An Enhanced Recovery Program for Elective Spinal Surgery Patients

From Musgrove Park Hospital, Taunton, England.

Abstract

• Objective: To describe a redesign of the clinical pathway for patients undergoing elective spinal surgery in order to improve quality of care and reduce length of stay.
• Methods: A multidisciplinary team undertook a process-mapping exercise and shadowed patients to analyse problems with the existing clinical pathway. Further ideas were taken from best evidence and other published enhanced recovery programs. Change ideas were tested using Plan-Do-Study-Act cycles. Measures included length of hospital stay, compliance with the pathway, and patient satisfaction.
• Results: The new pathway, the SpinaL Enhanced Recovery Program, is now used by 99% of elective spinal surgery patients with 100% of patients rating their care as good or excellent. Length of stay was reduced by 52%, improving from 5.7 days at the start of the intervention to 2.7 days. The pathway improved reliability of care, with preoperative carbohydrate drinks used in 83% of patients.
• Conclusion: The pathway improved reliability of care in our institution with excellent patient satisfaction and a significant reduction in length of hospital stay.

Enhanced recovery programs (ERPs) have been developed in many surgical specialties to improve patient outcomes and recovery after elective surgery. They involve multiple interventions throughout the patient journey, from preoperative patient education to postoperative mobilization and analgesia schedules. A meta-analysis of 38 trials involving 5099 participants showed ERPs could reduce length of stay and overall complication rates across surgical specialties [1].

There have been few studies of ERP for spinal surgery populations [2]. Most of them have studied selected patients or selected interventions such as analgesia schedules and did not use quality improvement methodology. For example, a small retrospective study compared patients undergoing multilevel spinal fusion surgery before and after introduction of a multimodal analgesia regimen [3]. A review of innovative perioperative and intraoperative treatment algorithms showed that they can influence postoperative recovery and patient outcomes from lumbar spinal surgery [4]. A study from the same group found that patient education and a “fast-track” pathway reduced length of hospital stay and improved patient satisfaction for patients undergoing 1- or 2- level lumbar spinal fusion [5].

At our hospital, a meeting of the clinicians and staff involved in elective spinal surgery was held to discuss the service. Leadership came from a consultant anesthesiologist and a consultant spinal surgeon, who recognized that care was not as efficient as it could be. A multidisciplinary team was formed consisting of 30 members, including surgeons, clinical nurse practitioners, physiotherapists, occupational therapists, and secretarial staff. The team undertook a process-mapping exercise that revealed that patients followed an ill-defined care pathway with variability in administrative processes and clinical care. Patient feedback and reports from both secretarial and community staff revealed that communications from the spinal team could be inconsistent, and patients had unclear expectations of their care and recovery. Lengths of stay for the same procedure could vary by 3 days.

With support from the hospital’s chief executive and medical director, the team embarked on a process to redesign the clinical pathway for patients undergoing elective spinal surgery at our hospital. We developed the SpinaL Enhanced Recovery Program; our primary aims were to to have 95% of patients managed according to the new pathway, to reduce length of stay by 30% without a rise in readmission rates, and to improve patient satisfaction.

Methods

Ethical Issues

This work met criteria for operational improvement activities and as such was exempt from ethics review. The team engaged patients who had undergone spinal surgery to serve as representatives to ensure that the improvements studied were important to them.

Setting and Patients

Our institution is a District General Hospital that serves a population of over 340,000 and has 3 consultant spinal surgeons. They work with 5 anesthesiologists on a regular basis and the patients are cared for by 3 clinical nurse practitioners. The patients are cared for on an elective orthopedic ward with nursing staff, physiotherapists, and occupational therapists who work regularly with spinal surgery patients. The mean age of our spinal surgery patients is 55 years and 55% are female. By age-group, 6.6% are aged 1–16 years, 50.8% aged 17–65 years, and 42.6% over 65 years. We define elective spinal surgery as non-emergency surgery, including discectomy, decompression, fusion and realignment operations to the cervical, thoracic and lumbar spine.

Developing the Pathway

To develop the new pathway, input from the expert team of anesthesiologists and surgeons, other clinicians and staff, as well as patients were sought. Four patients were approached prior to surgery and asked for their thoughts on the existing clinical pathway. They were then shadowed during their journey by clinical staff to see where improvements to their clinical care could be made.

In addition to gathering input from staff and patients, we reviewed the literature for the best available evidence. We found a Cochrane review of 27 trials involving 1976 surgical patients that concluded that preoperative carbohydrate drinks reduced length of stay [6]. Similarly, although laxatives have not been shown to improve length of stay [7], it is known that constipation is exacerbated by opioid analgesia and causes distress [8].

Finally, we examined the ERPs for patients undergoing hip and knee replacement that already existed in our institution. We found they used standardized anesthetic regimens as well as “patient passports,” leaflets given to give patients telling them what to expect during and following joint replacement surgery. They were also implementing methods to help patients set daily aims on the ward.