Fast-track surgery pleases patients, saves resources

Clinicians caution against unrealistic expectations

A new way of integrating technology with the art of medical practice has led to shorter wake-up times following general anesthesia. Known as "fast-tracking," the technique usually enables patients to bypass the phase I post-anesthesia care unit (PACU). They can leave the outpatient or inpatient surgical area, sometimes as soon as one hour.

Given shorter lengths of stay in the surgical unit, researchers suggest that salaried staff are freed up for other tasks and hourly personnel work fewer hours. While it’s logical to predict fast-tracking represents the future of anesthesiology practice, the arguments against it are worth considering. Experts are not entirely united in their support of the innovation.

The tool that enables fast-tracking is the Bispectral (BIS) Index, developed by Aspect Medical Systems in Natick, MA. A sensor strip, attached to the patient’s forehead, continuously measures the depth of the hypnotic state through EEG patterns or brain waves. The BIS monitor records and displays them as nu-merical values on a screen.

The real-time data allow the anesthesiologist to titrate anesthesia dosing with greater precision than the conventional methods of monitoring blood pressure, heart rate, and taking into account the patient’s physical characteristics.

BIS monitoring has been commercially available since 1998. While further studies of the potential cost savings are in progress, clinicians who discussed fast-tracking with QI/TQM are cautiously optimistic about its value.

In a recent study,1 researchers built a computer simulation model for calculating the potential cost benefits of fast-tracking. "[The model] takes the values of three- to six-minute savings per case and translates the small cost savings into personnel planning data for ambulatory surgery centers," explains Paul Manberg, PhD, vice president of clinical, regulatory, and quality assurance for Aspect Medical Systems. Manberg is a member of the research team; Aspect Medical Systems sponsored the study.

The research identifies several variables that determine the cost savings with fast-tracking:

• Staff compensation patterns in an ambulatory surgery facility. Decreased labor costs depend on whether staff are paid on salary or on hourly rates.

• Reductions in PACU nurse staffing achieved when patients go directly from the operating room to phase II PACU, bypassing phase I PACU. (In phase I PACU, care resembles that given in an intensive care unit.)

• Delays in surgical support processes such as wait times for test results, prescriptions, transport of patients out of the surgical area, or physician release allowing patients to go home.

• Number of patients anesthetized each day.

For ambulatory surgery centers, the study shows potential labor cost savings of $7.39 per case from the combination of new anesthetics and BIS monitoring. Those savings are most likely to occur at centers staffed by full-time nurses who are frequently required to work overtime.

It’s different in hospitals, notes another investigator on the study, Alex Macario, MD, MBA, Assistant Professor of anesthesia and health research and policy in the department of anesthesia of Stanford (CA) University School of Medicine. "Most of the costs in a hospital are overhead or fixed costs. So if you reduce patient time, you will not be saving a lot of dollars because you have to have the staff there anyway." However, the researchers suggest that fast-tracking could increase productivity by freeing staff for other work when they are not taking care of patients.

The study looked at staffing and clinical practice models originally designed for standard progression of patients through phase I and phase II PACU care. Other clinical and patient satisfaction features of fast-tracking make it attractive enough that clinicians foresee wider use.

If it becomes the norm, it could determine the architectural design of ambulatory and inpatient operating room suites in years to come. (One hospital already has made such a change. See "Brain wave monitor fine-tunes anesthesia doses," p. 28.) As data emerge from surgical units specially designed for fast-tracking, we may see different results than what present studies show. Meanwhile, clinicians familiar with fast-tracking like the quality improvements they see.

Clinical implications of fast-tracking

For patients to bypass phase I PACU, the surgical and postoperative procedures have to work like a tightly choreographed dance. "Fast-tracking forces you to do the QI process," observes Macario. "The physicians and nurses have to collaborate. It forces us to institute pathways that can eliminate duplicate tests and unnecessary steps. For example, if a cardiac bypass patient is to be extubated within four to six hours in the ICU, we have to talk about what needs to happen in the operating room."

Post-surgical pain management is another critical element of a fast-tracking plan, adds Suzanne Richins, RN, MBA, FACHE, director of Patient Care at McKay-Dee Hospital in Ogden, UT. The surgeon and anesthesiologist need to collaborate on medication plans because if the patient requires narcotics for postoperative pain, it negates the benefits of fast-tracking, she notes.

Though fast-tracking, by definition, bypasses phase I PACU, protocols must include procedures for emergency phase I PACU care. A patient can go into crisis in seconds, and there’s no time to call in special staff or equipment. "If someone goes badly in fast-tracking, you need airway management equipment close by," Richins points out. "While you don’t need the one-to-one patient-to-equipment ratio as in regular anesthesiology, the fast-tracking staff have to be equally trained to use the equipment."

Patient satisfaction could be pivotal factor

The consensus among those QI/TQM talked to is that patients want to spend the least possible amount of time in a medical facility. Richins cites data from patient surveys at McKay-Dee Hospital, which indicate equal satisfaction with surgery involving general anesthesia or fast-tracking. "We’ve had no complaints about fast-tracking." She calls it "perfect" for outpatient surgery, if followed by high-quality post-surgical pain management.

Franklin Dexter, MD, PhD, associate professor in the department of anesthesia at the University of Iowa in Iowa City, says his impressions of patient satisfaction concur with McKay-Dee Hospital’s data. Dexter is part of the research team that conducted the cost-savings study. "In my experience, patients are more satisfied with fast-tracking for ambulatory surgery, although I have no scientific studies to back it up," he says.

Prerequisites to high satisfaction include well-aligned patient and family expectations. "The patient and family need to expect that a patient who is undergoing monitored anesthesia care may be leaving an hour after the end of surgery." Another key is thorough education about home care, Dexter adds.

Wave of the future? Well, maybe

While they agree that fast-tracking holds great promise, health care professionals are not blind to the pressures that could temper widespread use. Dexter describes the clinical concerns of anesthesiologists and nurse anesthesiologists, for instance.

Patient safety could be jeopardized if the phase I and phase II PACU areas were separated. It could delay the availability of a crash cart or breathing equipment when seconds count.

"Another concern of many anesthesiologists and administrators of surgical suites is that billings could decrease with fast-tracking." Dexter says that if anesthesiologists and nurse anesthetists spend less time performing their clinical services, their billings decrease. With respect to a surgical facility’s billings, it would depend on whether its anesthesia fee is calculated partly on the length of time patients are anesthetized. If part of the facility’s anesthesia fee depends on time, then decreasing the duration of anesthesia time will decrease billings.

Macario says it’s too early to predict whether fast-tracking will be the norm in the future. "Typically, we might spend $35 to $45 for anesthesia drugs and supplies to put an outpatient to sleep for surgery. Each anesthesiologist and surgical suite needs to determine whether the extra $12 to $15 per patient [for the nonreusable BIS Sensor strip] provide enough value to ensure routine use."

On the other hand, Macario notes, patients often request fast-tracking because the innovation has garnered considerable media coverage. "But whether it will be used routinely in the future is still unknown."

Richins leans toward the odds of wider application of the practice. "Pharmacology [associated with surgery] will continue to improve. Fast-tracking will reduce the length of stay, and that will result in labor cost savings."

While Dexter admits "I have a personal bias that fast-tracking is the way to go," he cautions surgical units not to adopt it without spelling out their objectives and weighing them against the proven benefits of fast-tracking. (See "The business side of surgical fast-tracking," p. 29, for the typical objectives for fast-tracking and conditions for achieving them.)

Reference

1. Dexter F, Macario A, Manberg PJ, et al. Computer simulation to determine how rapid anesthetic recovery protocols to decrease the time for emergence or increase the phase I post-anesthesia care unit bypass rate affect staffing of an ambulatory surgery center. Anesth Analg 1999; 88:1,053-1,063.

Recommended reading

1. Gan TJ, Glass PS, Windsor A, et al. Bispectral Index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia. Anesthesiology 1997; 87:(4)808-815.

2. Song D, Joshi GP, White PF. Titration of volatile anesthetics using Bispectral Index facilitates recovery after ambulatory anesthesia. Anesthesiology 1997; 87:(4)842-848.