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Bess S, Line BG, Nunley P, Ames C, Burton D, Mundis G, Eastlack R, Hart R, Gupta M, Klineberg E, Kim HJ, Kelly M, Hostin R, Kebaish K, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Postoperative Discharge to Acute Rehabilitation or Skilled Nursing Facility Compared With Home Does Not Reduce Hospital Readmissions, Return to Surgery, or Improve Outcomes Following Adult Spine Deformity Surgery. Spine (Phila Pa 1976) 2024; 49:E117-E127. [PMID: 37694516 DOI: 10.1097/brs.0000000000004825] [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: 03/06/2023] [Accepted: 09/01/2023] [Indexed: 09/12/2023]
Abstract
STUDY DESIGN Retrospective review of a prospective multicenter adult spinal deformity (ASD) study. OBJECTIVE The aim of this study was to evaluate 30-day readmissions, 90-day return to surgery, postoperative complications, and patient-reported outcomes (PROs) for matched ASD patients receiving nonhome discharge (NON), including acute rehabilitation (REHAB), and skilled nursing facility (SNF), or home (HOME) discharge following ASD surgery. SUMMARY OF BACKGROUND DATA Postoperative disposition following ASD surgery frequently involves nonhome discharge. Little data exists for longer term outcomes for ASD patients receiving nonhome discharge versus patients discharged to home. MATERIALS AND METHODS Surgically treated ASD patients prospectively enrolled into a multicenter study were assessed for NON or HOME disposition following hospital discharge. NON was further divided into REHAB or SNF. Propensity score matching was used to match for patient age, frailty, spine deformity, levels fused, and osteotomies performed at surgery. Thirty-day hospital readmissions, 90-day return to surgery, postoperative complications, and 1-year and minimum 2-year postoperative PROs were evaluated. RESULTS A total of 241 of 374 patients were eligible for the study. NON patients were identified and matched to HOME patients. Following matching, 158 patients remained for evaluation; NON and HOME had similar preoperative age, frailty, spine deformity magnitude, surgery performed, and duration of hospital stay ( P >0.05). Thirty-day readmissions, 90-day return to surgery, and postoperative complications were similar for NON versus HOME and similar for REHAB (N=64) versus SNF (N=42) versus HOME ( P >0.05). At 1-year and minimum 2-year follow-up, HOME demonstrated similar to better PRO scores including Oswestry Disability Index, Short-Form 36v2 questionnaire Mental Component Score and Physical Component Score, and Scoliosis Research Society scores versus NON, REHAB, and SNF ( P <0.05). CONCLUSIONS Acute needs must be considered following ASD surgery, however, matched analysis comparing 30-day hospital readmissions, 90-day return to surgery, postoperative complications, and PROs demonstrated minimal benefit for NON, REHAB, or SNF versus HOME at 1- and 2-year follow-up, questioning the risk and cost/benefits of routine use of nonhome discharge. LEVEL OF EVIDENCE Level III-prognostic.
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Affiliation(s)
- Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Breton G Line
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Pierce Nunley
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas School of Medicine, Kansas City, KS
| | | | | | | | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael Kelly
- Department of Orthopedic Surgery, San Diego Children's Hospital, San Diego, CA
| | | | - Khaled Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Virgine Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Frank Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA
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Li C, Du Y, Wang S, Zhang J, Yang Y, Zhao Y, Zhang H, Ye X. Risk factors for intensive care unit admission following correction surgery for adult spinal deformity. J Orthop Surg Res 2023; 18:753. [PMID: 37794490 PMCID: PMC10548749 DOI: 10.1186/s13018-023-04227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/22/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE The literature currently available on the characteristics of patients who require intensive care unit (ICU) admission after correction surgery for adult spinal deformity is lacking; this study aimed to identify risk factors for postoperative ICU admission following correction surgery for adult spinal deformity. METHODS A retrospective review of patients who underwent primary posterior-based spinal fusion from 2015 to 2023 was performed. According to the ward they returned to, patients were further divided into an ICU group and a non-ICU group. Univariate and multivariate analyses were performed to evaluate preoperative and perioperative parameters to identify independent risk factors for postoperative ICU admission in adult spinal deformity patients. RESULTS A total of 274 patients were included, including 115 males (41.97%) and 159 females (58.03%). The mean age of the patients was 32.00 ± 11.16 years (19-77 years). Following adjusted analysis, the preoperative and perioperative factors that were independently associated with ICU admission were age, body mass index ≥ 28 kg/m2, neuromuscular spinal deformity, respiratory disease, grade III-IV American Society of Anesthesiologists (ASA) classification, a scoliosis Cobb angle ≥ 90°, a kyphosis Cobb angle ≥ 90°, and ≥ 12 fused segments. Compared with the non-ICU group, the ICU group had a higher incidence of complications, a longer hospital stay, and higher medical costs (P < 0.05). CONCLUSION This study identified independent risk factors associated with postoperative ICU admission in adult spinal deformity patients; and explored relative measures to decrease or avoid the risk of postoperative ICU admission. Surgeons could use these data to develop and plan appropriate perioperative care processes in advance and provide consultation for family members before surgery.
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Affiliation(s)
- Chenkai Li
- Department of Orthopedics, Peking Union Medical College Hospital, 1st Shuai Fu Yuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - You Du
- Department of Orthopedics, Peking Union Medical College Hospital, 1st Shuai Fu Yuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Shengru Wang
- Department of Orthopedics, Peking Union Medical College Hospital, 1st Shuai Fu Yuan, Dongcheng District, Beijing, 100730, People's Republic of China.
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, 1st Shuai Fu Yuan, Dongcheng District, Beijing, 100730, People's Republic of China.
| | - Yang Yang
- Department of Orthopedics, Peking Union Medical College Hospital, 1st Shuai Fu Yuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Yiwei Zhao
- Department of Orthopedics, Peking Union Medical College Hospital, 1st Shuai Fu Yuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Haoran Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, 1st Shuai Fu Yuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Xiaohan Ye
- Department of Orthopedics, Peking Union Medical College Hospital, 1st Shuai Fu Yuan, Dongcheng District, Beijing, 100730, People's Republic of China
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Shaw KA, Harris H, Sachwani N, Ruska T, Murphy JS, Fletcher ND. Avoiding PICU admission following PSF for neuromuscular scoliosis in non-ambulatory cerebral palsy managed with ERAS protocol. Spine Deform 2022; 11:671-676. [PMID: 36538190 DOI: 10.1007/s43390-022-00635-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Children with neuromuscular scoliosis (NMS) undergoing posterior spinal fusion (PSF) have historically been managed post-operatively in the pediatric intensive care unit (PICU) due to institutional tendencies. This study sought to define risk factors for PICU admission when using an enhanced recovery after surgery (ERAS) pathway. METHODS A retrospective review of children with non-ambulatory (GMFCS 4 or 5) cerebral palsy undergoing PSF for NMS performed at two institutions by 5 surgeons. Both institutions have a pre-existing ERAS pathway for NMS patients consisting of post-surgical transfer to the hospital floor with early reinstitution of feeding and mobilization. PICU admission is used at the discretion of the surgeon and anesthesiologist rather than by institutional decree. Patient and surgical factors were assessed for risk factors of PICU admission. RESULTS A total of 103 children were included (84% GMFCS 5, mean 14.52 years (± 3.4 years)). Forty children (38.8%) required postoperative PICU admission. PICU admission was associated with seizure disorder (P = 0.09), pre-existing feeding tube (P = 0.003), tracheostomy (P = 0.03), and modified GMFCS-5 subclassification (P = 0.003). Independent predictors of PICU admission include pre-existing feeding (Odd's ratio = 2.9, P = 0.02) and length of surgery (Odd's ratio = 2.6, P < 0.001), with surgery lasting ≥ 5.0 h having an 82.5% sensitivity and 63.5% specificity (AUC 0.8, P < 0.001) for post-operative PICU admission. CONCLUSION The majority of children with non-ambulatory cerebral palsy can be successfully managed on the hospital floor following PSF. The extent of central neuromotor impairment is significantly associated with PICU admission along with surgery lasting longer than 5 h.
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Affiliation(s)
- K Aaron Shaw
- Department of Pediatric Orthopaedic Surgery, Scottish Rite for Children, Dallas, TX, USA
| | - Hilary Harris
- Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Numera Sachwani
- Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Tracy Ruska
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Joshua S Murphy
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Nicholas D Fletcher
- Department of Pediatric Surgery, Children's Healthcare of Atlanta at Emory University, Atlanta, GA, USA.
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Ding H, Hai Y, Guan L, Liu Y, Pan A, Han B. The outcome of enhanced recovery after surgery vs. a traditional pathway in adolescent idiopathic scoliosis surgery: A retrospective comparative study. Front Surg 2022; 9:989119. [PMID: 36277279 PMCID: PMC9581125 DOI: 10.3389/fsurg.2022.989119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Methods Results Conclusions
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Affiliation(s)
| | - Yong Hai
- Correspondence: Yong Hai Li Guan
| | - Li Guan
- Correspondence: Yong Hai Li Guan
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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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Evaluation of Outcomes Before and After Implementation of a Standardized Postoperative Care Pathway in Pediatric Posterior Spinal Fusion Patients. Orthop Nurs 2021; 39:257-263. [PMID: 32701784 DOI: 10.1097/nor.0000000000000678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Standardized pathways decrease variability and improve outcomes and safety. PURPOSE The article aims to evaluate outcomes of a standardized postoperative care pathway compared with individual surgeon preference. METHODS A review of patients prestandardization and poststandardization was performed. Patients between the ages of 10-21 years with adolescent idiopathic scoliosis (ICD-9 code 737.30) admitted to the hospital for posterior spinal fusion (CPT code 22630) were included in the study. The prestandardization group (25 patients) was enrolled from April 1, 2010, through March 30, 2011, and the poststandardization group (25 patients) from April 1, 2014, to March 30, 2015. Exclusion criteria were renal disease, epilepsy, neurological disorder, or postoperative complications that led to change in routine care including ileus or fever greater than 102 °F. Data were analyzed using the Wilcoxon signed rank test, with significance set at p < .001. RESULTS The length of stay (p = .0166), time to ambulation (p < .0001), patient-controlled analgesia use (p < .0001), and postoperative time to resumption of regular diet (p < .0001) were all significantly decreased in the poststandardization group. There were no complications or readmissions in either group. CONCLUSION The standardized pathway resulted in shorter length of stay, decreased narcotic use, decreased time to regular diet, and decreased time to ambulation with no increase in complication rates.
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Song BM, Kadhim M, Shanmugam JP, King AG, Heffernan MJ. Enhanced Recovery After Pediatric Scoliosis Surgery: Key Components and Current Practice. Orthopedics 2020; 43:e338-e344. [PMID: 32745223 DOI: 10.3928/01477447-20200721-06] [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: 05/23/2019] [Accepted: 09/09/2019] [Indexed: 02/03/2023]
Abstract
With the goal of safety and efficiency in health care delivery, enhanced recovery protocols (ERPs) continue to gain traction throughout various surgical disciplines, including in pediatric scoliosis surgery. The growing body of literature reporting decreased length of stay and cost with no change in readmissions or complications has brought these protocols to the forefront. The key components of ERPs include preoperative patient counseling, perioperative pain management, and early patient mobilization. In this review, the authors aim to describe the foundational history and major components of ERPs following pediatric spine deformity surgery. [Orthopedics. 2020;43(5):e338-e344.].
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Predictors of cost for posterior spinal fusion in adolescent idiopathic scoliosis. Spine Deform 2020; 8:421-426. [PMID: 32096128 DOI: 10.1007/s43390-020-00053-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/16/2019] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Single-center retrospective review of pediatric patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVE To determine what clinical and operative factors influence inflation-adjusted hospital costs of posterior spine fusion surgery for AIS. With rising healthcare costs and the advent of bundled payments, it is essential understand the predictors of costs for surgical procedures. We sought to determine the components of hospital costs for AIS posterior spine fusion surgery using standardized, inflation-adjusted, line-item costs for services and procedures. METHODS The study population comprised 148 AIS patients who underwent spinal fusion surgery at a large tertiary care center between 2009 and 2016. Data on medical characteristics, curve type, curve magnitude, number of screws and the number of levels was collected through manual chart review of X-rays and medical records. Hospital costs from admission until discharge were retrieved from an institutional database that contained line-item details of all procedures and services billed during the hospital episode. Bottom-up microcosting valuation techniques were used to generate standardized inflation-adjusted estimates of costs and standard deviations in 2016 dollars. RESULTS Mean cost of AIS surgery was $48,058 ± 9379. Physician fees averaged 15% of the total cost ($7045 ± 1732). Implant costs and surgical/anesthesia/surgeon's fees accounted for over 70% of the hospital costs. Mean number of screws was 16 ± 4.5, mean number of levels fused was 11.2 ± 2.2, and the mean implant density (screws per level fused) was 1.45 ± 0.35. On multivariate analysis, the number of screws per level fused, number of levels fused, curve magnitude and length of stay were all significantly associated with hospital costs (p < 0.01). CONCLUSIONS Bundled payments for AIS surgery should include adjustments for number of levels fused and curve size. Areas for cost savings include further reduction in implant costs, shortening length of stay, and reducing intraoperative costs. LEVEL OF EVIDENCE III.
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Safety and effectiveness of minimally invasive scoliosis surgery for adolescent idiopathic scoliosis: a retrospective case series of 84 patients. 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 2020; 29:761-769. [PMID: 31637547 DOI: 10.1007/s00586-019-06172-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 08/24/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this study was to retrospectively evaluate a prospective series of patients with adolescent idiopathic scoliosis (AIS) who were treated with minimally invasive scoliosis surgery (MISS) technique with a minimum follow-up more than 1 year. MATERIALS AND METHODS We retrospectively analyzed the prospectively collected data of 84 patients with AIS treated with MIS technique using two or three coin hole size incisions and a muscle-splitting approach. The clinical and radiological data such as the correction of deformity, coronal and sagittal profile and record of the perioperative morbidity of the patients were analyzed. RESULTS The mean primary Cobb angle was corrected from 59.8° preoperatively to 18.6° postoperatively with a mean correction of 68.9% (p < 0.001). The mean kyphosis at T2 to T12 was maintained within normal range with an increase from 31.2° preoperatively to 35.3° postoperatively (p < 0.001). The 30-day perioperative complication rate was 7.14% with one deep infection and five cases of hemothorax. The mean operation time was 312.8 min; mean estimated blood loss was 846.6 ml (range 420-2800); and mean length of stay was 8.5 days (range 5 to 14). All data of postoperative SRS-22 questionnaire were significantly improved (p < 0.001). CONCLUSION MISS used for AIS provides adequate correction in both planes and acceptable rate of perioperative complications, with a low estimated blood loss and short length of stay. Considering all the positives, the application of MISS technique for AIS seems meaningful and can become a valid alternative to posterior approach in the routine use. These slides can be retrieved under Electronic Supplementary Material.
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Abstract
BACKGROUND Recently, there have been several reports of using an enhanced discharge pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). No previous studies have prospectively examined patient satisfaction of patients with AIS using an enhanced discharge pathway. The purpose of this study was to evaluate patient satisfaction with an enhanced discharge pathway for PSF and whether patients felt that their length of stay was appropriate. METHODS Patients with AIS undergoing PSF were prospectively enrolled. At their first postoperative clinic visit, patients were administered a survey regarding their experience. RESULTS Of the 46 patients enrolled (mean age, 14 y), 1 was discharged on postoperative day (POD) 2, 33 were discharged on POD 3, 9 were discharged on POD 4, and 3 were discharged on POD 5. Eighty (37/46) of patients felt that they were discharged at an appropriate time, whereas 20% (9/46) felt they were discharged too early. Patients who felt they were discharged at an appropriate time (mean, 3.2 d) had a trend toward shorter stays than those who felt they were discharged too early (mean, 3.7 d). Overall patient satisfaction of hospital stay was high with a mean of 9 on a 10-point scale (range, 1 to 10). There was no correlation between length of stay and patient satisfaction (P=0.723). Patients who felt they were discharged early had a significantly higher mean FACES pain scores than those who felt they were discharged about right both as inpatients (mean, 4.8 vs. 3.4; P=0.0319) and at their first postoperative clinic visit (5.4 vs. 2.9; P=0.004). CONCLUSIONS Eighty percent of patients with AIS who underwent PSF felt that the time of discharge was appropriate with an enhanced discharge pathway. There was no correlation between patient satisfaction and length of stay. LEVEL OF EVIDENCE Level II.
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Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO). Orthop Traumatol Surg Res 2020; 106:S101-S107. [PMID: 31522902 DOI: 10.1016/j.otsr.2019.05.012] [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: 11/30/2018] [Revised: 05/02/2019] [Accepted: 05/02/2019] [Indexed: 02/02/2023]
Abstract
"Enhanced recovery after surgery" is now the official term: ERAS. Patients come to a specialized center for surgery, and early recovery is ensured by minimizing the impact of surgical stress, controlling pain and stimulating autonomy. Patient information and education concerning the process and care organization enable short hospital stay with early discharge. The expected benefits are fewer postoperative complications and shorter hospital stay. There is nothing to prevent this kind of program being implanted for children, so long as age and the parent-child relationship are taken into account. Lessons should be drawn from existing pediatric therapeutic education programs, to adapt information and training to the child's cognitive, motor and psycho-affective development. Setting up an ERAS program is the result firstly of medical and surgical reflection. All healthcare actors need to be actively involved, to set up a management program for the parent-child duo. Implementation, monitoring and assessment are the responsibilities of the physicians who initiate the program. Fewer postoperative complications, with earlier discharge and rehabilitation, should reduce costs and improve patient management in hospital. Such is, indeed, usually the case, but unfortunately drastic health expenditure curbs greatly attenuate the expected benefit in terms of care organization and cost savings.
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Sethi RK, Yanamadala V, Shah SA, Fletcher ND, Flynn J, Lafage V, Schwab F, Heffernan M, DeKleuver M, Mcleod L, Leveque JC, Vitale M. Improving Complex Pediatric and Adult Spine Care While Embracing the Value Equation. Spine Deform 2019; 7:228-235. [PMID: 30660216 DOI: 10.1016/j.jspd.2018.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/02/2018] [Accepted: 08/12/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options. METHODS We summarize various methods by which value can be increased in complex spine surgery, both through the improvement of outcomes and the reduction of cost. These methods center around standardization, team-based and collaborative approaches, rigorous outcomes tracking through dashboards and registries, and continuous process improvement. RESULTS This manuscript reviews the expert opinion of leading spine specialists on the improvement of safety, quality and improvement of value of pediatric and adult spinal surgery. CONCLUSION Without surgeon leadership in this arena, suboptimal solutions may result from the isolated intervention of regulatory bodies or payer groups. The cooperative development of standardized, team-based approaches in complex spine surgery will lead to the high-quality, high-value care for patients.
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Affiliation(s)
- Rajiv K Sethi
- Virginia Mason Medical Center, University of Washington, 1100 9th Ave, Seattle, WA 98101, USA.
| | - Vijay Yanamadala
- Virginia Mason Medical Center, University of Washington, 1100 9th Ave, Seattle, WA 98101, USA; and Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Suken A Shah
- Dupont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA
| | | | - John Flynn
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Virginie Lafage
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | - Frank Schwab
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | | | - Marinus DeKleuver
- Sint Maartenskliniek, Radboud University Medical Center, PO Box 9011, 6500 GM, Nijmegen, the Netherlands
| | - Lisa Mcleod
- University of Colorado Denver, 1201 Larimer St, Denver, CO 80204, USA
| | - Jean Christophe Leveque
- Virginia Mason Medical Center, University of Washington, 1100 9th Ave, Seattle, WA 98101, USA
| | - Michael Vitale
- Morgan Stanley Children's Hospital, Columbia University, 3959 Broadway, New York, NY 10032, USA
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Brooks JT, Yaszay B, Bartley CE, Bastrom TP, Sponseller PD, Shah SA, Samdani A, Cahill PJ, Miyanji F, Newton PO. Do All Patients With Cerebral Palsy Require Postoperative Intensive Care Admission After Spinal Fusion? Spine Deform 2019; 7:112-117. [PMID: 30587303 DOI: 10.1016/j.jspd.2018.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 05/31/2018] [Accepted: 06/02/2018] [Indexed: 11/19/2022]
Abstract
STUDY DESIGN Retrospective review of a prospective cohort. OBJECTIVE To identify patient and surgical factors that alter the length of postoperative intensive care unit (ICU) stays after spinal fusion/instrumentation in patients with neuromuscular scoliosis secondary to cerebral palsy (CP). SUMMARY OF BACKGROUND DATA High perioperative complication rates in patients with CP contribute to the practice of utilizing the ICU postoperatively for monitoring. However, this is costly and little is known regarding which patients truly need this increased acuity of care. METHODS A prospective, multicenter database was queried for patients with CP who underwent spinal fusion and instrumentation. Patients with an ICU length of stay (LOS) ≤1 day were assumed to not have required postoperative ICU admission. Demographic and surgical characteristics were compared between those with ICU LOS of ≤1 day versus >1 day. A classification and regression tree (CART) analysis was utilized to create a decision algorithm for postoperative ICU admission. RESULTS Three hundred twenty-four patients were identified with a mean ICU LOS of 4.7 days (range 0-47). Sixty-eight patients (21%) had an ICU LOS ≤1 day and 256 patients (79%) had an ICU LOS >1 day. CART analysis demonstrated that the institution where the surgery was performed was the primary predictor with two groups: sites that almost routinely had ICU stay >1 day (92%) and those that were split (50.5% >1 day). In the latter group, an operative time greater than 4 hours was a risk factor for a longer ICU stay. CONCLUSION Because of their heterogeneous makeup, CP patients should be evaluated individually and their postoperative disposition should not be based on institutional tradition but instead on objective surgical factors. For those patients with surgical times less than 4 hours, discussions should be held regarding the safety of a postoperative disposition to a regular floor. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jaysson T Brooks
- Children's of Mississippi, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Burt Yaszay
- Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123, USA.
| | - Carrie E Bartley
- Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123, USA
| | - Tracey P Bastrom
- Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123, USA
| | - Paul D Sponseller
- The Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Suken A Shah
- Nemours Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA
| | - Amer Samdani
- Shriners Hospitals for Children, 3551 N. Broad St., Philadelphia, PA 19140, USA
| | - Patrick J Cahill
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, PA 19104, USA
| | - Firoz Miyanji
- British Columbia Children's Hospital, 4480 Oak St, Vancouver, Vancouver, BC, Canada
| | - Peter O Newton
- Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123, USA
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Haber LL, Womack ED, Sathyamoorthy M, Moss JA, Shrader MW. Who Needs a Pediatric Intensive Care Unit After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis? Spine Deform 2018; 6:137-140. [PMID: 29413735 DOI: 10.1016/j.jspd.2017.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hypotensive events (HEs) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can lead to delayed neurologic postoperative deficits (DNPD). This study aimed to determine the incidence of HEs (mean arterial pressure [MAP] <60 mmHg) after PSF for AIS and identify predictors for HEs. METHODS Medical records of 99 consecutive patients who had PSF for AIS were retrospectively reviewed (2011-2013). Perioperative data were collected. Patients were divided into two groups based on MAP readings by an arterial line in the pediatric intensive care unit immediately postoperatively into postoperative day one: Group 1 (MAP ≥60 mmHg) and Group 2 (multiple occurrences of MAPs <60 mmHg). Mean values were compared using the independent t test. Multiple logistic regression was used to estimate the association of preoperative and intraoperative parameters with multiple HEs. RESULTS Group 1 had 68 patients (68.7%) and Group 2 had 31 patients (31.3%). None of the compared parameters were associated significantly with multiple HE. However, patients who did not exhibit HEs within the first four hours postoperatively remained stable throughout the rest of the postoperative period. Only those with HEs in the first four hours experienced subsequent HEs in the first 24 hours. There were no DNPD or other major complications. CONCLUSION Results showed that the incidence of HEs after PSF in AIS can be as high as 31.3%. We did not find any significant risk factors. Although DNPD after PSF is a rare complication and we had none in this series, we suggest that these patients with multiple HEs may be at risk for DNPD as a result of hypotension and potential for cord ischemia. Therefore, all patients after PSF should be monitored in a pediatric intensive care unit-type environment or postanesthesia recovery room initially. If stable for, at least, the initial four hours, then patients should be good candidates for a less intensive environment. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Lawrence L Haber
- Department of Orthopaedic Surgery, Ochsner Hospital for Children, 1514 Jefferson Hwy, New Orleans, LA 70121, USA.
| | - Erika D Womack
- Department of Orthopaedic Surgery, University of Mississippi Center, 2500 N State St, Jackson, MS 39216, USA
| | - Madhankumar Sathyamoorthy
- Department of Anesthesiology, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - James A Moss
- Mississippi Sports Medicine and Orthopaedic Center, 1325 E Fortification St, Jackson, MS 39202, USA
| | - Michael Wade Shrader
- Department of Orthopaedic Surgery, University of Mississippi Center, 2500 N State St, Jackson, MS 39216, USA
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Rhodes CB, Eid A, Muller G, Kull A, Head T, Mamidala M, Gillespie B, Sheyn A. Postoperative Monitoring Following Adenotonsillectomy for Severe Obstructive Sleep Apnea. Ann Otol Rhinol Laryngol 2018; 127:783-790. [PMID: 30182728 DOI: 10.1177/0003489418794700] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Patients undergoing adenotonsillectomy (T&A) for severe obstructive sleep apnea (OSA) are usually admitted for observation, and many surgeons use the intensive care unit (ICU) for observation due to the risk of postsurgical airway obstruction. Given the limited resources of the pediatric ICU (PICU), there is a push to better define the patients who require postoperative monitoring in the PICU for monitoring severe OSA. METHODS Forty-five patients were evaluated. Patients who had cardiac or craniofacial comorbidities were excluded. Patients undergoing T&A for severe OSA were monitored in the postanesthesia care unit (PACU) postoperatively. If patients required supplemental oxygen or developed hypoxia while in the PACU within the 3-hour monitoring period, they were admitted to the PICU. RESULTS Overall, 16 of 45 patients were admitted to the ICU for monitoring. Patients with an Apnea-Hypopnea Index (AHI) >50 or with an oxygen nadir <80% were significantly more likely to be admitted to the PICU. The mean AHI of patients admitted to the PICU was 40.5, and the mean oxygen nadir was 69.9%. Patients younger than 2 years were significantly more likely to be admitted to the PICU. CONCLUSION Based on the data presented here and academy recommendations, not all patients with severe OSA require ICU monitoring.
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Affiliation(s)
| | - Anas Eid
- 1 University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Grant Muller
- 1 University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Amanda Kull
- 1 University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Tim Head
- 2 Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Madhu Mamidala
- 1 University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Boyd Gillespie
- 1 University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Anthony Sheyn
- 1 University of Tennessee Health Science Center, Memphis, Tennessee, USA
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de Bodman C, Miyanji F, Borner B, Zambelli PY, Racloz G, Dayer R. Minimally invasive surgery for adolescent idiopathic scoliosis. Bone Joint J 2017; 99-B:1651-1657. [DOI: 10.1302/0301-620x.99b12.bjj-2017-0022.r2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 07/20/2017] [Indexed: 01/11/2023]
Abstract
Aims The aim of this study was to report a retrospective, consecutive series of patients with adolescent idiopathic scoliosis (AIS) who were treated with posterior minimally invasive surgery (MIS) with a mean follow-up of two years (sd 1.4; 0.9 to 0 3.7). Our objectives were to measure the correction of the deformity and record the peri-operative morbidity. Special attention was paid to the operating time (ORT), estimated blood loss (EBL), length of stay (LOS) and further complications. Patients and Methods We prospectively collected the data of 70 consecutive patients with AIS treated with MIS using three incisions and a muscle-splitting approach by a single surgeon between June 2013 and February 2016 and these were retrospectively reviewed. There were eight male and 62 female patients with a mean age of 15 years (sd 4.5 ) with a mean body mass index of 19.8 kg/m2 (sd 5.4). The curves were classified according to Lenke; 40 curves were type 1, 15 were type 2, three were type 3, two were type 4, eight were type 5 and two were type 6. Results The mean primary Cobb angle was corrected from 58.9° (sd 12.6°) pre-operatively to 17.7° (sd 10.2°) post-operatively with a mean correction of 69% (sd 20%, p < 0.001). The mean kyphosis at T5 to T12 increased from 24.2° (sd 12.2°) pre-operatively to 30.1° (sd 9.6°, p < 0.001) post-operatively. Peri-operative (30 days) complications occurred in three patients(4.2%): one subcutaneous haematoma, one deep venous thrombosis and one pulmonary complication. Five additional complications occurred in five patients (7.1%): one superficial wound infection, one suture granuloma and three delayed deep surgical site infections. The mean ORT was 337.1 mins (sd 121.3); the mean EBL was 345.7 ml (sd 175.1) and the mean LOS was 4.6 days (sd 0.8). Conclusion The use of MIS for patients with AIS results in a significant correction of spinal deformity in both the frontal and sagittal planes, with a low EBL and a short LOS. The rate of peri-operative complications compares well with that following a routine open technique. The longer term safety and benefit of MIS in these patients needs to be evaluated with further follow-up of a larger cohort of patients. Cite this article: Bone Joint J 2017;99-B:1651–7.
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Affiliation(s)
- C. de Bodman
- Pediatric Orthopedics and Traumatology Unit, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - F. Miyanji
- Department of Pediatric Orthopedics, British Columbia’s Children’s Hospital, 4480 Oak Street, Vancouver V6H 3N1, British Columbia, Canada
| | - B. Borner
- Division of Paediatric Orthopaedics, Geneva University Hospitals, Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - P-Y. Zambelli
- Pediatric Orthopedics and Traumatology Unit, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - G. Racloz
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - R. Dayer
- Pediatric Orthopedics and Traumatology Unit, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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Kim E, Lee B, Cucchiaro G. Perioperative Surgical Home: Evaluation of a New Protocol Focused on a Multidisciplinary Approach to Manage Children Undergoing Posterior Spinal Fusion Operation. Anesth Analg 2017. [PMID: 28632535 DOI: 10.1213/ane.0000000000002030] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The concept of Perioperative Surgical Home has been gaining significant attention in surgical centers. This model is delivering and improving coordinated care in a cost-effective manner to patients undergoing surgical procedures. It starts with the decision for surgical intervention, continues to the intraoperative and postoperative periods, and follows into long-term recovery. Constant re-evaluation of outcomes and modifications of delivery provides a feedback loop for improvement. Children's Hospital Los Angeles initiated a new protocol in June 2014 to manage children undergoing Posterior Spinal Fusion (PSF) with the goal to improve patient experience and lower the hospital length of stay and cost. METHODS A retrospective chart review identified patients who underwent a PSF for idiopathic scoliosis before and after initiation of a new treatment protocol designed by a team of anesthesiologists, surgeons, nurses, and physical therapists. The new protocol included preoperative teaching of parents and patients, intraoperative anesthetic and surgical management, and immediate to long-term postoperative medical management. In addition to demographics, we examined length of stay, cost of hospitalization, pain scores on discharge, length of patient-controlled analgesia use, time to first solid food intake, and time to ambulation. RESULTS Thirty-six patients were identified preinitiation and postinitiation of the protocol (total n = 72). There was no statistically significant difference in age, sex, use of intrathecal morphine, or estimated blood loss. Patients enrolled in the new protocol had higher American Society of Anesthesiologists classification (P = .003), significantly lower duration of patient-controlled analgesia use, time to first solid food intake, and time to ambulation (P= .001). The pain scores were higher at the time of discharge, although the difference was not statistically significant. Length of stay was significantly shorter in the new protocol group (P = .001), accounting for $292,560 in cost savings for the hospital. CONCLUSIONS These data show that the cooperation of different teams in designing new management guidelines for patients requiring a PSF can significantly decrease the total length of stay and cost of hospitalization without altering quality of care.
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Affiliation(s)
- Eugene Kim
- From the Department of Anesthesiology Critical Care Medicine-Pain Service, Children's Hospital Los Angeles, Los Angeles, California
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18
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Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2017; 42:E547-E554. [PMID: 28441684 DOI: 10.1097/brs.0000000000001865] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Delphi process with multiple iterative rounds using a nominal group technique. OBJECTIVE The aim of this study was to use expert opinion to achieve consensus on various aspects of postoperative care following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Significant variability exists in postoperative care following PSF for AIS, despite a relatively healthy patient population and continuously improving operative techniques. Current practice appears based either on lesser quality studies or the perpetuation of long-standing protocols. METHODS An expert panel composed of 26 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting (one electronic and two face-to-face). Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. RESULTS Consensus was reached to support 19 best practice guideline (BPG) measures for postoperative care addressing non-ICU admission, perioperative pain control, dietary management, physical therapy, postoperative radiographs, surgical bandage management, and indications for discharge. CONCLUSION We present a consensus-based BPG consisting of 19 recommendations for the postoperative management of patients following PSF for AIS. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research. LEVEL OF EVIDENCE 5.
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19
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Use of a Novel Pathway for Early Discharge Was Associated With a 48% Shorter Length of Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Pediatr Orthop 2017. [PMID: 26214327 DOI: 10.1097/bpo.0000000000000601] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hospital stay after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) has decreased only modestly over time despite a healthy patient population. The purpose of this study was to evaluate the impact of a novel postoperative pathway on length of stay (LOS) and complications. METHODS A retrospective review of patients undergoing PSF for AIS in 2011 to 2012 was performed at 2 institutions evaluating demographics, preoperative Cobb angles, surgical duration, blood loss, LOS, and postoperative complications. Patients at one center were managed using an accelerated discharge (AD) pathway emphasizing early transition to oral pain medications mobilization with physical therapy 2 to 3 times/d, and discharge regardless of return of bowel function. Expectations were set with the family before surgery for early discharge. Patients at the other center were managed without a standardized pathway. RESULTS One hundred five patients underwent PSF and were treated by an AD pathway, whereas 45 patients were managed using a traditional discharge (TD) pathway. There was no difference in proximal thoracic and main thoracic Cobb magnitudes and a small difference in thoracolumbar curve magnitudes (35.2±13.0 degrees AD vs. 40.6±11.4 degrees TD, P=0.004) between groups. Surgical time was slightly shorter in AD patients (median 3.1 vs. 3.9 h, P=0.0003) with no difference in estimated blood loss. LOS was 48% shorter in the AD group (2.2 vs. 4.2 d, P<0.0001). There was no difference in readmissions or wound complications between groups. CONCLUSIONS Hospital stay was nearly 50% shorter in patients managed by the AD pathway without any increase in readmissions or early complications. SIGNIFICANCE Discharge after PSF for AIS may be expedited using a coordinated postoperative pathway. No increase in complications was seen using the AD pathway. Earlier discharge may reduce health care costs and allow an earlier return to normalcy for families. LEVEL OF EVIDENCE Level III-case control study.
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Thomson K, Pestieau SR, Patel JJ, Gordish-Dressman H, Mirzada A, Kain ZN, Oetgen ME. Perioperative Surgical Home in Pediatric Settings. Anesth Analg 2016; 123:1193-1200. [DOI: 10.1213/ane.0000000000001595] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gornitzky AL, Flynn JM, Muhly WT, Sankar WN. A Rapid Recovery Pathway for Adolescent Idiopathic Scoliosis That Improves Pain Control and Reduces Time to Inpatient Recovery After Posterior Spinal Fusion. Spine Deform 2016; 4:288-295. [PMID: 27927519 DOI: 10.1016/j.jspd.2016.01.001] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 01/05/2016] [Accepted: 01/09/2016] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Retrospective comparative cohort. OBJECTIVES To determine if a standardized multimodal analgesic and rehabilitation protocol (rapid recovery pathway [RRP]) in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) could improve pain control, reduce opioid-related complications, and expedite early mobilization. BACKGROUND Several reports have described postoperative recovery pathways for AIS patients undergoing PSF that shorten length of stay (LOS) without reporting the impact such pathways might have on patients' pain or quality of recovery. METHODS We compared two high-volume surgeons' patients managed on our conventional pathway (CP) or our RRP. The CP analgesia consisted of intraoperative methadone and postoperative patient-controlled analgesia (PCA) until tolerating oral analgesics, with adjunctive diazepam. Analgesia on the RRP includes intraoperative methadone and postoperative PCA; patients also receive preoperative gabapentin and acetaminophen, intraoperative intravenous acetaminophen, and postoperative diazepam, gabapentin, acetaminophen, and ketorolac. Ambulation and full diet are permitted beginning postoperative day 1. The primary outcome was mean daily pain scores. Secondary outcomes were LOS, time to pathway milestone completions, and frequency of opioid-related side effects requiring treatment. RESULTS There were 58 patients in the RRP group and 80 patients in the CP group. Patients on RRP had improved mean daily pain scores on postoperative days 0 (p = .027), 1 (p < .001) and 2 (p = .004). RRP patients were discharged home 31% earlier, discontinued from PCA 34% earlier and had their urinary catheters removed 26% earlier. Total opioid consumption decreased on postoperative day 0 (p < .001), but not postoperative day 1 (p = .773) or 2 (p = .343). Fewer patients on the RRP required medication for opioid-induced pruritus (p = .001), but there was no difference in the frequency of odansetron administration (p = .566). There were no differences in 30-day rates of readmission (p = .407). CONCLUSION Implementation of standardized RRP resulted in reduced pain, faster mobilization, reduced frequency of opioid-related side-effects, and earlier discharge.
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Affiliation(s)
- Alex L Gornitzky
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - John M Flynn
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Wudbhav N Sankar
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Basques BA, Bohl DD, Golinvaux NS, Smith BG, Grauer JN. Patient factors are associated with poor short-term outcomes after posterior fusion for adolescent idiopathic scoliosis. Clin Orthop Relat Res 2015; 473:286-94. [PMID: 25201091 PMCID: PMC4390920 DOI: 10.1007/s11999-014-3911-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 08/19/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterior spinal fusion (PSF) is commonly performed for patients with adolescent idiopathic scoliosis (AIS). Identifying factors associated with perioperative morbidity and PSF may lead to strategies for reducing the frequency of adverse events (AEs) in patients and total hospital costs. QUESTIONS/PURPOSES What is the frequency of and what factors are associated with postoperative: (1) AEs, (2) extended length of stay (LOS), and (3) readmission in patients with AIS undergoing PSF? PATIENTS AND METHODS Patients, aged 11 to 18 years, who underwent PSF for AIS during 2012, were identified from the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) Pediatric database. Patient were assessed for characteristics associated with AEs, extended LOS (defined as more than 6 days), and hospital readmission using multivariate logistic regression. Individual AEs captured in the database were grouped into two categories, "any adverse event" (AAE) and "severe adverse events" (SAEs) for analysis. A total of 733 patients met inclusion criteria. RESULTS Twenty-seven patients (3.7%) had AAE and 19 patients (2.6%) had SAEs. Both AAE and SAEs were associated with BMI-for-age ninety-fifth percentile or greater (AAE: odds ratio [OR], 3.31; 95% CI, 1.43-7.65; p=0.005. SAE: OR, 3.46; 95% CI, 1.32-9.09; p=0.012). Extended LOS occurred for 60 patients (8.2%) and was associated with greater than 13 levels instrumented (OR, 2.00; 95% CI, 1.11-3.61; p=0.021) and operative time of 365 minutes or more (OR, 2.57; 95% CI, 1.39-4.76; p=0.003). Readmission occurred for 11 patients (1.5%), most often for surgical site infection, and was associated with the occurrence of any complication during the initial hospital stay (OR, 180.44; 95% CI, 35.47-917.97; p<0.001). CONCLUSIONS Further research on prevention and management of obesity and surgical site infections may reduce perioperative morbidity for patients with AIS undergoing PSF. LEVEL OF EVIDENCE Level III, prognostic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bryce A. Basques
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| | - Daniel D. Bohl
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| | - Nicholas S. Golinvaux
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| | - Brian G. Smith
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
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Evaluation of dexmedetomidine and postoperative pain management in patients with adolescent idiopathic scoliosis: conclusions based on a retrospective study at a tertiary pediatric hospital. Pediatr Crit Care Med 2014; 15:e247-52. [PMID: 24743445 DOI: 10.1097/pcc.0000000000000119] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study evaluated the effectiveness of dexmedetomidine in decreasing opioid use in children with adolescent idiopathic scoliosis following posterior spinal fusion surgery at a pediatric tertiary care hospital over the past 10 years. DESIGN This was a retrospective chart review. Patients were separated into two groups: those that received opioid via patient-controlled analgesia pain therapy alone and those that received opioid via patient-controlled analgesia pain therapy with dexmedetomidine. SETTING A tertiary pediatric free-standing hospital. The study focused on care administered in the perioperative period, including the operating room, ICU, and general hospital floor. PATIENTS One hundred sixty-three children with adolescent idiopathic scoliosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Measurements included patient demographics, American Society of Anesthesiologists Physical Status Classification System, levels of spinal fusion, length of hospital stay, complications, numeric pain scores, opioid requirement, elastomeric pain pump use, length of time until ambulation, adverse effects, and naloxone use. Data were collected through the first 72 hours of the perioperative period. One hundred six patients received opioids via patient-controlled analgesia therapy with dexmedetomidine and 57 received opioids via patient-controlled analgesia alone. Within the groups, there were 46 patients who received local anesthetic infusions via elastomeric pumps in the patient-controlled analgesia with dexmedetomidine group and 16 patients had pumps in the patient-controlled analgesia-alone group. There was no overall difference in postoperative use of morphine (or equivalents) between the two groups. However, the use of elastomeric pain pumps demonstrated a statistically significant decrease in mean overall opioid consumption (42.6 mg vs 63.1 mg, p < 0.001). CONCLUSIONS There was no difference in opioid use related to dexmedetomidine on any postoperative day. The only variable showing a significant opioid sparing effect was the use of local anesthetic infusions via elastomeric pumps. Using continuous local anesthetic infusions instead of dexmedetomidine could eliminate the need for ICU admission, require shorter hospital stays, and reduce costs while still providing safe and effective pain control.
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Pandya NK, Otsuka NY, Sanders JO. What's new in pediatric orthopaedics. J Bone Joint Surg Am 2014; 96:345-50. [PMID: 24553894 DOI: 10.2106/jbjs.m.01367] [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]
Affiliation(s)
- Nirav K Pandya
- Department of Orthopedic Surgery, Children's Hospital of Oakland and Research Center/University of California, San Francisco, 747 52nd Street, Oakland, CA 94609. E-mail address:
| | - Norman Y Otsuka
- Center for Children, NYU Langone Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003
| | - James O Sanders
- Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642
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Kamath AF, McAuliffe CL, Gutsche JT, Kosseim LM, Hume EL, Baldwin KD, Kornfield Z, Israelite CL. Intensive care monitoring after total joint replacement. Bone Joint J 2014; 95-B:74-6. [PMID: 24187358 DOI: 10.1302/0301-620x.95b11.33093] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patient safety is a critical issue in elective total joint replacement surgery. Identifying risk factors that might predict complications and intensive care unit (ICU) admission proves instrumental in reducing morbidity and mortality. The institution's experience with risk stratification and pre-operative ICU triage has resulted in a reduction in unplanned ICU admissions and post-operative complications after total hip replacement. The application of the prediction tools to total knee replacement has proven less robust so far. This work also reviews areas for future research in patient safety and cost containment.
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Affiliation(s)
- A F Kamath
- University of Pennsylvania, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA
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