Fast-track Discharge Research Articles

Impact of fast-track discharge from cardiothoracic intensive care on family satisfaction

Dissatisfaction with the intensive care unit may threaten medical care. Clarifying treatment preferences can be useful in these settings, where physician direction may influence decision making and therefore medical treatment. This study aimed to evaluate whether fast-track discharge from intensive care units affects the satisfaction of family members [1].

Impact of fast-track discharge from cardiothoracic intensive care on family satisfaction.

BackgroundDissatisfaction with the intensive care unit may threaten medical care. Clarifying treatment preferences can be useful in these settings, where physician direction may influence decision making and therefore medical treatment. This study aimed to evaluate whether fast-track discharge from intensive care units affects the satisfaction of family members.MethodsWe used a single-center non-randomized trial, with all eligible family members involved. To evaluate family satisfaction, we used the Society of Critical Care Family Needs Assessment questionnaire (SCCMFNAQ). We hypothesized that those discharged within 24 h of intensive care unit admission and their families would have higher levels of satisfaction. Patients were scored using the therapeutic interventions scoring system (TISS) and additive EuroSCORE.ResultsTwo-hundred fifty-five family members were enrolled. The mean patient age was 53 years, and 92 % were male. The median satisfaction level among family members was 17.9 (range 14–31). Patients were divided into two groups, one receiving fast-track discharge (116 patients), and one whose members stayed longer (139 patients). The overall satisfaction was affected significantly by quality of the delivered care and dissatisfaction increased by lack of comfort in hospital settings, including the waiting room. No significant differences were seen between the two groups for overall satisfaction (p = 0.546) and individual components of the questionnaire. Higher satisfaction was linked to higher levels of education among family members (p = 0.045) and information being relayed by a senior physician p = 0.03 (two-tailed test).ConclusionsFast-track discharge from intensive care did not influence family satisfaction as hypothesized. Satisfaction relied on family members’ level of education and the level of seniority of the physician relaying information.

Décret d’anesthésie de 1994, chirurgie ambulatoire et responsabilité médicale : nécessaires réflexions sur l’inévitable conciliation entre réglementation et recommandations

Day surgery is often considered as a marker of the necessity of reorganizing the hospital to take care globally and so better meet the expectations of improvement of the management of patients. But the actual deployment of day surgery can also act as a real revelation of the stakes of conciliation between the regulations, which supervise professional practices and organization, and the functioning of hospitals. Between the regulations supervising hospitals and professional practices and the place of the recommendations, between the general legal framework of the medical activity and specific legal framework (decree of anesthesia of 1994) and the evidence-based medicine, the pretext of the improvement of the patient flow in day surgery, recommended by several institutions (Sfar, ANAP, HAS), questions about the legal obligation of the passage of all the patients in the postanesthesia care unit (PACU). Seen under the angle of a legal action against a medical doctor, the study of the French jurisprudence reveals that every practitioner has to respect the recommendations and the evidence-based medicine, and this in the standardized frame of the MD's activity and the respect for a very strict legal environment. The question of an obvious conciliation between all these measures arises today clearly. In the case of a potential conflict, the key of resolution, based only on legal standards (constitution, laws, decrees), is not enough for arbitrating. Applying that the only respect for the decree of anesthesia would be enough for exempting itself from any contentious risk does not satisfy more. There is a real difficulty defining the legal precise nature of the recommendations, so best practices as better organization, which are more and more frequently. Even if these recommendations originally had not their place in the hierarchy of the legal standards, they are brought in there today. There is a real brake in the deployment of the day surgery because the strict respect for the decree of 94 on the systematic passage in PACU can be paradoxical with a better quality of the care. Twenty years after the publication of the decree of anesthesia, it seems essential to ask at first if it's possible to fast-track discharge without any stay in the PACU and thus of the inevitable conciliation between all these measures. Secondly it's necessary of modifying this decree to impulse the deployment of the day surgery.

Décret d’anesthésie de 1994, chirurgie ambulatoire et responsabilité médicale : nécessaires réflexions sur l’inévitable conciliation entre réglementation et recommandations

Day surgery is often considered as a marker of the necessity of reorganizing the hospital to take care globally and so better meet the expectations of improvement of the management of patients. But the actual deployment of day surgery can also act as a real revelation of the stakes of conciliation between the regulations, which supervise professional practices and organization, and the functioning of hospitals. Between the regulations supervising hospitals and professional practices and the place of the recommendations, between the general legal framework of the medical activity and specific legal framework (decree of anesthesia of 1994) and the Evidence-Based Medicine, the pretext of the improvement of the patient flow in day surgery, recommended by several institutions (Sfar, ANAP, HAS), questions about the legal obligation of the passage of all the patients in the postanesthesia care unit (PACU). Seen under the angle of a legal action against a medical doctor, the study of the French jurisprudence reveals that every practitioner has to respect the recommendations and the Evidence-Based Medicine, and this in the standardized frame of the MD's activity and the respect for a very strict legal environment. The question of an obvious conciliation between all these measures arises today clearly. In the case of a potential conflict, the key of resolution, based only on legal standards (constitution, laws, decrees), is not enough for arbitrating. Applying that the only respect for the decree of anesthesia would be enough for exempting itself from any contentious risk does not satisfy more. There is a real difficulty defining the legal precise nature of the recommendations, so best practices as better organization, which are more and more frequently. Even if these recommendations originally had not their place in the hierarchy of the legal standards, they are brought in there today. There is a real brake in the deployment of the day surgery because the strict respect for the decree of 94 on the systematic passage in PACU can be paradoxical with a better quality of the care. Twenty years after the publication of the decree of anesthesia, it seems essential to ask at first if it's possible to fast-track discharge without any stay in the PACU and thus of the inevitable conciliation between all these measures. Secondly it's necessary of modifying this decree to impulse the deployment of the day surgery.

Feasibility of fast track discharge in breast cancer patients undergoing definitive surgery and impact on quality of life: a prospective study from tertiary care center in India.

To evaluate the feasibility and impact of fast track discharge in patients undergoing definitive breast cancer surgery. One hundred six breast cancer patients older than 20 years of age were assigned to undergo definitive breast cancer surgery. It was ensured that enrolled patients had a ready access to hospital, reasonable home circumstances. They were assessed by using post-anesthesia discharge scoring system (PADSS) for fast track discharge. Quality of life both in preoperative and postoperative period was assessed by Functional Assessment of Cancer Therapy-Breast cancer version 4 (FACT-B4) questionnaires. Overall 90 patients (84.9%) were fit for fast track discharge. Eighty-nine patients (83.96%) were successfully discharged within 48 hr. One patient (0.94%) could not be discharged despite being fit as she was of concern that it would put too much responsibility on the family. Mean duration of postoperative hospital stay in patients fit for fast track surgery was 42.27 ± 5.73 hr with a median of 44 hr. All patients undergoing breast conservation could be discharged on fast track basis with a mean postoperative hospital stay of 32.12 hr. Fast track discharges in breast cancer patients after definitive surgery are feasible in Indian setting.

Simplified fast-track laparoscopic Roux-en-Y gastric bypass.

The surgical management of complex or morbid obesity is increasing exponentially. Laparoscopic procedures are being increasingly utilized due to their similar efficacy but shorter hospital stay and faster convalescence when compared with open surgery. Despite this, many patients remain in hospital for a number of days after laparoscopic obesity surgery due to concerns about potential sequelae. We present the results of our simplified fast-track service, designed to enable discharge of all patients on postoperative day one following laparoscopic Roux-en-Y gastric bypass (LRYGB). All patients operated on by a single surgeon during a 3-year period underwent fast-track management and were included. Our simplified fast-track service has three components; it is applicable to all patients, patients are counselled regarding fast-track discharge and the only routine postoperative investigations are full blood count and serum C-reactive protein (CRP). CRP was investigated as a prognosticator for complications following LRYGB. One hundred twelve patients underwent a LRYGB during the study period (35 male, median age 44 [18-73], median BMI 49.4 [36.5-75.0]). Ninety-eight patients (87.5 %) were discharged the day after LRYGB. Five patients developed postoperative complications (three major, two minor). One patient required readmission following discharge on postoperative day 1. A CRP greater than 100 mg/L on postoperative day 1 was found to predict major complications with 100 % sensitivity and 95 % specificity with a diagnostic accuracy of 0.98. Our simplified fast-track LRYGB service allows the vast majority of patients to be safely and successfully discharged on postoperative day 1.

ANTICIPATORY PRESCRIBING: COMPARISON OF THE NUMBER OF DISCHARGE PRESCRIPTIONS WITH THE NUMBER OF FAST-TRACK DISCHARGES

BackgroundIn September 2012, an anticipatory prescribing policy, the ‘Just in Case Four Core Drugs’ (JiC4CD) was introduced across the healthcare economy after a multidisciplinary group of clinical experts reviewed current...

Outcomes of Fast-Track Program after Colorectal Cancer Surgery - Comparison with Conventional Method

Purpose: To assess the effectiveness of a care map for a fast-track discharge program after colorectal cancer surgery. Methods: Ninetynine patients who underwent colorectal surgery were retrospectively analyzed: 45 patients who were placed in a conventional program (January 3 to March 13, 2013) and 44 patients who were placed in a fast-track program using the care map (July 26 to September 24, 2014). Patients in the fast-track program started eating on postoperative day 1, while those in the conventional program started eating on post-operative day 2. complications, and pain were compared between the two groups. Results: A slight decrease in the average duration of hospitalization was observed for the fast-track group (5.31 ± 0.98 days) compared to the conventional group (5.38 ± 2.80 days), although this difference was not statistically significant. All other outcomes for the fast-track group were scored as 0. Furthermore, there was no statistically significant differences between pain, narcotics administration, and non-narcotic analgesics (aside from patient-controlled analgesia). Conclusion: The care map for the colorectal surgery fast-track program was effective and program validation and supplementation of the active standardization early recovery program should be performed using multi-disciplinary research.

Liposome bupivacaine (EXPAREL®) for extended pain relief in patients undergoing ileostomy reversal at a single institution with a fast-track discharge protocol: an IMPROVE Phase IV health economics trial

BackgroundPostoperative opioid use following ileostomy reversal procedures contributes to postoperative ileus. We assessed the impact of a liposome bupivacaine-based, opioid-sparing multimodal analgesia regimen versus a standard opioid-based analgesia regimen on postsurgical opioid use. We also assessed health economic outcomes in patients undergoing ileostomy reversal at our institution, which employs an enhanced recovery discharge protocol.MethodsIn this single-center, open-label study, patients undergoing ileostomy reversal received postsurgical pain therapy via multimodal analgesia that included a single intraoperative administration of liposome bupivacaine or opioid-based patient-controlled analgesia (PCA) with intravenous morphine or hydromorphone. Rescue analgesia (intravenous [IV] opioids and/or oral opioid + acetaminophen) was available to all patients. Primary efficacy measures included postsurgical opioid use, hospital length of stay (LOS), and hospitalization costs. Secondary measures included: time to first rescue opioid use; patient satisfaction with analgesia; additional medical intervention; and opioid-related adverse events.ResultsForty-three patients were enrolled and met eligibility criteria (IV opioid PCA group = 20; liposome bupivacaine-based multimodal analgesia group = 23). Postsurgical opioid use was significantly less in the multimodal analgesia group compared with the IV opioid PCA group (mean [standard deviation]: 38 mg [46 mg] versus 68 mg [47 mg]; P = 0.004). Postsurgical LOS between-group differences (median: 3.0 days versus 3.8 days) and geometric mean hospitalization costs (US $6,611 versus US$6,790) favored the multimodal analgesic group but did not achieve statistical significance. Median time to first opioid use was 1.1 hours versus 0.7 hours in the multimodal analgesia and IV opioid PCA groups, respectively; P = 0.035. Two patients in the multimodal analgesia group and one in the IV opioid PCA group experienced opioid-related adverse events.ConclusionA liposome bupivacaine-based multimodal analgesic regimen reduced postoperative opioid consumption in patients undergoing ileostomy reversal under a fast-track discharge protocol. A reduction of 21% in LOS (0.8 days) was noted which, although not statistically significant, may be considered clinically meaningful given the already aggressive fast-track discharge program.

Evaluating a fast-track discharge service for patients wishing to die at home

The UK Department of Health's End of Life Care Strategy highlighted the low percentage of patients who achieve their wish to die at home (~20%). Figures in south west London were below the London regional average. This paper reports an attempt to improve the proportion of patients from one hospital in the area achieving their preferred place of death. A funded initiative by two local primary care trusts allowed the development of a 7-day-per-week fast-track discharge service provided by the hospital palliative care team. The hospital team acted as coordinators, ensured that the correct medication and equipment would be available at the home, and personally transferred the patients to community services. Data is presented from the first representative period of fast-track discharging (June 2009-July 2010). A total of 110 discharges were facilitated over this time, with the rate increasing as the service developed. The vast majority of discharges occurred within 72 hours, and a significant number (~20%) occurred within 24 hours. The data indicate that the new service is effective. There are logistical problems in providing such a service and these are discussed. Further work is required to determine the feasibility of extending this service model to other acute hospitals and to evaluate its health-economic impact.

Achieving the preferred place of care for hospitalized patients at the end of life

Background: The Department of Health end-of-life strategy contains a number of quality markers which include taking into account patients’ wishes for their final place of care. There is a wide variation in how this information is recorded. Methods: An audit was conducted on discussion of preferred place of care (PPC) for all patients referred to the hospital palliative care team who died during the audit period. Barriers to achieving PPC and the efficacy of a fast track discharge service were also monitored. The audit was first done in 2007 and was repeated in 2009. Results: There was an increase in recording PPC. Overall PPC wishes were ascertained for 87% of the patients seen by the team. The PPC was achieved in 76% of cases. The number of patients wishing to die in hospital significantly increased over the audit cycle (from 10% to 30%). Approximately one-third of patients changed their minds regarding PPC. Conclusions: The data highlights the need to distinguish between preferred place of care and preferred place of death. Patients’ wishes regarding PPC change as death approaches. A greater number of patients wished to die in hospital than was expected.

Fast Track Minimally Invasive Transmyocardial Revascularization

: We evaluated the initial results of a fast-track discharge protocol for patients undergoing minimally invasive transmyocardial revascularization (MiTMR). : Fifteen male patients, aged 64.5 ± 9.2 years, with an ejection fraction of 46.8% ± 9.9%, underwent MiTMR through a mini-left anterior thoracotomy aided by robotic-controlled thoracoscopic assistance. A postoperative management protocol included immediate extubation, early chest tube and pulmonary artery catheter removal, and mobilization within 12 hours. : There were no operative arrhythmias or in-hospital mortalities. Three of 15 patients developed left lower lobe atelectasis, delaying discharge between 2 and 5 days. Overall hospital length of stay was 1.4 ± 1.2 days, although 12 of 15 patients (80%) were discharged to home in 23 hours. Mild-moderate cardiomyopathy (ejection fraction 30%-50%) was not associated with prolonged length of stay. Mean hospital profit margin was $1882.50. One 30-day readmission occurred on day 23 for rapid atrial fibrillation, and one death occurred on day 11. : Despite these high-risk patients having end-staged, ischemic coronary artery disease, most MiTMR patients can be discharged to home in less than 24 hours. Perioperative morbidity and mortality rates are relatively low, and hospital profit margins are modest.

Fast-Track Eligibility of Geriatric Patients Undergoing Short Urologic Surgery Procedures

Our primary objective was to assess the feasibility of geriatric patients (>65 yr) bypassing the postanesthesia care unit (PACU) after ambulatory surgery. A secondary objective was to compare recovery profiles when using three different maintenance anesthetics. Ninety ASA physical status I--III consenting outpatients (>65 yr) undergoing short urologic procedures were randomly assigned to one of three anesthetic treatment groups. After a standardized induction with fentanyl and propofol, anesthesia was maintained with propofol (75-150 microg center dot kg(-1) center dot min(-1) IV), isoflurane (0.7%-1.2% end tidal), or desflurane (3%-6% end tidal), in combination with nitrous oxide 70% in oxygen. In all three groups, the primary anesthetic was titrated to maintain an electroencephalographic-bispectral index value of 60-65. Recovery times, postanesthesia recovery scores, and therapeutic interventions in the PACU were recorded. Although emergence times were similar in the three groups, the time to achieve a fast-track discharge score of 14 was significantly shorter in patients receiving desflurane compared with propofol and isoflurane (22 +/- 23 vs 33 +/- 25 and 44 +/- 36 min, respectively). On arrival in the PACU, a significantly larger percentage of patients receiving desflurane were judged to be fast-track eligible compared with those receiving either isoflurane and propofol (73% vs 43% and 44%, respectively). The number of therapeutic interventions in the PACU was also significantly larger in the Isoflurane group when compared with the Propofol and Desflurane groups (21 vs 11 and 7, respectively). In conclusion, use of desflurane for maintenance of anesthesia should facilitate PACU bypass ("fast-tracking") of geriatric patients undergoing short urologic procedures. Geriatric outpatients undergoing brief urologic procedures more rapidly achieve fast-tracking discharge criteria after desflurane (versus isoflurane and propofol) anesthesia. Use of isoflurane was also associated with an increased need for nursing interventions in the early recovery period compared with desflurane and propofol.

Ultra–fast track hospital discharge using conventional cardiac surgical techniques

Background. Recent introduction of minimally invasive adult cardiac surgical techniques has emphasized the advantage of early hospital discharge. However, we chose an alternative approach to determine the safety, efficacy, and feasibility of ultra–fast track protocols while retaining both standard surgical exposure (median sternotomy) and conventional cardiac surgical techniques (hypothermia, cardiopulmonary bypass with cardiac arrest, and optimal myocardial protection). Methods. From September 1995 to January 1998, a total of 258 consecutive patients underwent cardiac procedures by a single surgeon. Acceleration of clinical pathways was used to initiate earlier discharges. Stringent postdischarge follow-up was implemented. Prospectively entered data were then analyzed retrospectively. Results. A variety of isolated as well as combined coronary and valve procedures were performed. Of the 258 patients operated on during this entire study period, a total of 144 patients (56%) were discharged within postoperative days 1 to 4 (ultra–fast track discharge). Over the past 12 months, this incidence increased to 70% (76 of 108 patients). Approximately 50% of these patients were operated on urgently or emergently. To date, there have been no deaths in this ultra–fast track group. There were eight brief readmissions, of which one was for rewiring of a noninfected sternal dehiscence, and the remaining were for cardiac diagnostic studies or a noncardiac problem altogether. Conclusions. Conventional cardiac operation can allow ultrafast hospital discharges while retaining the advantage of time-tested techniques and providing wider application without requiring new or additional training or equipment.