1. Now You See Them, Now You Don’t:
The Case for Fast-Tracking
Ambulatory Surgery Patients
A Process Improvement Initiative
Andi Stamper, DNP, CRNA
Chuck Vacchiano, PhD, CRNA, FAAN
NCANA Annual Meeting
November 5, 2016
2. Project Objectives
1. Understand process improvement, the general steps to
achieve it, and its value to the institution
2. Be able to define “Fast-Tracking” and be aware of its
potential to shorten the institutional recovery process
3. Discuss the planning and implementation of a Fast-
Tracking process in a community hospital
4. Review the outcomes associated with adoption of a Fast-
Tracking process in a community hospital
3. Definition of Quality / Process Improvement
Quality improvement is the science of process management
Quality improvement concepts and techniques have been used to
transform almost every major industry in the world
The last holdouts, the are primarily healthcare, higher education,
and government
Healthcare is very complex
Made up of thousands of interlinked processes
Focus on patient care processes one at a time
Can fundamentally change the game and deal with the
challenges facing healthcare
“A bad system will beat a good person every time.”
W. Edwards Deming
4. Why Should We Be Concerned With
Process Improvement?
Patient outcomes and satisfaction
Financial incentives are increasingly tied to
improvements in quality and efficiency
Leads institutions to seek opportunities to improve
quality and efficiency in the practice setting
Shift from Cost-Based to Bundled payment
Leads to adoption of practices that will decrease
complications and cost
5. What Does Process Improvement
Look Like?
Area of Focus
Set SMART Goals
Specific, Measurable, Attainable, Relevant & Time-based
Design the Process
Conduct a baseline data analysis
Analyze the Process
Determine the Opportunity for Improvement
Create an Action Plan
Implement
Monitor the Process and Review the Data
6. What is the Point of Fast-Tracking?
Goal in our clinical setting:
To decrease the time Ambulatory
Surgery Patients spend in the
institutional postsurgical recovery
process
7. What is “Fast-Tracking?”
Assessing patients as they emerge from
anesthesia for readiness to “bypass” the
postanesthesia care unit and go directly to
an ambulatory care unit to facilitate a faster
discharge from the facility.
8. What Does the Literature Say About
Fast-Tracking?
Fast-tracking studied since1996
Multiple studies have demonstrated an increased PACU-
bypass rate upon implementation of a fast-tracking process
9. The Organizational Setting
Community Hospital Southeast U.S.
369-bed acute care facility
18 Operating Rooms (ORs)
10 Postanesthesia Care Unit (PACU) Beds
15 Ambulatory Care Unit (ACU) Beds
More than 4,000 Ambulatory Surgical (AS)
procedures performed each year
10. Existing Postoperative Recovery Policy
All AS patients must be admitted to the
PACU following emergence from
anesthesia
Discharged from the PACU to the ACU
Has not always been the practice
11. What is the Potential for Fast-Tracking Hospital
Based Patients Having Ambulatory Surgery?
40%
Total ACU Surgeries
Other Surgeries
U.S: 2006 there were 34.7 million ambulatory surgery visits, 19.8
million (57.2%) were hospital based
Project Site: ACU Visits Tracked for January and February 2013:
64%
Total ACU Surgeries
ACU Patients Eligible for
Fast-Tracking
ACU Patients NOT Eligible
for Fast-Tracking
12. Project Design
Introduce Fast-Tracking in a medium size
community hospital and determine its effect on
the postoperative recovery process and cost in
Ambulatory Surgery patients
Compare outcomes data
Before implementation of Fast-Tracking
(Reference Period)…..
……and after implementation of Fast-Tracking
(Implementation Period)
13. Project Objectives
Primary Project Objectives:
Compare outcomes before and after implementation of Fast-
Tracking:
PACU bypass rates
Incidence of “OR Hold”
Length of Postoperative Hospital Stay (LOS)
OR, Anesthesia and PACU cost
Secondary Project Objectives:
Examine patient Demographics and Comorbidities
Determine Inter-rater reliability of a tool to determine patient
eligibility to be Fast-Tracked
14. Project Methods Overview
Acquire “Buy In” from affected departments
Anesthesia, Nursing, Executive Administration
Develop a plan to implement the Fast-Tracking
process
Agree on inclusion criteria and method to be
used to determine a patient’s eligibility to be
Fast-Tracked
Initiate the “Reference” Period
Follow with the “Implementation” Period
See what happens!
15. History of Tools used to Assess
Patients for Transfer
1970: The Aldrete Score
1980: JCAHO Mandate
1995: The Modified Aldrete Score (MAS)
1999: The White Fast Track Score
(WFTS)
16. How Have These Tools Been
Applied to Fast-Tracking Research
Tools utilized in fast-tracking research
Modified Aldrete Score (MAS)
White’s Fast-Track Score (WFTS)
Incorporates the most pertinent variables of the MAS
tool
Adds pain and emesis assessments
Anesthesia and Analgesia. 1999
17. Original White Fast-Track Score Tool
Level of Consciousness 0 – 2
Physical Activity 0 – 2
Hemodynamic Stability 0 – 2
Respiratory Stability 0 – 2
Oxygen Saturation0 – 2
Postoperative Pain 0 – 2
Postoperative Emesis 0 – 2
Possible range 0 - 14
18. Our Modification of the WFTS Tool
Postoperative Pain
None or mild discomfort (0-3) 2
Mod. to severe pain controlled / IV meds (4-7) 1
Persistent severe pain (8-10) 0
Maximum Score 14
Fast Track Eligible:
Total Score ≥12
No category = 0
19. Project Methods Specifics
Inclusion Criteria
Ambulatory surgery patients
18 years or older
Type of Anesthesia:
MAC/IVA
Local Infiltration
Peripheral nerve block
Combination of these
Exclusion Criteria
Other than Ambulatory Surgery
General, spinal or epidural anesthesia
20. Project Methods Specifics
Reference Period (Pre-Fast Tracking)
75 patients over a 3 week period assessed with the
WFTS tool
Administered by Anesthesia providers in OR
Administered by nurses on admission to ACU
Patients followed current standard recovery process
ACU OR PACU ACU
WFTS WFTS
Data Collection
How many patients could have been Fast-Tracked
Incidence and duration of OR Hold
21. Project Methods Specifics
Implementation Period (Post-Fast Tracking)
75 patients over a 3 week period assessed with the
WFTS tool
Administered by Anesthesia providers in OR
Administered by nurses on admission to ACU
Patients who met criteria now Fast-Tracked
PACU
ACU OR
ACU
WFTS WFTS
Data Collection
How many patients Fast-Tracked
Incidence and duration of PACU Hold
Evaluate inter-rater reliability
23. Results: Demographics
Total of 150 patients evaluated for eligibility to be Fast-
Tracked during the Reference and Implementation
Periods
No difference between those patients who met Fast-
Track criteria (120) and those who did not (30) in:
Age
Gender
ASA Classification
History of PONV
Anesthesia type
Demographic Fast-Track Non Fast-Track
Age 56 58
Gender (M/F) 43/77 9/21
ASA Classification 1=16 1=2
2=65 2=14
3=38 3=13
4=1 4=1
History of PONV Yes= 21 Yes=4
No = 99 No=16
26. Results: PACU Bypass Rate
Project Period Ambulatory
Surgeries
#
Eligible for
Assessment
#
Met PACU
Bypass
Criteria
#
Reference 191 75 61 (81%)
Implementation 186 75 59 (79%)
81% Could Have Bypassed the PACU during the Reference Period
79% Actually Bypassed the PACU during the Implementation Period
27. Results: OR Hold Incidence & Duration
A significant decrease in the incidence and duration of
OR Hold during the Implementation Period
Project Period Incidence of
OR Hold
Duration in
Minutes
Reference 18 350
Implementation 3 23
28. Results: Length of Stay
ACU LOS significantly longer for the Implementation Group?
Total LOS significantly shorter for the Implementation Group
Group N Mean
Minutes
Time in
ACU
Reference Period FT Eligible 61 71
Implement. Period Actually FT 59 89
Total Time
Postop to
Discharge
Reference Period FT Eligible 61 106
Implement. Period Actually FT 59 94
29. Results: Comorbidities
No single comorbidity was associated with ineligibility for Fast-Tracking
The Fast-Track Eligible group had on average 1 less Total Comorbidity
than the Non Fast-Track eligible group
Combined Reference and Implementation Periods
150 Patients
Mean #
Comorbidities
Fast Track Eligible (n=120) 3.23
Non Fast Track Eligible (n=30) 4.47
30. Kappa Coefficient
Kappa 0.966
ASE 0.024
95% lower confidence limit 0.920
95% Upper Confidence Limit 1.013
Anesthesia Providers and ACU Nurses agreed that
patients met the WFTS Fast-Track criteria 98% of the time
Results: WFTS Inter-Rater Reliability
31. Cost Analysis
Baseline Cost Used in the Cost Analysis
PACU Stay Cost: $606.99
Operating Room Time: $62/min
Anesthesia Time: $4.05/min
Reference Period / 3 Weeks
61 Patients / 350 minutes of “OR Hold”
PACU Cost: $37,026
OR Hold-Room Time Cost: $21,700
OR Hold-Anesthesia Hold Time Cost: $1,418
TOTAL Cost: $60,143 / 3 Weeks
Potential Annual Savings: $1,042,494
“Although every hospital has a charge
master, officials treat it as if it were an
eccentric uncle living in the attic.”
33. Sustainability
Potential for sustainability is high
Inter-rater reliability of the WFTS allows
the population to safely bypass the PACU
34. Conclusions
Implementation of a fast-tracking protocol
in a community hospital can:
Increase workflow efficiency
Decrease costs
Patient
Hospital
Third Party Payers
Journal of PeriAnesthesia Nursing, 2015
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