Lumbar discectomy path emphasizes pain control
Postoperative ambulation also is a priority
Case managers at University of Pittsburgh Medical Center are cutting costs and reducing length of stay for lumbar discectomy patients by taking a unique approach to pain management.
Since their lumbar discectomy pathway was implemented in December 1995, they’ve seen cost per case drop by about $1,000, while length of stay (LOS) has declined from 4.92 days to just under two days.
Before implementing the pathway, case managers identified pain and lack of activity as the main factors resulting in LOS greater than one day. In particular, inadequate postoperative pain management often results in increased LOS, delayed return to functional health status, and decreased satisfaction with health care services, says Lyda Dye, RN, MSN, case manager for neurosurgery, neurology, and cardiology at the medical center.
Patients’ preconceived notion that they would be in the hospital for a few days or until their pain was controlled may also have contributed to the center’s high initial length of stay, says Dye. With those factors in mind, case managers designed the pathway to address patient education related to pain control, postoperative physical activity, and discharge planning following surgery for lumbar discectomy. (See sample pathway, p. 92.)
Ironically, some insurers and health care providers have traditionally considered pain management an unnecessary cost center, says Dye. Indeed, a study conducted by the Ann Arbor-based Michigan Council on Pain found serious problems with existing attitudes about pain management, says Joel Saper, MD, director of the Michigan Pain and Neurological Institute and chair of the council. (See related story, above.)
"This cynicism on the part of some health professionals has filtered over to insurance companies and government agencies as well, making reimbursement for palliative care more difficult," Saper maintains. "Some of it is a scientific issue. We cannot objectify pain. And many physicians have an attitude that if it’s not objectifiable, it’s not legitimate. But I caution my colleagues that, before we developed the appropriate diagnostic tests, other illnesses were not objectifiable either. In other words, it’s not the legitimacy of the disorder, it’s the sophistication of diagnostic techniques that determines legitimacy."
Because it can be difficult to classify pain scientifically, patients’ self-reports become crucial, says Amy Blum, RRA, medical classification specialist at the National Center for Health Statistics in Hyattsville, MD. "The doctor and patient have to come to an agreement about how much pain is too much," she says. "And who wants to have any amount of pain, really?"
At the University of Pittsburgh Medical Center, Dye and her colleagues also encountered initial resistance from physicians regarding the amount of pain management patients should receive following surgery. "Doctors originally thought patients were being dosed too heavily on PCA [patient- controlled analgesia] and recommended PCA on a limited basis for some patients," she says.
Patients needing lumbar discectomy typically have a long history of pain that is unresponsive to more conservative treatments, says Dye. Many also have had friends or relatives who experienced long periods of recuperation following back surgery and worry that physical activity following surgery could damage their recovery. "Therefore, the postoperative period is complicated by their experience with pain as well as their fear of additional pain that may result from movement following surgery," Dye adds.
To counter such unproductive fears, case managers at the University of Pittsburgh Medical Center developed an easy-to-read, "patient-friendly" pathway to explain how caregivers will address their pain and how mild physical activity following surgery will help in speeding recovery. The patient pathway also discusses the timetable for discharge from the hospital. (See sample patient pathway, p. 93.)
"We’ve found that patients can prepare for discharge better when they have the expectation right up front that they’re likely to be out of the hospital a day after surgery," says Dye.
Other pathway elements include the following:
• Pre-printed physicians’ orders were developed to decrease variability.
• Patient activity was changed from bed rest the day of surgery to ambulating with assistance when fully awake.
• Because data analysis showed that lumbar discectomy patients averaged six individual blood tests prior to surgery, requirements for pre-admission blood work were reduced to more accurately reflect the needs of each patient.
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