Speeds Criteria vs. Modified Aldrete and Fast-Track Criteria for Evaluating Recovery in Outpatients

doi:10.4236/ojanes.2013.37068

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Open Journal of Anesthesiology, 2013, 3, 309-314

http://dx.doi.org/10.4236/ojanes.2013.37068 Published Online September 2013 (http://www.scirp.org/journal/ojanes) 309

Speeds Criteria vs. Modified Aldrete and Fast-Track

Criteria for Evaluating Recovery in Outpatients

Brent Burke1, Mark Kyker2

1Indiana Surgery Center East, Indianapolis, USA; 2St. Vincent Health, Carmel, USA.

Email: [email protected]

Received April 13th, 2013; revised May 15th, 2013; accepted June 10th, 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The authors have developed criteria utilizing the mnemonic “SPEEDS” (saturation, pain, extremity

movement, emesis, dialogue, stable vitals signs) to evaluate and predict which patients would not require phase I nurs-

ing intervention and could transition to phase II recovery. Methods: Seventy-three adult surgery patients underwent a

standardized general anesthetic. Patients were evaluated with the modified Aldrete, Fast-Track and SPEEDS criteria

immediately before leaving the OR and then 5, 10, 15 and 30 minutes after arrival in the recovery area. Results: Sig-

nificantly more patients met phase I bypass criteria when evaluated with Modified Aldrete (90%) and Fast-Track (94%)

as compared to SPEEDS (77%) (p < 0.0429 modified Ald rete vs. SPEEDS, p < 0.0038 Fast-Track vs. SPEEDS). How-

ever, SPEEDS was more sensitive having a lower number of patients meeting phase II criteria yet requiring phase I in-

tervention (32%) vs. Fast-track (43%) and Modified Aldrete (44%) (p < 0.001 SPEEDS vs. modified Aldrete and

Fast-Track). SPEEDS was more accurate (74%) in predicting which patients should move directly to phase II co mpared

to modified Aldrete (42%) (p < 0.001) and Fast-track (59%) (p = 0.05). Conclusion: SPEEDS criteria are as specific

and more sensitive in determining phase I nursing interventions for ambulatory surgery patients when compared to

Fast-Track and modified Aldrete criteria.

Keywords: Phase I Bypass; Fast Track; PACU Nursing Interventions

1. Introduction

With the advent of fast-track anesthesia, the elimination

of the traditional recovery room has become possible [1].

In fact, our ambulatory surgery center has incorporated

this type of design. However, in most traditional OR

suites, a phase I recovery area and a step-down or phase

II recovery exist in separate locations. In order to bypass

phase I recovery, surgical patients must be assessed in

the operating room immediately upon awakening and

determination is made concerning the suitability of by-

pass. An efficient assessment tool is needed to allow for

a rapid decision as to whether a patient is able to progress

to phase II and not require phase I type nursing care. The

modified Aldrete criteria [2] have been the traditional

method of evaluating patients for discharge to the surgi-

cal ward or phase II recovery for outpatients. Recently,

White and Song proposed a fast-track scoring system [3]

that incorporates not only the modified Aldrete criteria

but also an assessment of pain and nausea both of which

are typically treated in phase I recovery.

We have developed new, simplified criteria for evalu-

ating surgical patients recovering from general anesthesia

that is easily applied and utilizes the mnemonic

“SPEEDS”. This stands for oxygen saturation, pain con-

trol, emesis control, extremity movement, dialogue, and

stable vital signs. Instead of using a point system, the

SPEEDS criteria require a simple “yes” or “no” re-

sponse to each parameter. A patient must have a response

of “yes” to all parameters to progress to phase II recov-

ery (Appendix 1). We compared the new SPEEDS crite-

ria to both the modified Aldrete and the Fast-Track sys-

tem in an ambulatory surgery center where fast tracking

is emphasized. We hypothesized that SPEEDS criteria

would be as good as or better than existing scoring sys-

tems at predicting which patients would require phase I

nursing interventions.

2. Methods

After obtaining institutional review board approval and

written informed consent from all patients, recovery data

Speeds Criteria vs. Modified Aldrete and Fast-Track Criteria for Evaluating Recovery in Outpatients

310

was obtained from 73 adult outpatients selected from the

general population undergoing a wide range of surgical

procedures from April 2001 to July 2001. Exclusion cri-

teria included a pre-operative visual analogue pain score

greater than 4 or oxygen saturation less than 95% on

room air.

All patients were premedicated with Rofecoxib 50 mg

and Acetomenophen 1000 mg p.o. before induction with

propofol (1.5 - 2.0 mg/kg), fentanyl (1 - 1.5 ug/kg) and

succinylcholine (1 mg/kg) to facilitate intubation if nec-

essary and then maintained with desflurane, nitrous oxide,

and oxygen titrated to a BIS of 40 - 50. Droperidol

(0.625 mg) and dexamethasone (10 mg) IV were given

for anti-emetic prophylaxis. Local anesthetic infiltration

was provided with levobupivacaine 1%. Neuromuscular

blockade was obtained with mivacurium (2 - 4 mg) IV as

needed to maintain TOF ratio less than 0.2. Morphine (up

to 0.1 mg/kg) IV was given at the discretion of the anes-

thesiologist for post-op analgesia. Also, Fentanyl 50 ug

IV (up to 250 ug) or labetolol 5mg IV (up to 20 mg) was

given to control noxious and /or hyperdynamic responses

as deemed necessary. Patients were evaluated with the

modified Aldrete, Fast-Track and SPEEDS criteria im-

mediately before leaving the OR by the anesthesiologist

and then by the PACU nurse in the post-surgical suite at

5, 10, 15 and 30 minutes post arrival. All patients were

transferred directly to the step-down suite as our facility

was designed without a phase I recovery area. Phase I

interventions (defined as intravenous administration of

analgesics, antiemetics, antihypertensives and/or the ad-

ministration of oxygen therapy) could be given if neces-

sary at that location by a recovery nurse in the pre/post-

op suite.

In evaluating the SPEEDS criteria, a visual analogue

scale (VAS) score of less than 4 was considered a “yes”

response for pain control. Systolic blood pressure in the

range of 90 - 180 mm and a heart r ate in the rang e of 50 -

110 bpm was necessary to be considered hemodynami-

cally stable and receive a “yes” response for stable vital

signs. An oxygen saturation greater than 90 on room air

was considered adequate for oxygen saturation. Patients

were considered fast-track eligible if they achieved a

modified Aldrete score of greater than or equal to 9, a

Fast-Track score of greater than or equal to 12 (with no

score less than 1 in any individual category) or an all

“yes” response to the SPEEDS criteria. Individual types

of post-op nursing interventions (e.g. IV analgesics, IV

anti-emetics) were recorded along with discharge times

and any post-op complication s .

3. Data Analysis Methods

To summarize the validity and reliability of each of the

screening tests, seven measures were used including,

sensitivity, false positive rate, specificity, false negative

rate, positive predictive value, negative predictive value

and accuracy were calculated relative to nurse interven-

tion [4]. The positive predictive value is the probability

that a patient requires phase I nursing intervention, if th at

patient tests positive (does not meet ph ase I bypass crite-

ria). Likewise, the negative predictive value is the prob-

ability that a patient does not require phase I nursing in-

tervention, given that patient tests negative (does meet

phase I bypass criteria). Accuracy is the proportion of

all correct tests.

The method used to calculate the confidence interval

for a proportion is the Wilson score method without con-

tinuity correction [5]. It is a refinement of the simple

asymptotic method, and computationally much simpler

than the method of Clopper and Pearson [6] since closed-

form solutions for lower and upper limits are available,

both without and with [7] continuity correction. It has the

theoretical advantage among asymptotic methods of be-

ing derived from the “efficient score” approach [8].

Newcombe [9] shows that Wilson score confidence in-

tervals have logit scale symmetry property with conse-

quent log scale symmetry for certain derived intervals.

To test that the effect of several time points among the

three scales logistic regression was used. In this model,

time was used as a continuous independent variable and

scale was categorical.

To examine the overall performance between two

screening tests, each patient was classified according to

the result of their post-operative screening tests. There

were two possible agreeing-classifications and two cross-

classifications. For example, to assess the performance of

SPEEDS relative to the modified Aldrete, patients were

classified as, failed-failed, passed-failed, failed-passed,

and passed-passed, respectively. The two middle groups

were identified as the cross-classifications. The odds of

requiring nurse intervention can be calculated for each of

the four classifications.

If the two screening tests were similar then the odds

for the cross-classification groups would be near one. To

evaluate performance, we can compare the odds of the

cross-classifications. We fit a generalized linear model

[10] to the data by the method of maximum likelihood

estimation, using a logit link function and binomial vari-

ance structure. The independent variable was the scoring

test classification and the dependent variable was nurse

intervention. The contrast between cross-classifications

was tested using the Wald statistic.

4. Results

The patient demographic data and distribution of case

type show a wide range of ages and procedures in a

community setting (Table 1).

Phase I bypass rates were significantly higher with

Fast-Track (95.4%) and modified Aldrete (90.4%) crite-

Speeds Criteria vs. Modified Aldrete and Fast-Track Criteria for Evaluating Recovery in Outpatients 311

Table 1. Demographics.

Demographic (N = 73)

Women (%) 53.4

Men (%) 46.6

Age (years) 47 ± 17

Weight (kilograms) 82 ± 20

ASA Physical Status (%) I 31.5% (23)

II 48.5% (35)

III 17.8% (13)

IV 2.7% (2)

Case Types # of Patients

ENT 10

General Surgery 4

GU 11

Hysteroscopy 1

Inguinal Hernia 3

Laparoscopic 13

Lumbar Disc 4

Peripheral Extremity 25

Shoulder Surgery 2

ria compared to SPEEDS (76.7%) (p < 0.0429 modified

Aldrete vs. SPEEDS and p < 0.0038 Fast-Track vs.

SPEEDS). Longitudinal analysis showed a statistically

significant difference in bypass rates between Fast-Track

and modified Aldrete criteria vs. SPEEDS criteria at 5,

10, 15 and 30 minutes post-op (Table 2). Significantly

more bypass eligible patients required phase I interven-

tions with both modified Aldrete and Fast-Track criteria

vs. SPEEDS (Figure 1).

Table 3 provides performance summaries for the three

post-operative screening tests. SPEEDS provided a sta-

tistically significantly greater sensitivity when compared

to modified Aldrete and Fast-Track. All three screening

tests were highly specific in identifying patients who

would require nurse in tervention. The positive predictiv e

value for all three screening tests was adequate; h owever

the accuracy of SPEEDS was statistically significantly

greater than that of either modified Aldrete or Fast-

Track.

The overall performance of each screening test as

measured by the difference in the odds for correctly pre-

dicting nurse intervention was statistically significantly

30/69 *29/66 **

No. of

Patients

**p



001



43%

44%

Figure 1. Bypassed patients needing intervention. *p ≤ 0.001

—Speeds vs. Fast-Track; **p ≤ 0.001—Speeds vs. Modified

Aldrete.

Table 2. Bypass rates during 1st 30 minutes recovery (n =7

3).

minutes

Speeds 56 (77%)53 (73%) 54 (74%) 56 (77%)59 (81%)

Fast-Track 69 (94%)68 (93%) 69 (94%) 69 (94%)69 (94%)

Modified Aldrete 66 (90%)62 (85%) 65 (89%) 65 (89%)67 (92%)

p < 0.01. Speeds vs. fast-track & modified Aldrete at 0, 5, 10, 15, & 30

minutes.

greater for SPEEDS when compared to the modified

Aldrete (Table 4).

The majority of phase 1 interventions in bypass eligi-

ble patients were for IV analgesia, the second most

common being IV antiemetics (Figure 2). Note some

individual patients required more than one type of inter-

vention, e.g. both IV analgesics and anti-emetics.

Post-operative nausea and vomiting incidence was 9.6%

(7/73). Average case duration was 65 minutes with a

standard deviation of 39.4 minutes. Average time from

anesthetic discontinuation to PACU arrival was 6.6 min-

utes with a standard deviation of 1.7 minutes. Average

discharge time was 137 minutes with a standard devia-

tion of 85.4 minutes. One patient (1.3%) required a re-

turn to the emergency room for post-operative urinary

retention.

5. Discussion

In the present cost-conscious healthcare environ ment, the

use of fast tracking can have favorable financial implica-

tions for a hospital or ambulatory surgery center because

rapid discharge can reduce the cost of care. Macario [11]

showed that a decrease in OR and recovery times have a

greater economic impact than that achieved by reducing

anesthesia drug costs alone. Fast-track anesthesia in out-

patient care has been associated with substantial cost-

avings with no change in patient outcomes [12]. At 5 s

Speeds Criteria vs. Modified Aldrete and Fast-Track Criteria for Evaluating Recovery in Outpatients

312

Fast-TrackModified Aldr eteSpeeds

Criteria

IV Analgesia

IV Anti-Emetic

Anti-Hypertensive

Oxy g en

Supplementation

No.

Interventions

Figure 2. Types of intervention bypassed patients.

Table 3. Validation statistics (and 95% confidence intervals) for three post-operative screening tests predicting nurse inter-

vention in 73 patients.

SPEEDS (SPD) Modified Aldrete (MA)Fast-Track (FT) SPD vs. MA SPD vs. FT

Sensitivity 47.06 (31.45, 63. 26) 14.71 (6.45, 30. 13) 11.76 (4.67, 26. 62) p < 0.001 p < 0.001

False Positive Rate 52.94 (36.74, 68. 55) 85.29 (69.87, 93. 55) 88.24 (73.38, 95.33) p < 0.001 p < 0.001

Specificity 97.44 (86.82, 99.5 5) 94.87 (83.11, 98.5 8) 100.00 (91.0 3, 100.00)p = 0.478 p = 0.361

False Negative Rate 2.56 (0.45, 13.18) 5.13 (1.42, 16.89) 0.00 (0.00, 8.97) p = 0.478 p = 0.361

Positive Predictive Value 94.12 (73.02, 98. 95) 71.43 (35.89, 91. 78) 100.00 (51. 01, 100.00)p = 0.015 p = 0.453

Negative Predictive Value 67.86 (54.82, 78. 60) 56.06 (44.08, 67. 37) 56.52 (44.79, 67.57) p = 0.049 p = 0.056

Accuracy 73.97 (62.89, 82. 66) 42.47 (31.78, 53. 90) 58.90 (47.45, 69.47) p < 0.001 p = 0.005

Table 4. Performance odds of post-operative screening compared with SPEEDS relative to accurately predicting nurse inter-

vention.

Prognostic Test Odds of NI for Pass-Fail GroupOdds of NI for Fail-Pass GroupWald Statistic p-Value

Modified Aldrete 12.00 0.50 3.91 0.048

Fast Track 12.00 n/a 8.97 0.003

institutions, annualized savings of $50,000 to $160,000

per year were realized when phase I bypass rates of 14%

- 42% were achieved [12]. For many of the above rea-

sons we in corporated an aggressive fas t track program at

our surgery center. In refining our techniques, we felt a

simplified bypass criteria could be established as com-

pared to the criteria presently available. White and Song

showed that Fast-Track criteria offered advantages over

modified Aldrete for determining phase I bypass [3].

However, we felt Fast-Track criteria were too cumber-

Speeds Criteria vs. Modified Aldrete and Fast-Track Criteria for Evaluating Recovery in Outpatients 313

some as well as lenient. For example, currently accepted

criteria require calculating deviations from preoperative

hemodynamic parameters as well as allow a patient to

experience transient emesis and pain requiring intrave-

nous analgesia yet still meeting fast track criteria. It

should be noted the authors of Fast-Track criteria did

suggest further validation [3]. The current study was our

initial attempt to see if SPEEDS could predict which pa-

tients would not require phase I nursing treatment and

could proceed to phase II with confidence, thereby fa-

cilitating our fast track program.

In analyzing our data, we defined a po sitive test as be-

ing able to determine those patients who required phase I

nursing interventions. A very sensitiv e test would have a

low “false negative” rate or in this case, a low rate of

bypass for those who subsequently required phase I

nursing interventions. A very specific test would have a

low “false positive” rate or in this case, a low number of

patients who did not meet bypass criteria but did not re-

quire phase I nursing intervention post-op. All three tests

were specific in identifying patients that required phase I

nursing interventions post-operative. With SPEEDS cri-

teria, significantly more patients were co rrectly identified

as eligible for bypass. Only 32% of SPEEDS eligible

patients needed a phase I intervention compared to 44%

with Fast-Track criteria and 43% with modified Aldrete

(p < 0.001 vs. both Fast-Track and modified Aldrete). In

other words, when SPEEDS determined a patient could

move to phase II, the clinician is more assured that the

patient will not require phase I intervention. Also the

accuracy of SPEEDS was significantly greater than either

Fast-Track (74.0% vs. 58.9%; p = 00.005 or modified

Aldrete (74.0% vs. 42.5%; p < 0.0001). Th is may help an

institution in determining nurse to patient ratios.

Longitudinal analysis revealed statistically significant

differences in bypass rates at all times studied. SPEEDS

ineligible patients continued to not meet requirements

because of the need for phase I interventions; whereas,

the majority of these patients met criteria via the other

two methods over the first 30 minutes of recovery.

SPEEDS continued to be more sensitive and could be

used as criteria in the PACU for transition from phase I

to phase II.

The majority of phase I interventions in bypass eligi-

ble patients were for IV analgesia with all 3 criteria. This

data support Pavlin’s [13] findings that improvements in

pain therapy are needed to expedite recovery. Although

not specifically addressed in this study, surgical inva-

siveness seemed to correlate with suitability for bypass.

More invasive and hence painful procedures tended to

require more nursing intervention for post-operative an-

algesia and this need should be anticipated when imple-

menting bypass strategies [14]. The second most com-

mon intervention in bypassed patients was for IV anti-

emetic therapy. Similarly, anti-emetic prophylaxis for

patients at risk is a logical part of bypass strategies [14].

Opportunities exist for further study into the impact of

various pain management and anti-emetic modalities on

successful phase I bypa ss.

Readers may question whether our technique is to just

wait until the patient is ready for phase II, however; this

was not the case as our average time from discontinuing

the agent until arriving in the PACU was 6.6 minutes.

Some may question the value of utilizing bypass criteria

in a facility without a traditional recovery area. We have

found that SPEEDS criteria give a better idea as to which

patients are more likely to need phase I intervention and

thus require higher nursing acuity and feel this could be

used quite effectively in a traditional set up as well.

Although the accuracy of SPEEDS is significantly

better than the other criteria, a fairly large percent of pa-

tients are bypassed and eventually need Phase I interven-

tion. In part, this finding is a reflection of the dynamic,

changing nature of post-operative recovery. What seems

to be an adequate recovery can quickly change because

of motion-induced nausea and vomiting or the unmask-

ing of pain following the elimination of residual anesth e-

sia. Due to the interpatient variability in analgesic re-

quirements, it is difficult to predict which bypassed pa-

tients will require phase I nursing intervention and sub-

sequently relapse. Further efforts to control and eliminate

these issues are warranted.

In developing the SPEEDS criteria, one goal was a

user-friendly mnemonic. We felt that using extremity

movement to command would be an adequate substitute

for the standard 5 second head lift. Our goal is to have

the patient move to the gurney without assistance upon

completion of the surgery. Although the range of vital

signs may seem arbitrary, their utilization did not affect

patient outcomes. Perhaps, if a clinician is un comfortable

with these values, then they could substitute their own

values accordingly.

This study could be criticized for the relatively small

number of patients, although statistically viable. Also,

our surgery center is atypical in its layout, although we

feel it is an advantage in our practice. Lastly, we only

carried out the evaluation for 30 minutes which often is

not enough time to adequately control pain or nausea in

certain cases (e.g., laparoscopic cholecystectomy).

In summary, the authors examined the use of an easily

applied mnemonic for evaluating fast track recovery in

outpatients following general anesthesia. The SPEEDS

criteria are self-explanatory and require a yes/no re-

sponse without calculations for deviations from pre-ope-

rative blood pressure. SPEEDS criteria are significantly

more sensitive and accurate in identifying patients who

will require phase I nursing interventions. Therefore, it

appears SPEEDS has advantages over Fast-Track Scor-

Speeds Criteria vs. Modified Aldrete and Fast-Track Criteria for Evaluating Recovery in Outpatients

314

ing System and modified Aldrete criteria in evaluating

suitability for phase I recovery bypass following general

anesthesia.

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