A Safe Transitions Pathway for post-craniotomy neurological surgery patients: high-value care that bypasses the intensive care unit

View More View Less
  • 1 Department of Neurological Surgery and
  • 2 Division of Hospital Medicine, Department of Medicine, University of California, San Francisco;
  • 3 Department of Neurological Surgery, University of California, Irvine;
  • 4 University of California San Francisco Medical Center, San Francisco; and
  • 5 School of Medicine, University of California, San Francisco, California
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

High-value medical care is described as care that leads to excellent patient outcomes, high patient satisfaction, and efficient costs. Neurosurgical care in particular can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. The authors developed a “Safe Transitions Pathway” (STP) model in which select patients went to the postanesthesia care unit (PACU) and then the neuro-transitional care unit (NTCU) rather than being directly admitted to the neurosciences intensive care unit (ICU) following a craniotomy. They sought to evaluate the clinical and financial outcomes as well as the impact on the patient experience for patients who participated in the STP and bypassed the ICU level of care.

METHODS

Patients were enrolled during the 2018 fiscal year (FY18; July 1, 2017, through June 30, 2018). The electronic medical record was reviewed for clinical information and the hospital cost accounting record was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impressions of the hospital stay and of the recovery pathway.

RESULTS

No patients who proceeded to the NTCU postoperatively were upgraded to the ICU level of care postoperatively. There were no deaths in the STP group, and no patients required a return to the operating room during their hospitalization (95% CI 0%–3.9%). There was a trend toward fewer 30-day readmissions in the STP patients than in the standard pathway patients (1.2% [95% CI 0.0%–6.8%] vs 5.1% [95% CI 2.5%–9.1%], p = 0.058). The mean number of ICU days saved per case was 1.20. The average postprocedure length of stay was reduced by 0.25 days for STP patients. Actual FY18 direct cost savings from 94 patients who went through the STP was $422,128.

CONCLUSIONS

Length of stay, direct cost per case, and ICU days were significantly less after the adoption of the STP, and ICU bed utilization was freed for acute admissions and transfers. There were no substantial complications or adverse patient outcomes in the STP group.

ABBREVIATIONS CMI = case mix index; DVT = deep venous thrombosis; FY18 = 2018 fiscal year; ICU = intensive care unit; LOS = length of stay; MVD = microvascular decompression; NTCU = neuro-transitional care unit; PACU = postanesthesia care unit; PE = pulmonary embolism; SSI = surgical site infection; STP = Safe Transitions Pathway; UTI = urinary tract infection.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Michael W. McDermott: University of California, San Francisco, CA. mcdermottm@neurosurg.ucsf.edu.

INCLUDE WHEN CITING Published online May 29, 2020; DOI: 10.3171/2020.3.JNS192133.

Disclosures Dr. A. K. Chan reports receiving support of a non–study-related clinical or research effort from Orthofix Inc. Dr. McDermott reports being a consultant for Stryker.

  • 1

    Halpern NA. Can the costs of critical care be controlled? Curr Opin Crit Care. 2009;15(6):591596.

  • 2

    Norris C, Jacobs P, Rapoport J, Hamilton S. ICU and non-ICU cost per day. Can J Anaesth. 1995;42(3):192196.

  • 3

    Curtis JR, Engelberg RA, Bensink ME, Ramsey SD. End-of-life care in the intensive care unit: can we simultaneously increase quality and reduce costs? Am J Respir Crit Care Med. 2012;186(7):587592.

    • Search Google Scholar
    • Export Citation
  • 4

    Kelly DF. Neurosurgical postoperative care. Neurosurg Clin N Am. 1994;5(4):789810.

  • 5

    Awad IA. Intensive care after elective craniotomy: “all politics is local”. World Neurosurg. 2014;81(1):6465.

  • 6

    Hecht N, Spies C, Vajkoczy P. Routine intensive care unit-level care after elective craniotomy: time to rethink. World Neurosurg. 2014;81(1):6668.

    • Search Google Scholar
    • Export Citation
  • 7

    Hanak BW, Walcott BP, Nahed BV, Postoperative intensive care unit requirements after elective craniotomy. World Neurosurg. 2014;81(1):165172.

    • Search Google Scholar
    • Export Citation
  • 8

    Osorio JA, Safaee MM, Viner J, Cost-effectiveness development for the postoperative care of craniotomy patients: a safe transitions pathway in neurological surgery. Neurosurg Focus. 2018;44(5):E19.

    • Search Google Scholar
    • Export Citation
  • 9

    Wong JM, Panchmatia JR, Ziewacz JE, Patterns in neurosurgical adverse events: intracranial neoplasm surgery. Neurosurg Focus. 2012;33(5):E16.

    • Search Google Scholar
    • Export Citation
  • 10

    Steinwald B, Dummit LA. Hospital case-mix change: sicker patients or DRG creep? Health Aff (Millwood). 1989;8(2):3547.

  • 11

    Jackson C, Westphal M, Quiñones-Hinojosa A. Complications of glioma surgery. Handb Clin Neurol. 2016;134:201218.

  • 12

    Florman JE, Cushing D, Keller LA, Rughani AI. A protocol for postoperative admission of elective craniotomy patients to a non-ICU or step-down setting. J Neurosurg. 2017;127(6):13921397.

    • Search Google Scholar
    • Export Citation
  • 13

    Venkatraghavan L, Bharadwaj S, Au K, Same-day discharge after craniotomy for supratentorial tumour surgery: a retrospective observational single-centre study. Can J Anaesth. 2016;63(11):12451257.

    • Search Google Scholar
    • Export Citation
  • 14

    Sughrue ME, Bonney PA, Choi L, Teo C. Early discharge after surgery for intra-axial brain tumors. World Neurosurg. 2015;84(2):505510.

    • Search Google Scholar
    • Export Citation
  • 15

    Richardson AM, McCarthy DJ, Sandhu J, Predictors of successful discharge of patients on postoperative day 1 after craniotomy for brain tumor. World Neurosurg. 2019;126:e869e877.

    • Search Google Scholar
    • Export Citation
  • 16

    Mirian C, Møller Pedersen M, Sabers A, Mathiesen T. Antiepileptic drugs as prophylaxis for de novo brain tumour-related epilepsy after craniotomy: a systematic review and meta-analysis of harm and benefits. J Neurol Neurosurg Psychiatry. 2019;90(5):599607.

    • Search Google Scholar
    • Export Citation
  • 17

    Carrabba G, Venkatraghavan L, Bernstein M. Day surgery awake craniotomy for removing brain tumours: technical note describing a simple protocol. Minim Invasive Neurosurg. 2008;51(4):208210.

    • Search Google Scholar
    • Export Citation
  • 18

    Goettel N, Chui J, Venkatraghavan L, Day surgery craniotomy for unruptured cerebral aneurysms: a single center experience. J Neurosurg Anesthesiol. 2014;26(1):6064.

    • Search Google Scholar
    • Export Citation
  • 19

    Grundy PL, Weidmann C, Bernstein M. Day-case neurosurgery for brain tumours: the early United Kingdom experience. Br J Neurosurg. 2008;22(3):360367.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 538 538 178
Full Text Views 58 58 21
PDF Downloads 33 33 20
EPUB Downloads 0 0 0