1) A community hospital implemented a process to fast-track eligible ambulatory surgery patients by bypassing the post-anesthesia care unit (PACU) and sending them directly to an ambulatory care unit (ACU). 2) In the reference period before implementation, 81% of patients were eligible for fast-tracking based on a scoring tool. After implementing the fast-tracking process, 79% of patients bypassed the PACU, with decreased incidence and duration of operating room holds. 3) Length of stay in the ACU and total postoperative time were reduced in the implementation period. The process improvement was estimated to save over $1 million annually and demonstrated potential for sustainability through standardized eligibility criteria.

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

22. Project Timeline
Reference
Period
(3 Weeks)
Implementation
Period
(3 Weeks)
Education
Period
(5 Weeks)
Data Analysis
Period
(5 Weeks)
March 13 –
April 21
April 21 –
May 5
May 6 –
May 26
May 27 –
June 30
2013

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

24. Results: Variety of Procedures
 GYN
 Urology
 Ophthalmologic
 Orthopedic
 Neurologic
 Vascular
 MRI

25. Results: Patient Comorbidities
 Categories / Most Common Comorbidities
 Cardiovascular
 Hypertension
 Respiratory
 Smoker
 GU / Endocrine / Musculoskeletal
 Diabetes
 Reflux
 Neurologic
 Neuropathy

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.”

32. Limitations
 Provider Practice
 Work Culture

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

35. Questions?

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