If it's always rush hour in your recovery room, stretchers stacked and packed in every bay, the backup sometimes so bad that you have to hold post-op patients in the OR until a spot opens up, then you suffer from delayed PACU discharge.

I've seen patients stuck in PACU gridlock for 2 hours or more (I'd hate to see those satisfaction surveys!). And I've seen surgeons breeze through their first few cases of the day, only to see their operating room become a makeshift recovery room when the PACU is full. "OR holds" delay the start of every case thereafter and frustrate not only your surgeons and anesthesia providers, but also your nurses, your patients and, of course, you.

The good news: You can ease the congestion if you practice fast-tracking, the art of safely moving eligible ambulatory surgery patients through PACU as efficiently as possible and the science of assessing patients as they emerge from anesthesia to determine their eligibility for rapid discharge.

The most likely causes of delayed discharge are uncontrolled pain and nausea. If you were to ask patients what they're least looking forward to, it's not the incision or the surgery. It's the anticipated pain and the possibility of throwing up afterward. Surgeons can also inadvertently delay discharge. Patients have finished their ginger ale and crackers, and they're ready to go home but where's the surgeon? He's in the OR doing his next case or dictating the previous case — everywhere but in PACU signing the discharge order and writing prescriptions.

On average, patients should spend around 60 minutes in PACU in an ambulatory surgery center and 90 minutes in a hospital setting. Whatever's causing the discharge delay in your PACU, focus on what you can do to safely speed patients through recovery from the time the OR notifies PACU of an incoming patient to discharge. How are your providers anesthetizing patients — fast on, fast off is the goal (see "New Spinal Anesthetic Wears Off (Very) Fast" on p. 34) — and how are they treating pain and nausea? These factors and more can delay discharge by 30 to 60 minutes ... or more.

Can you learn to fast-track?

Can you teach a facility to fast-track? To find out, my fellow researchers and I put our theory to the test at Duke Regional Hospital in Durham, N.C., a 369-bed acute care facility with 18 ORs, 10 PACU beds and 15 recovery beds in the ambulatory care unit. The facility performs more than 4,000 ambulatory procedures per year and admits all patients to Phase I PACU following emergence from anesthesia — regardless of age, anesthetic or any other factor. Cervical fusion or cataract removal, it didn't matter. Their post-op recovery policy said to park all patients in Phase I PACU.

So the question became: Could we bypass Phase I PACU and send eligible patients straight to Phase 2 recovery? But before we could create a passing lane on the recovery highway, we had to teach Duke's anesthesia providers how to fast-track. We trained them to use the White Fast-Track Score to assess which patients were eligible to bypass Phase I PACU and go directly from the OR to Phase 2. We only considered patients undergoing ambulatory surgery who received IV sedation, peripheral nerve blocks or a combination of the two.

As we detailed in our study in the Journal of PeriAnesthesia Nursing (osmag.net/GP7geR), the results were dramatic. The hospital:

• achieved a 79% PACU-bypass rate;
• lowered post-op-to-discharge time from 106 minutes to 94 minutes; and
• significantly decreased the incidence and duration of OR hold.

Though we studied outpatients in a community hospital, our study produced lessons that apply to any outpatient OR, regardless of setting.

1. Segregate fast-track patients.

We implemented 2 post-operative phases of care: Phase 1 (require more nursing interventions; expected to be admitted) and Phase 2 (fast-track-eligible; ambulatory patients). We reserved a set of bays for Phase 2 patients and assigned them a team of PACU nurses (1:3 nurse-to-patient ratio) who facilitated faster discharge by, for example, moving to PO pain medications as first-line interventions, arranging for PT to prioritize PACU patients and asking surgeons to give prescriptions to family before surgery so they could have them filled while the patient was in surgery.

2. Minimally invasive anesthesia.

Other than surgical technique, the cornerstone of a successful fast-track program is anesthesia delivery. If your providers default to general anesthesia, perhaps they could place more regional blocks with a little bit of sedation? Opioid-sparing medications, such as ketamine, lidocaine and NSAIDs, that work on different pain pathways have been proven to control surgical pain and hasten emergence. Among other things, the side effects of opioids — nausea and vomiting, itching, sedation — delay discharge. Regional blocks (administered at the pre-op bay and, if necessary, at the PACU bedside), take-home pain pumps and long-acting local anesthetics that surgeons administer at the incision site at the end of cases are proven pain-control strategies that reduce opioid use and lead to faster discharge.

3. Plan ahead.

You can get ahead of the game by looking at the surgical schedule. For example, arrange for the physical therapist and the crutches to show up when you anticipate patients who'll need them will arrive in PACU.

4. PONV plan of attack.

It's critical to get ahead and stay in front of nausea and vomiting. Use a checklist of risk factors to identify vulnerable patients (a history of PONV tops the list) so you can treat them before, during and after the case. As a general rule, I administer 1 antiemetic per risk factor. For example, I'd instruct a patient with 4 risk factors — young female, GYN procedure, non-smoker, general anesthetic — to wear a scopolamine transdermal patch the night before surgery (and warn her of the dry mouth and dizzy side effects). Soon after induction, I'd add 4-8 mg of Decadron and 6.25-2.5 mg of Benadryl (by giving Benadryl up front, the antiemetic property should outlast the sedative effect). At the end of the procedure, I'd give Zofran (ondansetron), which takes 30 to 60 minutes to reach peak effect and should coincide with the PACU arrival time.

5. Let go of NPO.

It might be time to revisit the "no drinks after midnight" standard. Some patients can have clear liquids 2 hours before surgery, including carbohydrate-loaded drinks. They won't be as dehydrated and nauseated after surgery. The less time the patient is NPO, the better. If you can get patients awake, and taking food and drink as soon as possible so they can take pain medications by mouth, you'll bridge their pain from their anesthetic to their discharge.

6. Enlist your surgeons.

Ask the surgeon who's chronically late signing patients out if he would promptly write discharge instructions (and prescriptions, too!). It might be tough to get surgeons off of their own timelines, so enlist a well-liked doc to practice prompt paperwork in the hope that others will follow.

Long road home

When you wheel a patient through the recovery room doors for the final leg of her surgical journey, it should be nothing but green lights and open highways, all roads leading to the parking lot and the pain-free, nausea-free ride home. OSM