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Nurses at a day treatment centre in London have challenged the standard four-hour wait after surgery
When designing the day surgery unit in our new children’s day treatment centre at Evelina London Children’s Hospital, families wanted to know why – regardless of the type of procedure – their children had to wait four hours after general anaesthetic before discharge.
Nursing Management. 31, 1, 9-10. doi: 10.7748/nm.31.1.9.s3
Published: 01 February 2024
Some children undergo short or simple procedures or scans, and keeping them in hospital for four hours post-operation may not be beneficial or necessary.
I am passionate about improving the experience for children in hospital, in particular for those having day surgery. As a clinical nurse manager, I tried to establish why we had a four-hour wait.
Rather than there being any clinical guidance or evidence to say that something happens at four hours post-anaesthesia meaning a child can be discharged, the reason appeared to be more ‘because this is what we’ve always done’.
Due to the somewhat arbitrary nature of our existing discharge process we decided to develop instead a ‘criteria-led’ discharge process by consulting post-general anaesthesia guidelines. This process would allow children to return home sooner, when appropriate, without additional time spent waiting on the ward.
It is important for children to return to a familiar and comfortable setting, in a less busy and more private environment where they can recover. Hospital environments are generally loud and busy, especially on a short-stay postoperative ward.
Essentially, criteria-led discharge means there is a set of pre-defined criteria that each child must reach before they can be discharged.
These criteria include: observations being consistent with pre-operative baseline observations, the child being alert and having returned to their usual behaviour, pain is controlled, no nausea or vomiting, tolerating fluids, wound site clean and dry (if applicable), cannula removed and postoperative advice given and understood.
In addition there are three supplementary criteria, which are applied on a case-by-case basis by the surgical/medical team:
1. Passing urine (mainly for urology patients or those who have had caudal anaesthesia).
2. A minimum of three hours wait for some (mainly children who have had a tonsillectomy).
3. The child must be reviewed by the medical/surgical team before discharge.
Once the child has reached the generic criteria and any of the three other additional criteria, they can be discharged. Feedback after implementing the pathway has shown it benefits the family and the hospital. The amount of time children waited on the ward after their operation, particularly for plastic surgery and gastroenterology procedures, has been significantly reduced.
Criteria-led discharge also means that one bed space has the potential to be used multiple times in a day. Therefore, more children can receive the elective surgery or procedure that they have been waiting for. For example, in our new unit we have 13 bed spaces and we now have the capacity to treat up to 16 children a day.
Bringing in a new way of working was not without its challenges. Changing the mindset of the clinical team, who have always kept children for four hours and to make sure they pass urine after general anaesthetic, was the biggest.
‘It is nurses who are responsible for signing the child off as fit for discharge, so they needed to feel confident in their decisions and assessments’
I was involved in the planning for the new children’s day surgery unit ahead of its opening and the team decided that all children and young people should follow the criteria-led discharge pathway. A team made up of the clinical leads for the unit, a service improvement manager, a practice development nurse and the clinical nurse manager set about developing a criteria-led discharge process.
First, we conducted audits on different services and how long children were staying on the ward after their operation before being discharged. I created a teaching session for the ward nurses as well as a competency document to ensure that nurses had the appropriate training to be able to follow the new pathway. I added it to our handover sheet so that people were reminded about it every day.
Designing a survey
The other members of the pilot team presented criteria-led discharge to their own teams and encouraged them to fill out the forms. During the pilot period, we audited the timings again to establish what difference, if any, criteria-led discharge was making to the patient flow and discharge timings.
We designed a survey with the service improvement team to be given to staff and families to gain feedback about the process. This was positive, with all patients who responded to the survey telling us they felt they were sent home at the right time.
Ensuring that nursing staff felt confident enough to discharge patients sooner was crucial. It is nurses who sign the criteria-led discharge document meaning that they are responsible for signing the child off as fit for discharge, so they needed to feel confident in their decisions and assessments.
The change was implemented successfully because the project was collaborative, involving the contribution of nurses, anaesthetists and surgeons. This gave everyone a feeling of ownership, which was important when implementing the changes and making them successful.
Since introducing criteria-led discharge and presenting at various teaching sessions, other wards at Evelina London have been in touch to start adopting it. It has also been presented at a national forum and other wider teaching sessions, and I have been contacted by colleagues in other hospitals who are interested in introducing it to their practice.