Adolescent idiopathic scoliosis (AIS) is a common spinal condition that may require treatment with surgical intervention by posterior spinal fusion (PSF). Although hospital stay has dramatically decreased from weeks1 to several days,2 many patients still experience variation in their hospital care and length of stays.3 The “fast-track” approach to postoperative care has been applied to numerous surgical procedures, including joint arthroplasty,4,5 and has been shown to be safe. Moreover, surgical site infections in spinal surgeries of other patient populations have been shown to increase with prolonged hospitalization,6,7 demonstrating another potential benefit to the “fast-track” approach to PSF postoperative care.
In 2009, a multidisciplinary team consisting of pediatric orthopaedic surgeons, orthopaedic team nurses, floor nurses, inpatient physical therapists, pediatric anesthesiologists, and the pediatric pain team, which included pediatric anesthesiologists and pain nurses, at our children’s hospital met to improve and standardize postoperative care in PSF in AIS patients. This involved the creation of evidence-driven protocols for multidisciplinary care, and the creation of education packets and posters for patients and parents to establish milestones during hospitalization and track their progress toward discharge. The first protocol was implemented at the end of 2009. Revisions to the protocol requiring removal of the Foley catheter and epidural catheter a day earlier were implemented in the second protocol in July 2013. We hypothesized that by using standardized educational materials and protocolled postoperative care, AIS patients undergoing PSF would significantly reduce the time to mobility and to discharge while maintaining adequate pain control and patient satisfaction.
This work began as a quality improvement project. The team consisting of the clinical nurse specialist (CNS) from pediatric orthopaedics, the CNS and 2 staff nurses from the inpatient unit, the CNS from the pediatric anesthesia pain service, a physical therapist, and a child life specialist met monthly for over 15 months with periodic input from the pediatric orthopaedic surgeons. The goal of the project was to improve outcomes in adolescent patients undergoing PSF through the use of evidence-based guidelines and a comprehensive patient education program.
The project team performed a thorough literature search to review the most current practice recommendations for postoperative care. Evidence supported early resumption of feeding after surgery to promote return of elimination patterns and energy for mobilization.8,9 Evidence in postsurgical patients, including postoperative spine surgery patients, also supported the early removal of Foley catheters to reduce the risk of infection and facilitate early mobility.10,11 The routine use of multimodal bowel medications as soon as the patient begins taking oral fluids was shown to enhance return of bowel function.12 The literature showed better pain management with scheduled versus as-needed oral opioid administration after patient-controlled epidural analgesia.11,13 Other studies including a Scoliosis Research Society Morbidity and Mortality Committee Report suggested that early mobility increases appetite and bowel function, prevents infection, and promotes return to independent function.8,14
On the basis of the review of the literature, the group developed the first protocol that correlated with nursing care maps, which outlined interventions for each day of admission (Table 1). Patient educational materials are included as Appendices 1 and 2 (Supplemental Digital Content 1, http://links.lww.com/BPO/A62) and 2 (Supplemental Digital Content 2, http://links.lww.com/BPO/A63). Comprehensive staff-guided teaching modules were developed, and the entire nursing and physical therapy (PT) staff were mandated to complete them over the course of 1 month. The surgeons, anesthesiologists, and acute pain service also instructed their residents and staff in the new protocol. The orthopaedic CNS instructed the nursing staff in the ambulatory area and provided the new preoperative and postoperative patient education packets.
After the first protocol was implemented, we found patients were actually progressing through their admission faster than the prescribed 4 to 5 days. More frequent use of epidural pain medication and earlier discontinuation of the Foley catheter allowed patients to mobilize earlier. We updated our practice and developed the second protocol, rolling it out with the staff and updating the nursing care maps (Table 2).
Following institutional review board approval, the study was conducted. The study consisted of 2 parts: a retrospective chart review to gather inpatient data and factors related to care during their stay and a patient satisfaction survey, which were administered on the day of hospital discharge to patients. Inclusion criteria included patients 10 to 25 years old who underwent PSF for AIS between December 2008 and December 2014. The onset of the scoliosis for all patients was in the adolescent time period. Patients with neuromuscular scoliosis and those unable to participate in the survey even with a parent’s assistance were excluded from the study. Three groups were used for the IRB-approved retrospective chart review: preprotocol (December 2008 to December 2009, n=51), first protocol (December 2, 2009 to July 24, 2013, n=100), and second protocol (July 25, 2013 to June 1, 2014, n=39). Three groups were also used for patient satisfaction surveys: preprotocol (September 2009 to November 2009, n=12), first protocol (January 2010 to December 2010, n=57), and second protocol (June 2014 to December 2014, n=27). The patient satisfaction survey results from the preprotocol and first protocol groups used data collected from the quality improvement study conducted by the nursing team. The patient satisfaction survey data from the second protocol group used data collected from the prospective IRB-approved study. Figure 1 depicts a timeline for the data collection used in this study.
The protocols are depicted in Tables 1 and 2. In the first protocol, the patient-controlled analgesia (PCA)/epidural was discontinued on postoperative day (POD) 3, and patients were transitioned to oral pain control by POD3. Voiding was not affected by the use of the PCA/epidural as it contained only narcotic solution with no anesthetic. Patients were also instructed by PT to sit on the edge of their bed by POD1, took short walks on POD2, took long walks by POD3, and trained on stairs on POD4. In the second protocol, the PCA/epidural could be discontinued on POD2 and the patient could be transitioned to oral pain control. Another revision in the second protocol, walking stairs, was advanced to POD3 and physical therapists were given the option to allow patients to walk on POD1.
The patient’s medical record was reviewed to determine age, height, weight, preoperative curve magnitude, total time of surgery, pain scores, time to intake of regular diet, time to Foley catheter removal, time to epidural removal, time to sitting, time to walking, time to discharge by PT, time to discharge home, and complications within 30 days, 12 months, and after 12 months postsurgery.
For the survey analysis, custom surveys were administered on the day of discharge to determine patient preparedness for the postoperative care, satisfaction with the amount of information provided, satisfaction with pain control, and overall satisfaction scores (0 to 10, where 10 is the best). The questions are stated in Table 3.
Statistical analysis was performed using a 1-way analysis of variance (ANOVA) test using Tukey post hoc analysis. Data were compiled as mean±SD, and significance versus both preprotocol and first protocol was P<0.05.
During the study period, 190 AIS patients were included in the chart review data and 96 patients were included in the survey data. There were no significant differences in average age, height, or weight among the groups (Table 4). Surgical time significantly increased from preprotocol to second protocol (P=7.5×10−7).
Table 5 shows the surgical complications with all protocols. There were 6 (12%) surgical complications among the 51 patients in the preprotocol group, 1 (1%) surgical complication in the 100 first protocol patients, and 1 (3%) surgical complication in the 39 second protocol patients.
Pain scores (0 to 10) were monitored immediately after surgery and during postoperative hospitalization. Average pain scores (Fig. 2) were similar in all 3 groups.
Figure 3 shows time to sitting, walking, and discharge by PT. Time to sitting significantly decreased in both first (27.2±9.8 h, P=1.7×10−8) and second protocol (28.4±13.6 h, P=3.43×10−5) groups compared with preprotocol (40.2±15.4 h). Time to walking remained similar in all 3 groups. Time to discharge by PT significantly decreased by an average of 12 hours in second protocol (76.9±24.6 h, P=0.014) compared with first protocol (88.8±23.6 h).
Figure 4 depicts time to regular diet, time to Foley catheter removal, time to epidural/PCA removal, and time to discharge by the Orthopaedic Surgery team. There were no significant differences in time to regular diet. However, second protocol showed a significant decrease in time to both Foley catheter (42.1±13.6 h) and epidural/PCA (43.9±11.1 h) removal compared with both preprotocol (Foley=57.4±15.7 h, P=3×10−4; epidural/PCA=55.6±15.0 h, P=0.006) and first protocol (Foley=64.5±20.9 h, P=5.02×10−9; epidural/PCA=60.5±20.9 h, P=4.58×10−6). Time to discharge by Orthopaedic Surgery significantly decreased by 13 hours in second protocol (84.3±27.7 h) compared with first protocol (97.4±27.8 h, P=0.036).
Data from the survey administered on the day of discharge are shown in Figure 5. In all areas except for comfort, both first and second protocol patients were significantly more satisfied. Patients understood the information given about the operation and about postoperative care, felt prepared for the hospitalization, and felt that they handled the operation and hospitalization well after the plan of care was established. Although patient comfort decreased between first (7.8±1.2) and second protocol (5.9±2.9, P=1.7×10−4), patient satisfaction with both the information and care remained high in both first protocol (information=8.8±1.4, care=9.1±0.91) and second protocol (information=8.8±2.2, care=8.6±2.5) compared with preprotocol (information=4.25±1.8, care=6.5±1.2).
Before the use of protocols and PSF plan of care at our children’s hospital, the postoperative care of AIS patients undergoing PSF surgery had variable outcomes in reaching milestones such as time to sitting, walking, and removal of the Foley catheter. These variable outcomes not only affected the length of hospital stay but also may have resulted in the lower patient satisfaction values before the institution of evidence-driven protocols and posters to guide patient care (Fig. 5). Further, many of these significant differences were not observed until the use of the second protocol, which dictated an earlier removal of the Foley catheter and earlier PT milestones. The fast-track approach to postoperative care of patients has been previously applied to patients undergoing joint arthroplasty procedures and has been shown to both decrease hospital stay and to either increase or not change patient satisfaction.4,5,15–17 Following preoperative education, establishment of a protocol, and motivation of patients and their families to reach milestones, these metrics and the time to discharge all significantly decreased, conferring a significant benefit to the patient and a potential decrease in cost.18
This study observed a dramatic decrease in hospital stay after the application of the plan of care similar to Fletcher et al19 and a protocolled approach was taken to the postoperative care of AIS patients undergoing PSF. Similar to this study, Fletcher et al19 began mobilization with PT on POD1, transitioned to regular diet on POD2, and removed the Foley catheter and epidural by POD1. By accelerating these milestones, the authors achieved a decrease in length of stay of approximately 32.6 hours compared with the 15-hour decrease in length of stay found in this study. However, Fletcher et al19 saw an increase in surgical site complications from 2.4% to 3.25%, unlike the decrease in total complications found in this study from 14% (preprotocol) to 1% (first protocol) and 3% (second protocol). None of the complications in that group with the 12% complication rate were evident at the time of administration of the surveys (day of discharge). These were all complications noted >1 year postsurgery, therefore likely not affecting satisfaction scores in that group. Wound infection after PSF has been correlated with prolonged hospitalization,7,20,21 and has been shown to decrease by using the “fast-track” methodology.8 Our results corroborate these findings as surgical complications decreased after the establishment of the plan of care. Finally, similar to Blanco et al,22 the early removal of the epidural and transition to other pain control did not alter the minimum, maximum, or average reported pain scores of patients; however, patients rated their comfort lower with epidural/PCA removal 1 day earlier. Average comfort decreased between the first and second protocol, which may indicate that we are nearing the limits of maximizing comfort and safely mobilizing patients earlier. Despite this, patients were similarly satisfied with their care, as indicated in Figure 5.
In addition to establishing a faster discharge time, we were also interested in the effect of patient education before the surgery on overall comfort and satisfaction during the hospital stay. Preoperative patient education in joint arthroplasty surgeries has been shown to decrease length of stay.16,17,23 As observed in our survey results, patients in this study understood the information about the operation and the postoperative care, and felt prepared for the operation (Fig. 5). Moreover, other studies have investigated the effect of an accelerated pathway to postoperative care on patient satisfaction and saw either no change or dissatisfaction15,17 or an increase in patient satisfaction.5,24 Our data showed significant increases in patient comfort, in how prepared the patient felt about the procedure, and in the patient’s overall satisfaction with both the information provided and the care received after the fast-track approach was implemented.
A limitation in this study is that flexibility in the protocol made some milestones difficult to measure. For example, the protocol suggested walking on the stairs some time during POD3 and this required a provider to be physically present. As a result, there was variability in time measured in hours to discharge from PT based on time of day of the therapy session. This flexibility may have helped patient satisfaction by allowing patients and providers to individualize some aspects of the care. Also, time to discharge was dependent on extrinsic factors such as when prescriptions were filled at the pharmacy and when transportation to the patient’s home arrived. Another limitation of this study is the small sample size used in the second protocol group and the follow-up data of only 1 year from this group. We were unable to establish causality for the complications noted in Table 5 and therefore could only assert differences between the groups. Also, surgical time significantly increased likely due to a change in the use of intraoperative image-guided navigation for insertion of spinal instrumentation. Although patient satisfaction scores were high after the use of plan of care, numerous confounding variables exist in this subjective data such as experience with the staff and overall comfort while in the hospital.
A multidisciplinary protocolled approach to the postoperative care of AIS patients undergoing PSF was undertaken in this study. The application of a plan of care demonstrated significant decreases in time to mobility and time to removal of the Foley catheter and epidural, and a dramatic decrease in hospital stay of 15 hours while maintaining high patient satisfaction scores. The application of a multidisciplinary, evidence-driven plan of care for AIS patients undergoing PSF improves throughput and has beneficial effects on objective and patient-reported outcomes.
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