Effectiveness and Sustainability of a Standardized Care Pathway Developed with Use of Lean Process Mapping for the Treatment of Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

Abstract

Background: Recent changes in health care have begun to shift the industry from a volume-based to a value-based focus. This shift has led to standardized care pathways that decrease care variability, improve outcomes, and decrease cost. Although numerous studies have described standardized pathways for adolescent idiopathic scoliosis (AIS), few have demonstrated sustainability. We report the effectiveness and sustainability of a standardized care pathway for patients undergoing posterior spinal fusion for AIS. Methods: A standardized care pathway was developed and implemented (in March 2015) at our pediatric hospital for all patients undergoing posterior spinal fusion for AIS. This pathway was developed with use of the Lean process mapping technique to create an evidence-based protocol for preoperative, operative, postoperative, and post-discharge care. The 44 patients managed prior to implementation of the pathway (pre-pathway group) were compared with the 169 patients managed after implementation (post-pathway group). The post-pathway group was divided into 5 cohorts, each representing a 6-month time period. Clinical outcomes (pain scores, medication requirements, transfusions) and efficiency metrics (length of stay) were used to determine pathway sustainability. Results: The pre-pathway group included patients managed in the 8 months prior to implementation (July 2014 to February 2015) and the post-pathway group included patients who underwent surgery from March 2015 to July 2017, divided into 5 cohorts representing 6 months each. Patients in the post-pathway group had lower postoperative pain scores, and used significantly less opioids at each time interval, compared with the pre-pathway group. Perioperative transfusion requirements and postoperative length of stay were significantly lower across all post-pathway cohorts compared with the pre-pathway group. There were no significant differences in clinical results among the 5 post-pathway cohorts. Conclusions: Implementation of a standardized care pathway developed with use of Lean process mapping demonstrated effective and sustained improvements to the care of patients with AIS, as well as decreased postoperative length of stay. These outcomes have been maintained over 2.5 years, indicating that high-quality care for patients with AIS undergoing spinal fusion can be achieved and sustained with use of a standardized care pathway. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review

“…ERAS has a positive financial impact on the utilization of health care resources [ 27 ]. There are many factors that contribute to the overall cost of PSF in AIS patient with charges often exceeding $100,000 [ 8 , 20 ]. Fletcher et al[ 13 ] showed that when compared to traditional protocols, the use of ERAS protocols resulted in a 33% reduction in room charges ($1,885 ± 486 vs. $2,779 ± 617, p < 0.0001) and an 11% reduction in therapy charges ($554 ± 201 vs. $619 ± 219, p = 0.004).…”

“…To reduce the surgical time it was suggested to limit the fluoroscopy checks for verifying the placement of pedicle screws, but this of course needs to be balanced against patient safety [ 19 ]. It was also suggested to use power tools for placing the pedicle screws to reduce the surgical time [ 20 ]. Use of intra-thecal morphine injections (5 μg/kg up to 250 μg) along with subcutaneous bupivacaine wound infiltration at the end of surgery was utilized to enhance post-operative analgesia [ 15 , 18 , 19 ].…”

Process Mapping in Healthcare: A Systematic Review

“…Four projects [75][76][77][78] reported both "as-is" and "to-be" maps, while 5 describe the "to-be" process. [79][80][81][82][83] For example, in TDABC projects the analysis is focused on process costs and is mainly completed after the "as-is" process map is created. [84][85][86][87][88][89] In projects implementing evidence-based recommendations, a process analysis was completed before the creation of the ideal or "to-be" process map.…”

“…[84][85][86][87][88][89] In projects implementing evidence-based recommendations, a process analysis was completed before the creation of the ideal or "to-be" process map. [83] Most studies (78%) reported that additional information gathered during the PM exercise-such as delays, safety problems, or ow of information, resources and activity -is represented on the nal map. Only 48% of studies speci ed that the PM exercise had been reviewed for accuracy and con rmed by key stakeholders or external experts.…”

“…[65,74,80,86,97,98,[117][118][119] For example, some studies reported how PM helped to promote the integration of health services across different settings by developing clinical evidence-based recommendations agreed among different healthcare professionals. [66,79,81,83] Finally, studies describe how PM can be a valuable tool for documenting a care process for further dissemination. [95] This is bene cial, for example, in helping to inform patients and carers about their expected journey [67,93,[120][121][122]…”