A systematic multidisciplinary initiative for reducing the risk of complications in adult scoliosis surgery

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Systematic multidisciplinary approaches to improving quality and safety in complex surgical care have shown promise. Complication rates from complex spine surgery range from 10% to 90% for all surgeries, and the overall mortality rate is 1%–4%. These rates suggest the need for improved perioperative complex spine surgery processes designed to minimize risk and improve quality.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The Group Health Research Institute and Virginia Mason Medical Center implemented a systematic multidisciplinary protocol, the Seattle Spine Team Protocol, in 2010. This protocol involves the following elements: 1) a comprehensive multidisciplinary conference including clinicians from neurosurgery, anesthesia, orthopedics, internal medicine, behavioral health, and nursing, collaboratively deciding on each patient's suitability for surgery; 2) a mandatory patient education course that reviews the risks of surgery, preparation for the surgery, and postoperative care; 3) a dual-attending-surgeon approach involving 1 neurosurgeon and 1 orthopedic spine surgeon; 4) a dedicated specialist complex spine anesthesia team; and 5) rigorous intraoperative monitoring of a patient's blood loss and coagulopathy. The authors identified 71 patients who underwent complex spine surgery involving fusion of 6 or more levels before implementation of the protocol (surgery between 2008 and 2010) and 69 patients who underwent complex spine surgery after the implementation of the protocol (2010 and 2012). All patient demographic variables, including age, sex, body mass index, smoking status, diagnosis of diabetes and/or osteoporosis, previous surgery, and the nature of the spinal deformity, were comprehensively assessed. Also comprehensively assessed were surgical variables, including operative time, number of levels fused, and length of stay. The authors assessed overall complication rates at 30 days and 1 year and detailed deaths, cardiovascular events, infections, instrumentation failures, and CSF leaks. Chi-square and Wilcoxon rank-sum tests were used to assess differences in patient characteristics for patients with a procedure in the preimplementation period from those in the postimplementation period under a Poisson distribution model.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Patients who underwent surgery after implementation of the Seattle Spine Team Protocol had a statistically significant reduction (relative risk 0.49 [95% CI 0.30–0.78]) in all measured complications, including cardiovascular events, wound infections, other perioperative infections, and implant failures within 30 days after surgery; the analysis was adjusted for age and Charlson comorbidity score. A trend toward fewer deaths in this group was also found.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This type of systematic quality improvement strategy can improve quality and patient safety and might be applicable to other complex surgical disciplines. Implementation of these strategies in the treatment of adult spinal deformity will likely lead to better patient outcomes.</jats:p></jats:sec>

Spine Instrumented Surgery on a Budget—Tools for Lowering Cost Without Changing Outcome

“…Several efforts have been published to develop more comprehensive preoperative evaluation protocols, including multi-disciplinary conferences and careful anesthetic preparations prior to complex spine operations. 48 , 49 These team approaches to complex spine operations have been shown to reduce reoperation, wound infection, deep venous thromboembolism, and other perioperative complications. 50 Spinal surgeons and insurance payers are increasingly focused on optimizing modifiable patient risk factors prior to surgery, such as smoking, osteoporotic bone density, and elevated hemoglobin A1C.…”

Frailty Syndrome and the Use of Frailty Indices as a Preoperative Risk Stratification Tool in Spine Surgery: A Review

“…In complex ASD surgeries, the implementation of risk reduction protocols, such as the Seattle Spine Team Protocol, have accounted for decreased complication rates [48,49]. Sethi et al [49] reported that the combined use of a multidisciplinary spinal surgery conference, a patient education course, dual operating surgeons, a dedicated complex spine anesthesia team, and enhanced intraoperative monitoring of laboratory measurements and vitals, led to a 51% decline in the 30-day complication rate for complex ASD surgery patients. The use of frailty index scores and the consequent estimation of mortality and complication rate could provide clinically pertinent information to the multidisciplinary team.…”

Surgical Risk Assessment and Prevention in Elderly Spinal Deformity Patients

“…A multidisciplinary preoperative conference, dual attending surgeons, and a detailed protocol for coagulopathy/blood loss in the operating room are part of the Seattle spine team approach. 48,93 The presence of dual attending surgeons can decrease operative time. Utilization of the anesthesia team to implement a transfusion protocol reduced perioperative blood loss and coagulopathy.…”