OUTPATIENT SURGERY
Over 50% of all surgical procedures are performed on an outpatient
basis, which is safe and effective for properly chosen patients (also see Chapter
65
). These patients will need to be able to leave the facility shortly
after discharge from the PACU. Patients should always be accompanied by another
person. Because virtually all anesthetic techniques impair psychomotor skills, driving
or operating machinery should not be attempted for 24 hours.
Fast Tracking
Increasing efforts are being directed at having patients completely
bypass ("fast tracking") the phase 1 PACU after general anesthesia. The phase 1
PACU may or may not be a separate physical location from the phase 2 PACU. However,
it indicates a certain intensity of nursing care that requires a 1:2 nurse-to-patient
ratio, whereas a phase 2 PACU requires a 1:3 ratio or less.
Low-solubility inhaled anesthetics and propofol, the increasing
frequency of minimally invasive surgery, and titration of anesthetic drugs by using
the processed electroencephalographic bispectral index (BIS) (Aspect Medical Systems,
Natick, MA) may allow patients to be awake, alert, and mobile enough with no bleeding
or nausea at the end of an operative procedure such that they can safely bypass the
PACU.[195]
[196]
[197]
[198]
For example, a study of 302 patients receiving a propofol-alfentanil-nitrous
oxide anesthetic at four institutions found that patients in the BIS group required
lower propofol infusion rates, were tracheally extubated sooner (11.22 versus 7.25
minutes; P < .003), had a higher percentage of
patients oriented on arrival at the PACU (43% versus 23%; P
< .02), had better PACU nursing assessments (P
< .001), and became eligible for discharge sooner (37.77 versus 31.70 minutes;
P < .04).[199]
A separate study involved a multidisciplinary effort to safely increase bypass of
the phase 1 PACU after same-day surgery from 16% to 58% in three community-based
hospitals and two freestanding ambulatory surgical centers.[200]
The expected change in full-time nurse staff achievable by bypassing
the phase 1 PACU has been calculated by computer simulation.[201]
Computer simulation is a useful tool to address this issue because it allows one
to build an experimental model that will "act like" (simulate) the system of interest
(the PACU). Simulation models allow the user to characterize a real-world situation
as a system of formulas that reflect the relationships among the various components
of the situation, including the uncertainties and dynamic interdependencies that
make the problem difficult to solve. The simulation model can then be run multiple
times with varying parameters to address "what if?" questions ( Fig.
71-14
).
The simulation model predicts that the bypass rate would have
to increase by at least 40% to 80% to reduce the required number of staff. To achieve
this objective, two thirds of the 60% of patients receiving general anesthesia would
need to bypass the PACU ( Table 71-6
).
PACUs can substitute values appropriate for their institution into the table. Let's
take the example of an ambulatory surgery center that cares for approximately 20
patients each day. Forty percent of patients who undergo monitored anesthesia care
bypass the phase 1 PACU. Patients admitted to the phase 1 PACU have an average length
of stay of 30 minutes. Patients are typically discharged from the phase 2 PACU to
home in 1 hour. The PACU employs five full-time nurses. The potential benefits
of fast tracking need to be considered against any possible disadvantages such as
the perception by patients that they are being rushed out of the PACU too quickly.
