Patel, Ramesh I. MD*,; Verghese, Susan T. MD*,; Hannallah, Raafat S. MD*,; Aregawi, Azeb RN†,; Patel, Kantilal M. PhD‡
With the use of rapid and shorter-acting drugs, patients are often awake and breathing adequately in the operating room (OR). Many patients will have met the traditional postanesthesia care unit (PACU) discharge criteria when they leave the OR. Yet these patients are still routinely required to go to the PACU before they are transferred to the second-stage recovery unit (SSRU).
“Fast-tracking” is a term used to describe a process wherein patients who meet specific criteria while still in the OR are allowed to bypass the PACU and proceed directly to the SSRU after surgery. Ambulatory patients are discharged home directly from the SSRU. Bypassing the PACU and reducing the length of the SSRU stay are crucial elements of the fast-tracking process in the ambulatory setting. As a result of space limitations at most institutions, parents are not allowed in the PACU but are present in the SSRU. Therefore, children have an additional benefit of fast-tracking in that they are more quickly reunited with their parents. The primary objective of this study was to examine the feasibility and benefits of faster parent-child union (fast-tracking) during the recovery phase after short surgical procedures. We postulated that children in the Fast-Track group will be discharged home earlier and that their parents will be highly satisfied with fast-tracking after ambulatory surgery.
The IRB approved the study, and written informed consent was obtained from the parents. Children older than 7 yr, ASA I or II, undergoing surgical procedures lasting <90 min were studied in a randomized clinical trial. After the initial consultation with the surgeon, parents and children were given educational materials regarding the recovery process. A preoperative health screening was performed 2–5 days before surgery via telephone. All parents were offered a chance to take a presurgical tour of the surgery suite. Halothane or sevoflurane was used for mask induction and propofol for IV induction. Standard monitors were used. Anesthetics, muscle relaxants, intraoperative narcotics, and regional or local blocks were administered at the discretion of the anesthesiologist. The airway was maintained via a face mask, laryngeal mask airway (LMA), or tracheal intubation. When LMA or tracheal tube was used, awake extubation was performed.
After surgery, study patients were assessed for recovery while they were still in the OR with discharge criteria for children based on the modified Aldrete scoring system (Appendix 1). Patients who scored at least 8 of 10 of the discharge score were entered into the study. Just before transport from the OR to the recovery unit, an envelope was opened that randomly assigned patients to one of two groups: Control group and Fast-Track group. Patients in the Control group were first admitted to the PACU and then discharged to the SSRU. Patients in the Fast-Track group bypassed the PACU and were admitted directly to the SSRU and united with their parents. Supplemental oxygen at 4 L/min was administered via blow-by technique during transport to the PACU or the SRRU. Anesthesia residents and fellows participated in the anesthetic management, along with the three staff members involved with the study. Trainees were informed about the study methodology before the induction of anesthesia. The PACU and SSRU nurses were aware of the patients who were entered into the fast-track study.
Vital signs, airway assessment, motor activity, consciousness, and Spo2 monitoring were assessed on arrival at the PACU. Vital signs were then measured every 15 min per routine standards. Parents were not present in the PACU. Patients were continually assessed to determine whether they had met PACU discharge criteria. The nurse noted the time when criteria were met. Pain was assessed by the PACU or SSRU nurse on a scale of 0–5. Analgesics were administered for a score of ≥ 2. The modified children’s Aldrete score of 10 (Appendix 1) was used to discharge patients from the PACU to the SSRU.
Vital signs, airway assessment, motor activity, consciousness, and room air Spo2 monitoring were assessed on patient arrival to the SSRU from the OR. Thereafter, vital signs were measured every 30 min per routine SSRU standards. Parents were escorted to the SSRU to be with their child as soon as the surgeon had discussed the operative findings with them. The pain, anxiety, recovery, and discharge assessments were performed by the recovery nurses. There was no minimum mandatory time required in either the PACU or the SSRU. The PACU paperwork was eliminated for patients admitted directly to SSRU. A fast-track notation was made in the PACU records.
During the recovery phase, supplemental blow-by oxygen was administered to children who had Spo2 <95%. Pulse oximetry monitoring was discontinued when room air Spo2 was >95%. Patients’ recovery was continually assessed to determine when they met discharge criteria, and results were recorded every 10 min and at the point when discharge criteria were met. Patients were discharged home when they met SSRU discharge criteria (Appendix 2). Parents completed a satisfaction survey just before leaving the SSRU (Appendix 3). A follow-up telephone call was made the next morning by a recovery nurse to inquire about general well-being, complaints, and potential complications and to answer questions.
The OR recovery time was defined as the time from the end of surgical procedure and dressing to when the patient was ready for transport to a recovery unit. The PACU recovery time was the interim between arriving in the PACU and meeting criteria for discharge from the PACU (modified Aldrete score). The SSRU time was the interval between arrival in the SSRU and meeting home discharge criteria. Finally, the total recovery time was the interval between arrival in the PACU or SSRU and meeting home discharge criteria.
Demographic data, anesthesia time, duration of surgery, total fluid intake during recovery phase, OR recovery times, PACU and SSRU times, total recovery time, medications administered in each unit, complications, and parental satisfaction were recorded.
The χ2 analysis (or Fisher’s exact test) was used to compare noncontinuous variables. For continuous variables, the Kruskal-Wallis test was used, with P < 0.05 considered statistically significant.
Consent for the study was obtained from 175 parents. One hundred fifty-five children, 4 mo to 20 yr old, weighing between 5.9 and 53 kg, met entry criteria for the study. Twelve patients were ineligible because their surgery lasted longer than 90 min, one child had airway obstruction after extubation, and seven children were too sedated after the surgical procedure to be eligible for the study. These children did not meet the children’s PACU discharge criteria in the OR and were admitted to PACU.
The age, weight, surgical times, anesthesia times, and airway management (mask, LMA, or endotracheal tube) were similar in both groups (Table 1). The types of surgery were similar in both groups. The number of airway cases was also similar in both groups. Seventeen patients underwent adenoidectomy with or without ear tubes. Seven of them were in the PACU group, and the rest were in the Fast-Track group. Midazolam was administered to one patient in each group. A total of 11 patients in the Control group and 13 patients in the Fast-Track group received antiemetic therapy. The relative frequency for midazolam or prophylactic antiemetic administration was not significantly different (P > 0.05). Almost 60% of children in the PACU group, vs 40% in the Fast-Track group, required pain medications during the recovery phase (Table 2). The total recovery time was longer in the PACU group than the Fast-Track group (99.4 ± 48.6 vs 79.1 ± 48.3 min;P = 0.008).
The total length of stay for children who received pain medication was 102.7 ± 48.8 min, compared with 95.4 ± 48.7 min (Table 3) for children who did not receive analgesics in the PACU (P < 0.05). Time to discharge was not affected by age, weight, surgical time, extubation time, or pain and anxiety score of the patients.
More parents of children in the Control group reported that their child was calm when first seen in the SSRU (Table 4)compared with children in the Fast-Track group (69% vs 84.3%;P = 0.037). After a few minutes, an equal number of parents in both groups felt that the child was calm. In the Control group, 87.1% of parents felt that their child was pain free after surgery vs 76.2% of parents in the Fast-Track group (P = 0.10). On the follow-up telephone call, all except one parent expressed satisfaction with fast-tracking.
It is desirable to minimize parent-child separation during the perioperative period. Some institutions allow parents to be present during the induction. Although this may not be possible at every facility, parental presence during recovery is essential, because it reassures the child and decreases anxiety. Many institutions allow parents into the PACU, whereas others transfer the child to the SSRU almost immediately after he or she is awake. Some institutions have a single-phase recovery unit, thereby combining the PACU and SSRU into one room.
When children are admitted to the PACU after surgery, they may remain in the PACU for 15–45 minutes before discharge to the SSRU. They are often fully awake but are separated from their parents. As a result, many children become anxious and start crying. When a postsurgical child starts to cry in the PACU, he or she often is treated with an anxiolytic or with sedative medications. Alternatively, crying is interpreted as a sign of pain, and the child receives an analgesic. The administration of sedatives or narcotics delays home discharge, and many children may, therefore, be staying in the ambulatory center longer than necessary.
It may be argued that the longer recovery time in the PACU group is partially caused by the time needed for transfer of the patient from the PACU to the SSRU. Our PACU and SSRU are next to each other, separated by a single wall, so the transfer time is minimal. The patient-to-nurse ratio in the PACU is 2:1, with no parental presence. The ratio is 4:1 in the SSRU, where parents are also attending to the child. Whether we would have obtained the same results if parents were allowed in the PACU is an interesting question. Future studies should address this issue.
Because many children are unable to tell us that they are in pain, it is difficult to separate pain, restlessness, and anxiety in pediatric patients. Patients in both groups had equal access to regional anesthetic techniques, including field blocks by surgeons, because neither the anesthesiologist nor the surgeon knew during surgery which group the patient was to be in. Of interest, more parents of the children in the Fast-Track group felt that their child was not calm on arrival at the SSRU. It would appear that children in the PACU group received analgesics (fentanyl or morphine) when they exhibited signs of restlessness. Therefore, although their recovery time was longer, they were calm when first seen by parents. After spending a few minutes with the parents, children in both groups were calm, possibly because of consoling by the parents.
Clinical practice patterns of physicians, including workforce modifications, are now being examined to determine whether they are associated with the best outcome at the most reasonable cost (1–4), a concept termed “value-based anesthesia care”(2). Increased value can be obtained by achieving either the same outcome at a decreased cost or a better outcome at the same or a slightly increased total cost (2). Streamlining the recovery process by bypassing the PACU decreases recovery time, allows parents to be present with their child immediately after surgery, and may have economic implications. It has been noted that anesthetists can safely identify in the OR those patients who are most suitable to bypass the PACU. 1
Watcha and White (2), after a metaanalysis of cost-data, concluded that if the patient can go directly from the OR to the SSRU (which usually has a larger patient/staff ratio), there is a potential for cost savings. Song et al. (5) have also shown that titrating the anesthetics by using a bispectral index monitor contributed to a faster emergence from anesthesia in adults. However, there are no comparative studies with bispectral index monitoring in children.
We used a modified Aldrete postanesthetic recovery score to determine fast-track eligibility. This score does not include evaluation of pain and need for antiemetics. The use of PACU discharge criteria, such as the modified Aldrete’s Postanesthetic Recovery Score to fast-track patients, has been questioned. White and Song (6) noted that the Aldrete score was not designed to assess the patient’s ability to bypass the PACU after major ambulatory procedures under general anesthesia. They demonstrated that 22%–29% of adult outpatients judged to be fast-track eligible with the modified Aldrete scoring system subsequently required IV analgesics and antiemetics (6). Our study concurs with their findings, in that 23.8% of parents in the Fast-Track vs 12.8% of parents in the PACU group felt that their child was not pain free after surgery.
White and Song (6) have developed new fast-track criteria that can be used to determine whether outpatients can be transferred directly from the OR to the SSRU. It includes assessment of pain and vomiting in the criteria for fast-tracking outpatients. For pediatric patients, we need to modify the criteria proposed by White and Song to suit the needs of children and parents. For example, physical activity in children varies according to age and development of the child. Children may not move their extremities on command because they may not understand the command. Appendix 3 presents modified fast-track criteria for children. A minimal score of 10 (with no score <1 in any individual category) would be required for a child to be fast-tracked. The criteria for pain, vomiting, Spo2, physical activity, and respiration have been modified to accommodate the needs of children. The criterion for nausea and vomiting is eliminated because children do not have nausea, and of the children who have emesis, most vomit after drinking fluids, on ambulation, or after a few minutes in the recovery unit. The criterion for physical activity is modified to include the developmental stages of children. Because the major respiratory problem in children is airway obstruction, including croup, the respiratory criterion is modified to include crying, hoarseness of voice, stridor, and retraction of the chest. Use of these criteria to fast-track children eliminates the restlessness noted by parents and the discomfort felt by patients who are fast-tracked by using recovery discharge scores such as Steward’s simplified discharge score or the modified Aldrete score.
In conclusion, children admitted directly to the SSRU were discharged home earlier, and fewer patients required pain medications compared with those who were admitted to the PACU. Although children in the Fast-Track group were more likely to display restlessness when initially seen by parents, they became calm after a few minutes. In general, parents had a very positive response to fast-tracking children undergoing ambulatory surgical procedures.
1Bell S, Hill N. Factors facilitating PACU bypass in ambulatory surgery [abstract]. Anesthesiology 1997;87:A34. Cited Here...
Modified Aldrete Score for Children TABLE Cited Here...
SSRU Discharge Criteria (CNMC) TABLE Cited Here...
Criteria for Fast-Tracking Children TABLE Cited Here...