From the operating room to home: A revolution in discharging patients
Anesthetics allow bypass of PACU and revised criteria
Same-day surgery (SDS) is on the verge of a change as dramatic as when patients who had been staying in the hospital after minor procedures began going home the day of surgery. Not keeping up with this new trend could mean losing the opportunity for a competitive edge in your marketplace.
It is the beginning of a revolution. With the widespread use of fast-acting, short-emergence anesthetic agents, such as propofol, some patients are able to walk out of the operating room and, within minutes, prepare for discharge. The result is quick discharge times that were once unthinkable.
SDS programs on the forefront of this trend are expected to benefit with substantial cost savings and greater efficiency that attract payers and patients.
Jeffrey Apfelbaum, MD, a Chicago-based anesthesiologist who has been at the forefront of pharmacologic and technological advances, recalls a fellow anesthesiologist who underwent a 41¼2 hour endoscopic sinus procedure.
"[The patient] was able to sit, stand, and walk away from the operating table," says Apfelbaum, who is professor and vice chairman of clinical affairs and director of outpatient surgery in the department of anesthesia and critical care at the University of Chicago Hospitals. "He went to the step-down unit, had a cup of coffee, and left with his wife 15 minutes later."
As an anesthesiologist, that patient was extraordinarily knowledgeable about his discharge and recovery needs. But others, such as cataract patients, are also capable of bypassing the postanesthesia care unit (PACU), Apfelbaum says. "We’ve been having some patients bypass the recovery room for five to eight years now," says Apfelbaum.
This month, Apfelbaum expects the first results from the "short-activating, fast emergence" (SAFE) study, showing the cost-savings of faster discharge. Apfelbaum notes that a PACU is essentially an intensive-care unit for postsurgical patients. That makes it extremely expensive and, for some patients, unnecessary, he says. (For more information on the SAFE study, see Same-Day Surgery, May 1996, p. 57. For contact information, see source box, p. 113.)
A shift toward faster discharge begins with patient education about what to expect with modern anethestics, Apfelbaum says. Patients have to know that a very short recovery stay is a possibility, he says. "They need to know that they may be so awake and alert at the end of surgery that they may not need intensive care," Apfelbaum says.
Discharge criteria need updating
To make way for shorter stays in the PACU and phase-two recovery, same-day surgery managers are reviewing their discharge criteria and removing outdated elements. For example, minimum stays in recovery and requirements for patients to drink or void may be unnecessary, anesthesiologists say.
In fact, even bypassing the PACU is based on standard discharge criteria that determine whether the patient is ready to proceed to the step-down unit or second-stage recovery, Apfelbaum says. (For a list of Apfelbaum’s discharge criteria, see above.)
"We believe that by using the exact same discharge criteria that institutions are using today, but assessing recovery at an earlier point in time, that anesthesiologists will find that their patients have in fact recovered to the same point that they would be ready for discharge," he says. "In many centers, this recovery is so rapid it actually is achieved while the patient is in the operating room."
What are the important discharge criteria? According to an as-yet unpublished study by Deborah Manzi, RN, research nurse coordinator at the department of anesthesiology at Hartford (CT) Hospital, doctors and nurses at the nation’s ambulatory surgery centers agreed on the importance of pain control, alertness, absence of bleeding, and the patient’s ability to take oral fluids.
Mandatory length of stay after depressant medication and ability to void ranked among the lowest priorities in discharge decisions.
In March 1994, Manzi sent a 48-question survey to medical directors and nurse managers at 365 freestanding surgery centers, including at least two in every state. She received responses from 259 sites, or a response rate of 71%.
Most of the surgery centers reported a trend toward faster discharge, but only 59% said they had revised their discharge criteria since 1990. Outdated discharge criteria create a quandary for nurses and SDS managers, Manzi says.
"If the nurses are pushed to get patients out, but the discharge criteria that allow them to discharge the patient haven’t been amended, they could be in jeopardy" from a risk-management standpoint, she says.
Manzi recommends that SDS managers form PACU work teams of nurses, physicians, and managers to focus on discharge criteria. They should review the criteria and compare it to what actually happens in the PACU and second-stage recovery. The written criteria may need to change to reflect current practice, she says.
"There’s a need for good communication between the medical director of the ambulatory surgery center and the nurses," Manzi says. "Overall, we found there was good agreement among physicians and nurses throughout the country. But when it came down to people in the same institution, they didn’t always agree on the content of their discharge criteria."
A scoring system can make the discharge criteria easier to use, says Frances F. Chung, MD, FRCPC, deputy anaesthetist-in-chief at The Toronto Hospital and author of the Post-Anesthesia Discharge Scoring System and Modified PADSS.1 (See box, p. 112.)
"If you have a scoring system, nurses are much more comfortable in tracking the patient because they have something they can point to," Chung says.
Chung reported that when used at her facility, the PADSS scoring system allowed 86% of patients to be discharged more quickly. The modified PADSS eliminates drinking and voiding requirements and allows even shorter PACU stays, she says.
Starting with the Aldrete method
At the Toronto Hospital, Chung first uses the common Aldrete method that assesses activity, respiration, circulation, consciousness, and skin color for phase one recovery. Then she applies the PADSS for discharge to home.
"We have been using it for many years, and it’s been very successful," she says, pointing to fast but safe discharge of more than 30,000 patients.
Even discharge criteria for pediatric patients are changing to allow much faster discharge. (For a related story on voiding and drinking, see p. 111.) For example, at the Children’s Hospital of Philadelphia, minimum stays in the PACU have dropped from an hour to 15 minutes for children who had mask anesthesia.
"I think what we’re going to move toward in the future is defining physiologic criteria when the child is wide awake, sending them home," says Mark S. Schreiner, MD, associate professor of anesthesia at Children’s Hospital and the University of Pennsylvania.
"I think time is an emotional issue for people," Schreiner says. "How could you send him home 30 minutes after this surgery?’ But if the child is awake and doing fine, why shouldn’t he go home?"
Reference
1. Chung F. Are discharge criteria changing? J Clin Anesth 1993; 5(Suppl 1):64S-68S.
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