nurse-to-patient ratio) who facilitated faster discharge by, for exam-
ple, moving to PO pain medications as first-line interventions, arrang-
ing for PT to prioritize PACU patients and asking surgeons to give pre-
scriptions to family before surgery so they could have them filled
while the patient was in surgery.
2. Minimally invasive anesthesia. Other than surgical tech-
nique, the cornerstone of a successful fast-track program is anesthesia
delivery. If your providers default to general anesthesia, perhaps they
could place more regional blocks with a little bit of sedation? Opioid-
sparing medications, such as ketamine, lidocaine and NSAIDs, that
work on different pain pathways have been proven to control surgical
pain and hasten emergence. Among other things, the side effects of
opioids — nausea and vomiting, itching, sedation — delay discharge.
Regional blocks (administered at the pre-op bay and, if necessary, at
the PACU bedside), take-home pain pumps and long-acting local anes-
thetics that surgeons administer at the incision site at the end of cases
are proven pain-control strategies that reduce opioid use and lead to
faster discharge.
3. Plan ahead. You can get ahead of the game by looking at the
surgical schedule. For example, arrange for the physical therapist and
the crutches to show up when you anticipate patients who'll need
them will arrive in PACU.
4. PONV plan of attack. It's critical to get ahead and stay in front
of nausea and vomiting. Use a checklist of risk factors to identify vulnera-
ble patients (a history of PONV tops the list) so you can treat them
before, during and after the case. As a general rule, I administer 1
antiemetic per risk factor. For example, I'd instruct a patient with 4 risk
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