Ask the Clinical Instructor

I am an RT, and on a recent Joint Commission survey, they mentioned that we need to do the Aldrete Score. What is that, and how does it pertain to me?   
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Coincidentally, my facility recently completed The Joint Commission (TJC) survey as well. We have been using the Aldrete Score for some time, and the surveyors always like that. We will explain that in this article, as well as a new standard that TJC seems to be looking for, the Mallampati Score.

Let me give you my thoughts on the last part of your question first….how it pertains to you. First, you may actually see Aldrete questions on a registered cardiovascular invasive specialist (RCIS) exam, as it is listed in their matrix for the exam (https://cci-online.org). Also, the Aldrete Scale is pertinent to everyone who sees the patient before, during and after anesthesia care. Almost all of our patient receive some form of anesthesia. In the cath lab, this is most often conscious sedation.

One of the requirements of patient assessment and care after sedation is to evaluate the patient’s recovery as the sedation wears off. This is very important on the Post-Anesthesia Care Unit (PACU) after a surgery with general anesthesia. The staff will utilize this scale to decide when the patient is “recovered” enough to move through the phases of PACU, and ultimately to go home or back to their room.

In the cath lab, this can be a very important tool to determine when the patient is able to be discharged home, or in some cases, taken back to their room. The patients move through these processes fairly fast with conscious sedation.

To apply this scale, it is very important to know the patient “pre-anesthesia” score. Some patients may have “normal” abnormalities that change the score. To know, and have documented, what the pre-sedation assessment was is very important in order to determine the post-sedation assessment as the patient returns to their “normal” status.

The Aldrete Score has been around for some time, but has changed slightly over the years. In the past, skin color was utilized as a component of the assessment. This was often found to be subjective, and sometimes difficult to assess from person to person. The advent and utilization of pulse oximetry has replaced the skin color assessment, and it is called the ‘modified’ Aldrete scale.

The scale is easy to use, and can quickly be completed. Please see Chart 1.

The total score possible is 10. In most cases, a score of ≥ 8 (or a return to pre-anesthesia status) is required for discharge from the recovery area. Of course, your facility’s protocols and standards will dictate the levels necessary to move through any recovery phase, or to be discharged to home.

There are often some questions as to how often to perform these assessments. As a general rule:
 

• 3 points below baseline: Every 5 minutes with constant (1:1) monitoring.
• 2 points below baseline: Every 15 minutes with constant monitoring of vital signs.
• 1 point below baseline: Every 15-30 minutes with vital signs depending upon patient condition.
• Baseline: Utilize your facility’s protocols for standard post-procedural care.

While not on the RCIS exam matrix, the Mallampati score is something that TJC mentions during their survey. The Mallampati score (it can also be called classification) is used to determine the patient’s ease of intubation (Figure 1).

The base of the uvula and the appearance of the soft palates are visualized and scored. A high score (class 3 or 4) is a predictor of a more difficult intubation. It also is a predictor of sleep apnea, and the Mallampati score is utilized in that manner as well.¹

The assessment is preferably done with the patient in an upright position, which makes it difficult to do if the patient is already on the cath lab table. To meet TJC requirements, the physician is required to complete a pre-sedation assessment on the patient. When the Mallampati because a requirement in the eyes of TJC, this will be a challenge to the processes of most cath labs.
The Aldrete Scale is an important tool to maintain assessment of the post-anesthesia patient as they move through their stay in the department and in the hospital. If everyone understands the basic guidelines of the scoring, it can help to more quickly identify recovery, or decompensation, of these patients.

Please send any questions you may have to Cath Lab Digest at rkapur@hmpcommunications.com (indicate it is for “Ask the Clinical Instructor”) or to me directly at tginapp@rcisreview.com. You may also post any questions you might have on the RCIS Review Facebook page at www.facebook.com/rcisreview.

Reference

1. Mallampati S, Gatt S, Gugino L, Desai S, Waraksa B, Freiberger D, Liu P. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32(4): 429-434.