An Enhanced Recovery Program for Elective Spinal Surgery Patients

Outcomes

Working with the IT department and data collection tools attached to the medical records, we collected data on key measures every 2 weeks. Statistical process control charts (Process Improvement Products, Austin, TX)  [9,10] were used to analyze the data.

Since the revised pathway was implemented in May 2014, the percentage of patients receiving laxatives has increased from 20% to 75% ( Figure 1) and continues to improve. Currently, 87% of eligible patients receive preoperative carbohydrate drinks (Figure 2). Daily aims setting is consistently high (95%, Figure 3). Patient satisfaction with the pathway as measured by a single-item questionnaire at discharge is also outstanding, with a median of 100% of patients (range 95–100) rating their care as good or excellent as of April 2015.

Length of stay was reduced by 52% (Figure 4), improving from an average of 6 days during the baseline period to 2.9 days by April 2015. Readmissions for elective spinal surgery patients did not increase and in fact were reduced from 7% to 3%.

By October 2014, 99% of eligible patients were managed on the new pathway and most patients were receiving key 

interventions.

Discussion

The new pathway, the SpinaL Enhanced Recovery Program, improved reliability of care in our institution, with excellent patient satisfaction. It also exceeded its target in reducing length of stay for elective spinal surgery patients 

while not increasing rates of readmission. The financial impact of reducing length of stay by 52% is not insignificant. With a bed cost of £174/day, our results equate to a theoretical savings of £78,00 per year.

One of the main strengths of this work was the use of small scale testing for each change idea using PDSA cycles, ramping up the idea prior to full implementation. The team could see the impact of changes on a small scale, then make adaptations in the next cycle to increase the likelihood of success.

The development and implementation of the pathway has led to a positive culture change. The spinal team has taken ownership of the pathway and continues to monitor its impact. Seeing the impact of their work on improving the quality of patient care has enhanced the team’s self-efficacy.

The methods used to plan and study our interventions, as well as some of the change ideas themselves, may be helpful for other elective spinal surgical teams. The simple application of the interventions without the improvement process may not have delivered the same outcome. Meeting regularly as a team to discuss ideas and implement new interventions with the guidance of a quality improvement advisor (M.W.) was felt to be the most important factor for success. The team also felt that it was important to collect data by any means possible to monitor interventions and motivate staff before better automated systems were implemented.

The SpinaL Enhanced Recovery Program pathway has now become “business as usual,” and the team plans to incorporate the process and outcome measures onto a monthly performance dashboard to continue to monitor the interventions. Further interventions are planned, including improving preoperative education with a patient pathway video. The team has started to try to stagger admissions for all-day theatre lists, to avoid patients having to wait all day for an afternoon operation. Further improvements in the reliability of care will also potentially allow the team to run controlled studies of single interventions to see how these can impact quality of patient care in a stable process.

Acknowledgments: The authors acknowledge Deborah Ray, Institute for Healthcare Improvement; Sandra Murray, Associates in Healthcare Improvement; Matthew Beebee, Clinical Nurse Practitioner Spinal Surgery; Debbie Vile and Lorraine Sandford, Clinical Nurse Practitioners Spinal Surgery; Sophie Hudson and Sallie Durman, Secretaries; Eleanor Palfreman, Occupational Therapist; Sarah Woodhill, Physiotherapist; Lee Scott, Improvement Nurse; Gervaise Khan-Davis, Directorate Manager; and “SG,” previous patient.

Corresponding author: Dr Julia Blackburn, Musgrove Park Hospital, Taunton, England, TA1 5DA, jlrkblackburn@doctors.org.uk.

Financial disclosures: None.