Save up to $160,000 by bypassing phase I
Save up to $160,000 by bypassing phase I
Study affirms cost benefits of quicker discharge
How would you like to save from $50,000 to $160,000 annually in your same-day surgery program? You can do it with one change your patients will love, say the leaders of the recently completed Short Acting, Fast Emerg-ence (SAFE) study. The cost savings were accomplished by bypassing phase I recovery and sending patients directly from the operating room to the step-down unit. Thus, same-day surgery programs were able to reduce their lengths of stay by about one hour per patient and use less intensive nursing care in the step-down unit than patients would have received in phase I recovery.
Bypass up to 40% of general anesthetics
The question studied was whether same-day surgery programs need to have patients who may be fully recovered from surgery and anesthesia in the phase I recovery unit, which essentially is an intensive care unit, says Jeffrey Apfelbaum, MD, professor and vice chairman of clinical affairs and director of outpatient surgery in the department of anesthesia and critical care at the University of Chicago Hospitals. Apfelbaum was the originator of the SAFE study concept. (For details, see "SAFE Study at a Glance," p. 6.)
"Although none of the places we went before the SAFE study were able to bypass patients who had general anesthesia, at the end of the study, all of the facilities were able to bypass 15% to 40% of patients who had received general anesthetics and between 85% and 98% of patients having monitored anesthesia care," Apfelbaum says.
To top off the study results, morbidity was no higher when patients bypassed phase I, and the unplanned inpatient admission rate was less than .17%, he adds.
So can these results be applied to the same-day surgery field at large? "I think frankly this is the next logical step," Apfelbaum says. "Now we’ve determined that with the use of SAFE anesthetics and newer advanced minimally invasive surgical techniques, patients have the potential to be so awake and alert at the end of surgery, they don’t need the intensive care still being provided in a recovery room."
He discusses dilation and curettage (D&C), which formerly was performed as a three-day hospital stay, as an example. "Now it’s entirely possible, and frequently done, that patients can arrive in the institution at 7:15, in 10 minutes have a D&C, and be back in the parking lot before 8 a.m. The recovery is extremely rapid."
Move up time of assessment
So how are such discharge times accomplished? By moving up the time of assessment, Apfelbaum says. The criteria for discharge from the recovery room and bypassing phase I are essentially the same. Instead of keeping patients in the recovery room for an hour to see if they meet the criteria, those criteria are used to discharge patients from the OR directly to second-stage recovery. "The key is to have rigorously applied criteria, and patients must meet those criteria," he says.
You’re not necessarily making patients happier by keeping them longer, says Ted Grasela, PharmD, president, Pharmaceutical Outcomes Research in Williamsville, NY, an independent consulting firm that works with pharmaceutical companies on outcomes studies. The SAFE study originally was sponsored Glaxo Wellcome in Research Triangle Park, NC, which manufactures some of the drugs in the study. Pharmaceutical Outcomes Research is offering a benchmarking service designed to help ambulatory care facilities improve perioperative efficiency. (To contact the company, see sources, p. 7.)
"More is not necessarily always better if you have a person who can be discharged sooner," Grasela says. "That person may be just as happy to move on with normal activities rather than spending additional time in the recovery room."
To help same-day surgery staff accept such an idea, Apfelbaum and other study leaders met with anesthesiologists, nurse anesthetists, surgeons, OR nurses, recovery room nurses, and hospital managers at the participating facilities. They showed how to apply a rigorous set of criteria for patients in the OR following ambulatory surgery. (See list of discharge criteria, p. 7.)
Anesthesiologists could compare their performance against that of their peers, Apfelbaum says. "If one anesthesiologist consistently had a recovery profile of two hours, and another was able to bypass [phase I] regularly, the first doc would look at data and ask, What is that doctor doing differently? I might be able to modify my practice.’"
Also, facility managers could see how their programs compared with others in the study, Grasela says. "If one site develops a unique solution or innovative solution to problem, we were able to share those experiences with other sites."
For example, one surgery center that was having difficulty with pain management after surgery decided to dedicate one full-time anesthesiologist to that issue. "We had another center with a similar problem," he says. "That gave them food for thought, in terms of how to handle and who to manage."
The value of data collection was one of the key lessons from the SAFE study. "There’s a lot of pressure on health care to deliver high quality care at the lowest cost," Grasela says. "By using that information better, we can make patient care decisions that deliver care that is high quality, low cost."
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