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Ambulatory Discharge Criteria
TEXTIntraop II · 8 min read
Stable, oriented, ambulating, controlled pain, responsible escort, understanding of instructions. Six items, done.
After this lesson you can
3 min read9 sections- Apply Aldrete and PADSS for PACU discharge.
- Recognize ambulatory discharge requirements.
- Identify reasons to admit a planned-outpatient.
- Document the discharge decision.
PADSS — the scoring framework
Five categories, each scored 0-2 for a max of 10: vital signs, ambulation, nausea/vomiting, pain, surgical bleeding.
Score ≥9 = ready for discharge home.
Modified PADSS removes mandatory voiding from the original — most ambulatory patients can discharge without PO trial or voiding (case-specific exceptions below).
PADSS is the durable scoring standard; Aldrete is the equivalent for PACU discharge to floor, not for going home.
Vital signs stable + trending appropriately
Trending appropriately — not just isolated normal values.
No persistent tachycardia from pain or undisclosed anxiety.
No hypoxia on room air, or stable on home O₂ if applicable.
Temperature ≥36°C with active warming discontinued and no rebound hypothermia.
Patients who required vasopressor or significant fluid resuscitation in PACU need extended observation before vital-sign criteria are met.
Oriented + ambulating to baseline
Following commands consistently — not just rousable.
Ambulating safely at the patient's pre-op level (with their usual assist device or walker if applicable).
Steady gait, no syncope on standing (orthostatic vitals if any concern).
After regional, document return of sensation in the blocked dermatomes before discharge.
PONV controlled
Mild nausea acceptable if patient is tolerating PO or chewing ice.
Multimodal prophylaxis is the prevention — ondansetron, dexamethasone, sometimes haloperidol or aprepitant in high-Apfel patients.
Rescue with a DIFFERENT class than what was given prophylactically (5HT3 used? give droperidol or promethazine).
High-Apfel patient with active nausea + risk of admission: discuss with surgical team — consider 23-hr observation rather than discharging into a vomiting cascade.
PO tolerance + voiding (case-specific)
- GI surgery
- prolonged ileus risk
- severe PONV history
Voiding: NOT routinely required (modified PADSS allows).
- spinal/epidural anesthesia (risk of urinary retention from sacral block)
- urologic procedures
- prostate surgery
- anorectal surgery
Bladder ultrasound for retention concerns — if >500-600 mL retained, straight cath, then discharge with instructions.
Patients sent home without voiding should be told: 'if you cannot urinate in 4-6 hours, call us / return to ED.'
Pain controlled on PO regimen
Pain controlled to ≤4/10 or patient's stated acceptable level.
- scheduled acetaminophen
- NSAID if no contraindication (renal, GI bleed, asthma in some)
- low-dose short-acting opioid (oxycodone 5 mg q4-6h prn) for breakthrough only
Patient understands medication schedule, dosing limits, drug interactions, side effects.
Sufficient supply for 24-72 hours.
Avoid sending patient home on long-acting opioids after ambulatory surgery — respiratory depression risk + diversion potential.
Discuss safe opioid disposal.
Responsible adult escort + supervision plan
Escort understands and acknowledges: patient cannot drive, sign legal documents, operate machinery, or make important decisions for 24 hours after general anesthesia.
Plan for an adult to stay with patient at minimum 4-6 hours, ideally overnight.
If no escort: surgery is cancelled or admission required.
Document escort's name + relationship + acknowledgement.
Uber/Lyft alone is NOT acceptable — patient must have responsible adult, not just transportation.
Written + verbal discharge instructions — teach-back
- 24-hour restrictions (no driving, alcohol, important decisions, signing documents)
- wound/surgical-site care
- expected symptoms vs concerning symptoms
- when to call vs when to return to ED
- 24-hr anesthesia line if available
- surgical office
- after-hours triage
Follow-up appointment scheduled + confirmed before discharge (not 'we'll call you').
Teach-back: 'Can you tell me in your own words what to do tonight?' Patient + escort both acknowledge understanding by signature.
Common reasons for unanticipated admission
- refractory PONV
- uncontrolled pain
- urinary retention (regional anesthesia)
- surgical bleeding
- oversedation from opioids or sedatives
- prolonged regional block
- social factors (no escort)
- unanticipated diagnosis intraop
- everything above — aggressive PONV prophylaxis
- multimodal analgesia
- neuraxial with short-acting agents for ambulatory
- careful patient + procedure selection
Track institutional admission rate as a QI metric and learn from each case.
⚠ Common pitfalls
- Discharging without verifying a responsible adult escort.
- PACU discharge before pain control achieved — bounce-back risk.
- Discharging the OSA patient too early — observe extended period post-anesthesia.
- Forgetting to verify voiding for spinal anesthesia patients before discharge.
💎 Clinical pearls
- Aldrete ≥9/10 for PACU discharge; PADSS ≥9/10 for ambulatory discharge home.
- Modified Aldrete includes O₂ saturation; original used color.
- Ambulatory discharge requirements: stable vitals, controlled pain, no PONV, ambulation, void (if spinal/regional in pelvic), escort.
- Fast-tracking: skipping PACU phase 1 → direct phase 2 for low-risk patients post-MAC.
Recap
- Aldrete ≥9/10 for PACU discharge; PADSS ≥9/10 for ambulatory discharge home.
- Modified Aldrete includes O₂ saturation; original used color.
- Ambulatory discharge requirements: stable vitals, controlled pain, no PONV, ambulation, void (if spinal/regional in pelvic), escort.
- Fast-tracking: skipping PACU phase 1 → direct phase 2 for low-risk patients post-MAC.
Mark each section done to complete the module.