New Tools for Fast-Tracking: Single Phase Recovery Units and Simplified Bypass Evaluation
Matthew J. Shiveley, MD and Michael F. Mulroy, MD
Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA

With the increased use of ambulatory surgery and the development of rapid emergence general anesthetic agents, there has been an increased focus on accelerating the discharge process for ambulatory surgery (SS) patients. Many patients in this situation are eligible for “Phase II” recovery care at the end of surgery, and the cumbersome process of two-stage recovery delays their discharge in a Phase I and Phase II PACU. Elaborate scoring systems have been developed to assess whether patients are eligible to bypass Phase I (1) and such PACU bypass has been shown to accelerate discharge times. A more recent innovation has been the concept of discharging patients immediately from Phase I to home, which has also been shown to accelerate discharge times (White). In February 2004, we opened a new Ambulatory Surgery Unit (ASU) in a subsection of our operating room that included five operating rooms and a small recovery space. We adopted a modification of the approach of Watkins and White to consolidate both phases of short stay recovery into one unit, avoiding the challenge of transferring patients from Phase I to Phase II. We also evaluated the appropriateness of a simplified scoring system for identifying patients in the other 15 operating rooms who would be eligible for immediate transfer to the short stay recovery area, specifically the “self transfer” (ST) test. We compared the impact of accelerated ASU/PACU treatment to the standard two-phase recovery, and also assessed the impact of Phase II eligibility on discharge times compared to the impact of a combined unit.
Methods
With IRB approval, during May and June of 2004, the PACU and discharge times of 130 SS patients were recorded, 68 in the new combined Phase I & II ASU PACU, and a comparison group of 62 similar SS patients having surgery in other operating rooms and admitted first to the Phase I PACU before transfer to the ASU PACU. Anesthesia was administered in a standard fashion at the discretion of the anesthesia team using either inhalational sevoflurane or intravenous propofol for general anesthetic cases. “Phase I bypass eligibility” was determined by 3 tools in the ASU PACU: subjective RN assessment, modified Aldrete
scoring, and the ST test. Discharge times were compared between the two groups of patients, using the time from admission to Phase I or to the combined unit, to the actual time of discharge. Discharge times of the patients admitted to the ASU PACU as either Phase I or Phase II patients were also compared. The “self transfer” test for eligibility for Phase 1 PACU bypass was performed by asking the patients at the end of the procedure if they could move onto the stretcher from the operating room table by themselves. On arrival in the PACU, the same patients were then evaluated immediately by the PACU nurse (who was blinded as to their ability to self transfer) and scored on a modified Aldrete scoring system to assess their eligibility for Phase I bypass. The modified Aldrete scoring system included an assessment of pain and nausea and vomiting, which were additional criteria for Phase II eligibility.
Results
The self-transfer test appeared to be just as reliable as the Aldrete scoring or subjective nursing assessment in predicting the eligibility for Phase II admission for these SS patients (Table 1). The discharge times for patients who were admitted directly to the accelerated ASU PACU were 41 minutes faster than the discharge times for patients first admitted to a Phase I unit, and then transferred to the ASU for their ultimate discharge (104 ± 39vs 145 ±. 56 min). Within the ASU unit, patients deemed eligible for Phase II did not show a faster discharge than patients not eligible (94 ± 37 vs 111 ± 35 min), suggesting that the combined ASU PACU arrangement was more significant than perceived Phase II eligibility.

Discussion
In our experience, the use of a combined, accelerated ASU PACU (which incorporated Phase I and Phase II recovery stages in the same physical location) appears to be able to accelerate discharge times by 41 minutes, and was a more important factor than perceived Phase I bypass eligibility. The use of the selftransfer test to evaluate eligibility for direct admission to this unit appears to be as valid as the more complex scoring systems currently used for Phase I bypass eligibility, and has now been adopted as our standard criteria for suitability for direct admission to the ASU PACU from our main operating rooms. Accelerated discharge and Phase I bypass have not been shown to decrease nursing care or total cost.
However, in our unit with limited space, it has proven to be an effective way to increase the utilization of spaces and has reduced the frequency with which patients have to be held in the operating room for available PACU space. These tools might be useful and helpful in other ambulatory units to accelerate the discharge process. Further evaluation would be needed to assess any true economic benefit or improvement in patient satisfaction.
References:
1. Apfelbaum JL, et al. Anesthesiology. 2002;97:66-74.
2. White PF, Rawal S, Nguyen J, Watkins A. J Perianesth Nurs. 2003;18:247-53.

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