Lumbar discectomy procedure cuts 5-day LOS to 1 day
By Lyda Dye, RN, MSN
Case Manager, Neurosurgery
April Langford, MBA, CPA
Administrative Director, Collaborative Case Management
University of Pittsburgh Medical Center
Inadequate postoperative pain management for lumbar surgery patients can result in increased length of stay (LOS), delayed return to functional health status post-discharge, and dissatisfied customers.
Many reasons have been cited for inadequate pain control, including lack of caregiver knowledge about monitoring pain and lack of patient ability to objectively report it. The challenge associated with staff education on post-op care is further complicated by a constantly changing group of physicians and nurses at the University of Pittsburgh Medical Center (UPMC). The unsuccessful results associated with conventional teaching methods led the medical and nursing community at UPMC to seek alternative avenues, such as a critical pathway, to change practice and improve patient outcomes with an eye on cost effectiveness.
A retrospective chart review of all patients who underwent lumbar discectomy surgery during the previous year revealed that postoperative pain was a major contributor to increased LOS. As a result, now patients can be placed on either of two paths at UPMC: a one-day path or a same-day surgery path.
Prior to developing the paths for lumbar discectomy at UPMC, the average LOS for DRG, diagnostic, and procedural codes 214, 215, 722.10, and 80.51 was 4.92 days. The lumbar discectomy without fusion pathway was developed with an expected LOS of three days and was implemented for pilot study in February 1995.
Inclusion of pain management experts on the pathway development team was crucial for the development of the lumbar discectomy critical pathway. Initial critical pathway development was only the beginning of an ongoing process. Aside from development, the pathway process included data analysis and a revised pathway incorporating further LOS reductions. (To see how pain is managed using medications, see the Lumbar Discectomy Without Fusion critical pathway, pp. 8-9.)
All neurosurgeons with admitting privileges at UPMC were included on the pathway development team. Changes in practice based on the findings from the data analysis enabled staff to reduce costs while maintaining quality of care and expected patient outcomes.
During the eight-month trial period, 70 patients were admitted to the hospital for lumbar discectomy without fusion. The average LOS was 2.16 days, resulting in a total savings of 193 inpatient days over the eight-month period.
Some reductions in the average LOS for this procedure were noted prior to implementing the lumbar discectomy path. For example, physician practice pattern changes in related areas had an effect on the LOS for lumbar patients.
When the total pilot group was analyzed by DRG, findings revealed that an even greater reduction in LOS was experienced by the group with comorbidities. In fact, 40% of the group with comorbidities had a LOS of one day. DRGs 214 and 215, with and without comorbidities, were equally represented by those with a LOS of one day.
Analysis during the pathway's revision revealed that physicians often did not follow the pathway as intended. In an effort to encourage compliance with the path's recommended actions, pre-printed physician order forms were revised to help reduce costs and the patient's hospital stay.
The pathway development team set the LOS goal for one day for both DRGs with the diagnostic and procedure codes mentioned above. In an effort to meet our expected LOS of one day, greater attention was given to pain, activity, and patient education. Pathway revision was completed in December 1995.
Attention was given to pain management and decreased activity associated with pain because a patient's fear of pain in the immediate post-op period can create psychological stress. Patients often attempt to avoid pain during the post-op period by not moving or by taking shallow breaths, which might increase the risk of physiologic complications, such as venous stasis or pulmonary congestion.
Goals for a 1-day LOS
Recommendations from the development team to help meet the pain management goals for a one-day LOS included:
* infiltration of area of incision with bupivacaine 0.25% prior to skin incision and infiltration of subcutaneous tissues/skin with bupivacaine at closure to anesthetize the area for six to eight hours;
* starting a patient-controlled analgesia (PCA) device in the recovery room that is discontinued at 8 a.m. the following morning;
* administration of an oral opioid analgesic when the PCA was discontinued, and then every four hours for two days;
* administration of ibuprofen 600 mg three times a day for three days to be started when the patient was awake enough to take oral medication.
The patient's response to treatment, however, is the final determining factor in whether discharge will occur the day following surgery.
Patient activity is now encouraged sooner. Recommendations for patient activity were changed from "bed rest the day of surgery" to "ambulating with assistance when awake" to optimize the period of analgesia. In addition
to ambulating the day of surgery, the patient receives education in stretching and strengthening exercises from a physical therapist the morning following surgery and prior to discharge. The use of a bedpan or urinal is discouraged in an effort to increase activity following surgery.
Patient education improves
Additionally, many patients did not anticipate being discharged the day following surgery, which could have contributed to an increased LOS. Educating patients about the procedure and their care is important in achieving the desired LOS.
A patient-friendly version of the critical pathway was developed to help educate patients, families, and significant others. Pain control, activity, and the discharge plans for the day following surgery are emphasized on the patient path.
An additional pathway was developed during the revision process to reflect an even more efficient procedure: same-day surgery. Since implementation of the pathway for same-day surgery and discharge in October 1995, 33 patients have been included on the pathway.
Of that group of 33 patients, 97% went home the day of surgery as they had been instructed prior to surgery. That finding helped us determine that patient education regarding expected day of discharge for the inpatient group was equally important in meeting the goal of a one-day LOS.
During the initial pathway development process, the expected outcomes identified included absence of radicular pain and absence of new neurological deficits. In the original study group, the expected outcomes were met in 97% of the cases.
Critical pathways at UPMC are reviewed daily by the assistant head nurse, or unit-based patient care manager, and case manager. All events that are completed as indicated on the pathway are initialed. An asterisk is placed beside each event that varies from the pathway. The primary care nurse discusses all variances from the pathway with the physician.
Physicians are responsible for including documentation to support variances in the medical record. Variances also are documented by the case manager on a summary critical pathway individualization report used for variance tracking.
Additionally, the case manager compiles an itemized statement of both outcomes and costs for every patient on a pathway. The itemized statement serves as a tool to assist in retrospective data analysis and is essential for analyzing care. *
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