Surgical fast-tracking: When is it beneficial?
Rapid recovery could save $7.39 per case
To speed up the recovery process of surgery patients and decrease staffing costs, many hospitals have embraced fast-tracking — keeping patients in a lightly anesthetized state so they regain consciousness sooner than they would under heavier anesthesia. But is fast-tracking patients a good idea under all circumstances?
Researchers led by Franklin Dexter, PhD, MD, at the University of Iowa College of Medicine in Iowa City, studied the economic benefits of fast-tracking patients in hospitals. The researchers found variable results; depending on how staff are paid, the strategy may or may not save an institution money. They also concluded that results depend on how many operating rooms (ORs) routinely run concurrently and on how many patients undergo general anesthesia.1
Before hospitals were forced to become thrifty, patients usually spent days in the hospital following surgery. Now, many walk out an hour or two after waking up. The sped-up process is enabled by fast-tracking. Patients wake up more quickly, leave the OR sooner, and may not have to stay in the recovery room as long as if they were heavily sedated. Fast-tracking is embraced as a way to decrease an institution’s costs while maintaining quality care because less staffing time is required.
Dexter, associate professor of anesthesia at University of Iowa College of Medicine, used computer simulation to address two questions:
• What is the decrease in an OR staff if the time from which surgery is completed to the time the patient leaves the OR is decreased?
• What is the decrease in post-anesthesia care unit (PACU) nursing staffing if patients proceed from the OR directly to the phase II PACU, bypassing phase I PACU (where the length of stay may be 30 minutes to an hour)?
Dexter and his colleagues found that whether fast-tracking allows a hospital to reduce staffing costs depends upon the institution’s labor payment structure. If a hospital pays its staff an hourly rate and the fast-tracking reduces substantial overtime, the decrease in labor costs can be significant. But if a hospital pays a set salary, the time savings may not translate into financial savings. Their results showed potential decreases in a center’s labor costs to be $7.39 per case.
"Characteristically, the cost of care in the surgical suite is charged and/or apportioned proportional to the time that a patient is in the OR or PACU," says Dexter. "However, this does not mean decreasing the time in the OR or PACU will decrease costs proportionately. Generally, it does not."
Dexter wrote that what his team really found is that there is no one, single answer. "The economic impact is going to vary among institutions depending on how people are paid," Dexter wrote. "Many hospitals and ambulatory surgery centers are considering the adoption of new medicines and monitors so that their patients can leave within an hour or two after surgery. These institutions can use our analysis to better predict the financial impact of this fast-tracking."
Some new anesthetic agents permit more rapid anesthetic recovery after general anesthesia. "For example," says Dexter, "patients recover more rapidly with the newer volatile anesthetic desflurane than with the older agent isoflurane."
Dexter’s study was funded in part by Aspect Medical Systems in Natick, MA, which has developed technology to measure a patient’s level of consciousness during surgery. The company’s BIS (Bispectral Index) monitor helps anesthesia staff titrate the dose of the anesthetic agent precisely so patients are given just enough medication to keep them unconscious during surgery, but in a state from which they can awaken soon after the procedure.
According to Dexter, there is no other such product on the market that measures the patient’s depth of anesthesia. "Many clinical studies have been performed showing [the BIS monitor’s] clinical efficacy," he says.2 The U.S. Food and Drug Administration approved Aspect Medical Systems’ single-use, disposable BIS Sensor Plus on Feb. 23.
Dexter suggests that if OR managers are considering an investment in a new technology to decrease labor costs, such as a BIS monitor, they should contact a consultant to run a financial analysis of their fast-tracking plans. The analysis would include the use of a computer simulation that incorporates institution-specific figures.
Hospital Case Management asked Dexter if any harmful effects have been documented regarding the use of the newer volatile anesthetics. "I am not aware of any harmful effects from having patients recover more quickly from general anesthesia," he answers. "Most research focuses on determining the magnitude of the benefit of having patients recover more quickly. We do not fully understand how to balance . . . the benefits of more rapid recovery from general anesthesia vs. the increased cost from using the newer pharmaceutical products and the BIS monitor itself."
Is there a danger of a patient waking on the surgery table? "There is no data suggesting that the use of monitors and agents that permit more rapid awakening of patients after the end of surgery increases the risk of awakening during surgery," he says.
Despite the varied financial implications, Dexter says he thinks fast-tracking is here to stay. "From the patient’s point of view, it’s an advantage because it gets them out of the hospital quicker so they can be at home, be with their families," Dexter says. "From a hospital’s point of view, even if large decreases in costs cannot be expected, fast-tracking will increase the productivity of the work force so staff members can do other things with their time. It may not cut costs, but rest assured that it is going to increase productivity."
As an example, according to Wendy O’Dea, spokeswoman for Aspect Medical Systems, 71% of the cases at Community Hospitals in Indianapolis are fast-tracked (4,380 cases out of 6,128 per year).
For more information, contact Franklin Dexter, PhD, MD, department of anesthesia, University of Iowa College of Medicine, Iowa City. Telephone: (319) 356-1616. E-mail: [email protected].
References
1. Dexter F, Macario A, Manberg PJ, et al. Computer simulation to determine how rapid anesthetic recovery protocols to decrease the time for emergence of increase the Phase 1 postanesthesia care unit bypass rate affect staffing of an ambulatory surgery center. Anesth Analg 1999; 88:1,053-1,063.
2. Flaishon R, Windsor A, Sigl J, et al. Recovery of consciousness after thiopental or propofol. Anesthesiology 1997; 86:613-619; Glass PS, Bloom M, Kearse L, et al. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology 1997; 86:836-847.
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