Validation of the Italian version of the White Fast-track Scoring Criteria: a prospective, observational study
10.54103/dn/18293
BACKGROUND: patients undergoing surgery are subject to adverse events, in the hours immediately after discharge from the operating theatre. The White Fast-Track scoring criteria scale is suitable for early detection of the risk of postoperative complications, but it has not been validated into Italian. Moreover, it should be completed with additional parameters, to allow complete postoperative surveillance. AIM: this study is aimed to translate and validate into Italian the White fast-track scoring criteria and to produce a modified version, to obtain a more complete assessment of major surgery operations.
METHODS: Quantitative, observational, prospective, monocentric study, on a non-randomized sample of patients aged 18 or more, undergoing general, thoracic, vascular, urological, orthopedic, gynecological, endocrinological, breast, nose-throat, or facial surgery, in the recovery room of a teaching hospital in Milan.
RESULTS:250 patients were enrolled. The original scale showed good inter-rater reliability, internal consistency, and test-retest reliability. The same applied to the modified version. The original scale allowed identifying 18 patients at risk; the modified version identified 20, who could have been discharged according to the original criteria, who actually developed postoperative complications.
DISCUSSION:The Italian White fast-track scoring criteria is a valid tool, and it can be used by nurses to perform appropriate postoperative surveillance, as well as to prevent early postoperative complications. CONCLUSIONS: The modified version reflects the real surveillance performed in a recovery room, and shows satisfactory reliability, sensitivity, and specific if compared to the original tool.
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Claudia Maria Sansone
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Dissertation Nursing
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Validazione della versione italiana della White Fast-track Scoring Criteria: uno studio prospettico osservazionale
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2022-07-29
2022-07-11
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2022-07-29
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DN
Claudia Maria Sansone
2022/07/29
10.54103/dn/18293
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U.O. Terapia Intensiva Neonatale, Policlinico San Matteo, Pavia
2785-7263
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prevenzione
it
37
Ead H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery. J perianesthesia Nurs Off J Am Soc PeriAnesthesia Nurses. 2006 Aug;21(4):259–67.
Validazione della versione italiana della White Fast-track Scoring Criteria: uno studio prospettico osservazionale
https://riviste.unimi.it/index.php/dissertationnursing/article/download/18293/16265
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                                                                                                                               DOI: 10.54103/dn/18293




              DISSERTATION NURSING
         Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing/
Observational Study



   Validation of the Italian version of the White Fast-track
         Scoring Criteria: a prospective, observational study
                1
Paola Casati      , Claudia Maria Sansone2
1 Operating   Theatre, San Raffaele Hospital, Milan, Italy
2 Neonatal   Intensive Care Unit, Policlinico San Matteo hospital, Pavia, Italy



Findings:                                              ABSTRACT
    o    A tool for early detection of the risk        BACKGROUND: Patients undergoing surgery are subject to adverse events, in
         of post-operative complications is            the hours immediately after discharge from the operating theatre. The White Fast-
         translated and validated.                     Track scoring criteria scale is suitable for early detection of the risk of postoperative
                                                       complications, but it has not been validated into Italian. Moreover, it should be
    o    A modified version of the previous
                                                       completed with additional parameters, to allow complete postoperative surveillance.
         tool is produced and validated to
         achieve a more comprehensive
                                                       AIM: This study is aimed to translate and validate into Italian the White fast-track
         assessment of major surgery.
                                                       scoring criteria and to produce a modified version, to obtain a more complete
                                                       assessment of major surgery operations.

                                                       METHODS: Quantitative, observational, prospective, monocentric study, on a
                                                       non-randomized sample of patients aged 18 or more, undergoing general, thoracic,
                                                       vascular, urological, orthopedic, gynecological, endocrinological, breast, nose-throat,
                                                       or facial surgery, in the recovery room of a teaching hospital in Milan.

                                                       RESULTS: 250 patients were enrolled. The original scale showed good inter-rater
                                                       reliability, internal consistency, and test-retest reliability. The same applied to the
                                                       modified version. The original scale allowed identifying 18 patients at risk; the
                                                       modified version identified 20, who could have been discharged according to the
                                                       original criteria, who actually developed postoperative complications

                                                       CONCLUSION: The Italian White fast-track scoring criteria is a valid tool, and it
                                                       can be used by nurses to perform appropriate postoperative surveillance, as well as
                                                       to prevent early postoperative complications. The modified version reflects the real
                                                       surveillance performed in a recovery room, and shows satisfactory reliability,
                                                       sensitivity, and specific if compared to the original tool.


                    KEYWORDS: adult, critical care, perioperative care, postoperative complications, surgical procedures,



        Corresponding author:                                                     28                               Submission received: 11/07/2022
        Paola Casati: p.casati91@gmail.com                                                                  End of Peer Review process: 25/07/2022
        San Raffaele Hospital                                                                                                Accepted: 25/07/2022
        Via Olgettina 60, 20132 Milan, Italy              Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                          This work is licensed under a Creative Commons
         Dissertation Nursing 1 (29/07/2022)                                              Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                               DOI: 10.54103/dn/18293




               DISSERTATION NURSING
           Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing/

Studio Osservazionale

          Validazione della versione italiana della White Fast-track
          Scoring Criteria: uno studio prospettico osservazionale
                 1
Paola Casati      , Claudia Maria Sansone 2
1 Comparto     Operatorio, Ospedale San Raffaele, Milano
2 Unità   di Teapia Intensiva Neonatale, Policlinico San Matteo, Pavia



Riscontri:                                            ABSTRACT
     o      Viene tradotto e validato uno             INTRODUZIONE: Nelle ore immediatamente successive alla dimissione dalla sala
            strumento per rilevare precocemente       operatoria i pazienti sottoposti a intervento chirurgico sono soggetti a eventi avversi.
            il rischio di complicanze post-           La scala “White Fast-Track” è adatta a rilevare precocemente il rischio di
            operatorie.                               complicanze postoperatorie, tuttavia, non risulta esser validata in italiano. Inoltre, per
                                                      consentire una sorveglianza post-operatoria complete, dovrebbe essere completata
                                                      con parametri aggiuntivi.
     o      Viene realizzato e validato una
            versione modificata dello strumento       OBIETTIVO: Questo studio si propone pertanto di tradurre e validare in italiano la
            precedente per ottenere una               scala “White fast-track scoring criteria” e di realizzarne una versione modificata per
            valutazione più complete degli            ottenere una valutazione più completa degli interventi di chirurgia maggiore.
            interventi di chirurgia maggiore.
                                                      METODI: Studio quantitativo, osservazionale, prospettico, monocentrico, su un
                                                      campione non randomizzato di pazienti di almeno 18 anni, sottoposti a chirurgia
                                                      generale, toracica, vascolare, urologica, ortopedica, ginecologica, endocrinologica,
                                                      mammaria, naso-gola o facciale, nella sala di rianimazione di un ospedale universitario
                                                      di Milano.

                                                      RISULTATI: Sono stati arruolati 250 pazienti. La scala originale ha mostrato una
                                                      buona affidabilità inter-rater, consistenza interna e affidabilità test-retest; lo stesso
                                                      vale per la versione modificata. La scala originale ha permesso di identificare 18
                                                      pazienti a rischio; la versione modificata ne ha identificati 20 che avrebbero potuto
                                                      essere dimessi secondo i criteri originali e che in realtà hanno sviluppato complicanze
                                                      postoperatorie.

                                                      CONCLUSIONI: La versione italiana della “White fast-track scoring criteria”
                                                      sembra attestarsi come uno strumento valido e può essere utilizzato dal personale
                                                      infermieristico per effettuare un'adeguata sorveglianza postoperatoria finalizzata a
                                                      prevenire le complicanze postoperatorie precoci. La versione modificata riflette la
                                                      reale sorveglianza effettuata in recovery room e mostra affidabilità, sensibilità e
                                                      specificità soddisfacenti rispetto allo strumento originale.




                     KEYWORDS: Continuità dell'assistenza, passaggio di consegne, comunicazione, consegne infermieristiche



          Corresponding author:                                               29                                   Submission received: 11/07/2022
          Paola Casati: p.casati91@gmail.com                                                                End of Peer Review process: 25/07/2022
          San Raffaele Hospital                                                                                              Accepted: 25/07/2022
          Via Olgettina 60, 20132 Milan, Italy            Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                          This work is licensed under a Creative Commons
           Dissertation Nursing 1 (29/07/2022)                                            Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                  DOI: 10.54103/dn/18293




          DISSERTATION NURSING
       Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing/



BACKGROUND                                                             general, thoracic, vascular, urological, orthopedic,
Surgical patients are subject to alterations of their                  gynecological, endocrinological, senological, nose-
physiological functions, which continue in the                         throat, or facial surgery, in the recovery room of the
postoperative period, because of anesthesiology and                    San Paolo teaching hospital in Milan (Italy) during
surgery (1-3).                                                         two consecutive months. This study was originally a
In literature (4,5) it is known that adverse events                    project related to a bachelor’s degree thesis in
occur in 5-30% of the cases, in the hours immediately                  Nursing; the period of data collection, and therefore
after discharge from the operating theatre.                            the sample size, were dictated by the academic
Continuous surveillance as well as patient assessment                  calendar.
after the operation are crucial to prevent potential
complications and critical situations.                                 Data were collected by two persons (a Nursing
                                                                       student in her final year, and a nurse working in the
Expert personnel, in a dedicated recovery room (4),                    recovery room). The White fast track scoring criteria
must carry out such surveillance, which includes (but                  was translated into Italian by two independent
is not limited to) vital signs (6), hemostasis and signs               translators, then back-translated by a teacher of
of shock (7), temperature (2,3), type and quantity of                  English; the original authors approved the back-
drained material, urine volume (8, 9), pain (10), and                  translated version. We assessed the characteristics of
postoperative nausea and vomiting (11-13). Several                     internal consistency (Cronbach’s alpha), inter-rater
scoring systems have been proposed, to assess the                      reliability (Spearman’s rho coefficient), test-retest
risk of early postoperative complications; such tools                  stability (Mann-Whitney Test), face and content
allow objective assessment and comparison, as well as                  validity (Content validity index), sensitivity, specificity,
to document the vital parameters over time (6,7).                      positive and negative predictive value regarding early
Among the scales validated in literature, White and                    postoperative complications. The study was
Song have proposed the White fast-track scoring                        conducted according to the principles of the
criteria in 1999 (14), which derives from previous                     Declaration of Helsinki, and to the Italian regulations
tools (15) is suitable for postoperative surveillance,                 on data privacy. We complied with the rules of the
but has not been translated into Italian so far. This                  local ethical committee, and obtained the approval of
tool has originally been used for outpatients surgery                  the institutional review board. The authors of the
(4) and for this reason needs to be integrated with                    original scale gave their permission to use the tool. All
further parameters (blood losses, urine volume) to                     participants gave their informed consent. This study
obtain a complete scale. We aimed to translate into                    was registered in the Research Registry website
Italian and validate the White Fast-track scoring                      (Unique Identification Number researchregistry2534).
criteria, to assess the risk of early postoperative
complications. To modify and integrate the scale, in                   We enrolled patients coming from surgical units
order to obtain a complete assessment of patients                      (including day surgery), as well as persons coming
after major surgery; to validate the new tool, in terms                directly from the Emergency Department, and then
of sensitivity, specificity, and internal consistency.                 transferred to one of the abovementioned wards.
                                                                       Assessment was performed at their admission to the
METHODS                                                                recovery room, and then every 15 minutes until
We conducted a prospective, observational study, on                    discharge, in order to assess and prevent early
a non-randomized sample of patients aged 18 or                         postoperative complications. Data collection was
more, undergoing scheduled or emergency surgery, in                    performed by means of a form, through analysis of
      Corresponding author:                                      30                                   Submission received: 11/07/2022
      Paola Casati: p.casati91@gmail.com                                                       End of Peer Review process: 25/07/2022
      San Raffaele Hospital                                                                                     Accepted: 25/07/2022
      Via Olgettina 60, 20132 Milan, Italy   Via Festa del Perdono 7, 20122 Milan, Italy
                                                                             This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                   Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                  DOI: 10.54103/dn/18293




          DISSERTATION NURSING
       Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing/



patients records and anesthesiology documentation.                     excluded from the final score. During statistical
Data including administrative information regarding                    analysis, several cutoff values were taken into
admission, clinical data, anesthesiology, and surgical                 consideration, in order to maximize the balance
technique. In major surgical operations, blood loss                    between sensitivity and specificity. Table 1 and 2 (in
and urine volume need evaluation, but the original                     the Appendices section) show the modified scale in
scale does not include such parameters; at the end of                  English and Italian respectively.
data collection, we performed statistical validation of
the back-translated scale, with the original items only.
                                                                       RESULTS
After that, the analysis was repeated taking into
consideration the additional parameters, thus                          250 patients were assessed for eligibility and enrolled,
obtaining a revised scale and its complete validation.                 137 males (54.8%) and 113 (45.2%), aged 57±17, with
Sensitivity and specificity of the new scale were                      mean BMI of 25±4 kg/m2. 243 patients (97,2%)
assessed by concurrency with the original White fast-                  underwent scheduled surgical operations, the
track scoring criteria as a gold standard. Several                     remaining 7 (2.8%) were operated in urgency. No
cutoffs were used to maximize the predictive values                    patients dropped out; we had no missing data. Video
of the new scale. Preliminary meetings with nurses                     laparoscopy and laparotomy were most frequent
working in recovery rooms showed that the original                     (respectively 104 and 96 cases) followed by
White fast track scoring criteria was suitable for                     orthopedic osteosynthesis (n=18), laparotomic
general postoperative surveillance; the content validity               prostesys (n=16), non-laparotomic prostesys (n=14)
index (16), based on the evaluation expressed by 5                     and thoracotomy (n=2). Table 3 shows the number
nurses experienced in surgery, was 0.92. However, in                   of patients undergoing each type of operation.
several real situations, it is often necessary to
investigate further aspects, as well as to establish                        TYPE OF SURGERY                                   N.           %
additional criteria, in order to determine severity of
potential clinical complications that patients may                                    Abdominal                                53       21,2%
encounter.                                                                             Thoracic                                 6       2,4%
                                                                                           Facial                              18       7,2%
Based on literature findings, we decided to integrate
the scale with blood losses (7) and urine volume (17-                                Orthopedics                               30       12%
19) thus obtaining a modified tool. As regards blood                                 Gynecology                                15        6%
losses, we adopted the criteria proposed in the
                                                                                        Urology                                37       14,8%
PADSS scale (20), another validated tool: the patient
scored 2 points in case of minor hemorrage,1 in case                        Endocrinology/senology                             15        6%
of mild hemorrhage, and 0 in case of severe                                             Vascular                                8       3,2%
hemorrhage. As regards urine volume, we considered                                   Nose-throat                               23       9,2%
the criteria used by urologists to identify oliguria or
                                                                                     Day Surgery                               45       18%
anuria (10): 2 points in case of urine production over
1 ml/kg/h, 1 point between .5 and .9 ml/kg/h, and 0                                        Total                              250       100%
points if volume was less than .5 ml/kg/h. Not all
operations required assessing all parameters: for                             Table 3: number and type of the surgical procedures
instance, minor surgery hardly ever requires drainage.
In such situations, the item of the scale was simply
      Corresponding author:                                      31                                   Submission received: 11/07/2022
      Paola Casati: p.casati91@gmail.com                                                       End of Peer Review process: 25/07/2022
      San Raffaele Hospital                                                                                     Accepted: 25/07/2022
      Via Olgettina 60, 20132 Milan, Italy   Via Festa del Perdono 7, 20122 Milan, Italy
                                                                             This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                   Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                   DOI: 10.54103/dn/18293




          DISSERTATION NURSING
       Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing/



General anesthesia was used in 74.8% of the cases                          PARAMETER                         C.       P.C.        NoA.   TOTAL
(n=187), loco-regional in 12.8% (n=32) and local                       Level of conscience                    9         94         147      250
associated with sedation in 12.4% (n=31). According
                                                                       Activity                              27         99         124      250
to the ASA classification (American Society of
Anesthesiology), 76 patients had risk 1, 132 had risk                  Pain                                   1        109         140      250
2, 39 had risk 3, and 3 had risk 4.                                    Arterial pressure                      7         47         196      250
                                                                       Breathing                              3         11         236      250
After the operation, 239 patients (95.6%) were                         Oxygen saturation                      5         60         185      250
transferred to non-intensive surgical units. 8 patients
                                                                       Postoperative nausea
(3.2%) had been identified as “dischargeable” but                                                             0         11         239      250
were transferred to intensive care units, differently                  and vomiting
from the original plan. Finally, 3 patients (1.2%) had                 Hemorrage                              1          2          91      94*
the need for a second operation, to confront                           Urine                                  5          3          81      89*
compilations. One of them returned to a surgical
                                                                       Hypothermia                          176         74           /   250**
ward, the other was transferred to the intensive care
unit.                                                                  Chill                                168         82           /   250**
                                                                       C = Complications                  PT = Potential Complications
Since not all patients required assessment of all                      NoA = No Alterations
parameters, we decided how to assign scores with                       * The final count is less than 250, because the parameters
both the original White scale and the modified
                                                                       need assessment in some operations only
version. In the first case, we maintained the criteria
originally adopted by the authors: the patient was                     ** Only 2 possible values: 0=absence, 1=presence
considered not at risk with a score less then 12, with                     Table 4: characteristics of patients at the admission to the
no null partial score, and without chill or                                                              recovery room
hypothermia. For patients assessed with the new
scale, the cutoff was still 12 as in the original, but a               Content validity was assessed by comparing the
score of 2 in both urine losses and urine volume was                   parameters in the scales with data coming from the
needed, in order to define the patient as                              literature, as well as with real monitoring activities
dischargeable. Patients evaluated with the modified                    carried out in recovery room. Internal consistency of
scale were 130 out of 250 (52%). In such group, both                   the original scale was assessed by means of
additional parameters were measured in 53 cases, only                  Cronbach’s alpha coefficient, which resulted .61. This
urine volume in 36, and blood loss for the remaining                   value can be considered acceptable, considering that
41. Table 4 illustrates the characteristics of patients at             not all parameters occur simultaneously. The
the admission to the recovery room.                                    modified scale had alpha coefficient of .61. As regards
                                                                       sensitivity and specificity, the original scale identified
Content validity of both scales was assessed by asking                 18 patients at risk out of 250 (7.2%) while the
a qualitative judgement to the nurses involved in data                 modified scale identified 20 out of 130 (15.3%). Two
collection. Their opinion was positive in terms of ease                patients who could have been discharged according to
of use and time required for the application. Actually,                the original scale, had surgical site hemorrhage and
both tools allowed surveillance every 15 minutes.                      acute urine retention; the modified scale had correctly
                                                                       identified the as patients at risk for complications.

      Corresponding author:                                      32                                    Submission received: 11/07/2022
      Paola Casati: p.casati91@gmail.com                                                        End of Peer Review process: 25/07/2022
      San Raffaele Hospital                                                                                      Accepted: 25/07/2022
      Via Olgettina 60, 20132 Milan, Italy   Via Festa del Perdono 7, 20122 Milan, Italy
                                                                              This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                    Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                          DOI: 10.54103/dn/18293




           DISSERTATION NURSING
         Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing/



However, these complications are not related to                                The positive predictive value of the modified scale
specific risk factors, thus making it necessary to                             was .55, the negative predictive value was 1.
continuously assess vital parameters during the                                Therefore, the new scale had better predictive
immediate postoperative period. Test-retest stability                          capacity if compared to the original White fast-track
did not point out statistically significant differences, in                    scoring criteria.
presence of the same clinical situation (table 5).


             Data collection        Data collection            P-
 Scale
                     #1                       #2             value
                  Me = 12                Me = 12              p=
Original
              IQR = [11;13]           IQR = [11;13]           0.07

                  Me = 14                    Me=15            p=
Modified
              IQR = [13;15]           IQR = [13;16]           0.20


         Table 5 – Test-retest stability of the two scales
                                                                                                   Figure 1: area under ROC curve


As regards inter-rater reliability, the two raters
                                                                               DISCUSSION
produced scores without significant differences, as
                                                                               Our results show that the modified scale correctly
shown in table 6.
                                                                               identified all the patients indicated as being at risk by
                                                                               the original scale, plus two more, who actually had
   Scale         Student           Nurse              p-value                  postoperative complications, but were not correctly
                 Me=12             Me=12                                       identified by the original White scoring criteria.
   Original                                           p = 0.99
                 IQR=[11;13] IQR=[11;13]                                       In both cases, the complications could not be
                 Me=14             Me=14                                       prevented; this makes early recognition even more
   Modified                                           p = 0.99
                 IQR=[13;15] IQR=[13;15]                                       important, and points out the usefulness of blood
                                                                               losses and urine volume as additional clinical
                                                                               parameters for postoperative assessment.
                Table 6 – Inter-rater reliability                              In conclusion, the original scale has been translated
                                                                               into Italian and validated, with satisfactory results.
ROC analysis, carried out by taking the original scale                         The modified White fast-track scoring criteria,
as a gold standards, produced an area under curve of                           presented in this paper, seems even more reliable and
97.9% (Figure 1), thus accounting for good                                     compliant with actual monitoring carried out in
characteristics of sensitivity and specificity of the                          recovery rooms.
modified scale.                                                                A limitation of this study is the non-randomized
The positive predictive value of the original scale was                        nature of the sample; the study might be repeated in
.50, the negative predictive value was .99.                                    the future with probabilistic sampling techniques.

      Corresponding author:                                              33                                   Submission received: 11/07/2022
      Paola Casati: p.casati91@gmail.com                                                               End of Peer Review process: 25/07/2022
      San Raffaele Hospital                                                                                             Accepted: 25/07/2022
      Via Olgettina 60, 20132 Milan, Italy           Via Festa del Perdono 7, 20122 Milan, Italy
                                                                                     This work is licensed under a Creative Commons
         Dissertation Nursing 1 (29/07/2022)                                         Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                  DOI: 10.54103/dn/18293




          DISSERTATION NURSING
       Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing/



However, giving the sample size and characteristics,                             Ikenaga K, Mori T, et al. The impact of
we think that the White fast-track scoring criteria can                          intraoperative   hypothermia   on    early
be safely adopted in the type of surgical operations                             postoperative adverse events after radical
described in this paper.                                                         esophagectomy for cancer: a retrospective
                                                                                 cohort study. J Cardiothorac Vasc Anesth.
CONCLUSIONS                                                                      2014 Aug;28(4):943–7.
In this paper, we prepared and validated the Italian
version of the White fast-track scoring criteria, which                3.        Lenhardt R. Monitoring and thermal
showed good properties of sensitivity and specificity,                           management. Best Pract Res Clin Anaesthesiol
the modified version we prepared, led to further                                 [Internet]. 2003;17(4):569–81. Available from:
improvement of such characteristics, with excellent                              https://www.sciencedirect.com/science/articl
negative predictive value and better capacity of                                 e/pii/S152168960300048X
identifying patients at risk for early postoperative                   4.        Celotto S, Nesci M, Lucchini A, Bellani S,
complications.                                                                   Bombino M. [Vital signs of hemodynamic
In recovery room, regardless to the use of assessment                            monitoring]. Minerva Anestesiol. 2003
tools, nurses must be able to recognize early the onset                          Apr;69(4):289–96.
of complications, as well as to identify situations at
risk for complications, in order to avoid major                        5.        McAlister FA, Bertsch K, Man J, Bradley J,
damages to the patients. Assessment tools are                                    Jacka M. Incidence of and Risk Factors for
certainly useful in this context; both the original and                          Pulmonary Complications after Nonthoracic
the modified White fast-track scoring criteria are                               Surgery. Am J Respir Crit Care Med [Internet].
suitable for this purpose, and can be easily used by                             2005 Mar 1;171(5):514–7. Available from:
nurses in recovery rooms. Using this type of scales                              https://doi.org/10.1164/rccm.200408-
makes it easier to conduct clinical audits and surveys                           1069OC
regarding surgical outcomes and early detection of
                                                                       6.        Burke B, Kyker M. Speeds Criteria vs.
complications. Even though the present study is non-
                                                                                 Modified Aldrete and Fast-Track Criteria for
randomized, the sample size and the characteristics of
                                                                                 Evaluating Recovery in Outpatients. Open J
patients in terms of surgical operations and clinical
                                                                                 Anesthesiol. 2013;03(07):309–14.
situation, account for good generalizability of the
results obtained. The White scoring system, in both                    7.        Neveleff DJ, Kraiss LW, Schulman CS.
version, is easy to use and can be actually used by                              Implementing       Methods     to    Improve
nurses in recovery rooms.                                                        Perioperative Hemostasis in the Surgical and
                                                                                 Trauma Settings. AORN J [Internet]. 2010
                                                                                 Nov      1;92(5):S1–15.    Available    from:
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      Corresponding author:                                      34                                   Submission received: 11/07/2022
      Paola Casati: p.casati91@gmail.com                                                       End of Peer Review process: 25/07/2022
      San Raffaele Hospital                                                                                     Accepted: 25/07/2022
      Via Olgettina 60, 20132 Milan, Italy   Via Festa del Perdono 7, 20122 Milan, Italy
                                                                             This work is licensed under a Creative Commons
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          DISSERTATION NURSING
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15.   Aldrete JA, Kroulik D. A postanesthetic
      Corresponding author:                                      35                                   Submission received: 11/07/2022
      Paola Casati: p.casati91@gmail.com                                                       End of Peer Review process: 25/07/2022
      San Raffaele Hospital                                                                                     Accepted: 25/07/2022
      Via Olgettina 60, 20132 Milan, Italy   Via Festa del Perdono 7, 20122 Milan, Italy
                                                                             This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                   Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                 DOI: 10.54103/dn/18293




         DISSERTATION NURSING
      Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing/



APPENDICES
Table 1 – Modified White scale (English)
                     PARAMETER                       SCORING
                                                     Awake = 2
                   Level of conscience               Responsive to verbal stimulation = 1
                                                     Responsive to pain = 0
                                                     Moves any extremity at command = 2
                          Activity                   Weakness in moving extremities = 1
                                                     Unable to voluntarily move extremities = 0
                                                     Systolic blood pressure (SBP) ± 15% of preoperative values = 2
                 Hemodinamic stability               SBP±30% of preoperative values = 1
                                                     SBP>30% of preoperative values = 0
                                                     Able to breath deeply= 2
                   Respiratory stability             Tachypnoea with ability to cough = 1
                                                     Dyspnea and weak cough = 0
                                                     >92% without oxygen therapy = 2
                      Pulse oxymetry                  ≥90% with oxygen therapy = 1
                                                     <90% with oxygen therapy = 0
                                                     NRS≤3 = 2 points
        Postoperative pain (numerical rating
                                                     4≤NRS≤7, controlled with analgesics = 1 point
                            scale)
                                                     NRS≥8: 0 points
                                                     Absent, or slight nausea = 2
                 Postoperative vomiting              Transient vomiting, or retching = 1
                                                     Severe/persistent vomiting or nausea = 0
      Blood losses (including drainage tubes),       Absent = 2
       to be assessed according to the type of       Moderate = 1
                          operation                  Severe = 0
                                                     ≥1 ml/kg/hour = 2 points
                       Urine volume                  0.5-0.9 ml/kg/hour = 1 point
                                                     <0.5 ml/kg/hour = 0 points
                        Total score                  (sum of the above partial scores)
                                              Chill ☐           Hypothermia ☐



     Corresponding author:                                      36                                   Submission received: 11/07/2022
     Paola Casati: p.casati91@gmail.com                                                       End of Peer Review process: 25/07/2022
     San Raffaele Hospital                                                                                     Accepted: 25/07/2022
     Via Olgettina 60, 20132 Milan, Italy   Via Festa del Perdono 7, 20122 Milan, Italy
                                                                            This work is licensed under a Creative Commons
      Dissertation Nursing 1 (29/07/2022)                                   Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                    DOI: 10.54103/dn/18293




         DISSERTATION NURSING
      Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing/



Table 2 – Modified White scale (Italian)


              PARAMETRO                     PUNTEGGIO
                                            Sveglio e orientato = 2
            Livello di coscienza            Risponde agli stimuli verbali =1
                                            Risponde agli stimuli dolorosi=0
                                            Muove tutte le estremità a comando =2
                Attività fisica             Debolezza nel muovere le estremità =1
                                            Incapace di muovere volontariamente le estremità =0
                                            Pressione arteriosa sistolica (PAS) ± 15% rispetto al preoperatorio =2
          Stabilità emodinamica             PAS±30% rispetto al preoperatorio = 1
                                            PAS>30% rispetto al preoperatorio = 0
                                            In grado di respirare profondamente = 2
            Stabilità respiratoria          Respiro superficiale (tachypnea) con capacità di tossire = 1
                                            Dispnea con debole capacità di tossire = 0
                                            >92% in aria ambiente = 2
         Saturazione di ossigeno            ≥90% con ossigenoterapia = 1
                                            <90% con ossigenoterapia = 0
                                            NRS≤3 = 2 punti
          Dolore postoperatorio
                                            4≤NRS≤7, controllato con analgesici = 1 punto
        (Numerical Rating Scale)
                                            NRS≥8: 0 punti
                                            Assente o lieve nausea = 2
          Vomito postoperatoria             Vomito transitorio o conati = 1
                                            Nausea o vomito severi e persistenti = 0
                                            Assenti o lievi = 2
      Perdite ematiche (da valutare
                                            Moderate = 1
       in base al tipo di intervento)
                                            Severe = 0
                                            ≥1 ml/kg/ora = 2 punti
               Quantità urine               0.5-0.9 ml/kg/ora = 1 punto
                                            <0.5 ml/kg/ora = 0 punto
             Punteggio totale               (somma dei punteggi parziali sopra riportati)
                                                  Brivido ☐             Ipotermia ☐



     Corresponding author:                                         37                                   Submission received: 11/07/2022
     Paola Casati: p.casati91@gmail.com                                                          End of Peer Review process: 25/07/2022
     San Raffaele Hospital                                                                                        Accepted: 25/07/2022
     Via Olgettina 60, 20132 Milan, Italy      Via Festa del Perdono 7, 20122 Milan, Italy
                                                                               This work is licensed under a Creative Commons
      Dissertation Nursing 1 (29/07/2022)                                      Attribution-NonCommercial-NoDerivatives 4.0 nternational
