On
the fast track |
On
the fast track |
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By
Barbara Tone, RN Thousands of surgical patients are enjoying record-breaking recovery times, thanks to new surgical technologies, anesthetic agents, and postoperative drugs. "Fast-track" anesthesia is moving patients out of the postanesthesia care unit to hospital beds, or home, in an increasingly shorter period. Sometimes they bypass the PACU completely. Many experts point out that fast-tracking allows quicker recoveries, less pain, and fewer complications. But PACU nurses say that unless fast-track programs are implemented carefully, nurses can become too rushed to do their jobs and patient care may suffer. Advanced techniques Laser surgery, better induction agents, and improved pain control are just some of the advances that make fast-tracking possible. Fast-track patients may have peripheral nerve blocks and may receive prophylactic drugs for postoperative nausea and vomiting and pre-emptive pain control through local anesthesia at the surgery site. Some patients are discharged with "pain pumps" that give a continuous infusion of local anesthetic for two days following surgery. It used to be that someone using the term fast-track was talking about cardiac surgery patients who had early extubation and were moved more quickly through the recovery period. But the term now includes a much broader range of surgical patients. Done correctly, fast-tracking has many advantages. Patients spend less time under anesthesia, have fewer postoperative complications and less pain, and are awake much earlier than in the past. "These ultra-short-acting induction agents allow patients to wake extremely clear-headed, and the narcotics given during surgery have a rapid peak effect and are totally metabolized in a very short period of time," said Sandra Tunajek, MSN, CRNA, director of practice for the American Association of Nurse Anesthetists. The clinical advantages are accompanied by significant economic benefits. Though the new drugs and technologies are expensive, the cost is far offset by the savings in staff time. A study by Jeffrey L. Apfelbaum, MD, of the University of Chicago, showed annual savings ranging from $50,000 to $158,000 in the five participating surgical centers. Proceed carefully Done incorrectly, there can be significant risk. "If [fast-tracking is] abused, like most innovations, it can be a disaster," said Ramona Conner, MSN, RN, perioperative nursing specialist in the Center for Nursing Practice, Health Policy, and Research at the Association of Operating Room Nurses. "Our concern is people being fast-tracked without clear-cut guidelines." If programs are poorly planned, there may be pressure to discharge a patient to make room for incoming patients, PACU nurse ratios may be stretched beyond the limits of patient safety, and patients may go home feeling rushed or without a clear understanding of their postoperative care. "Unfortunately, we have heard stories of hospitals that announce, ‘We’re going to fast-track next week’ and about nurses who are reprimanded for focusing on the patient’s needs," said Myrna Mamaril, MS, RN, president-elect of the American Society of PeriAnesthesia Nurses, who is certified in postanesthesia and ambulatory perianesthesia. Experts caution that some form of back-up is crucial for those times when patients do not progress as expected; additional staff must be available or there must be a way to stop the inflow of new patients. "I’ve been in situations where there was such pressure to get the patients out that I didn’t feel confident about the stability of patients being discharged," said Genny Carpenter, RN, a former PACU nurse from Simi Valley, Calif., who prefers not to identify her former employer. "When there are eight operating rooms going at once, you can really end up with a slew of patients. There has to be allowance for the what-ifs." Remember what matters most Mamaril urges that discharge criteria focus solely on the patient’s status. "We are always patient-centered," said Mamaril, who is also nurse manager for preadmission testing, ambulatory surgery, and inpatient postanesthesia care at St. Joseph Medical Center in Towson, Md. "Ethically and morally, we need to be patient advocates. Even if they have met discharge criteria, we always ask our patients if they feel comfortable with leaving." If the PACU is becoming overloaded, some mechanism must be in place to keep nursing ratios at the defined level. "In our facility, the operating room calls before they bring a patient to us," said Pam Windle, MSN, RN, a nurse manager at St. Luke’s Episcopal Hospital in Houston who is certified in postanesthesia and ambulatory perianesthesia. "If we don’t have staff or beds, they keep the patients until we are able to safely care for them and delay or cancel surgeries if need be." Nursing experts agree that fast-track programs must have well-defined criteria for both discharge and entry. Certain patients are not eligible for fast-track care and should be screened out before an operation is even scheduled. "We screen our patients very carefully," said Mary Margrave, RN, a PACU nurse at Center for Orthopedic Surgery in Van Nuys, Calif., that has a policy of not allowing identification of the facility. "If the patients lack coping skills, have complicated health problems or poor support systems at home, they may not be the best candidates for fast-track." Respectful collaboration among all care providers can keep risks to a minimum. "There has to be a free flow of information—about patients, policies, problems and problem solving—from the preoperative through the discharge phases of care," Margrave said. "There has to be an atmosphere without repercussions, or you are stripped of your role as patient advocate, and the patient is left vulnerable." |
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