We commend Dr. Norris for his thoughtful comments. Indeed, if an institution can overcome care-process bottlenecks by creating fast-track paths from existing time points (e.g. , by eliminating phase 2 instead of bypassing phase 1 recovery), congratulations to such institutions for reengineering such costly and complex processes!

When using published criteria to determine discharge eligibility from any phase of recovery, a modified Aldrete score1of 10 is typically recommended. However, it should be noted that it is difficult to achieve such a score in nerve block patients because of (1) residual block and (2) patients’ inability to move the blocked extremity. Discharge eligibility scores relating to limb mobility are relevant, but the modified Aldrete score threshold of 10 technically forbids same-day discharge eligibility when nerve blocks are in place. As a result, the modified Aldrete score may not be the most well-suited home-discharge criterion in the practice of peripheral nerve block anesthesia in ambulatory surgery.

As Dr. Norris alludes, duration of the surgical procedure is an independent risk factor both for a higher rate of unplanned hospital admissions2and for increased risk of postoperative nausea and vomiting.3As anesthesiologists, however, we can only control anesthesia selection, not the duration of the surgical procedure.

Therefore, this reply seeks not to explain or rationalize the importance of teaching in teaching hospitals and the likely effect that teaching has on increasing surgical case durations. Rather, with the referenced report4and accompanying editorial,5we have attempted to raise awareness that routine use of much-improved nerve blocks in outpatient orthopedic surgery (1) offers multiple, independent recovery advantages over routine use of general anesthesia with volatile agents and (2) calls for a revision of recovery scoring parameters when peripheral nerve blocks are used and extremities are rendered temporarily immobile or insensate in otherwise stable patients.

* University of Pittsburgh, Pittsburgh, Pennsylvania. williamsba@anes.upmc.edu

Aldrete JA: The post-anesthesia recovery score revisited. J Clin Anesth 1995; 7:89–91
Gold BS, Kitz DS, Lecky JH, Neuhaus JM: Unanticipated admission to the hospital following ambulatory surgery. JAMA 1989; 262:3008–10
Sinclair DR, Chung F, Mezei G: Can postoperative nausea and vomiting be predicted? Anesthesiology 1999; 91:109–18
Hadzic A, Arliss J, Kerimoglu B, Karaca PE, Yufa M, Claudio R, Vloka JD, Rosenquist R, Santos AC, Thys DM: A comparison of infraclavicular nerve block versus  general anesthesia for hand and wrist surgery in day-case surgery. Anesthesiology 2004; 101:127–32
Williams BA: For outpatients, does regional anesthesia truly shorten the hospital stay, and how should we define postanesthesia care unit bypass eligibility? Anesthesiology 2004; 101:3–6