Date of Paper/Work


Type of Paper/Work

Doctor of Nursing Practice Project

Degree Name

Doctor of Nursing Practice



First Advisor

Alice Swan


Doctor of Nursing Practice


The purpose of this systems change project was to review and analyze the literature as well as evaluate patient data related to the practice of bypassing the post anesthesia recovery room (PACU), or Phase 1 recovery, in a Critical Access Hospital. The overarching question for this project was: When is it safe for the total joint replacement patient receiving spinal anesthesia with or without sedation to bypass Phase 1 recovery in a Critical Access Hospital?

Methods: This project was grounded in Participative Action Research, Change Theory and the nursing theory of Relationship Based Care. A chart review of 168 patients who had total joint replacement surgery over a 6 month period was completed during summer 2011. Data abstracted included pre-surgical data: age, body mass index, and ASA score as well as post-surgical data: Aldrete score, patient vital signs including mean arterial pressure (MAP), type and length of surgery, estimated blood loss during surgery, need for oxygen supplementation, nausea, vomiting, itching, and pain.

Results: Of the total sample of 168 patients, 66 (39.3 %) had an Aldrete score of less than or equal to 7 in the first hour postoperatively, 32 (19%) had a MAP ≤ to 63 in the first hour and 21 (12.5%) had a MAP ≤ to 60. Age, ASA scores and BMI were not associated with decreased Aldrete scores or MAP. Patients with total hip arthroplasty and bilateral total knee arthroplasty had a higher incidence of lower Aldrete scores and lower MAP than unilateral total knee arthroplasty patients.

Conclusions: Because nearly 40% of the sample had Aldrete scores of 7 or less within the first hour postoperatively, and most PACUs have as one of the criterion for discharge as Aldrete scores of 8 or higher, it is clear that patients who receive total joint replacement arthroplasty in this setting should receive a higher level of nursing care in the immediate postoperative hour.