible for monitoring patient recovery, assessing readiness for discharge using criteria like the Aldrete score, collaborating with physicians for diagnosis and treatment, coordinating care with respiratory therapists and pharmacists, and providing aftercare instructions and education to patients and their families.

PACU anesthesiologists oversee medical practice, diagnose and manage postoperative complications, administer cardiopulmonary resuscitation, collaborate with other medical specialties as needed, and ensure safe patient discharge to home or an appropriate level of care.

Respiratory therapists closely collaborate with PACU nurses and anesthesiologists to manage respiratory treatment and airway-related issues, including the use of respiratory devices, nebulization treatments, and mechanical ventilation for patients with preexisting respiratory conditions or acute postoperative respiratory insufficiencies.

Pharmacy personnel prepare and deliver discharge medications and instruct patients on proper medication use.

Additionally, the PACU may involve other medical specialists as required, such as surgeons addressing chest tubes, drains, or surgical site bleeding, or ophthalmologists evaluating corneal abrasions.

Effective interprofessional collaboration and communication are vital to facilitate early and safe discharge or transition of care from the PACU. This ensures minimal complications, shorter hospital stays, and improved patient outcomes and satisfaction. [Level 5] All healthcare team members contribute their valuable expertise toward delivering high-quality, patient-centered care.

In summary, by optimizing the use of discharge criteria like the Aldrete score and fostering collaborative teamwork, the PACU can achieve early and safe patient discharge or transition of care, leading to improved outcomes and patient satisfaction.