Safe Transitions Pathway for Postcraniotomy Neurological Surgery Patients: High-Value Care That Bypasses the Intensive Care Unit

Abstract

INTRODUCTION High-value medical care is described as excellent outcomes, high patient satisfaction, and efficient costs. Neurosurgical care can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. At our institution, we implemented a “safe transitions pathway” where select patients would go to the transitional care unit (TCU) rather than the neuroscience intensive care unit (ICU) following a craniotomy. METHODS Patients who were enrolled during the fiscal year (FY) 2018 were included in the study. The electronic medical record was reviewed for clinical information and the hospital bill was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impression of the hospital stay and recovery pathway RESULTS No patients who proceeded to the TCU post operatively were upgraded to ICU level of care overnight. There were no deaths in the STP patients and no patient required a return to the operating room during their hospitalization. There was a trend towards less 30-day readmissions in the STP patients than the standard pathway patients (1.2% vs 5.1%, P = .058). The mean number of ICU days saved per case was 1.20. The average post-procedure LOS was reduced by 0.25 d for STP patients. Actual FY18 direct cost savings from 94 patients who went through the Safe Transitions Pathway was $422 128. CONCLUSION Length of stay, direct charges, total costs, and ICU days were significantly decreased while net revenue was significantly increased by the adoption of a STP. There were no substantial complications or adverse patient outcomes.

A Novel Protocol for Reducing Intensive Care Utilization After Craniotomy

“…Tumor details are presented in Table 5. Histology included meningioma (9), glioblastoma (1), anaplastic astrocytoma (2), diffuse astrocytoma (2), ganglioglioma (1), gemistocytic astrocytoma (1), oligodendroglioma (1), epidermoid inclusion cyst (1), and metastatic disease (2). Median tumor size was 22 mm (range 2-65 mm) in the largest dimension.…”

“…However, several recent studies have proposed admission to a dedicated neurosurgical ward with frequent neurological checks to bypass postoperative ABBREVIATIONS: MVD, microvascular decompression; NICE, Non-Intensive CarE; PACU, postanesthesia care unit ICU admissions in carefully selected craniotomy patients. 1,2 Circumventing the ICU could, in theory, improve availability of ICU beds and reduce costs. Additionally, by promoting earlier mobilization in the ward setting (eg, removal of arterial lines, Foley catheters), avoiding ICU admission may reduce length of stay.…”

A Protocol for Reducing Intensive Care Utilization After Craniotomy: A 3-Year Assessment

“…10,11 Two studies listed intraoperative events as criteria, including status epilepticus and blood transfusion. 7,12 Finally, 2 studies excluded patients with a ventriculostomy drain in place at the conclusion of the surgery. 9,11 Our criteria are similar to those in the studies by Florman and et al and Young and et al and may include a broader set of indications for select patients, including supratentorial and infratentorial tumors, MVD, Chiari I decompressions, cavernoma resections, ventriculoperitoneal shunt placements, craniotomies for deep brain stimulation electrode implantations, and EC-IC bypasses.…”

“…9,11 Our criteria are similar to those in the studies by Florman and et al and Young and et al and may include a broader set of indications for select patients, including supratentorial and infratentorial tumors, MVD, Chiari I decompressions, cavernoma resections, ventriculoperitoneal shunt placements, craniotomies for deep brain stimulation electrode implantations, and EC-IC bypasses. However, our protocol is more conservative for age; although other published protocols include all adult patients, 7-12 our criteria limit the NICE protocol to patients younger than age 65 years. Moreover, similar to Young and colleagues, 12 our protocol excludes patients with an estimated blood loss exceeding 500 mL, but is less conservative in that our protocol excludes patients with an operative time exceeding 8 hours instead of 5.…”

“…However, our protocol is more conservative for age; although other published protocols include all adult patients, 7-12 our criteria limit the NICE protocol to patients younger than age 65 years. Moreover, similar to Young and colleagues, 12 our protocol excludes patients with an estimated blood loss exceeding 500 mL, but is less conservative in that our protocol excludes patients with an operative time exceeding 8 hours instead of 5.…”