Editorial II: Fast-tracking in day surgery. Is your journey to the recovery room really necessary?

Abstract

Fast-tracking, or bypassing the recovery room or Post Anaesthesia Care Unit (PACU), is claimed to streamline day surgery with faster patient recovery time and discharge and therefore reduced cost, particularly in the office-based surgery now popular in the United States. [1][2][3][4][5] Many fasttracking studies have looked at different anaesthetic regimes to achieve fast-track criteria and whether this resulted in shorter recovery times in those patients who were able to bypass recovery. [5][6][7][8][9] Cost savings were assumed if more expensive phase I recovery was avoided. In this issue Song and colleagues 10 are the first to look at this more rationally by prospectively randomizing patients having a standard general anaesthetic to fast-track or conventional recovery, and looking at outcomes, which included recovery times and costing.While cost savings appear to be the driving motivation for fast-tracking, we also need to know if fast-tracking is safe and feasible, if it has any direct benefits for patients, and whether it is applicable to different ways of working (and costing) in other health care systems than in North America.The scoring systems used to determine fast-track eligibility require the same criteria as those used to determine discharge from the recovery area. The original Aldrete score, 11 commonly used to measure recovery, only considered stable vital signs and alertness. White's fast-track criteria 12 also include pain and emesis, common causes of delayed discharge from phase I recovery. 8 This is the scoring system used in Song and colleagues' study. 10 It does not include surgical complications. These criteria are similar to the criteria for discharge from the recovery area stipulated in the recommendations produced by the Association of Anaesthetists of Great Britain and Ireland. 13 Reassuringly, almost certainly because fast-track criteria are the same as those for discharge from recovery, serious complications in the immediate postoperative period are not reported to be increased by fast-tracking. One patient 14 is reported to have developed pulmonary oedema in phase II recovery, but no details are given of the time of onset and whether this would have been prevented by conventional recovery.However, children who were fast-tracked were considered by parents to be more restless initially, and to have more pain, although not significantly so. 3 The authors comment that the presence of the parents in the recovery room might have changed these results, as restlessness in the recovery room usually resulted in the child being given analgesia so that they were calmer and sleepier before returning to phase II recovery.

Cost-Effective Utilization of a Private Facility to Perform Outpatient Surgery in Public Hospital Waiting List Patients

“…This kind of collaboration between public and private hospitals has not been analyzed and reported in the literature, while collaboration between university and county hospitals has already been published, but was on a different basis [9,10,11,12]. …”

“…The procedure was carried out by the public hospital senior surgeon and one of the residents as an assistant. After the procedure, the patient was observed in the recovery room and returned home the same day if standardized discharge criteria were fulfilled [9,10]. These are essentially the acronym AAAAM (awake, analgesia, ambulating, alimentation and miction).…”

Factors affecting recovery and discharge following ambulatory surgery

“…It is apparent that many factors can influence costs of ambulatory surgery, and fast-tracking requires control of related factors to demonstrate true benefits and cost savings. 14 …”

Rising to the challenges of achieving day surgery targets

“…Adopting this 'fast-tracking' system may theoretically allow cost savings by reducing the staffing levels in the recovery area. Whether this concept is appropriate will depend on local factors, such as case mix [22]. Protocols should be established to identify when a patient may be 'fast tracked'.…”