Risk factors associated with fast-track ineligibility after monitored anesthesia care in ambulatory surgery patients

BACKGROUND: Fast-tracking after ambulatory anesthesia has been advocated as a pathway to improve efficiency and maxmuize resources without compromising patient safety and satisfaction. Studies reporting successful fast-tracking focus primarily on anesthesia techniques and not on specific patient factors, surgical procedure, or process variables associated with unsuccessful fast-tracking. We performed this retrospective study to implement a process for improving fast-tracking, measure change over time, and identify variables associated with patients unable to fast-track successfully after monitored anesthesia care. METHODS: A fast-track protocol for all patients receiving monitored anesthesia care based on the Modified Aldrete Score was instituted. It consisted of written policy changes and weekly review at physician and nursing department meetings for the first month, followed by monthly feedback during a 6-mo intervention period. Data collected for a 3-mo baseline and the consecutive 6-mo intervention period included fast-track status, surgical service and procedure, surgeon and anesthesiology provider, age, gender, ASA status, total time in operating room, and total postoperative time (end of surgery to actual discharge). RESULTS: Three hundred and thirty-two cases were completed during the 3-mo baseline period, and 641 cases were completed during the 6-mo intervention period. Fast-track success rate improved from 23% to 56%, P < 0.001. Independent risk factors for fast-track ineligibility identified by multivariate regression analysis were significant for patients <60 yr-old, ASA III versus 1, general surgery versus orthopedics and ophthalmology, month after implementation, and total postoperative time. Total postoperative time was significantly shorter by 64 min in the fast-track group, P < 0.001. CONCLUSION: Fast-track success rate can be improved and sustained over time by education and personnel feedback. We identified risk factors that were significantly associated with fast-track ineligibility. If those factors are found to be associated with fast-track ineligibility in a prospective investigation, they should enable development of multidisciplinary patient and procedure-specific guidelines for fast-tracking.