Is fast-track surgery suffering from an image problem? Liane S. Feldman, MD, a general surgeon specializing in laparoscopy at McGill University Health Center in Montreal, thinks so. And she's pretty sure it has to do with the name.
"A lot of people don't like the term fast-track," says Dr. Feldman. "They think all you're trying to do is get the patient out the door faster."
So at McGill, it isn't Fast-Track Surgery. It's Multimodal Rehabilitation. Or Accelerated Recovery. Anything but the F-word. Whatever the name, the benefits are the same: helping patients recover faster from surgery. "But we don't want them to leave faster so that they can lay on the couch at home," says Dr. Feldman. "We want them to recover quicker so that they can get back into life."
Here's a look at some key elements of McGill's rapid recovery program.
- Don't move patients. All-in-one stretchers that serve as the patient's prep table, operating table and recovery bed eliminate the need to move the patient around and can save considerable time.
- Manage patient expectations. What does the knee arthroscopy patient who thinks he'll be off his feet for only 6 hours after surgery have in common with the knee arthroscopy patient who thinks he'll be off his feet for 6 days after surgery? They're both right. "What patients expect has a lot to do with what happens," says Dr. Feldman. Patient education is an often overlooked, yet important, component of a quicker recovery. "The more armed patients are with information, the more they feel in control of the process," she says. "If you tell the patient that he's going to have tons of pain and he has tons of pain, he'll be satisfied." Dr. Feldman suggests making a nurse responsible for educating patients about the process of surgery, including what kind of pain they'll experience and how they'll manage that pain. "Don't just hand the patient a pamphlet," she says. "Give them targeted education."
- Exercise. There's not good evidence to prove this, but Dr. Feldman feels that exercising before surgery as little as taking four 30-minute walks a week relieves anxiety and helps patients get involved in the process of surgery. "Surgery is a stressor on the system, both physically and mentally. Education and exercise help prepare patients to deal with those stressors," she says.
- Optimize the use of regional anesthesia. When you develop your anesthesia and analgesia protocols, optimize the use of regional techniques, the benefits of which include improved pulmonary function, decreased cardiovascular demands, reduced ileus and improved pain relief, says Dr. Feldman. She calls this a stumbling block for many facilities because of the specialized training involved. Another tip: Use local, long-acting anesthetics in the wound before the incision is made.
- Use of minimally invasive procedures. The advantages of minimally invasive procedures are many, including less pain, shorter stays, faster recoveries, less blood loss, less scarring and frequently fewer complications.
- Minimize the incision length. Think about the location of the incision. In colon surgery, consider a transverse instead of a midline incision.
- Prevent hypothermia. Beyond patient comfort, keeping your patient warm reduces infection and the stress response.
- Prevent PONV. Have a structured approach to identify patients at risk for PONV. Avoid inhalational anesthetics and use IV anesthesia in high-risk patients.
- Standardize orders. You don't want to reinvent the wheel for each case. Standardize orders that you can modify as necessary. "It helps takes the confusion out when nurses in the recovery room know what they're doing for every hernia patient's post-op pain," says Dr. Feldman.
- Set PACU protocols. Standardize discharge criteria. "If Surgeon X wants hernia patients to urinate, but Surgeon Y doesn't, those two surgeons need to get together and standardize," says Dr. Feldman. Same goes for post-op pain relief, she says. "You can't have some surgeons using narcotics for post-op pain while others take a multimodal approach to anesthesia and use NSAIDs and acetaminophen around-the-clock for the first 48 hours."
Keep in mind that numerous studies have demonstrated that the combination of regional anesthesia, minimally invasive techniques and optimal pain control reduces patients' stress response and organ dysfunction and so shortens their recovery time. Hopefully, these tips will assist your fast-track surgery program. Or whatever it is that you call it.