From anesthesia to throughput, the term fast-tracking can have several meanings. In this case, we're referring to the process of bypassing Phase 1 of post-operative recovery and taking appropriate patients directly from the operating room to Phase 2 or the pre-discharge phase of their recovery. As you'll see in these 6 tips for success, it has everything to do with your anesthesia and nursing teams working in tandem.

1. Have an objective patient scoring system and use it consistently.
Unless your anesthesia providers and the perioperative nurses are all on the same page, you can't have an effective fast-tracking program. To ensure that all fast-tracked patients are evaluated using the same criteria each time, I suggest you create a scoring system, on paper or on the EMR, so that you have an objective measure for fast-tracking patients. It also gives the nursing staff a quick idea of the condition of the patient and why the anesthesia provider decided to fast-track the patient.

The Aldrete scoring system is the most commonly used system for determining when you can safely transfer patients from Phase 1 to Phase 2 of recovery. While this system addresses a patient's mental and cardio-respiratory status, it doesn't include an assessment of post-operative pain control or nausea. These very important factors must be taken into consideration when determining a patient's appropriateness for Phase 1 bypass.

Simply adding post-op pain and PONV categories to the existing 10-point Aldrete score remedies this problem. Consider adding a 2-point pain score with 0 points for severe pain, 1 point for moderate to severe pain requiring IV analgesics and 2 points for no or mild pain. Similarly, you can add a PONV score, with 0 points for persistent nausea and vomiting, 1 point for transient vomiting or retching and 2 points for no or mild nausea. You now have a 14-point scoring system that anesthesia providers can use to evaluate a patient before leaving the operating room. Patients with a score of 13 or more are appropriate to bypass Phase 1 of recovery.

2. Start post-op teaching in pre-op.
Remember that any time you may save bypassing Phase 1 can be lost during the necessary steps of traditional PACU discharge procedures. Although a patient may meet discharge criteria, he may still have some short-term memory issues that can make discharge instructions difficult to remember just a few minutes after receiving them. You can save time after surgery by starting the discharge process before surgery. Give the patient and family post-operative instructions when they arrive and send them home with written instructions before discharge. For example, if an orthopedic patient is going to use a cold therapy unit at home, staff can show the patient and family how it works before surgery, when the patient and family are more likely to remember it.

3. Use regional anesthesia whenever possible.
Regional anesthesia, accompanied by sedation or light general anesthesia, has been shown to reduce wake-up time in the OR, minimize PONV and provide superior pain control without the need for parenteral narcotics. These 3 factors are key in any successful fast-track program. In addition, since the patient has no surgical pain, the anesthesiologist can turn off the sedation before the surgical dressings are on. This will give the patient more time to fully wake up before leaving the operating room. If your anesthesia providers are able to place perineural catheters in your orthopedic patients, these can be attached to ambulatory pain pumps to provide excellent, prolonged post-operative pain control.

4. Have your surgeons infiltrate local anesthetics into wounds.
Do this whenever possible, but it's especially helpful for portal incisions, wound closures, intra-articular spaces and tissue beds. The local anesthesia will let your anesthesia provider turn off the sedation or general anesthesia sooner, and will lessen the need for narcotics. As a result, the patient will awaken more rapidly with less pain and less risk of PONV.

5. It's better to prevent PONV than to treat it.
We all know that PONV is among the most frustrating side effects of general anesthesia, for both the patient and the nursing staff. The greatest risk factors include being female, being a nonsmoker, having a history of PONV or motion sickness and the use of volatile anesthetics or opioids. Plus certain types of surgery, such as eye, maxillofacial, abdominal, gynecological and urologic, are also associated with an increased risk of PONV.

The Society for Ambulatory Anesthesia's guidelines for the management of PONV, published in 2007, call for risk assessment, risk reduction and aggressive prophylaxis for patients at risk. While low-risk patients scheduled for low-risk procedures may not need prophylaxis, almost all other patients will benefit from it. Adequate hydration is also very important, since relative dehydration is associated with increased PONV.

The best way to prevent PONV is to avoid the use of nausea-producing anesthetics. Regional anesthesia with benzodiazepine or propofol sedation poses very little risk of causing PONV. When this is not possible, prophylaxis is necessary. The most-common drugs used to prevent PONV are the 5-HT3 receptor antagonists (ondansetron and dolasetron), steroids (dexamethasone), butyrophenones (droperidol) and anticholinergics (transdermal scopolamine).

For patients at moderate-to-severe risk, SAMBA recommends a combination therapy of drugs with different mechanisms of action. The most widely studied combinations use a 5-HT3 receptor antagonist with either dexamethasone or droperidol. Ideally, dexamethasone should be given at induction. Droperidol and the 5-HT3 antagonists are given at the end of the surgery.

In our practice, all patients receiving general anesthesia receive 4mg to 5mg of dexa-methasone at induction and 4mg of ondansetron at the end of the surgery. Since we've standardized this practice, our incidence of PONV has become very low. For patients at extremely high risk, such as those with a history of PONV despite aggressive prophylaxis, consider using total intravenous anesthesia.

6. Use a consciousness monitor with general anesthesia.
The routine use of consciousness monitors has been controversial for some time. However, several studies demonstrate that BIS-guided emergence from propofol or desflurane anesthesia results in faster awakening, an improved recovery profile and a higher percentage of patients meeting fast-track criteria. If your facility receives lots of general anesthesia patients, I say it's worth looking at the cost-benefit ratio of using this technology.

Give it a try
Incorporating these 6 tips into your facility's practice can result in increased patient throughput and perioperative efficiency as well as improved patient and staff satisfaction. It is important to monitor outcomes in your particular center, and to adjust procedures as needed. These steps have worked extremely well in our facility, and I believe they can work just as well in yours.