New HSS Study Shows Dramatic Spine Surgery Mgmt Gains

A new Hospital for Special Surgery (HSS) study documents how innovations in deformity spine surgery management can reduce days in the hospital by nearly 30%, ICU time from 30% to zero and discharge to rehab from 95% to 65%.

These remarkable findings came from a study of an enhanced recovery pathway for complex spine surgery which HSS adopted in February 2019.

The new HSS study tracked 40 patients who’d received fusions for at least five vertebrae in the lower back and where HSS employed an enhanced recovery pathway protocol.

Their work, “Enhanced recovery pathway in adult patients undergoing thoracolumbar deformity surgery,” was presented at the recent annual meeting of the American Academy of Orthopaedic Surgeons and published in the May 2021 edition of Spine.

“Traditionally, these patients stayed in the hospital for at least seven or eight days,” says Han Jo Kim, M.D., HSS spine surgeon and principal investigator. “This procedure has a high reported complication rate, and a high rate of revision surgeries, 90-day readmissions and dependence on rehabilitation facilities upon discharge. For those reasons, we thought it would be an important operation to evaluate when we started targeting methods to improve complex spine surgery.”

Making the new treatment pathway unique was the protocol of always using the same surgical team, including surgical technicians, nurses, and anesthesiologists—as well as postop physical therapists. The surgeons aimed to minimize blood loss and OR time; when possible, powered surgical instruments were used. Procedures were divided into four stages of one hour each, the logic being that all members of the team would know what to expect during the next phase of surgery.

The team backed away from prescribing narcotics postoperatively, encouraged patients to leave their beds on the day of surgery, and had patients do physical therapy three times a day as opposed to twice a day.

Set against those who did not have the optimized pathway, the study population achieved “remarkable” results. No one went to the ICU postoperatively (typical rate is 30%). Patients’ hospital stays were decreased from 7.3 days to 4.5 days (average). In addition, a higher rate of patients were discharged home versus to a rehabilitation facility (95% versus 65%).

Dr. Kim told OTW, “One interesting milestone was allocating appropriate resources to the physical therapist in order to allow for a three-a-day mobilization schedule. Normally patients are mobilized twice daily and increasing this for the enhanced recovery pathway was challenging. In addition, we advocated for mobilizing the patients the same day of surgery which had never been done before. This involved a cultural shift in the way these patients are mobilized during the immediate post-operative time period.”

“We were surprised to see how minor tweaks in the care pathway led to such impressive changes in the entire episode of care. It is a testament to how every little bit counts when it comes to developing efficiencies for care delivery.”