The influence of preoperative risk stratification on fast-tracking patients after pulmonary resection.

Fast-tracking protocols or postoperative care computerized algorithms have been shown to reduce hospital length of stay and reduce costs; however, not all patients can be fast-tracked. Certain patient characteristics may put patients at increased risk to fail fast-tracking. Additionally some patients have multiple risk factors that have an additive effect that puts them at an even increased risk to fail fast-tracking, and more importantly, to significant morbidity. It is a mistake to force these protocols on all patients because it can lead to increased complications, readmissions, and low patient and family satisfaction. By carefully analyzing surgical results via accurate prospective databases, the types of patients who fail fast-tracking and the reasons they fail can be identified. Once these characteristics are pinpointed, specific changes to the postoperative algorithm can be implemented, and these alterations can lead to improved outcomes. The authors have shown that by using pain pumps instead of epidurals in elderly patients we can improve outcomes and still fast-track octogenarians with minimal morbidity and high-patient satisfaction. We have also shown that the increased use of physical therapy and respiratory treatments (important parts of the care of all patients after pulmonary resection, but a limited resource in most hospitals) may also lead to improved surgical results for those who have low FEV1% and DLco%. Further studies are needed. Although fast-tracking protocols cannot be applied to all, the vast majority of patients who undergo elective pulmonary resection, even those at high risk, can undergo safe, efficient, and cost-saving care via preset postoperative algorithms. When the typical daily events are convened each morning and the planned date of discharge is frequently communicated with the patient and family before surgery and each day in the hospital, most patients can be safely fast-tracked with high satisfaction and outstanding results.