title: Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery.
abstract: OBJECTIVE
  (1) To incorporate regional anesthesia options for common outpatient orthopedic surgery into clinical pathways; (2) to use the clinical pathway format and the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as management tools to measure postoperative same-day surgery processes and discharge outcomes; and (3) to determine the effects of general, regional, and combined general-regional anesthesia on these processes and outcomes.
  
  
  METHODS
  Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathway existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group.
  
  
  METHODS
  Ambulatory surgery center in a teaching hospital.
  
  
  RESULTS
  The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients selected general anesthesia (+/- femoral nerve block) or epidural anesthesia, after which the remainder of the perioperative anesthesia process was standardized with respect to the drugs and equipment used. 1995-1996 patients did not necessarily have a choice in anesthesia technique and did not have a standardized perioperative anesthetic course with respect to specific drugs and supplies. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient 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 increased pharmacy and materials costs and increased turnover time. 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 epidural 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 anesthesia care for outpatient orthopedics may have a significant role in simultaneously containing costs and improving both process efficiency and patient outcomes.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh Medical Center, Montefiore University Hospital, PA 15213-2582, USA.
authors.forename: B A
authors.initials: BA
authors.lastname: Williams
authors.forename: B M
authors.initials: BM
authors.lastname: DeRiso
authors.forename: C M
authors.initials: CM
authors.lastname: Figallo
authors.forename: J W
authors.initials: JW
authors.lastname: Anders
authors.forename: L B
authors.initials: LB
authors.lastname: Engel
authors.forename: K A
authors.initials: KA
authors.lastname: Sproul
authors.forename: H
authors.initials: H
authors.lastname: Ilkin
authors.forename: C D
authors.initials: CD
authors.lastname: Harner
authors.forename: F H
authors.initials: FH
authors.lastname: Fu
authors.forename: N J
authors.initials: NJ
authors.lastname: Nagarajan
authors.forename: J H
authors.initials: JH
authors.lastname: Evans
authors.forename: W D
authors.initials: WD
authors.lastname: Watkins
mesh_terms: D000328:Adult; D000556:Ambulatory Surgical Procedures / Q000191:economics / Q000451:nursing*; D000762:Anesthesia Recovery Period; D000765:Anesthesia, Conduction / Q000191:economics / Q000451:nursing*; D016118:Anterior Cruciate Ligament / Q000601:surgery; D019985:Benchmarking; D003362:Cost-Benefit Analysis; D019091:Critical Pathways / Q000191:economics / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D019637:Orthopedic Procedures / Q000191:economics / Q000451:nursing*; D018401:Sample Size; D016896:Treatment Outcome