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McIntosh A, Lachmann E, Datcu A, McLeod C. Posterior spinal fusion for adolescent idiopathic scoliosis and the impact of postoperative intravenous dexamethasone supplementation. PAEDIATRIC & NEONATAL PAIN 2024; 6:19-26. [PMID: 38863457 PMCID: PMC11163225 DOI: 10.1002/pne2.12117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/05/2023] [Accepted: 10/24/2023] [Indexed: 06/13/2024]
Abstract
Postoperative care pathways for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion have demonstrated decreases in postoperative opioid consumption, improved pain control, and lead to decreased lengths of stay. Our objective was to implement postoperative steroids to reduce acute postoperative opioid consumption, pain scores, and length of stay. Dosing consisted of intravenous dexamethasone 0.1 mg/kg up to 4 mg per dose for a total of three doses at 8, 16, and 24 h postoperatively. As part of a quality initiative, we compared three cohorts of patients. The initial retrospective epidural cohort (EPI) (n = 59) had surgeon placed epidural catheters with infusion of ropivacaine 0.1% postoperatively for 18-24 h. Following an institutional change in postoperative care, epidural use was discontinued. A second cohort (n = 149), with prospectively collected data, received a surgeon placed erector spinae plane block and wound infiltration with a combination of liposomal and plain bupivacaine (LB). A third cohort (n = 168) was evaluated prospectively. This cohort received a surgeon placed erector spinae plane block and wound infiltration with liposomal and plain bupivacaine and additionally received postoperative dexamethasone for three doses (LB + D). Compared to the LB cohort, the LB + D cohort demonstrated statistically significant decreases in oral milligram morphine equivalents per kilogram at 0-24, 24-48, and 48-72 h. There was a statistically significant difference in median pain scores at 24-48 and 48-72 h in LB + D versus LB. The LB + D cohort's median length of stay in hours was significantly less compared to the LB cohort (52 h vs. 70 h, p < 0.0001). Postoperative intravenous dexamethasone was added to an established postoperative care pathway for patients undergoing posterior spinal fusion for idiopathic scoliosis resulting in decreased VAS pain scores, opioid consumption, and shorter length of stay.
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Affiliation(s)
- Amy McIntosh
- Department of Orthopedic Surgery, Scottish Rite for ChildrenUT Southwestern Medical CenterDallasTexasUSA
| | - Emily Lachmann
- Department of Orthopedic SurgeryScottish Rite for ChildrenDallasTexasUSA
| | - Anne‐Marie Datcu
- Department of Orthopedic SurgeryScottish Rite for ChildrenDallasTexasUSA
| | - Christopher McLeod
- Department of Anesthesiology, Scottish Rite for ChildrenUT Southwestern Medical CenterDallasTexasUSA
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Aksu H, Manduz B, Armagan M, Satoglu İS, Hanci V. Early complications in scoliosis surgery and relation to preoperative factors: A single-center retrospective study. Medicine (Baltimore) 2024; 103:e37529. [PMID: 38552046 PMCID: PMC10977596 DOI: 10.1097/md.0000000000037529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/15/2024] [Indexed: 04/02/2024] Open
Abstract
In this study, we aimed to investigate the perioperative complications of the patients who underwent scoliosis surgery in our hospital and the factors that may affect the outcome. Between 2014 and 2018, scoliosis patients recorded data was examined retrospectively. Age, gender, height, body weight, comorbidity, Cobb index, scoliosis etiology, operation time, preoperative and postoperative hemoglobin, hematocrit, leukocyte, blood urea nitrogen, creatinine, coagulation value, operation time, level of instrumentation, intraoperative and postoperative blood loss, blood transfusion, intraoperative fluid administration, preoperative pulmonary function test values, blood gas values, urine outputs, hospital (LOS) and post anesthesia care unit stays, complications and mortality rates were examined. The files of 77 patients (48 female, 29 male) were retrospectively analyzed. The average age was 19.54 ± 16.32 years and 98.7% were elective surgery. The mean of LOS was 13.55 ± 9.13 days. As the preoperative hematocrit value decreases, LOS increases significantly. In patients with chronic obstructive pulmonary disease, smokers and high ASA scores, LOS is prolonged in patients with previous operations. As intraoperative colloid administration increased, crystalloid and blood products increased, it was also observed that the amount of crystalloid increased LOS. As the amount of intraoperative colloid or red blood cell administration increases, the duration of surgery and anesthesia increases, also increases the duration of post anesthesia care unit. Compared to patients with complications (n = 29) to the patients without complications (n = 47), it was found that they had longer anesthesia, and surgery times, also longer LOS times (P < .05). Our study showed that chronic obstructive pulmonary disease in the preoperative period, smoking, high ASA score, excessive use of colloid, prolonged duration of surgery and anesthesia, and long intubation durations increase the length of hospital stay. Preoperative comorbidity is directly related to postoperative complications and causes longer hospitalization after reconstructive scoliosis surgery.
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Affiliation(s)
- Hale Aksu
- Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Busra Manduz
- Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Mustafa Armagan
- Orthopedics and traumatology, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - İsmail Safa Satoglu
- Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey
- Orthopedics and traumatology, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Volkan Hanci
- Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey
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Benjamin HJ, Perri MM, Leemputte J, Lewallen L, DeVries C. Opioids and Youth Athletes. Sports Health 2024; 16:269-278. [PMID: 38366642 PMCID: PMC10916775 DOI: 10.1177/19417381241228629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
CONTEXT The ongoing opioid epidemic and associated adverse effects impart a large burden on our current healthcare system. The annual economic and noneconomic cost of opioid use disorder and fatal opioid overdose is currently estimated at $1 trillion. OBJECTIVE This review presents the prevalence, frequency of use, need, and effectiveness of opioid analgesia in the youth and adolescent athlete population. It identifies current indications for opioid versus nonopioid analgesic use in the setting of acute orthopaedic injuries, postoperative management, concussion, and chronic pain. Current knowledge of youth athlete opioid use, risks related to use, misuse, diversion, and addiction are reviewed. DATA SOURCES A PubMed, Medline, and Cochrane Library search was conducted in February 2023 to review opioid pain management strategies in the pediatric athlete population from 2000 to present. STUDY SELECTION Searches were restricted to English language articles and human subjects. Initial reviews of titles and abstracts were performed by all authors and relevant full-text articles were selected. Priority was given to systematic and narrative reviews, meta-analyses, and prospective studies. STUDY DESIGN Narrative review. LEVEL OF EVIDENCE Level 3. DATA EXTRACTION First author name, publication year, study design, study country, subject demographics, and data on the frequency, type, and duration of analgesic treatments for musculoskeletal injuries, postsurgical care, chronic pain disorders, and concussion were extracted. RESULTS Pediatric athletes comprise a high-risk population seeking analgesic relief for injury-related pain. Participation in high school sports is associated with increased risk of opioid use. An average of 28% to 46% of high school athletes have used opioids in their lifetime. Participation in ≥1 high school sport puts adolescents at 30% greater odds of future opioid misuse. CONCLUSION The use of opioids in the pediatric athlete population is common and associated with both short- and long-term risks of misuse and addiction.
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Changoor S, Giakas A, Sacks K, Asma A, Lang RS, Yorgova P, Rogers K, Gabos PG, Shah SA. The Role of Liposomal Bupivacaine in Multimodal Pain Management Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Faster and Farther With Less Opioids. Spine (Phila Pa 1976) 2024; 49:E11-E16. [PMID: 37159268 DOI: 10.1097/brs.0000000000004702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023]
Abstract
STUDY DESIGN Retrospective controlled cohort. OBJECTIVE To evaluate the effect of intraoperative liposomal bupivacaine (LB) infiltration on postsurgical pain management in adolescent idiopathic scoliosis (AIS) patients by analyzing postoperative opioid consumption, ambulation, and length of stay (LOS). SUMMARY OF BACKGROUND DATA Optimal postoperative pain control for AIS patients undergoing posterior spinal fusion (PSF) is challenging. Multimodal pain management protocols provide adequate analgesia while decreasing opioid consumption. LB was recently approved for pediatric patients; however, use in AIS patients is understudied. METHODS 119 consecutive patients with AIS who underwent PSF were included. Patients were divided into 2 groups: patients who received LB as erector spinae block in addition to the standard postoperative pain management protocol (Group A), and patients who received only the standard postoperative pain protocol (Group B). Oral morphine equivalents, intravenous opioid and valium consumption, pain scores (VAS), nausea/vomiting, ambulation distance and LOS were assessed. RESULTS Group A experienced significantly lower total opioid consumption compared to Group B (44.5 mg vs. 70.2 mg). Morphine use was lower in Group A on postoperative day (POD) 0, and oxycodone use was lower in Group A on PODs 1 and 2. There was a higher proportion of patients who used only oral opioids in Group A (81% vs. 41%). Of patients requiring any intravenous opioids, 79% did not receive LB. A significantly higher proportion of LB patients were discharged on POD 2 (55% vs. 27%); therefore, LOS was shorter for Group A. Group A ambulated further postoperatively. There were no differences in pain scores, valium requirements or nausea/vomiting. CONCLUSIONS LB was associated with decreased total opioid use, shorter LOS, and improved ambulation in AIS patients undergoing PSF. Including LB in multimodal pain management protocols proved effective in reducing opioid use while increasing mobilization in the immediate postoperative period. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Stuart Changoor
- Department of Orthopedic Surgery, St. Joseph's University Medical Center, Paterson, NJ
| | - Alec Giakas
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Jefferson Health, Philadelphia, PA
| | - Karen Sacks
- Department of Anesthesia, Nemours Children's Health, Wilmington, DE
| | - Ali Asma
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
| | - R Scott Lang
- Department of Anesthesia, Nemours Children's Health, Wilmington, DE
| | - Petya Yorgova
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
| | - Kenneth Rogers
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
| | - Peter G Gabos
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
| | - Suken A Shah
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
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DeVries Z, Nucci N, Smit K, Tice A, Romeo J, Jarvis JG. Determining the factors associated with a prolonged length of stay for adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion in a single-payer health care system: are these factors different than those in the United States? Spine Deform 2024; 12:133-139. [PMID: 37672201 DOI: 10.1007/s43390-023-00750-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/02/2023] [Indexed: 09/07/2023]
Abstract
INTRODUCTION Rapid recovery pathways (RRP) for adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion (PSIF) have been shown to be successful in reducing hospital length of stay (LOS). Although the majority of patients are discharged within 3 days, some patients require longer hospital admission. Previous studies in the United States have identified predictors of prolonged LOS for this patient population. The goal of this project was to determine if these predictors are the same for Canadian scoliosis patients and to identify those features which are different under this single-payer system. METHODS A RRP for scoliosis surgery was implemented in March 2015 at a single, tertiary referral children's hospital in Canada. Previously identified features, along with numerous other patient factors, were collected. Spearman correlations were used to determine the factors most associated with hospital LOS and those factors were used in a multivariable regression model. RESULTS A total of 161 patients were included in the analysis. Of the previously identified patient factors, only receiving a peri-operative transfusion was found to be significant (ρ = 0.24; p = 0.002). None of the other pre-identified variables were found to be significantly correlated with LOS. Variables not previously examined that were found to be significantly correlated with hospital LOS included ASA status (ρ = 0.19, p = 0.046), fusion involving both the thoracic and lumbar spine (ρ = 0.18, p = 0.025), and receiving celecoxib on post-operative day 1 (ρ = - 0.16; p = 0.038). The features that had the greatest association with LOS through multivariable regression was receiving a blood transfusion (B = 0.48; 95%CI 0.096-0.89; p = 0.017). CONCLUSIONS In this study, we found that many of the features found to be significantly correlated with prolonged hospital LOS in the United States are not transferable to the Canadian healthcare system. This is important for the Canadian, and other surgeons in a single-payer system, in order to identify pre-operative or immediate post-operative factors that may extend patient LOS following PSIF and plan resources accordingly. LEVEL OF EVIDENCE III; therapeutic.
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Affiliation(s)
- Zachary DeVries
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Nicholas Nucci
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Kevin Smit
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Andrew Tice
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Jessica Romeo
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - James G Jarvis
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
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Flynn R, Cassidy C, Dobson L, Al-Rassi J, Langley J, Swindle J, Graham ID, Scott SD. Knowledge translation strategies to support the sustainability of evidence-based interventions in healthcare: a scoping review. Implement Sci 2023; 18:69. [PMID: 38049900 PMCID: PMC10694920 DOI: 10.1186/s13012-023-01320-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/13/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Knowledge translation (KT) strategies are widely used to facilitate the implementation of EBIs into healthcare practices. However, it is unknown what and how KT strategies are used to facilitate the sustainability of EBIs in institutional healthcare settings. OBJECTIVES This scoping review aimed to consolidate the current evidence on (i) what and how KT strategies are being used for the sustainability of EBIs in institutional healthcare settings; (ii) the reported KT strategy outcomes (e.g., acceptability) for EBI sustainability, and (iii) the reported EBI sustainability outcomes (e.g., EBI activities or component of the intervention continue). METHODS We conducted a scoping review of five electronic databases. We included studies describing the use of specific KT strategies to facilitate the sustainability of EBIs (more than 1-year post-implementation). We coded KT strategies using the clustered ERIC taxonomy and AIMD framework, we coded KT strategy outcomes using Tierney et al.'s measures, and EBI sustainability outcomes using Scheirer and Dearing's and Lennox's taxonomy. We conducted descriptive numerical summaries and a narrative synthesis to analyze the results. RESULTS The search identified 3776 studies for review. Following the screening, 25 studies (reported in 27 papers due to two companion reports) met the final inclusion criteria. Most studies used multi-component KT strategies for EBI sustainability (n = 24). The most common ERIC KT strategy clusters were to train and educate stakeholders (n = 38) and develop stakeholder interrelationships (n = 34). Education was the most widely used KT strategy (n = 17). Many studies (n = 11) did not clearly report whether they used different or the same KT strategies between EBI implementation and sustainability. Seven studies adapted KT strategies from implementation to sustainability efforts. Only two studies reported using a new KT strategy for EBI sustainability. The most reported KT strategy outcomes were acceptability (n = 10), sustainability (n = 5); and adoption (n = 4). The most commonly measured EBI sustainability outcome was the continuation of EBI activities or components (n = 23), followed by continued benefits for patients, staff, and stakeholders (n = 22). CONCLUSIONS Our review provides insight into a conceptual problem where initial EBI implementation and sustainability are considered as two discrete time periods. Our findings show we need to consider EBI implementation and sustainability as a continuum and design and select KT strategies with this in mind. Our review has emphasized areas that require further research (e.g., KT strategy adaptation for EBI sustainability). To advance understanding of how to employ KT strategies for EBI sustainability, we recommend clearly reporting the dose, frequency, adaptations, fidelity, and cost of KT strategies. Advancing our understanding in this area would facilitate better design, selection, tailored, and adapted use of KT strategies for EBI sustainability, thereby contributing to improved patient, provider, and health system outcomes.
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Affiliation(s)
- Rachel Flynn
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College of Cork, College Road Cork, Cork, T12 AK54, Ireland.
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - Christine Cassidy
- School of Nursing, Faculty of Health, Dalhousie University, Room N21, Forrest Bldg., PO Box 15000 5869 University Avenue Halifax, Nova Scotia, B3H 4R2, Canada.
| | - Lauren Dobson
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Joyce Al-Rassi
- School of Nursing, Faculty of Health, Dalhousie University, Room N21, Forrest Bldg., PO Box 15000 5869 University Avenue Halifax, Nova Scotia, B3H 4R2, Canada
| | - Jodi Langley
- School of Nursing, Faculty of Health, Dalhousie University, Room N21, Forrest Bldg., PO Box 15000 5869 University Avenue Halifax, Nova Scotia, B3H 4R2, Canada
| | - Jennifer Swindle
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
- The Centre for Implementation Research, Ottawa Hospital Research Institute, 501 Smyth Road, Box 241, Ottawa, Ontario, K1H 8L6, Canada
| | - Shannon D Scott
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
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Locke LL, Rhodes LN, Sheffer BW. Accelerated Protocols in Adolescent Idiopathic Scoliosis Surgery. Orthop Clin North Am 2023; 54:427-433. [PMID: 37718082 DOI: 10.1016/j.ocl.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Treatment depends on the degree of curvature, skeletal maturity, and age of the patient. Once the curve reaches 50 degrees, posterior spinal fusion (PSF) is necessary to stabilize the spine and prevent further progression of the curve. PSF causes significant trauma to the tissues and often results in significant pain postoperatively. The purpose of this article is to provide the audience with a review of preoperative, intraoperative, and postoperative pain control with an accelerated protocol in patients with AIS undergoing PSF.
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Affiliation(s)
- Lindsey L Locke
- Le Bonheur Children's Hospital, Memphis, TN, USA; College of Nursing, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Leslie N Rhodes
- Le Bonheur Children's Hospital, Memphis, TN, USA; College of Nursing, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Benjamin W Sheffer
- Le Bonheur Children's Hospital, Memphis, TN, USA; Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
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Martin BD, Gordish-Dressman H, Mirzada A, Kelly SM, Pestieau SR, Cronin J, Oetgen ME. A dedicated surgical team for posterior spinal fusion in patients with adolescent idiopathic scoliosis improves OR efficiency. Spine Deform 2023; 11:643-649. [PMID: 36681754 PMCID: PMC9867539 DOI: 10.1007/s43390-022-00639-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/30/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Standardized care pathways for adolescent idiopathic scoliosis (AIS) patients undergoing PSF improve clinical outcomes. We hypothesized that having dedicated spine personnel would decrease surgical time and improve clinical outcomes. METHODS 367 patients with AIS had a PSF within a standardized perioperative care pathway. Cases with 1-3 dedicated spine team members (any combination of circulating nurse, surgical technologist, and anesthesiologist) were compared to teams with none. The impact of individual members was also analyzed. Parametric or non-parametric tests were used for each outcome based on the distribution of the data points. These included one-way ANOVA models, Kruskal-Wallis tests, and Fisher's exact tests. RESULTS Surgical time and total OR time were significantly decreased with the participation of each additional dedicated team member resulting in 43.86 min less surgical time and 50.8 min less total OR time when three team members were present compared to no team members. If the nurse was a spine member, the surgical time was lower (p = 0.037). If the technologist was a team member, the surgical time and total OR time were lower (p = 0.002 and p = 0.001, respectively). Lastly, if the anesthesiologist was a member of the team, the anesthesia time was lower (p = 0.003). No significant clinical differences were observed. CONCLUSION Having dedicated surgical team members decreases surgical and total OR time for AIS patients undergoing PSF, and this OR efficiency improves as the dedicated team is more robust. OR surgical teams did not influence clinical outcomes. Hospitals should strongly consider developing surgical teams to improve OR efficiency of PSF cases.
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Affiliation(s)
- Benjamin D. Martin
- grid.239560.b0000 0004 0482 1586Division of Orthopaedic Surgery & Sports Medicine, Children’s National Hospital, 111 Michigan Avenue, Washington, DC 20010 USA
| | - Heather Gordish-Dressman
- grid.239560.b0000 0004 0482 1586Research Center for Genetic Medicine, Children’s National Hospital, Washington, DC USA
| | - Ariana Mirzada
- grid.239560.b0000 0004 0482 1586Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, DC USA
| | - Shannon M. Kelly
- grid.239560.b0000 0004 0482 1586Division of Orthopaedic Surgery & Sports Medicine, Children’s National Hospital, Washington, DC USA
| | - Sophie R. Pestieau
- grid.239560.b0000 0004 0482 1586Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, DC USA
| | - Jessica Cronin
- grid.239560.b0000 0004 0482 1586Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, DC USA
| | - Matthew E. Oetgen
- grid.239560.b0000 0004 0482 1586Division of Orthopaedic Surgery & Sports Medicine, Children’s National Hospital, Washington, DC USA
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Sethi RK, Drolet CE, Pumpian RP, Shen J, Hanson K, Guerra S, Louie PK. Combining time-driven activity-based costing and lean methodology: an initial study of single-level lumbar fusion surgery to assess value-based healthcare in patients undergoing spine surgery. J Neurosurg Spine 2022; 37:639-645. [PMID: 35901774 DOI: 10.3171/2022.4.spine211516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Measuring costs across entire episodes of care, time-driven activity-based costing (TDABC) has recently been described as a novel cost accounting arm of value-based care organizations. Lean methodology is a system used to understand pathways of care at a granular level, allowing for standardization. The current work presents an attempt at combining the 2 methodologies to detect meaningful variation in a patient's care following single-level spine fusion. The objective of this study was to evaluate the combination of TDABC and lean methodologies in detecting meaningful variability in time-based care in patients undergoing single-level spine fusion surgery. METHODS This study is a consecutive case series of patients who underwent single-level spine fusion performed by 1 of 5 fellowship-trained spine surgeons. Patients were diagnosed with either lumbar stenosis or spondylolisthesis. Additional inclusion criteria included inpatient stays from 1 to 3 days, discharge to home, and no readmission within 30 days of surgery. Patient demographic data were obtained. Time spent on activities for each personnel role was aggregated in 15-minute increments occurring preoperatively, intraoperatively, and postoperatively. Patients were analyzed in 3 groups based on the duration of their in-hospital stay. RESULTS Patients discharged on postoperative day (POD) 3 had statistically significantly more total time spent than those discharged on POD 2. Patients discharged on POD 1 had less total time than those in the former 2 groups. The amount of time spent with patients did not differ for personnel in either preoperative or postanesthesia care unit phases of care. There was a statistically significant difference in time spent in surgery for surgeons, anesthesia attendings, circulators, and scrub technicians. CONCLUSIONS In a healthcare setting run by lean methodology, TDABC may detect meaningful variability in an episode of care for single-level spine fusion. Clinicians and administrators can use this combination to allocate costs appropriately, optimize value care streams, and help improve patient care.
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Affiliation(s)
- Rajiv K Sethi
- 1Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle; and
- 2Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | - Caroline E Drolet
- 1Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle; and
| | - Rebecca P Pumpian
- 1Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle; and
| | - Jesse Shen
- 1Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle; and
| | - Kelsey Hanson
- 1Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle; and
| | - Sofia Guerra
- 1Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle; and
| | - Philip K Louie
- 1Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle; and
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Sundar SJ, Enders JJ, Bailey KA, Gurd DP, Goodwin RC, Kuivila TE, Ballock RT, Young EY. Use of a Standardized Perioperative Care Path for Adolescent Idiopathic Scoliosis Leads to Decreased Complications and Readmissions. Clin Spine Surg 2022; 35:E41-E46. [PMID: 34261869 DOI: 10.1097/bsd.0000000000001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective review of patients ages 10-18 who underwent posterior fusion for adolescent idiopathic scoliosis (AIS) at a single institution from 2014 to 2019. OBJECTIVE The aim was to evaluate a standardized Care Path to determine its effects on perioperative outcomes in patients undergoing spinal fusion for AIS. SUMMARY OF BACKGROUND DATA AIS is the most common pediatric spinal deformity and thousands of posterior fusions are performed annually. Surgery presents several postoperative challenges, such as pain control, delayed mobilization, and opioid-related morbidity. Optimizing perioperative care of AIS is a high priority to reduce morbidity and improving health care efficiency. MATERIALS AND METHODS A total of 336 patients ages 10-18 were included in this study; 117 in the pre-Care Path cohort (2014-2015) and 219 in the post-Care Path cohort (2016-2019). Data compared included intraoperative details, length of stay, timing of mobilization, inpatient complications, emergency room (ER) visits, readmissions after discharge, postoperative complications, and reoperations. RESULTS The post-Care Path cohort had improved mobilization on postoperative day 0 (pre 16.7%, post 53.3%, P<0.00001), reduced length of stay (pre 4.14 days, post 3.36 days, P=0.00006), fewer total inpatient complications (pre 17.1%, post 8.1%, P=0.0469), and fewer instances of postoperative ileus (pre 8.5%, post 1.9%, P=0.0102). Within 60 days of surgery, the post-Care Path cohort had fewer ER visits (pre 12.8%, post 7.2%, P=0.0413), decreased postoperative infections (pre 5.1%, post 0.48%, P=0.00547), decreased readmissions (pre 6.0%, post 0.48%, P=0.0021), and decreased reoperations (pre 5.1%, post 0.96%, P=0.0195). There was a decrease in inpatient oral morphine equivalents in the Care Path cohort (pre 118.7, post 84.7, P=0.0003). CONCLUSIONS Our Care Path for AIS patients demonstrated significant improvements in postoperative mobilization and decreases in length of stay, complications, infections, ER visits, readmissions, and reoperations.
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Affiliation(s)
| | | | - Kevin A Bailey
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - David P Gurd
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Ryan C Goodwin
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Thomas E Kuivila
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Robert T Ballock
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Ernest Y Young
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
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Comparison of interventions and outcomes of enhanced recovery after surgery: a systematic review and meta-analysis of 2456 adolescent idiopathic scoliosis cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3457-3472. [PMID: 34524513 DOI: 10.1007/s00586-021-06984-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 05/30/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this meta-analysis and systematic review is to compare the methodology and evaluate the efficacy of Enhanced recovery after Spine Surgery (ERAS) for adolescent idiopathic scoliosis (AIS) and to compare the outcomes with traditional discharge (TD) pathways. METHODS Using major databases, a systematic search was performed. Studies comparing the implementation of ERAS or ERAS-like and TD pathways in patients with AIS were identified. Data regarding methodology and outcomes were collected and analyzed. RESULTS Fourteen studies (n = 2456) were included, comprising 1081 TD and 1375 ERAS or ERAS-like patients. Average age of patients was 14.6 ± 0.4 years. Surgical duration was on average 35.6 min shorter for the ERAS group compared to TD cohort ([2.8, 68.3], p = 0.03), and blood loss was 112.3 milliliters less ([102.4, 122.2], p < 0.00001). ERAS group reached first ambulation 29.6 h earlier ([11.2, 48.0], p-0.002), patient-controlled-analgesia (PCA) discontinuation 0.53 day earlier ([0.4, 0.6], p < 0.00001), urinary catheter discontinuation 0.5 day earlier ([0.4, 0.6], p < 0.00001), and length-of-stay (LOS) was 1.6 days shorter ([1.4, 1.8], p < 0.00001). Rates of complications and 30-day-readmission-to-hospital were similar between both groups. Pain scores were significantly lower for ERAS group on days 0 through 2 post-operatively. CONCLUSIONS Use of ERAS after AIS is safe and effective, decreasing surgical duration and blood loss. ERAS methodology effectively focused on reducing time to first ambulation, PCA discontinuation, and urinary catheter removal. Outcomes showed significantly decreased LOS without a significant increase in complications. There should be efforts to incorporate ERAS in AIS surgery. Further studies are necessary to assess patient satisfaction. LEVEL OF EVIDENCE III Meta-analysis of Level 3 studies.
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12
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Temby SE, Palmer GM, Penrose SP, Peachey DM, Johnson MB. Implementation of an enhanced recovery pathway in Australia after posterior spinal fusion for adolescent idiopathic scoliosis delivers improved outcomes. Spine Deform 2021; 9:1371-1377. [PMID: 33822322 DOI: 10.1007/s43390-021-00340-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/25/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Traditionally, spinal surgery for Adolescent Idiopathic Scoliosis (AIS) has seen long hospital length of stay (LOS) and slow mobility progression. Postoperative enhanced recovery pathways (ERP) for this population in North America and Asia have successfully reduced LOS and hospital costs without increasing complications. This study assessed if ERP introduced in an Australian center achieves similar results. METHODS A pre-post intervention study compared a historical AIS cohort having a posterior spinal fusion (PSF) who received conventional care (CC) (2013-2014) with prospectively assessed ERP recipients (2016-2018) separated by 1-year implementation period. Patient characteristics, surgical details, postoperative analgesia, mobilization, LOS and complication outcomes were collected. RESULTS The 32 CC and 61 ERP recipients had similar demographics. ERP recipients had 44% decreased LOS (mean LOS 3.5 ± 0.9 days vs. CC 6.3 ± 0.9 days, p < 0.001) as all ERP milestones were achieved sooner including transition to oral analgesia (MD - 2 days, 95% CI 1.8-2.3), oral intake (MD - 2.3 days, 95% CI 2.0-2.6) and mobilization, with fewer physiotherapy sessions (5.2 vs 8, p < 0.001). Postoperative in-hospital costs were 50.2% less for ERP vs CC (AUD $8234 vs $16,545). Due to small sample size, no differences between the groups were detectable for complications (4.9% vs 6.3%) or readmission (1.6% vs 3.1%). CONCLUSION An ERP for AIS after PSF in this Australian center improved functional recovery reducing LOS and by associated postoperative inpatient costs. Other Australian hospitals should consider an ERP for this population with larger-scale audit to assess impact upon complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sarah E Temby
- Physiotherapy Department, The Royal Children's Hospital, Melbourne, VIC, Australia.
| | - Greta M Palmer
- Department of Anaesthesia and Pain Management Service, The Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,University of Melbourne, Melbourne, VIC, Australia
| | - Sueann P Penrose
- Department of Anaesthesia and Pain Management Service, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Donna M Peachey
- Department of Orthopaedics, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Michael B Johnson
- Department of Orthopaedics, The Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
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Fletcher ND, Murphy JS, Austin TM, Bruce RW, Harris H, Bush P, Yu A, Kusumoto H, Schmitz ML, Devito DP, Fabregas JA, Miyanji F. Short term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2021; 9:1013-1019. [PMID: 33460022 DOI: 10.1007/s43390-020-00282-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Enhanced Recovery after Surgery (ERAS) pathways have been shown to decrease length of stay (LOS) after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to compare immediate post-operative outcomes following an ERAS pathway with a traditional pathway for AIS. METHODS A prospective dual-center study of patients treated using an ERAS pathway (203 patients) or a traditional discharge (TD) pathway (73 patients) was performed with focus on pain at discharge, quality of life at one month, and return to school/work. RESULTS LOS was 55% less in the ERAS group (4.8 days TD vs. 2.2 days ERAS, p < 0.001). Length of surgery (4.8 h TD vs. 2.8 h, p < 0.001) and EBL (500 cc vs. 240 cc, p < 0.001) were greater in the TD group, likely related to larger curve magnitudes ((62.0° TD vs. 54.0° ERAS, p < 0.001), a higher percentage of patients undergoing osteotomies (94% vs. 46%, p < 0.001) and more levels fused (11.4 ± 1.6 vs. 10.1 ± 2.6, p < 0.001) in the TD group. Regression analysis showed no difference in Visual Analog Score (VAS) score at discharge or quality of recovery using the QOR9 instrument between groups at follow up. There was no difference in return to school (p = 0.43) and parents' return to work (p = 0.61) between the groups. CONCLUSION Patients managed with an ERAS pathway had similar pain scores at discharge than those managed with a TD pathway. Both groups showed evidence of rapid return to normalcy by the first follow up visit.
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Affiliation(s)
- Nicholas D Fletcher
- Department of Orthopaedic Surgery, Center for Advanced Pediatrics, Children's Healthcare of Atlanta, 1400 Tullie Rd, Atlanta, GA, 30329, USA.
| | - Joshua S Murphy
- Department of Orthopaedic Surgery, Center for Advanced Pediatrics, Children's Healthcare of Atlanta, 1400 Tullie Rd, Atlanta, GA, 30329, USA
| | - Thomas M Austin
- Department of Anesthesiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Robert W Bruce
- Department of Orthopaedic Surgery, Center for Advanced Pediatrics, Children's Healthcare of Atlanta, 1400 Tullie Rd, Atlanta, GA, 30329, USA
| | - Hilary Harris
- Department of Orthopaedic Surgery, Center for Advanced Pediatrics, Children's Healthcare of Atlanta, 1400 Tullie Rd, Atlanta, GA, 30329, USA
| | - Patricia Bush
- Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Austin Yu
- Albany Medical College, Albany, NY, USA
| | | | - Michael L Schmitz
- Department of Orthopaedic Surgery, Center for Advanced Pediatrics, Children's Healthcare of Atlanta, 1400 Tullie Rd, Atlanta, GA, 30329, USA
| | - Dennis P Devito
- Department of Orthopaedic Surgery, Center for Advanced Pediatrics, Children's Healthcare of Atlanta, 1400 Tullie Rd, Atlanta, GA, 30329, USA
| | - Jorge A Fabregas
- Department of Orthopaedic Surgery, Center for Advanced Pediatrics, Children's Healthcare of Atlanta, 1400 Tullie Rd, Atlanta, GA, 30329, USA
| | - Firoz Miyanji
- British Columbia Children's Hospital, Vancouver, BC, USA
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Kwan MK, Loh KW, Chung WH, Chiu CK, Hasan MS, Chan CYW. Perioperative outcome and complications following single-staged Posterior Spinal Fusion (PSF) using pedicle screw instrumentation in Adolescent Idiopathic Scoliosis (AIS): a review of 1057 cases from a single centre. BMC Musculoskelet Disord 2021; 22:413. [PMID: 33947368 PMCID: PMC8097957 DOI: 10.1186/s12891-021-04225-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background There has been a growing interest in using all pedicle screw construct in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) surgery in recent years. However, studies focusing on perioperative outcome and complications utilizing only pedicle screw system in AIS population are lacking. This study aims to evaluate perioperative outcomes and to determine the prevalence of major and minor complications following single-staged PSF for AIS. Methods In this retrospective study of prospectively collected data, 1057 AIS patients operated between 2012 and 2019 were included. Main outcome measures were operative time, intraoperative blood loss, allogeneic blood transfusion rate, length of hospital stay after surgery, complication rate, and mean drop of haemoglobin (Hb) level. We documented the number of fusion levels, screw density, and postoperative radiographic parameters. Results There were 917 females and 140 males. Majority were Lenke 1 curve type (46.9%). Mean age was 15.6 ± 3.7 years, with mean BMI of 18.6 ± 3.2 kg/m2. Mean operative time was 146.8 ± 49.4 min. Average intraoperative blood loss was 952.9 ± 530.4 ml with allogeneic blood transfusion rate of 5%. Mean screw density was 1.27 ± 0.21 screws per fusion level. Average hospital stay after surgery was 3.5 ± 0.9 days. Twenty-four complications were documented: twelve superficial infections (1.14%), five transient neurological deficits (0.47%), two deep infections (0.19%), two superior mesenteric artery syndrome, and one case each (0.09%) for massive intraoperative blood loss, intraoperative seizure, and lung atelectasis. Conclusion AIS patients treated with single-staged PSF using pedicle screw construct had a 0.95% rate of major complications and 1.32% rate of minor complications. Rate of neurologic complication was 0.47% while non-neurologic postoperative complications was 1.80% with infection being the leading complication at 1.32%.
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Affiliation(s)
- Mun Keong Kwan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Kwong Weng Loh
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Weng Hong Chung
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Chee Kidd Chiu
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Chris Yin Wei Chan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
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Antonacci G, Lennox L, Barlow J, Evans L, Reed J. Process mapping in healthcare: a systematic review. BMC Health Serv Res 2021; 21:342. [PMID: 33853610 PMCID: PMC8048073 DOI: 10.1186/s12913-021-06254-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 03/08/2021] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare. METHODS We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach. RESULTS The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions. CONCLUSION The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM. TRIAL REGISTRATION Prospero ID: CRD42017082140.
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Affiliation(s)
- Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Laura Lennox
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
| | - James Barlow
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Liz Evans
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, London, UK
| | - Julie Reed
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, London, UK
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Gadiya AD, Koch JEJ, Patel MS, Shafafy M, Grevitt MP, Quraishi NA. Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review. Spine Deform 2021; 9:893-904. [PMID: 33725329 PMCID: PMC8270839 DOI: 10.1007/s43390-021-00310-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/13/2021] [Indexed: 12/28/2022]
Abstract
STUDY DESIGN A systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS. OBJECTIVE To systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS. ERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published. METHODS A systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with < 5 patients were excluded. Length of stay (LOS), complication and readmission rates were used as outcome measures. Statistical analysis was done using the random effects model. RESULTS Of a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p < 0.00001). There was no significant difference in the complication (p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy. CONCLUSION This systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Akshay D. Gadiya
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Jonathan E. J. Koch
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Mohammed Shakil Patel
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Masood Shafafy
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Michael P. Grevitt
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Nasir A. Quraishi
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
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DeVries Z, Barrowman N, Smit K, Mervitz D, Moroz P, Tice A, Jarvis JG. Is it feasible to implement a rapid recovery pathway for adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion in a single-payer universal health care system? Spine Deform 2020; 8:1223-1229. [PMID: 32488767 DOI: 10.1007/s43390-020-00146-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/19/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of this project was to determine if it is feasible to implement a rapid recovery pathway (RRP) for the surgical treatment of adolescent idiopathic scoliosis (AIS) within a single-payer universal healthcare system while simultaneously decreasing length of stay (LOS) without increasing post-operative complications. METHODS A retrospective analysis was completed for all patients who underwent posterior spinal fusion for AIS at a tertiary children's hospital in Canada between March 2010 and February 2019, with date of implementation of the RRP being March 1st, 2015. Patient demographic information was collected along with a variety of outcome variables including: LOS, wound complication, infection, 30-day return to the OR, 30-day emergency department visit, and 30-day hospital readmission. An interrupted time series analysis was utilized to determine if any benefits were associated with the implementation of the RRP. RESULTS A total of 244 patients were identified, with 113 patients in the conventional pathway and 131 in the RRP. No significant differences in demographic features or post-operative complications were found between the two cohorts (p > 0.05). Using a robust linear time series model, LOS was found to be significantly shorter in the RRP group, with the average LOS being 5.2 [95% IQR 4.3-6.1] days in the conventional group and 3.4 [95% IQR 3.3-3.5] days in the RRP group (p < 0.05). CONCLUSION This study shows that it is possible to implement a RRP for the surgical treatment of AIS within a single-payer universal healthcare system. Use of the pathway can effectively reduce hospital LOS without increasing the risk of developing a post-operative complication. This has the upside potential to reduce healthcare and family costs. LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Zachary DeVries
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Kevin Smit
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Deborah Mervitz
- Division of Anaesthesiology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Paul Moroz
- Division of Orthopaedic Surgery, Shriners Hospitals for Children-Honolulu, 1310 Punahou Street, Honolulu, HI, 96826-1099, USA
| | - Andrew Tice
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - James G Jarvis
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
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McIntosh AL. Dexamethasone Administration Decreases Opioid Usage After Posterior Spinal Fusion in Patients with Adolescent Idiopathic Scoliosis: Commentary on article by Nicholas D. Fletcher, MD, et al.: "Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis". J Bone Joint Surg Am 2020; 102:e120. [PMID: 33086358 DOI: 10.2106/jbjs.20.01488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Fletcher ND, Ruska T, Austin TM, Guisse NF, Murphy JS, Bruce RW. Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Bone Joint Surg Am 2020; 102:1807-1813. [PMID: 33086348 DOI: 10.2106/jbjs.20.00259] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgeons have hesitated to use steroids in patients undergoing posterior spinal fusion because of the risk of wound complications. The literature has supported the use of postoperative steroids in other areas of orthopaedics on the basis of more rapid recovery and improved postoperative pain control. We hypothesized that a short course of postoperative dexamethasone following posterior spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS) would decrease opioid usage without increasing wound-healing problems. METHODS Consecutive patients undergoing posterior spinal fusion for the treatment of AIS from 2015 to 2018 at a single hospital were included. A review of demographic characteristics, curve characteristics, surgical data, and postoperative clinic notes was performed. Opioid usage was determined by converting all postoperative opioids given into morphine milligram equivalents (MME). RESULTS Sixty-five patients underwent posterior spinal fusion for the treatment of AIS without postoperative steroids (the NS group), and 48 patients were managed with 3 doses of postoperative steroids (the WS group) (median, 8.0 mg/dose). There was no difference between the groups in terms of curve magnitude, number of vertebrae fused, or estimated blood loss. There was a 39.6% decrease in total MME used and a 29.5% decrease in weight-based MME used in the group receiving postoperative steroids (82.0 mg [1.29 mg/kg] in the NS group versus 49.5 mg [0.91 mg/kg] in the WS group]; p < 0.001). This difference persisted after accounting for gabapentin, ketorolac, and diazepam usage; surgical time; curve size; levels fused; and number of osteotomies (median decrease, 0.756 mg/kg [95% CI, 0.307 to 1.205 mg/kg]; p = 0.001). Three patients in the NS group (4.6%) and 4 patients in the WS group (8.3%) developed wound dehiscence requiring wound care (p = 0.53). One patient in the NS group required surgical debridement for the treatment of an infection. Patients in the WS group were more likely to walk at the time of the initial physical therapy evaluation (60.4% versus 35.4%; p = 0.013). CONCLUSIONS A short course of postoperative steroids after posterior spinal fusion was associated with a 40% decrease in the use of opioids, with no increase in wound complications. Surgeons may consider the use of perioperative steroids in an effort to decrease the use of postoperative opioids following posterior spinal fusion for the treatment of AIS. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Tracy Ruska
- Children's Healthcare of Atlanta, Atlanta, Georgia
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Harris AB, Gottlich C, Puvanesarajah V, Marrache M, Raad M, Petrusky O, Skolasky R, Njoku D, Sponseller PD, Jain A. Factors associated with extended length of stay in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2020; 8:187-193. [PMID: 31925765 DOI: 10.1007/s43390-019-00008-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/06/2019] [Indexed: 12/14/2022]
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVES To investigate whether certain patient, surgical, and recovery-related factors may be associated with extended LOS following posterior spinal fusion for Adolescent Idiopathic Scoliosis (AIS). Understanding determinants of hospital length of stay (LOS) following surgical procedures is important for perioperative planning and improvements in quality of care. METHODS Using a private insurance claims database, AIS patients ages 10-21 that underwent posterior spinal fusion from 2010 to 2016 in the United States were identified. Extended LOS was defined as > 7.2 days (+ 1 standard deviation from the mean). Univariate and multivariate analyses were performed to identify factors associated with extended LOS. Significance was set at p < 0.05. RESULTS 5864 patients met the inclusion criteria (mean age 14.4 ± 2.2 years; 75% girls). Mean LOS was 4.7 ± 2.5 days (median 4 days). 69% patients had 7-12 levels fused, and 25% had 13+ levels fused. On multivariate analysis, factors associated with extended LOS were: longer fusion construct (13+ levels fused) (OR 2.1, p = 0.020), thoracoplasty (OR 3.8, p < 0.001), and postoperative complications: wound problems (OR 13, p < 0.001), respiratory problems (OR 7.9, p < 0.001), urinary tract infection (OR 6.0, p < 0.001), and constipation (OR 2.4, p < 0.001). Postoperative ICU admission, female gender, and surgery performed on Wednesday were significant on univariate analysis but not on multivariate analysis. Extended LOS was associated with an increase of $50,494 in net hospital payments (p < 0.001). CONCLUSION Patient, surgical and recovery factors are associated with extended LOS in AIS patients who undergo posterior spinal fusion surgery. Extended LOS significantly increases healthcare spending. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Caleb Gottlich
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Olivia Petrusky
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Richard Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Dolores Njoku
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA.
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Factors affecting length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2020; 8:51-56. [PMID: 31960355 DOI: 10.1007/s43390-020-00042-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 05/21/2019] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency. METHODS A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay. RESULTS Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p < 0.001), increased number of fusion levels (p = 0.034), and higher volume of crystalloid administered (p = 0.011). Significant postoperative factors were higher average pain scores on the first postoperative day (p < 0.001) and higher cumulative morphine use (p < 0.001). CONCLUSIONS Use of a standardized care pathway for the treatment of patients with AIS can decrease postoperative length of stay. Despite a carefully designed pathway, variability persists in aspects of care that can impact length of stay, including surgical efficiency, intraoperative fluid and blood management, and postoperative pain management. Continued process improvement focused on these variables will likely further improve the effectiveness of standardized pathways for patients with AIS. LEVEL OF EVIDENCE Level III.
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