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Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of an Evidence-Based Clinical Care Pathway

Bradywood, Alison, RN, MPH, MN; Farrokhi, Farrokh, MD; Williams, Barbara, PhD; Kowalczyk, Mark, BS; Blackmore, C. Craig, MD, MPH

doi: 10.1097/BRS.0000000000001703

Study Design. Quality improvement with before and after evaluation of the intervention.

Objective. To improve lumbar spine postoperative care and quality outcomes through a series of Lean quality improvement events designed to address root causes of error and variation.

Summary of Background Data. Lumbar spine fusion procedures are common, but highly variable in process of care, outcomes, and cost.

Methods. We implemented a standardized lumbar spine fusion clinical care pathway through a series of Lean quality improvement events. The pathway included an evidence-based electronic order set; a patient visual tool; and multidisciplinary communication, and was designed to delineate expectations for patients, staff, and providers. To evaluate the effectiveness of the intervention, we performed a quality improvement study with before and after evaluation of consecutive patients from January 2012 to September 2014. Outcomes were hospital length of stay and quality measures before and after the April 1, 2013 intervention. Data were analyzed with chi-square and t tests for before and after comparisons, and were explored graphically for temporal trends with statistical process control charts.

Results. Our study population was 458 patients (mean 65 years, 65% women). Length of stay decreased from 3.9 to 3.4 days, a difference of 0.5 days (CI 0.3, 0.8, P < 0.001). Discharge disposition also improved with 75% (183/244) being discharged to home postintervention versus 64% (136/214) preintervention (P = 0.002). Urinary catheter removal also improved (P = 0.003). Patient satisfaction scores were not significantly changed.

Conclusion. Applying Lean methods to produce standardized clinical pathways is an effective way of improving quality and reducing waste for lumbar spine fusion patients. We believe that quality improvements of this type are valuable for all spine patients, to provide best care outcomes at lowest cost.

Level of Evidence: 4

Virginia Mason Medical Center, Seattle, WA.

Address correspondence and reprint requests to Dr. Farrokh Farrokhi, MD, Virginia Mason Medical Center, 925 Seneca St., Mailstop X7-NS, Seattle, WA 98101; E-mail:

Received 25 August, 2015

Revised 13 March, 2016

Accepted 23 April, 2016

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: royalties.

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