Patients undergoing lower back surgeries had shorter hospital stays and fewer complications after a team at the Vanderbilt Spine Institute identified best practices for perioperative care and implemented them under a standardized protocol.
The average length of stay for patients who underwent elective surgery for degenerative lumbar spine diagnosis decreased from 2.9 days to 2.5 days. The complication rate improved to 4 percent from 13 percent.
The protocols implemented at Vanderbilt University Medical Center (VUMC) could translate into significant savings in national health care spending if adopted on a larger scale. Hospital adjusted expenses per inpatient day in the U.S. are $2,271, according to The Henry J. Kaiser Family Foundation.
“Then when you take in the effect of a complication, some of these complications can contribute 30 percent of the overall cost of care,” said Clinton Devin, M.D., associate professor of Orthopaedic Surgery. “If you can reduce that beyond just the length of stay, that’s not small.”
The team did an extensive review of medical literature, selected best practices to follow, put them into order sets, ensured compliance and then began compiling and comparing data.
The protocol was implemented in June 2014 for all elective spine surgeries at VUMC. While improvements occurred across spine surgeries, the change with lumbar procedures was the most dramatic.
The researchers presented their findings in February at the annual meeting of the Southern Neurosurgical Society, where the work received an award for impactful research.
“Everybody is writing and talking about improving quality and reducing cost in health care in order to increase value,” said Ahilan Sivaganesan, M.D., a Vanderbilt neurosurgery resident who worked on developing, implementing and monitoring the protocol. “We did something where the rubber hits the road. It represents an actual change in practice. We can look at the impact before and after.”
A registry for monitoring patients was already in place. Devin and colleagues had developed the system to track patient outcomes and use that information to improve spine care. The registry allows for a granular understanding of the safety of care provided and the impact the surgery had on the patients’ quality of life.
The researchers analyzed data on 151 post-protocol patients, comparing that information to outcomes on 1,594 patients already in the registry. They plan to continue comparing data as more post-protocol patients come into the registry.
“Improvements can’t be purely around cost,” Devin said. “You need to understand what impact that reduction in cost may have on the patient-reported outcome, or in other words, how the patient views the improvement or decline in quality of life following the intervention.
“This careful tracking of the quality of care provided creates a plug-and-play infrastructure, whereby an intervention can be inserted and the impact of that intervention seen as patients are followed out to two years postoperatively.”
The protocols implemented include changes with pain control, antibiotics, back braces, drain removal, deep venous thrombosis (DVT) prophylaxis and mobilization following a durotomy.
“If you are able to adequately control pain yet minimize opioids, people tend to do much better,” Devin said. “I think that was a very important part of this protocol that we created in addition to some of the other key points. Braces can cost any where from $400 to $1,200. Also, what you do with a dural tear?
“A lot of the patients we see are undergoing revision spine surgery with all of the associated complexity. We have to work in and around nerve roots that are scarred, and in freeing them up, it’s not uncommon to get a tear. If you can get a nice repair on it, what we have found is you can get them up immediately. You don’t have to keep them flat, which was the historical approach that significantly increased length of stay.”
Adopting the protocol required a commitment from the entire care team, ranging from nurses to physical therapists. Christy Cherkesky, ACNP, played an instrumental role in the literature search and compliance, and Letha Mathews, MBBS, interim chief of Neuroanesthesiology, is now working to create a new intraoperative protocol, Devin said.
The research began before all patients undergoing elective spine surgeries were assigned to one floor at VUMC. Now, all patients are on the sixth floor, which makes the logistics of carrying out the standard protocol even smoother.
“Essentially, we developed a best-practices protocol for various dimensions of care surrounding elective spine surgery,” Sivaganesan said. “There is novelty in this approach — to gather the best practices from around the country.
“We then translated that into a concrete protocol that was agreed upon between all the orthopaedic and neurosurgeons that perform elective spine surgeries. So it is an institution-wide protocol. That in and of itself was a formidable undertaking.”
