Here are seven innovative ways to move more patients directly to the secondary stage recovery unit (SSRU), thereby bypassing the postanesthesia care unit (PACU) and saving your facility time and money.

Improved screening and education
Fast-tracking criteria can be either patient-based, procedure-based or both, says Larry Grossman, MD, a Philadelphia-based anesthesiologist and a surveyor for one of the major accreditation agencies. Cases that generally pose lower risks of complications and PONV, such as hand and podiatric surgery and orthopedic procedures such as shoulder arthroscopy, are excellent fast-tracking possibilities.

In the patient-based mode, everyone is potentially eligible for fast tracking, regardless of the procedure or anesthetic method. Facilities eliminate candidates with significant morbidities, those who are unusually anxious or who have poor home support systems. For example, if the patient lacks timely transportation home, faster discharge doesn't make much sense.

Until recently, you probably wouldn't have even considered fast-tracking a general anesthesia procedure such as laparoscopic GYN surgery. The risks of post-op pain and PONV were simply too high. But that's slowly changing. Margarita Coloma, MD, and her colleagues at the Department of Anesthesiology and Pain Management at the University of Texas Southwestern Medical Center in Dallas, looked at 92 healthy women who underwent outpatient laparoscopic surgery under general anesthesia. They found that 78 percent of the patients were fast-track eligible after screening and 68 percent of these patients successfully bypassed PACU.

Staffwide participation and education about fast-track criteria are crucial. Dr. Apfelbaum and colleagues used SAFE (Short Acting Fast Emergence) anesthetics for ambulatory surgeries involving nearly 5,000 patients in five hospitals and surgicenters. Within a month of completing facility-wide education, the fast-tracking rate jumped from 15.9 percent to 58.9.[1]

Refined PACU bypass criteria
Anesthesia providers commonly use such measurement scales as the Aldrete scale to assess patients' readiness to move from one stage of care to the next. With the rise of fast tracking, providers have tweaked some of these well-established scales to more accurately and efficiently measure patients' ability to bypass PACU.

One measurement tool specifically designed for fast tracking is a scale that combines a modified Aldrete scale and post-anesthesia discharge scoring system (PADSS) (see "Two Measurement Tools: The Aldrete Scale and PADSS"). The scale, as discussed by Rebecca Twersky, MD, of Brooklyn, N.Y., condenses the 10 criteria of the two different scales into a single seven-category scale.

In the "fast-track" scoring system, the provider assigns points on a scale of 0 to 2 for the patient's level of consciousness, physical activity, hemodynamic stability, oxygen saturation status, postop pain control, PONV symptoms and respiratory stability. To bypass PACU, the patient must have a postop score of 12 points (of a maximum 14), without a zero in any category.[2]

Use of SAFE inhalational anesthetics
While they cost more to purchase, some of the newer anesthesia agents have gained the reputation of being ideal for fast tracking because patients completely and quickly metabolize the drugs and wake up clear headed. For example, compared to some other IV and inhalational anesthetics, propofol, desflurane, sevoflurane and remifentanil all provide superior recovery periods. According to Dr. Twersky, there is not a significant difference with respect to the later recovery "end points" that would be experienced in Phase II care. Rather, the potential time savings are in transport readiness from OR to PACU and PACU to SSRU.

In the SAFE study, however, Dr. Apfelbaum and the other researchers found that the average time fast-tracked patients spent in the SSRU was "significantly shorter" than for patients who did not bypass PACU, with no significant differences in patient outcomes.

Strategic PONV prophylaxis
Dr. Grossman notes that there are numerous PONV prophylaxis strategies available to avoid PONV-related PACU stays. Here are two of them:

• Improved criteria for determining at-risk patients and procedures. Across-the-board use of antiemetics is neither cost-effective nor clinically effective. Current research has identified those with histories of PONV and/or motion sickness, those with preop nausea, young females, non-smokers and the obese as being at higher risk for PONV. Likewise, higher PONV rates are associated with ENT surgery, laparoscopy, major breast procedures, intra-abdominal and GYN surgery. Providers are now planning prophylaxis strategies accordingly.
• Use of NSAIDs. The pre-op and postop use of non-steroidal anti-inflammatory drugs, especially the so-called Cox-2 inhibitors (such as rofecoxib [Vioxx] and celecoxib [Celebrex]), has become a simple but effective way to provide PONV-free analgesia to fast-track patients, reducing the need for opioids. Experts caution, however, that even the Cox-2 NSAIDs (which are associated with much lower risks of stomach distress than traditional NSAIDs) are not magic bullets and are contraindicated in patients with hypertension and kidney and liver diseases.

Increased use of peripheral nerve blocks
The growth of ambulatory fast tracking has led to a significant rise in facility demand and practitioner interest in regional anesthesia, either as the sole technique or as an adjunct to other anesthetics. The reasons:

• Improved fast-tracking odds. Admir Hadzic, MD, and colleagues in the Department of Anesthesiology at St. Luke's-Roosevelt Hospital Center in New York conducted a study of 51 patients undergoing same-day knee arthroscopy. Twenty-five patients received a peripheral nerve block (lumbar plexus/sciatic block) with propofol sedation and the other 26 received a "fast-track general" anesthetic (Propofol/ Desflurane/LMA), followed by an intraarticular injection of bupivicaine. A PACU nurse unaware of the type of anesthesia and the goals of the study graded the patients' PACU bypass eligibility. The result: 72 percent of patients in the nerve-block group were successfully fast-tracked, as opposed to 24 percent of the general anesthesia group.[3]
• Reduced use of opioids. While drugs such as fentanyl have a rapid onset of action and excellent analgesic and sedative properties, these drugs also can have many adverse effects. These include protracted PONV, respiratory depression, apnea, muscle rigidity and bradycardia. Properly administered, regional anesthesia (such as interscalene, infraclavicular, femoral and popliteal blocks) can be a valuable way to reduce these risks. Regional blocks can foster sufficient pain control and thus significantly reduce the need for opioids. Regional blocks provide lighter sedation, rapid awakening and much lower incidences of PONV, according to Eugene Viscusi, MD, the director of acute pain management and regional anesthesia at Thomas Jefferson University Hospital in Philadelphia. A regional anesthetic can provide pain relief for as long as 18 hours postoperatively.
• Lower PONV rates. While regional anesthesia can't eliminate PONV, it can dramatically reduce it. Nathan Schwartz, MD, and Emil Dilorio, MD, who practice in the Allentown, Pa., area, note that they admit about 4 percent of patients at their orthopedics ASC to the hospital because of excessive PONV after general anesthesia. Since switching to exclusive regional anesthesia, the PONV rate dropped below 1 percent with no admissions. Patients in the pre-op "block room" typically receive a low dose of Versed or Propofol with the regional injection.
• Lower cost. The cost for a one-hour inhalational anesthetic is about $100 compared to about $15 for a regional block with local agents such as lidocaine, say Drs. Schwarz and Dilorio.
• Faster overall discharge time. One of the main knocks on regional anesthesia is that the blocks take a long time to work. If the anesthesia time takes too long, and the OR is held up waiting for the case, the savings go out the window. As expensive as the PACU is, the OR is the most expensive piece of real estate in the facility. Facilities overcome this drawback by having the patient come in early to have enough time to administer the block. Dr. Viscusi's facility has three block rooms. Patients come in an hour before surgery, and the block is administered about 15 to 30 minutes before surgery. This way, he says, "the ORs have to catch up with us."

In Dr. Hadzic's study, the induction time for the regional anesthesia patients was somewhat longer (12 vs. eight minutes), causing slightly longer surgical times. However, because patients were conscious and ambulatory sooner, total OR time was shorter (97 vs. 91 minutes), patients attained home readiness significantly faster (62 vs. 94 minutes) and discharges were quicker (72 vs. 96 minutes), with superior pain control.

Of course, no single anesthesia is perfect in all cases, and there are risks associated with improperly administered regional anesthesia. "Although there are relatively few reports of serious complications from regional anesthesia, the risks are real," Dr. Hadzic says. "The proper training and equipment are the best means to avoid them."

With repetition, practitioners who only wish to use regional blocks as an adjunct to general anesthesia can become sufficiently adept at safely providing basic blocks to see positive results, adds Dr. Viscusi.

Better equipment
An even more dramatic, if controversial example, is the use of "consciousness" monitors (such as the Bispectral Index monitor, Patient State Analyzer 4000 or SNAP handheld EEG monitor) to facilitate rapid and smooth emergence by reducing the amount of anesthetic needed for sedation. Monitor proponents swear by their ability to assist in shorter, safer, cheaper anesthesia that, in the ambulatory realm, is often conducive to fast tracking. One study that compared desflurane- and propofol-infused GYN patients found that those who underwent BIS monitoring and vital-signs monitoring could more reliably be predicted for PACU bypass eligibility.[4] Detractors, however, say BIS monitors are too expensive and that you can fast-track cases at virtually the same rates without them.

Regional anesthesia has also progressed. Nerve block needles have gotten much better, as have nerve stimulators, say Drs. Viscusi and Hadzic. Nerve stimulators elicit specific and objective responses for the provider, leading to increased precision in applying blocks.

Integration of CRNAs
Nurse anesthetists can apply patient perioperative assessment criteria, monitoring, analgesic administration, IV and general anesthesia, says Sandra Tunajek, ND, CRNA, the director of practice for the American Association of Nurse Anesthetists. While a CRNA cannot write a post-op prescription, the surgeon or an anesthesiologist can, depending upon the practice.

Dr. Viscusi's facility uses a care team approach in cases involving regional anesthesia. The physicians perform the blocks in advance outside the OR and then the CRNAs take over as part of the care team. "Docs and CRNAs working together really facilitate OR turn-around," he says.

References:
1. Apfelbaum, Jeffrey L. "Current Controversies in Adult Outpatient Anesthesia." Lecture at American Society of Anesthesiologists Conference, Orlando, Fl., October 2002.
2. Twersky, Rebecca S., "Recovery and Discharge of the Ambulatory Anesthesia Patient." Lecture presented at American Society of Anesthesiologists Conference, Orlando, Fl., October 2002.
3. Visan A, Hadzic A, Vloka J, Hobeika P, Karaca P, Santos AC, Thys DM. "Peripheral Nerve Blocks (PNB) are Superior to General Anesthesia (GA) in Reducing Intensive Postoperative Care in Same-Day Knee Arthroscopy Patients," 2003 (conference presentation pending).
4. Song D, van Vlymen J, White PF. The Bispectral "BIS" Index Predicts Fast-Track Eligibility After Ambulatory Anesthesia" Anesthesiology 1998;89:A16.