Policies & Procedures

Title: DAY SURGERY PATIENTS ON INPATIENT

NURSING UNITS

I.D. Number: 1008

Authorization: Source: Nursing

Reaffirmed: April. 2018. ( Pre-tests now 90 days)
[X] Nursing Practice Committee Date Revised: November 2017
Date Effective: March 2007
Scope: SHR Urban Acute Care and HDH

Any PRINTED version of this document is only accurate up to the date of printing 18-Apr-18. Saskatoon Health Region (SHR)
cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedure site for the
most current versions of documents in effect. SHR accepts no responsibility for use of this material by any person or
organization not associated with SHR. No part of this document may be reproduced in any form for publication without
permission of SHR.

1. PURPOSE

1.1 To ensure consistent and safe patient care for Day Surgery patients throughout their stay.

2. POLICY

2.1 When patients have procedures that qualify as “Day Surgery” performed when the Day
Surgery Unit is closed or over capacity, they shall be cared for on an inpatient unit.

2.2 Pre-operative criteria shall be met for each patient before undergoing a surgical
procedure.

2.3 Post-op/discharge criteria shall be met for each patient prior to discharge.

3. PROCEDURE

3.1 The nurse ensures that all pre-operative criteria are met for each patient before
undergoing a surgical procedure.

3.1.1 A completed History and Physical sheet is signed and dated within 90 days
prior to current admission.

NOTE: Contact surgeon if not completed.

3.1.2 Tests completed, within 90 days prior to current admission, as ordered with
results available or directed to the Operating Room (OR).

NOTE: If any changes to the patient’s medical condition, repeat tests as

appropriate.

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3.1.3 Consent for Surgery (form #100362) signed and dated. (See SHR policy 7311-
50-002).

NOTE: The surgeon and/or OR staff may be notified if consent incomplete.

3.1.4 A completed Day Surgery Record (form #101724).

NOTE: A Nursing Admission Data Base and Careplan do not need to be

completed if patient’s stay is less than 24 hours. The patient signs the Day
Surgery Record preoperatively, once pre and postoperative routines have
been reviewed with the patient and questions answered, as applicable.
Patients receive discharge instructions, as available (see Tri Site Day
Surgery List of Discharge Instruction” Appendix (A)

3.1.5 A completed Pre-operative Checklist (form #101284).

3.1.6 A completed and signed Preadmission Medication List/Physician Order Form (form
#102728) with the best possible medication history. This includes reviewing with the
patient all his/her prescriptions, over-the-counter, herbal medicine use and any
prescriptions that will not show up on this list i.e. Cancer Clinic or TB medications.
The date and time of his/her last dose will be noted for each medication and
signed as a DSU review if the patient had a previous Pre Assessment Clinic (PAC)
visit.

3.1.7 A completed Allergy/Intolerance Record (form #103420 (NCR) / #103420-1(Non

NCR)) or Allergy/Intolerance Record Addendum if needed (form#103617
(NCR)/#103617-1 (Non NCR)).

3.1.8 The Release and Indemnification form (#102532 Appendix D) is explained and
completed to ensure patient is informed of precautions to be taken following
anesthesia/sedation.

3.1.9 All pre-operative physician orders are implemented including those on the
Operating Room (OR) Booking Slip and Practitioners’ Orders. Medications given
pre-operatively in hospital are documented on the Day Surgery Record.

3.1.10 Abnormal test results and concerns regarding the patient’s medical condition and
medication history, or untoward changes, which may have an impact upon the
surgical procedure or recovery, shall be reported to the surgeon/anesthetist.

3.1.11 Medical Directives, as appropriate, are completed and documented.

3.1.12 On admission all patients are given a discharge instruction sheet pertaining to
his/her surgery, if applicable. This sheet is reviewed with the patient and questions
answered. (See Tri Site Day Surgery List of Discharge Instructions – Appendix A).

3.1.13 Discharge teaching is documented on the Day Surgery Record. The patient must
sign pre-operatively (prior to anesthetic/sedation) on the Day Surgery Record that
he/she has received the Discharge Instructions.

3.1.14 The entire chart may remain on a clipboard.

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3.1.15 The adult accompanying a child (up to 18 years of age) or mentally challenged
adult is aware that he/she must remain with the patient during the patient’s stay,
as per unit policy.

3.1.16 The nurse documents patient’s compliance with the SHR Fasting Guidelines, as
below:

3.1.16.1 Children: Nothing other than the following after midnight.

• Breast Milk: up to 4 hours prior to surgery time
• Infant formula: up to 6 hours prior to surgery time
• Non-human milk: up to 6 hours prior to surgery time
• Clear fluids: up to 2 hours prior to surgery time

3.1.16.2 Adults: Nothing other than clear fluids after midnight.

• Clear fluids: up to 2 hours prior to surgery time
NOTE: Clear fluids include water, apple juice, non-alcoholic and carbonated
beverages, clear tea and black coffee. Sugar may be added to tea or
coffee.

NOTE: The surgeon/anesthetist is notified of any non-compliance with these

fasting guidelines.

3.2 The nurse ensures safety and comfort of the patient pre and post-operatively.
3.2.1 Patients have been oriented to the nursing units. This will include patient
telephone, bathroom and bedside unit.

3.2.2 Each patient has a call bell within reach.

3.2.3 A bedside report has been received from the PACU nurse on the patient’s return.

3.2.4 Side rails are up on stretchers/beds/cribs post-operatively on return from PACU and
following the administration of sedation, narcotic or anesthetic.

3.2.5 Patients are allowed to rest as necessary prior to eating and ambulation.

3.2.6 Patients are assisted with the first ambulation after surgery.

NOTE: Assist with 2 nurses if patient has had a spinal anesthetic or lower limb
peripheral block.

3.2.7 The patient has the opportunity to express concerns and questions regarding their
entire pre/post-operative experience and staff will provide answers /reassurance
as appropriate.

3.3 The nurse ensures that all post-op/discharge criteria are met for each patient prior to
discharge:

3.3.1 An assessment of the patient is done on arrival from PACU and repeated at least
once prior to discharge and documented.

3.3.2 A Post Anesthetic Discharge Scoring System based on five main criteria (vital signs,
activity, nausea and vomiting, pain, surgical bleeding) is used to guide the

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postoperative assessment and aid in assessing patient’s readiness for discharge.

(See Post Anesthetic Discharge Scoring – Appendix B)

3.3.3 To qualify for discharge the patient must score > 9 or as directed by the surgeon.
Discharge scoring is documented on the Day Surgery Record. (See Day Surgery
Record Pre-Op Data – Appendix C)

3.3.4 The patient must have a score of 2 in the vital sign category to be eligible for
discharge.

3.3.5 The patient, who has had anesthetic and/or sedation, must be accompanied
home by a responsible adult in a car, taxi or ambulance (not public transit). It is
recommended a responsible adult stay overnight with the patient. (See Release
and Indemnification form #102532).

3.3.6 If the patient does not meet the discharge criteria, the surgeon will be notified.

3.3.7 Written discharge orders will be transferred to the appropriate Discharge

Instruction (Appendix A) form and reviewed with the patient and/or family and
sent home. A copy will be kept on the chart.

3.3.8 Patients will not be sent home after midnight unless the patient, family or physician
specifically request and all other discharge criteria are met.

3.3.9 The patient will be required to void spontaneously prior to discharge in the
following instances:
• If ordered
• Following the removal of an indwelling catheter
• If the patient has a previous history of voiding difficulties

NOTE: Consider use of a bladder scanner on spinal anesthetic patients on

admission from the Post Anesthetic Care Unit (PACU) to assess post-
operative urinary retention. For surgical procedures where voiding is not a
criteria for discharge, the patient should be advised to contact the
responsible physician if unable to void within 6-8 hours after discharge.

3.3.10 The patient will be monitored after narcotic administration to ensure an

appropriate outcome and peak effect has been achieved without adverse
effects.
• The patient will be monitored for a minimum of 30 minutes post IV injection,
maintaining IV access.
• The patient will be monitored for a minimum of 45 minutes post IM injection.
• The patient will be monitored for a minimum of 60 minutes with respiratory rate,
sedation & pain scale at baseline and 45 - 60 minutes after every oral dose of
Dilaudid or Morphine, and documented.

3.3.11 Drinking is not a criteria for discharge unless specifically indicated. The patient
should be able to swallow oral fluids.

3.3.12 If the patient has received Epidural/Intrathecal Epimorph, the physician will need
to arrange for patient’s overnight admission for observation.

3.3.13 If the patient has been ordered analgesic to be sent home on discharge from DSU,
12 hours of doses of either Dilaudid or Tylenol #3s can be sent home with the

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patient( See SHR Policy 7311-60-004). An information sheet on the side effects of
the narcotic and proper labelling will be done as per the “Tabs to Go” Project (SHR
Infonet, Pharmacy, Resources/Apps
http://infonet.sktnhr.ca/pharmaceuticalservices/Pages/MedicationstogoProject.as
px

3.3.14 In addition to the appropriate discharge instructions/criteria, Tonsillectomy/

Adenoidectomy patients are required to stay a minimum of 3 hours post surgery,
must remain within 60 minutes of a hospital with 24 hour emergency care until the
following morning and must go to the Emergency Room (ER) at the first sign of
bleeding. These patients are required to have their pharynx checked by the
surgeon or nurse prior to discharge. If the child does not allow this, the child can
still go home if there are no external signs of bleeding.

3.3.14.1 Adenoidectomy patients must stay a minimum of 2 hours post surgery.

3.3.15 In addition to appropriate discharge instructions/criteria, Total Laparoscopic

Hysterectomy/Laparoscopic Assisted Vaginal Hysterectomy (TLH/LAVH) patients
must stay 6 hours post surgery in the DSU as per TLH/LAVH protocol.

4. REFERENCES

Are You Watching the Clock? Let Criteria Define Discharge Readiness. Barnes, S. Journal of
Perianesthesia Nursing 2000. June: 15 (3): 174-6.

Discharge Criteria – a new trend. Frances Chung, MD, FRCP. Dept. of Anesthesia, University of
Toronto, Toronto Hospital. Canadian Journal of Anesthesia, 1995, pp 1056-1058.

Discharge Criteria and Complications After Ambulatory Surgery. Scott Marshall, FRCA, and
Frances Chang, FRCPC. International Anesthesia Research Society, Volume 80 (3), March 1999,
pp 508-517.

Discharge Criteria and Post-Discharge Complication. Frances Chung. Depatment of

Anesthesia, Ambulatory Medical/Surgical Unit. Toronto Western Hospital, University of Toronto,
Toronto, Canada. Course Outline April 7, 2001. European Society of Anesthesiologists Refresher
Course. Website: www.euroanesthesia.org/education/rc_gothenburg/2rcl.html

Discharge Criteria: are they keeping up with practices? OR Manager. 15 (9):1,17, 19 passion,
1999 Sept. Patterson, P.

Evaluation of the Pediatric Post anesthesia Discharge Scoring system in an ambulatory Surgery
Unit. Pediatric Anesthesia. Vol 25 (2015) pp 636-641. Moncel, Jean Benoit et al.

Factors Affecting Recovery and Discharge Following Ambulatory Surgery. Canadian Journal of
Anesthesia, Vol 53, No. 9 2006, pp858-872. Awad, Imad and Chung, Frances.

Integrative Literature review: Ascertaining Discharge Readiness for Pediatrics After Anesthesia.
Journal of Perianesthesia Nursing. Vol 31, No. 1 (February) 2016. pp 23-35. Whitley, Deborah.

Modifications to the Postanesthesia Score for Use in Ambulatory Surgery. J. Antonio Albrite, MD,
MS. Journal of Perianesthesia Nursing, Vol. 13, No. 3 (June) 1998, pp 148-155.

Modified PADSS (Post Anaesthetic Discharge Scoring System) for Monitoring Outpatients
Discharge. Ann. Ital. Chir. Vol 84, No. 6, 2013. pp 661-665. Palumbo, Piergaspare et al.

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Postoperative Issues Discharge Criteria. Anesthesiology Clin. Vol 32, 2014. pp 487-493. Abdullah,
Hairil Rizal and Chung, Francis. www.anesthesiology.theclinics.com.

Postoperative Voiding Criteria for Ambulatory Surgery Patients. AORN Journal, Vol 89, No.5
(May) 2009, pp871-874. Ruhl, M.

Region wide Guidelines for: Discharge Following Day Surgery, Exclusion/Inclusin Criteria, Adult
Day Surgery Post-Operative Vital Signs. Capital Health, Edmonton, Alberta. Royal Alexandra
Hospital. March 1997.

Surgical Executive Committee, former Saskatoon Health Region, Saskatchewan Health

Authority. Increasing the accepted pre- operative test times from 30 days to 90 days .

University Health Network. Toronto General Hospital, Toronto Wester Hospital, Princess Margaret
Hospital. Day Surgery Unit Record. February 1998.

Use of a Modified Postanesthesia Recovery Score in Phase II Perianesthesia Period of

Ambulatory Surgery Patients. Perianesthesia Nurse, 2001. April; 16(2): 82-9. Saar, L.M.

Vancouver Hospital and Health Science Center. Discharge of Ambulatory Surgical Patients –
Patient Care Guidelines. July 2003.

Potter, P., Perry, A., & Ostendorf, W. (2014). Clinical Nursing Skills and Techniques, (8th Edition).
Elsevier.

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APPENDIX A

DAY SURGERY
SASKATOON HEALTH REGION

TRI SITE DAY SURGERY LIST OF DISCHARGE INSTRUCTIONS

NAME OF DISCHARGE INSTRUCTION FORM

NUMBER

ANESTHESIA
Adult Discharge Pain Medication Chart 103753
PEDIATRIC Discharge Pain Medication Chart 103797
Paravertebral Nerve Block 103877
Femoral Nerve Block 103729
Infraclavicular Nerve Block 103730
Interscalene or Supraclavicular Nerve Block 103731
Popliteal Nerve Block 103732
Spinal Anesthesia 103879

CARDIOVASCULAR
Coronary Angiogram/Percutaneous Coronary Intervention 102551
Pacemaker Insertion 102518
PEDIATRIC Cardiac Catheter Copy for now
Power Pack Replacement Instructions 103725

DENTAL
Dental Extractions 102546
Minor Dental Surgery 102547
Rapid Palate Expansions 104135

DIAGNOSTIC IMAGING
Angiogram/Angioplasty 103995
Cerebral Angiogram 102556
Kidney Biopsy 102553
Liver Biopsy 102555
Lung Biopsy 102554
Outpatient Biopsy 103885
Outpatient Central Venous Port (Arm) 103986
Outpatient PICC 103987
Paracentesis 103988
Pleurx Catheter 103812

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Radiofrequency Ablation (RFA)/Microwave Ablation 104204

Thoracentesis 103989
Thyroid Biopsy 102552

ENDOSCOPY
Bronchoscopy 101415
EBUS –Endobronchial Ultrasound Coming
ERCP -Endoscopic Retrograde Cholangiopancreatography 101416
Esophageal Dilation 102188
Gastroscopy / Upper Endoscopic Ultrasound 102189
Hemorrhoid Banding 101420
Sigmoidoscopy/Colonoscopy/ Lower Endoscopic Ultrasound 101417

ENT
Adenoidectomy 103049
Auditory Brainstem Response (ABR) 103990
Cochlear Implant 103993
Direct Laryngoscopy or Microlaryngoscopy 103050
Myringotomies ( Ear Tubes ) 102436
Nasal Surgery 102435
Stapedectomy 103991
Tonsillectomy and Adenoidectomy - Adult 101762
Tonsillectomy and Adenoidectomy - Pediatric 101753
Tympanomastoidectomy 103992
Tympanoplasty 102437

GENERAL SURGERY
Breast Biopsy or Lumpectomy 101738
Hemorrhoidectomy 101646
Hernia Repair 101661
Laparoscopic Cholecystectomy 101739
Pilonidal Abscess, Perianal Fistula/Abscess, Seton Suture 101658
Varicose Vein Stripping/Ligations 101752

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GYNECOLOGY
Bartholin’s Cyst Drainage 102461
Carbon Dioxide Treatment of External Genital Lesions (Vulva) 102466
Carbon Dioxide Treatment of Lesion of the Cervix 102464
Cone Biopsy 102467
Endometrial Ablation/Novasure 102470
Essure Tubal Sterilization 103387
Hysteroscopy/D&C 102468
Labial Reduction 103811
Laparoscopic Conservative Surgery for Endometriosis 102471
Laparoscopic Tubal Sterilization 100427
Laparoscopy 100423
Laser Ablation of Warts 102473
LEEP (Loop Electrocautery Excision Procedure) 102474
Myomectomy 104120
Myosure 104121
Pudendal Blocks/Trigger Point Injections 104103
Shirodkar Suture Procedure 102478
Tension-Free Vaginal Tape (TVT) 102545
Therapeutic D&C 102479
Total Laparoscopic Hysterectomy/ Lap Assisted Vaginal Hysterectomy Coming
DC Instructions Following Vaginal or Vulvar Procedures 103386

NEUROSURGERY
Glycerol Injection for Trigeminal Neuralgia 102482
Lumbar Discectomy 102475

OPHTHALMOLOGY
Cataracts 103627
Corneal Transplant(Partial Thickness) 103629
Dacryocystorhinostomy (DCR) 103625
Descemet Stripping and Automatic Endothelial Keratoplasty (DSAEK) 103624
Enucleation 103623
Pterygium Surgery Coming
Scleral Buckle 103630
Strabismus 100419
Tear Duct Probing Coming
Trabeculectomy 103631
Vitrectomy 103632
General Ophthalmology Procedure 103626

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ORTHOPEDICS
Acromioplasty 103882
Bankart Repair and/or Capsular Shift Repair 103883
Bunionectomy 104049
Cast Care 101715
Hand or Arm Surgery 104048
Knee Arthroscopy 103880
Leg and Ankle Surgery 104045
Orthopedic Hardware Removal 104046
Physio Anterior Cruciate Ligament Reconstruction Manual 101912
Physio Rotator Cuff Manual 102179
Rotator Cuff Repair 102544
Shoulder Arthroscopy 103881
Ulnar Nerve Transposition 104047
Using Crutches 103426

PLASTICS
Abdominoplasty new 104104
Axillary Sweat Glands Excision 104106
Blepharoplasty 102462
Breast Reconstruction with Expanders and Implants 103726
Breast Reduction 102463
Carpal Tunnel Release/Endoscopic Carpal Tunnel Release (ECTR) 102465
Dupuytren’s Contracture 102469
Excisions-Ambulatory Care new 104111
Fat Grafting 103727
Gynecomastia 102472
Hand or Arm Surgery (Plastics) 104105
Jaw Fracture Repair new 104107
**Blended Diet – Dieticians 101463
Otoplasty 102476
Rhinoplasty (Plastics) 102477
Skin Grafts new 104109
Toenail Removal – Ambulatory Care 104110

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UROLOGY
Botox Injections for the Bladder 104134
Bulkamid (replaces Contingen) 103898
Circumcision 102417
Cystoscopy 104006
Green Light Laser 103087
How to Care for Your Catheter 102095
Hydrocelectomy/Spermatocelectomy 103895
Lithotripsy 104004
Mitomycin 103073
Nesbit 103897
Prostate Biopsy 104005
Scrotal Orchidectomy/Orchidopexy 102418
TURBT 104044
Ureteral Stent 103896
Ureteroscopy/with Laser +/- Stent Insertion 104001
Ureteroscopy with Stone Extraction 104002
Urethrotomy 104000
Varicocelectomy 104003
Vasectomy 101533
Vasectomy Reversal /Vasovasotomy 103999

MISCELLANEOUS
Electroconvulsive Therapy 102636
Discharge Instructions (No Incision) 103747
Discharge Instructions (With Incision) 103746
Going Home with a JP Drain 104124
Renal – Patient Instructions for new AV Graft or AV Fistula From RU
Renal – Patient Instructions for New CAPD-RU staff will give to Pt.
VAC / Negative Pressure Wound Therapy 104108

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APPENDIX B

Post Anesthetic Discharge Scoring:

The following are the areas that require scoring and/or consideration when determining the
patient’s readiness for discharge.

The Discharge Scoring system does not replace critical thinking and individual patient assessment.

VITAL SIGNS:
Vital signs must be stable and consistent with age and preoperative baseline. The patient must
score a 2 to be eligible for discharge
2 BP and HR +/- 20% of pre-op and O 2 sat greater than92% on room air
1 BP and HR +/- greater than 20% and less than 40% of pre-op and/or O 2 sat greater than 90%
on oxygen
0 BP and HR +/- greater than 40% of pre-op and/or O 2 sat greater than90% on oxygen

ACTIVITY:
The patient must be able to ambulate at preop level.
2 steady gait, no dizziness, able to ambulate consistent with surgical procedure or equivalent
to pre-op status
1 requires assistance not consistent with procedure or pre-op status
0 unable to ambulate, i.e. due to dizziness

NAUSEA AND VOMITING:

The patient should have minimal nausea and vomiting prior to discharge.
2 no nausea or mild nausea with no active vomiting or controlled with medications
1 transient vomiting or retching
0 persistent moderate-severe nausea and vomiting

PAIN:
The patient should have minimal or no pain prior to discharge. Pain should be controlled by oral
analgesics. The location, type and intensity of pain should be consistent with anticipated post-
operative or procedural discomfort.
2 no pain or mild pain controlled with oral analgesics
1 moderate to severe pain controlled with IV analgesics
0 persistent severe pain

SURGICAL BLEEDING:
Postop bleeding should be consistent with expected blood loss for surgical procedure.
2 dressing/operative site dry and clean without evidence of active or unexpected bleeding
and circulation, sensation, and movement adequate
1 dressing/operative site wet, but marked and not increasing and circulation, sensation, and
movement adequate, if applicable
0 growing area of bleeding or circulation, sensation, and movement not adequate, if
applicable

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APPENDIX C

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APPENDIX D

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