BENCHMARKING THE PERIOPERATIVE PROCESS - III - EFFECTS OF REGIONAL ANESTHESIA CLINICAL PATHWAY TECHNIQUES ON PROCESS EFFICIENCY AND RECOVERY PROFILES IN AMBULATORY ORTHOPEDIC-SURGERY

Study Objectives: (1) To incorporate regional anesthesia options for c ommon outpatient orthopedic surgery into clinical pathways; (2) to use the clinical pathway format and the Procedural Times Glossary publish ed by the Association of Anesthesia Clinical Directors (AACD) as manag ement tools to measure postoperative same-day surgery processes and di scharge outcomes; and (3) io determine the effects of general, regiona l, and combined general-regional anesthesia on these processes and out comes. Design: Hospital database and Patient chart review of consecuti ve patients undergoing anterior cruciate ligament reconstruction (ACLR ) during academic years (AY) 1995-1996 and 1996-1997. Patient data fro m AY 1995-1996, during which no intraoperative anesthesia clinical pat hway existed, served as historical controls. Data from AY 1996-1997, d uring which intraoperative anesthesia clinical pathways were used, ser ved as the treatment group. Setting: Ambulatory surgery center in a te aching hospital. Measurements and Main Results: The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients s elected general anesthesia (+/- femoral nerve block) or epidural anest hesia, after which the remainder of the perioperative anesthesia proce ss was standardized with respect to the drugs and equipment used 1995- 1996 patients did not necessarily have a choice in anesthesia techniqu e and did not have a standardized perioperative anesthetic course with respect to specific drugs and supplies. Intervals described in the AA CD Procedural Times Glossary, anesthesia drug and supply costs, and pa tient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by anesthesia technique used , were measured. Combined general-regional anesthesia care for ACLR in 1996-1997, when compared with general anesthesia alone led to increas ed pharmacy and materials costs and increased turnover lime. However, patients with the combined technique showed improved recovery profiles and lower unexpected admission rates, and they required fewer nursing interventions for common postoperative symptoms. Patients receiving e pidural anesthesia showed discharge outcomes similar to those patients receiving general anesthesia with femoral nerve block. Postanesthesia care unit bypass (fast-tracking) was more likely in clinical pathway regional anesthesia patients, when compared with the clinical pathway general anesthesia used. Conclusions: Clinical pathway regional anesth esia care for outpatient orthopedics may have a significant rob in sim ultaneously containing costs and improving both process efficiency and patient outcomes. (C) 1998 by Elsevier Science Inc.