A clinical pathway in a post-anaesthesia care unit to reduce length of stay, mortality and unplanned intensive care unit admission

Context The immediate post-operative period is critical with regard to post-operative outcomes. Objective To assess the impact of a clinical pathway implemented in a post-anaesthesia care unit on post-operative outcomes. Design A retrospective cohort study based on electronic patient records. Setting A post-anaesthesia care unit in a Swiss University Hospital. Patients Adult patients after elective and non-elective surgery. Intervention Implementation of a clinical pathway with a nurse-driven fast-track programme for uncomplicated patients (systematic use of Aldrete score and systematic discharge without physician) and a physician-driven slow-track programme for complicated patients (systematic handover between operating theatre and post-anaesthesia care unit, and between post-anaesthesia care unit and ward, systematic rounds, systematic use of standardised care for post-operative events, strict discharge criteria). Main outcome measures Post-anaesthesia care unit length of stay, in-hospital mortality and unplanned admission to the ICU after post-anaesthesia care unit stay. Methods Comparison of the periods before and after implementation using median and interquartile range (IQR) and rates (%). Statistical analysis: unpaired Student's t-test, chi(2) test, Wilcoxon rank test. Differences were adjusted through multivariate analyses with linear and logistic regression (level of significance: P < 0.05) and expressed as odds ratio (OR) with 95% confidence interval (95% CI). Results After implementation, the median post-anaesthesia care unit length of stay decreased for all patients from 163 min (IQR 103-291) to 148 min (IQR 96-270; P < 0.001); in the American Society of Anaesthesiologists 1-2 patients, it decreased from 152 min (IQR 102-249) to 135 min (IQR 91227; P < 0.001). In-hospital mortality decreased for all patients from 1.7 to 0.9% [adjusted OR 0.36 (95% CI 0.22-0.59), P < 0.001]. The number of unplanned admissions to the ICU decreased from 113 (2.8%) to 91 (2.1%) [adjusted OR 0.73 (95% CI 0.53-0.99), P - 0.04]. Conclusion A clinical pathway in a post-anaesthesia care unit can significantly reduce length of stay and can improve postoperative outcome. Eur J Anaesthesiol 2011;28:859-866