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Outcomes of an accelerateddischarge pathway after
spinal fusion
Sarah TembyThe Royal Children’s Hospital
March 2017
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• Scoliosis = Lateral curvatureand rotation of the spine
• Adolescent Idiopathic Scoliosis• most common type of scoliosis• affects children 10 – 18 years• has no identifiable cause
• Posterior Spinal Fusion = surgery to stopcurve progression and reduce the curve tosome degree
Background
Posterior Spinal Fusion
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• Fletcher et al. developed accelerateddischarge pathway following posterior spinalfusion in patients with adolescent idiopathicscoliosis (AIS)
• Results =• Length of stay 48% shorter in pathway group• Decrease hospital cost by 33%• No difference in wound or medical
complications(Fletcher et al. 2014)
Background
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RCH practice Fletcher et al.Accelerated
Discharge PathwayTransition fromintravenous to oral painmedication
Day 3 or Day 4 post surgery
Mobilise withPhysiotherapist
Sit over edge of bed Day 1Step transfers to chair Day 2Walking Day 3Seen x2 daily
Removal of urinarycatheter
Once mobilisingApprox Day 3
Transition to eating Once bowel sounds heardApprox Day 2 or Day 3
Discharge Day 5 – 7 post surgery
Background
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RCH practice Fletcher et al.Accelerated
Discharge PathwayTransition fromintravenous to oral painmedication
Day 3 or Day 4 post surgery Day 1 post surgery
Mobilise withPhysiotherapist
Sit over edge of bed Day 1Step transfers to chair Day 2Walking Day 3Seen x2 daily
Walking Day 1 morningSeen x 2 daily
Removal of urinarycatheter
Once mobilisingApprox Day 3
Day 1
Transition to eating Once bowel sounds heardApprox Day 2 or Day 3
Day 1 as tolerated(despite bowel sounds)
Discharge Day 5 – 7 post surgery Day 2 or 3 post surgery
Background
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• Meet with each team involved in care
• No increase in complications• No increase in readmission• No compromise to patient/family
satisfaction• Reduce length of stay• Reduce hospital costs
Planning PhaseMultidisciplinary Team
Objectives
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Preparation Phase1. Patient Criteria for Pathway
• Age 10 and older• Uncomplicated Posterior Spinal Fusion for
AIS• No significant co-morbidities
• Standardised post operative orders• Mobilising as tolerated, no brace,
can sit up in bed
2. Post Operative Orders
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Preparation Phase3. Resources Developed• Pathway formulated
• for staff
• Pre admission clinic handout• for family/patient
• Daily goal sheet• for family/patient
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Implementation1. Education and Training
• Surgeon identified if patient planned forpathway• Surgeon and Scoliosis Coordinatoreducated patient/family on pathway
• Daily goal sheetin the patient’s room
2. Preadmission Review
3. Ward Management
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OutcomesSix Month ReviewRetrospective Audit•2013
• 17 patients•2014
• 15 patients
Prospective Audit•Feb – July 2016 (6 months)
• 19 patients
•No difference in cohorts at time of surgery• Age, gender, pre surgery curve angle, past
medical history, number vertebrae fused, numberpedicle screws used
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Changes in Post Surgical Care after SpinalFusion
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
2012 2013 2014 2015 2016
Day
afte
r Sur
gery
Year
Patient controlled analgesia removed Urinary tube removedEating solid food Sitting out of bedWalking
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Hospital Length of Stay
6.16.5
3.4
0
1
2
3
4
5
6
7
2013 2014 2016
Days
in h
ospi
tal
YearFebruary – July 2016
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Number of Physiotherapy Sessions
7.6
8.5
5.5
0
1
2
3
4
5
6
7
8
9
2013 2014 2016
Num
ber o
f ses
sions
YearFebruary – July 2016
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Cost Saving per Patient
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Complication and Readmission Rate
2013n = 17
2014n = 15
Complication Rate 1 0
Readmission Rate 1 1
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Complication and Readmission Rate
2013n = 17
2014n = 15
2016n = 19
Complication Rate 1 0 1
Readmission Rate 1 1 0
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Patient/Family Satisfaction Survey
• Global satisfaction rating = 9.2/10• Communication with parent = 9.3/10• Communication with child = 9.1/10• Attention to safety & comfort = 8.5/10
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Summary
Introduction of an Accelerated DischargePathway for AIS
• Reduced length of stay and hospital costs
• No compromise in patient safety
• No compromise in patient satisfaction
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Reference:Fletcher, N., Shourbaji, P., Mitchell, P.,Oswald, T., Devito, D. & Bruce, R. (2014).Clinical and economic implications ofearly discharge following spinal fusion foradolescent idiopathic scoliosis. J ChildOrthop, 8:257-263.
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Thank you