The efficiency that ambulatory surgery strives for depends above all on patients who wake comfortably, mobilize quickly and discharge on time. Meeting these goals isn't just the job of your PACU staff, however. According to clinicians who've mastered the art of surgical throughput, enabling efficient exits is a product of the entire perioperative process. Read on for their views on the steps that can make a difference in discharges.

Begin before the beginning
There's an argument to be made that efficient discharges begin before the patient even reaches the OR. Adding advance preparations to your perioperative routine and starting off a day on the right foot — or on the left shoulder, as the case may be — can reap improvements on the other end of the process.

For Chuck Strasser, RN, executive director of Allied Physicians Surgery Center in South Bend, Ind., efficient recoveries begin at the scheduling desk. As with the busy orthopedic lineup at Mr. Strasser's multispecialty center, your cases are probably booked by side: All of the right-side scopes done consecutively, for example, then all the left, in order to minimize the need to reposition equipment throughout the day, keep room turnover time down and reduce staff fatigue. "We try to stay on the same side as long as we can," says Mr. Strasser.

Also group cases by their anticipated length, level of difficulty or type of anesthesia to be used, with the more demanding cases first. Aside from the obvious advantages of a fresher surgical team for more in-depth cases, this advice better accommodates patients in PACU. "We do our heavier cases earlier in the day, and our lighter ones later," says Linda Powell, RN, CNOR, director of nursing for the Surgical Center at Columbia (Mo.) Orthopaedic Group. Rotator cuff and ACL repairs not only take much longer than simple scopes, they also require deeper anesthesia and their patients take longer to wake and ambulate, she says. Doing general anesthesia cases in the morning — while saving local anesthesia and peripheral nerve block cases for the afternoon — gives patients more time to wake and avoids prolonged discharges that keep your PACU staff overtime.

Preparing the patient
The opportunities for your staff to make contact with a patient ahead of the day of surgery are often limited to a pre-op assessment phone call, a mailed packet of forms and informational material, maybe a visit to your website. Once the patient arrives on site, though, opportunity begins anew: Anything you can do to prepare the patient for his surgical experience can lower his anxiety and give him the tools to better negotiate recovery.

"Reducing anxiety should be a big factor in patient preparation," says Nick Crofut, CRNA, MS, the QI and practice development director for Anesthesia Staffing Consultants in Bingham Farms, Mich., as well as an adjunct professor of nursing anesthesia at Michigan State University. "A lot of the time anxiety is not talked about, but we know it raises blood pressure and the heart rate, and the patient's perceived pain can go to 10 out of 10."

If you lower patients' anxiety, you potentially lower their post-op pain score and speed their way through PACU. One way to defuse the uncertainty that may stoke an anxious response is for staff to discuss patients' expectations for surgery and its outcomes with them. Nurses might describe specialty-specific results, such as the bloated or crampy feeling many GI and laparoscopy patients feel after surgery, while anesthesia providers might walk patients through the process. "Patients may expect to sleep through the whole thing," says Mr. Crofut, and aren't expecting "the roughness of their waking in the OR as the procedure ends." Letting them know in advance that they may experience discomfort on emergence could smooth the way, he says.

Another important pre-op discussion that can influence PACU efficiency is assessing and addressing post-op pain. "Some patients have asked me, 'Am I going to have any pain?'" says Mr. Crofut. "They're thinking that after surgery, there'll be no pain." That misunderstanding could make for an unpleasant and difficult stay in recovery, he says.

Since there will be pain, be sure to help patients psychologically prepare for it, he says. Using any of the various pain scales available, nurses can ask patients to judge how they're feeling in pre-op to obtain a baseline for later comparison. Pain is of course subjective, but let them know what they might feel after their procedures, how to gauge and communicate it to you and what options will be available to make them more comfortable.

Besides educating patients, pre-op preparation can streamline the post-op process. At many surgical facilities, post-op care instructions are explained to patients while they're waiting in pre-op. Delivering the in-depth details while you have their full attention, and consciousness, lets you cover the bases with a quick review and take-home instructions afterward, when retention is less certain and their focus is likely centered on just going home. For short, above-the-neck procedures such as cataract surgeries, some facilities have also found that letting patients wear their street clothes throughout the procedure saves the time and potential disorientation of changing out of a gown and back into their clothes for the trip home.

The anesthesia angle
Each patient's recovery is individual and progresses to discharge on its own timeline. One of the major influences on how quickly a patient recovers, though, is the anesthesia they've been given.

"Having outpatient anesthesia — that is, anesthesia providers who understand ambulatory techniques and surgery centers — is very important," says Mr. Strasser, since the choice of anesthesia has a direct effect on discharge. Granted, anesthesia providers may be in large part bound by the treatment decisions of the attending surgeons, but efficiency-minded administrators should be able to find plenty of evidence-based studies for them that back a lighter touch for anesthesia, when applicable. "Use less gas and more pharmacology," says Mr. Strasser, since monitored anesthesia care, regional and local anesthesia provide easier emergence and a lessened need for narcotics against post-op pain.

From the anesthesia provider's perspective, outsmarting post-op pain is key to a speedy discharge, and the most effective way to do that is by treating pain perioperatively. "The pain management agent we prescribe has a big influence," says Mr. Crofut.

Pre-medicating an intraoperative patient with narcotics means no post-op pain, and pre-medicating with antiemetics means no post-op nausea and vomiting, both of which mean a shorter stay in recovery. Maybe. "Some patients don't have good receptors for some drugs," says Mr. Crofut. "We get so rushed, we try to treat every patient quickly, proficiently, with this cookie-cutter mentality, but we can't." There's a genetic basis for which drugs are most effective on which patients, he says, but on the day of surgery, "we've got to talk to our patients. They know what works for them and what doesn't."

Continuous local anesthetic pumps, also known as "pain pumps," are another pain management strategy that eases the path through PACU and even follows patients home. "They leave here pain-free," says Carole Faucette, RN, surgery manager at Memorial Mission Surgery Center in Chattanooga, Tenn. While this option may come at a cost — many insurers don't reimburse for their use, leaving patients to foot the bill — there is a payoff.

"Pain pumps are break-even at best," says Brent A. McLean, MHA, Memorial Mission Surgery Center's administrator. "But the upshot is, less narcotics, less pain, quicker recovery. ASCs sometimes get a bad rap for pushing down costs, but our center made a decision to spend the money for quality of care. It's not just about the bottom line." The word-of-mouth marketing generated by patients whose post-op pain was kept under control is likely to increase your case volume, he says.

PACU pointers
Once your patients arrive in PACU, the necessary steps are standard practice: Are their vital signs stable? Have medication orders been carried out? Is pain under control? Are they nauseated or vomiting? Can they eat and drink?

Your PACU staff will be able to monitor these discharge criteria immediately and efficiently if they're kept in the loop throughout the perioperative process. Alert them when patients are on the way and make sure charts and paperwork reach them before the patient does, to prevent waiting. At Memorial Mission, says Ms. Faucette, "all departments inform and are informed about what is going on during the day, so communication is not lost between the different stages of patient care." It's a good idea to keep whoever's waiting for the patient in the reception area updated as well.

Pain medications are often given post-operatively and your anesthesia providers should be available for consultation between surgery and discharge. Outside of pharmacology, though, consider non-narcotic distraction strategies that can help take patients' minds elsewhere, says Mr. Crofut. Patient warming or ice for cooling, elevating the surgical site or allowing a family member to the bedside can make a difference in recovery. A little music can reduce anxiety, but be aware that reducing the amount of noise around the patient bays can also help. "It can get so loud in pre-op and post-op without you even noticing it," says Mr. Crofut. "This adds stress and raises blood pressure levels."

If it's not standard practice at your facility to explain post-op care instructions in pre-op, then it's urgent that a family member or other responsible party listens in during the review in PACU and signs the discharge form on behalf of the patient, says Jean Frank, RN, a PACU nurse at the Paoli (Pa.) Surgery Center. This requires that the patient's escort be at your facility around the time the patient has met discharge criteria and is ready to leave, since you can't consider a discharge complete until the patient is out the door.

"We had a patient who was waiting here 2 to 3 extra hours," says Ms. Frank. While it's not uncommon for escorts to drop off patients, then go to work or run errands before picking them up, she says, you should know when they'll be returning and know how to contact them. During check-in, your office staff must ask the patient who is their ride home, and what is that person's cell phone number. "That patient should have been out long before then. What they needed most for their recovery was to get home, and get to bed."