President's Page

Fast Tracking:
Are Patients Slipping Through the Cracks?
Maureen Iacono, BSN, RN, CPAN
ASPAN President, 1998-99

 

Maureen Iacono, BSN, RN, CPAN
ASPAN President, 1998-99
I take pride in the working relationship the perianesthesia nurses in my hospital and surgery center have with the anesthesia Care Team. We treat each other as professionals with respect and high regard for the special practice and skills, expertise and unique contributions we all make to patient-centered care. We believe that the practice of anesthesia and perianesthesia specialty nursing is high level, high tech and high touch. The bodies of knowledge are distinct and refined. Many of you also work with professionals who are devoted to the development, promotion and maintenance of standards of care.

We can be lighthearted about cartoons we have seen about minimarket medicine, drive through surgery or revolving door practice. It is not amusing, and is indeed disgraceful, when we hear reports of patients who have been rushed through the system to speed up the surgical process and ensure quick turnover times with little regard for safe and appropriate practice. ASPAN has received various reports of postoperative patients who have received general anesthesia and have bypassed PACU with little or no plan in place to care for them at another level. I had the opportunity to express concern about this issue at the American Society of Anesthesiologists Annual Meeting this October in Orlando. Both the ASA and ASPAN hope that these are rare occurrences, but our fear is that we cannot know the scope of inappropriate practice unless we ask!

Fast-tracking is becoming the buzz word in many of our institutions. Its definition and implementation, however, vary greatly in practice. In some situations, no plan has been developed between Anesthesia, PACU, SDS and nursing units for fast tracking/bypass of PACU; no dialogue has even taken place. Discharge criteria, determined on a case by case basis at the discretion of the Anesthesia Care Provider, is the sole determinant of patient selection. What does ASPAN say about fast tracking? (See article in Breathline Volume 17, Number 7: January/February 1998, page 12.)1 When clear practice guidelines are developed within your facility, including patient selection, informed consent and uniform discharge criteria, fast tracking can change the ways we have traditionally practiced. (The change, if well planned, can indeed be healthy and advantageous.) However, when dramatic changes are initiated in a haphazard manner, disastrous outcomes are more likely. The focus on cost cutting and decreasing patients length of stay should be secondary; safety and appropriateness of care delivery are primary. Patient advocacy is everyone’s business. It needs to be everyone’s concern.

I present each of you with a twofold challenge. First, we must identify the current level of practice. We ask you:

Are patients bypassing Phase I PACU? 
If so, do you have a protocol in place? 
Was that protocol mutually developed by all parties involved? 
Are you seeing unsafe situations with poor outcomes? 
Did they occur when you had protocols in place?
Do you have a program that works safely, with a good plan?

Your help is required in problem identification. Send anecdotal statements substantiated with facts to ASPAN. (Please send to Debra Goodwin, BSN MS RN CAPA, 2019 Wesley Court, Safety Harbor, Florida 34695; email debgoodwin@juno.com) ASPAN will collect and work with the data, and it will be published and shared with you and our concerned anesthesia colleagues. We want to know about the situations in your workplace and your community, that you think defy safe and appropriate practice for perianesthesia patients. We are particularly interested in outcome data related to inappropriate patient bypass of perianesthesia nursing units. The following example may help you to identify scenarios you can share.

Following general anesthesia for a total abdominal hysterectomy, a patient was transported from the OR by an orderly. The anesthesia care provider had indicated that this patient was to bypass PACU. The patient was on a stretcher in the hallway, crying, when found by a PACU nurse. The patient indicated that she was in pain. The nurse brought her into PACU, but had to argue with the anesthesiologist to admit her and obtain orders for pain medication.

Second, and of greater importance than reporting these clinical practice scenarios to ASPAN, is to voice your concerns when inappropriate and/or unsafe patient care occurs. Discuss your concerns with your manager and supervisor; establish dialogue with the Anesthesia Department. Ask that these issues be placed on the agenda of the Surgical Services, Anesthesia QA, Risk Management and Clinical Practice Committees. Accept nothing less than the standard of care for the patients entrusted to the experts in your facility.

The commitment we have made to society to practice nursing with integrity, accountability and constant vigilance compels us to ensure ethical practice in our daily work. We owe it to ourselves and our patients.

References
1. Mamaril, Hooper, Fast Tracking Versus Bypassing Phase I. Breathline 17 (7): 12. American Society of PeriAnesthesia Nurses 1998.

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