John Radcliffe Hospital, Oxford OX3 9DU, UK, E-mail: jean.millar{at}nda.ox.ac.uk
Fast-tracking, or bypassing the recovery room or Post Anaesthesia Care Unit (PACU), is claimed to streamline day surgery with faster patient recovery time and discharge and therefore reduced cost, particularly in the office-based surgery now popular in the United States.15 Many fast-tracking studies have looked at different anaesthetic regimes to achieve fast-track criteria and whether this resulted in shorter recovery times in those patients who were able to bypass recovery.59 Cost savings were assumed if more expensive phase I recovery was avoided. In this issue Song and colleagues10 are the first to look at this more rationally by prospectively randomizing patients having a standard general anaesthetic to fast-track or conventional recovery, and looking at outcomes, which included recovery times and costing.
While cost savings appear to be the driving motivation for fast-tracking, we also need to know if fast-tracking is safe and feasible, if it has any direct benefits for patients, and whether it is applicable to different ways of working (and costing) in other health care systems than in North America.
The scoring systems used to determine fast-track eligibility require the same criteria as those used to determine discharge from the recovery area. The original Aldrete score,11 commonly used to measure recovery, only considered stable vital signs and alertness. White's fast-track criteria12 also include pain and emesis, common causes of delayed discharge from phase I recovery.8 This is the scoring system used in Song and colleagues' study.10 It does not include surgical complications. These criteria are similar to the criteria for discharge from the recovery area stipulated in the recommendations produced by the Association of Anaesthetists of Great Britain and Ireland.13
Reassuringly, almost certainly because fast-track criteria are the same as those for discharge from recovery, serious complications in the immediate postoperative period are not reported to be increased by fast-tracking. One patient14 is reported to have developed pulmonary oedema in phase II recovery, but no details are given of the time of onset and whether this would have been prevented by conventional recovery.
However, children who were fast-tracked were considered by parents to be more restless initially, and to have more pain, although not significantly so.3 The authors comment that the presence of the parents in the recovery room might have changed these results, as restlessness in the recovery room usually resulted in the child being given analgesia so that they were calmer and sleepier before returning to phase II recovery.
Fast-tracking puts pressure on anaesthetists to achieve this either by using more expensive anaesthetics or by cheating on fast-track eligibility. Nurses have commented that patients who were fast-tracked did not arrive with the criteria met.2 Patients having laparoscopy who were said to be fast-track eligible nevertheless did not end up being fast-tracked because of residual sedation,14 suggesting that they did not actually meet the criteria. Concerns have been raised about potential intra-operative awareness if anaesthetists feel under pressure to reduce anaesthetic dosage to achieve fast-tracking.15
Are there any benefits for the patient in being fast-tracked? In one large study, there were fewer complications in the fast-track group compared with those who were unable to be fast-tracked, principally less drowsiness, pain, nausea, and unplanned overnight admission.1 However, these results are predictable and biased because only 32% of patients having a general anaesthetic were able to be fast-tracked, and the ones who did not fulfil the criteria might be expected to have a more complicated recovery. Song's study10 is the only one prospectively to randomize patients to PACU or fast-track with a standard anaesthetic technique: there was no difference in postoperative complications.
In general, patients might be expected to fare better under good fast-tracking as in order to achieve it, they must receive a state of the art multimodal day surgery anaesthetic with NSAIDs, appropriate local analgesia, routine antiemetic prophylaxis, and rapid wake-up anaesthetics, often monitored with Bispectral or Auditory Evoked Potential indices to titrate dosage.16 17 The ability to fast-track has been investigated with short-acting but more expensive anaesthetic techniques using desflurane, sevoflurane, or propofol,5 6 14 remifentanil,9 17 and esmolol.9 However, it has generally been difficult to establish cost-savings with the use of shorter acting agents.18 Although patients may feel better, with reduced nausea and vomiting, and clinical recovery is perceived as improved, this may not translate into cost savings. The additional cost of propofol infusion may give better quality recovery and greater patient satisfaction,5 17 18 unless antiemetics, usually ondansetron, are given with the volatile agent.6
In the UK, day surgery usually means high throughput. If waiting to achieve fast-track fitness means that the patient remains in the operating theatre for longer, this could seriously compromise throughput and might cost more in the long run if fewer procedures can be carried out. The two Canadian studies2 10 found that theatre time was not increased in the fast-track group. However Song and colleagues10 comment that it is their standard practice that all patients should open their eyes to command before going to PACU. In the UK, patients are often taken to the recovery room asleep and with a laryngeal mask airway in placea different approach from that in North America. Where times to achieve fast-track eligibility have been given, these vary widely from a few minutes2 5 10 to much longer.1 16 In laparoscopic surgery, using auditory evoked potential index monitoring with a desflurane anaesthetic16 reduced the time to achieve fast-track eligibility from 56 to 29 min, times that would be unlikely to encourage the introduction of fast-track.
Even using expensive anaesthetics and fast-track criteria, only 3590% of patients actually manage to bypass the recovery room, depending on the surgery.2 14 In Song's study,10 97% of arthroscopy patients could be fast-tracked but only 72% of laparoscopies. Coloma and colleagues14 found that although 4194% of patients having laparoscopy were fast-track eligible according to the criteria, only 3553% actually bypassed recovery because of anaesthetic factors, mainly residual sedation, and surgical complications. Usually sicker or fatter patients and more major procedures are excluded from fast-track studies, despite an aging population and the drive to carry out more invasive surgery on a day case basis. What this comes down to is that fast-tracking does not eliminate the recovery roomit still needs to be available and staffed.
Once the fast-tracked patient reaches the ward area or phase II recovery they have been reported to be fit for discharge sooner. Usually the time difference is modest and varies according to the surgery: 3543 min earlier in minor surgery but no difference in laparoscopy.10 In another study, patients having laparoscopy had similar discharge times whether they were fast-tracked or not.14 Patients who are fast-tracked may need more nursing intervention once they reach phase II recovery;4 10 in other words, the nursing care was merely shifted. Small differences in time to being fit for discharge are probably meaningless to the individual patient and to the institution, as the patients do not leave immediately. Nursing processes and waiting for escorts increase the actual time to discharge.14
Fast-tracking seems to work best in small units with flexible staff who are used to working in phase I as well as phase II recovery. Nursing complaints about fast-tracking have been reported:2 nurses were not always available to take over the patient immediately, and patients did not always meet the criteria on arrival and were cold. Those in a hospital where they did not routinely do phase I recovery were more unhappy about fast-tracking. In compact Day Surgery Units where the staff are used flexibly, there might be some advantage, although probably little cost saving, in the staff caring for patients in the ward area rather that the recovery room. Where the operating theatre is some distance from the actual day surgery ward, there could be significant delays if the anaesthetist either had to go to the ward or wait for a nurse to come for the patient.
One advantage in fast-tracking would be if it reduced frequent log jams in recovery and promoted a better patient flow through the theatre suite. A common cause of delayed discharge from recovery in many hospitals is the non-availability of the ward nurse to come and fetch the patient. If the ward area was adjacent, there could be advantages in taking the patient straight there, but not if the nurse was unavailable to receive the patient. Throughput on fast-tracked lists because of delays in patient handover has not been measured and in Duncan and colleagues' study,2 anaesthetists were told not to expect immediate reception by the nurses.
Finally, the whole justification for fast-tracking is that it saves money. Savings in recovery room charges are assumed as the staff:patient ratio is higher than in phase II recovery. Small changes in time spent in recovery have already been shown to be unlikely to decrease staff costs.19 Dexter and colleagues20 used a computer simulation to estimate the effect of fast-tracking on staffing and costs. If phase I recovery is bypassed altogether, cost savings are complex to calculate and are dependent on how the staff are compensated (salaried vs hourly rate), on whether frequent overtime is routine, and on the throughput of patients. Case mix was not considered but is also likely to affect staffing. Money is only saved if nurses are either reduced in number or are not paid when they are not working. Unless large numbers of patients could reliably bypass the recovery room, recovery nurses cannot be dispensed with, and there must generally be a minimum of two when patients are present, representing an irreducible number of staff. A nurse costs exactly the same whether she is nursing a patient or waiting for one. And as shown before, fast-track does not guarantee that the recovery room is unneededno study has achieved 100% fast-track rate.
In Song's study,10 nursing interventions could be costed individually. Nursing workload and associated costs were not reduced and no savings were found. The same number of interventions was needed but took place in phase II rather than phase I recovery. Even if some patients are fit for recovery 45 min earlier, costs are unlikely to be reduced unless nursing hours can be reduced.
In the UK, fast-tracking would need to be evaluated carefully before introducing it. Subtle interactions in patient throughput, and the staffing and layout of day surgery facilities, together with potential delays in handover are likely to affect its economic success. However, for selected lists with a predictable patient populationsay, an arthroscopy liststaff scheduling might allow limited staff reduction. This would require careful planning and at least two nurses would still need to be available to staff the recovery room for failed fast-track patients.
We have all arrived in day surgery recovery with an alert comfortable patient and wondered why we did not just send them straight to the ward. Fast-tracking is an interesting idea. It is probably safe, provided that sensible criteria are adhered to. It is not feasible for all patients and procedures, limiting its use to selected lists. As Song and colleagues10 have demonstrated, it does not produce meaningful improvements in patient recovery or reduce cost. The layout of day surgery facilities and fast throughput of cases are also likely to affect its effectiveness.
More and better evaluation with properly randomized studies in different healthcare systems is needed before fast-tracking can be introduced into routine clinical practice.
References
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