Trust introduces a spinal enhanced recovery programme to decrease length of stay and improve quality of care, reducing length of stay by 52% and achieving high patient satisfaction

Aim was to improve quality of care length of stay by redesigning pathway for patients undergoing elective spinal surgery, using prospective cohort study of SpinaL Enhanced Recovery Programme (SLERP). We process-mapped patients through the existing pathway.

Further ideas were from best-evidence. All interventions were tested using Plan-Do-Study-Act (PDSA) cycles. All patients undergoing elective spinal surgery were included from January 2013 to the present. The SLERP pathway is now used by 99% of spinal surgery patients with 100% (range 95-100) of patients rating their care as good or excellent and reduced length of stay by 52%, from 6 to 2.9 days.

Challenges

•Poor Process Mapping - an exercise by our MDT revealed that patients followed an ill-defined care pathway with variability in administrative processes and clinical care.

•Inconsistent communication - Patient feedback and reports from both secretarial and community staff highlighted that communications from the spinal team could be inconsistent. This was felt to be confusing for patients who had unclear expectations of their care and recovery and a length of stay (LOS) for individual procedures that varied by 3 days.

•Excessive Length of Stay - In addition to its negative effect on patient safety and patient experience, the financial impact of reducing length of stay by 30% would equate to a saving of 450 bed days per year. With a bed cost of £174/day this would lead to a theoretical saving of £78,000/year, or increase capacity to generate additional income.

•Poor Patient Satisfaction Rates - We thought our patient experience was poor as evidenced by low patient satisfaction rates (65%). This needed to be improved.

•Low Staff Morale - Leadership came from a Consultant Anaesthetist and a Consultant Spinal Surgeon who took a business case to the Chief Executive and Medical Director. Both were enthusiastic about the SLERP pathway and felt that in light of recent upheaval in the department, investment in the team now would also enhance morale. The primary study question was to see if SLERP could improve length of stay for elective spinal surgical patients. Secondary questions were whether the pathway could improve reliability and quality of care as measured by compliance with the pathway and patient satisfaction.

Actions

•Process Mapping exercise with a 36 member MDT.

•Use of preoperative carbohydrate drinks and pre and post op laxatives based on evidence that they reduced length of stay.

•Standardised Anaesthetic and post operative pain relief regimens to improve patient experience and reduce discharge delaying side effects.

•Patient Passports, defined Expected Date of Discharge and Daily Aims Board so that patients and staff were consistent in their knowledge, aims and expectations.

•Data collection that was robust and analysed by an IT program with published results every two weeks. SLERP MDT meetings were held every 4 weeks to discuss results and plan further interventions. Changes were based on PDSA (Plan-Do-Study- Act) cycles.

Results

•We reduced length of stay by 52% improving from an average of 6 days at the start of the intervention in April 2013, to 2.9 days by April 2015.

•Patient satisfaction with the SLERP pathway was also outstanding, with a median of 100% of patients (range 95-100) rating their care as good or excellent by April 2015.

•In terms of process measures, by October 2014 99% of eligible patients were managed on the SLERP pathway and most patients were receiving key interventions. By April 2015, laxatives were used in 82% and preoperative carbohydrate drinks in 83% of eligible patients. Daily aims were set for 95% of patients and the EEDD was recorded in 73%.

•Readmission of elective spinal surgery patients did not increase.

Value

•The financial impact of reducing length of stay by 52% equates to a saving of 780 bed-days per year. With a bed cost of £174/day, this would lead to a theoretical saving of £135,720 / year or capacity to generate additional income by treating more patients

•Patient Satisfaction Surveys and Friends and Family test done by all patients at the time of discharge indicate that good and excellent ratings have improved from 65% pre-project to 95-100% as a result of our SLERP project.

•IT expertise used during the project has standardised the analysis and presentation of data from PDSA cycles for such improvement projects across our Trust.

•As important as all the above and more difficult to measure objectively, is the culture change brought about by the SLERP project. The spinal team have taken ownership of the pathway for improving quality of care for their patients and taken responsibility for monitoring their service. Their success has also allowed the team to believe in their ability to effect change for the betterment of patient care.

In detail

Ambition

The Aims and intended improvement of our Project were to make the SLERP (SpinaL Enhanced Recovery Program) pathway improve

1.length of stay for elective spinal surgical patients by 30%

2.patient satisfaction to 80%

3.reliability and quality of care as measured by 95% compliance with the pathway with no compromise in patient safety

A meeting of spinal surgery MDT discussed the service. A process-mapping exercise revealed that patients followed an ill-defined care pathway with variability in administrative processes and clinical care. Existing best practice and evidence for ERPs (See References SLERP for HSJ in Supporting Material) A meta-analysis of 38 trials involving 5099 participants showed ERPs could reduce length of stay and overall complication rates across surgical specialties. [1].

There have been few studies of ERP in spinal surgery[2] and most chose only selected patients or selected interventions such as analgesia schedules and did not use quality improvement methodology. A Cochrane review of 27 trials in 1,976 surgical patients concluded that preoperative carbohydrate drinks reduced length of stay[6]. Similarly, although laxatives themselves have not been shown to improve length of stay[7], it is known that constipation is exacerbated by opioid analgesia and causes distress[8]. Finally we examined the ERPs for patients undergoing hip and knee replacement that already existed in our institution for other ideas. A driver diagram was used to visualise the components of the process and the changes required to reach the aim (Driver Diagram SLERP) in Supporting Material). All interventions were then tested using PDSA (Plan, Do, Study, Act) cycles. This is Improvement Methodology. Elimination of Unwanted Variation

The following are now routine practice in all parts of the service and eliminated unwanted variation

1.Preoperative Preparation

a.Preoperative carbohydrate drink given to all patients two hours preoperatively on the day of surgery

b.Perioperative laxatives prescribed on day of admission for all patients, pre and post op.

c.Procedure specific Patient Passports given to all patients at preoperative assessment clinics

d.Earliest Estimated Discharge Day (EEDD) documented to ensure patients and staff know how long a patient may remain in hospital, transport home and home care.

2.Intraoperative Processes

a.Surgical techniques use minimally invasive surgery wherever possible.

b.Pain relief –use liberal safe regional infiltration and single shot in-out epidural instillation of dilute long acting local anaesthetic solution at the end of surgery without motor blockade.

c.Anaesthetic regimen –use short acting anaesthetic agents

d.Analgesia regimen –use reproducible, laminated anaesthetic “Recipes” with emphasis on non narcotic pain killers, Tramadol, very short acting IV narcotics, neuropathic pain drugs, antiemetics and local anaesthetic infiltration in full doses to achieve post operative VAS for pain of 0-2/10.

3.Postoperative Processes

All of these measures were adopted after ensuring that patient safety remained paramount

a.Patient daily aims written on bespoke white boards in patient rooms

b.’Bums off Beds’ – patient mobilized by Consultants or other team members on the day of surgery

c.Food and drink on day of surgery as soon as safely possible

d.Catheter leg bags if catheterised

e.Daily Consultant Ward Round

f.Postoperative concerns and advice

g.Follow up information at discharge.

Outcomes

1.We reduced length of stay by 52% (see LOS Driver Diagram SLERP in Supporting Material), improving from an average of 6 days at the start of the intervention in April 2013, to 2.9 days by April 2015.

2.Patient satisfaction with the SLERP pathway was also outstanding, with a median of 100% of patients (range 95-100) rating their care as good or excellent by April 2015.

3.In terms of process measures, by October 2014 99% of eligible patients were managed on the SLERP pathway

4.By April 2015, laxatives were used in 82% and preoperative carbohydrate drinks in 83% of eligible patients.

5.Daily aims were set for 95% of patients and the Expected Date of Discharge was recorded in 73%.

6.Readmission of elective spinal surgery patients did not increase. These results indicate that the project surpassed its original goals

Spread

The methodology and consistency of the results during and beyond the study indicates that it is and can be embedded in culture, is potentially scalable and can be replicable in any other in-patient surgical service. We ourselves have successfully advised on its use in some other subspecialties in orthopedics and in other departments such as gynecology and colorectal surgery.

Value (to our patients, unit, department and Trust)

1.Reduced length of stay by 52% equates to a saving of 780 bed-days per year. With a bed cost of £174/day, this would lead to a theoretical saving of £135,720 / year or capacity to generate additional income by treating more patients.

2.Patient Satisfaction Surveys and Friends & Family test done at discharge indicate that good and excellent ratings have improved from 65% pre project to 95-100% after SLERP.

3.IT expertise has standardised the analysis and presentation of data from PDSA cycles and is now used for all such Improvement Projects across our Trust.

4.The culture change brought about by the SLERP project has seen the spinal team take ownership of the pathway for improving quality of care for their patients and take responsibility for monitoring their service.

Involvement

Team Involvement

We had staff conversations with our multi-disciplinary team members. This MDT included patients (past and present), CNPs, nurses, physiotherapists, OTs, ESPs, HCAs, Was, catering staff, theatre staff, spinal unit secretaries, IT and Improvement personnel, trainee doctors, anaesthetists and spinal surgeons. All team members were involved in a process-mapping exercise and development of the ideal care pathway. Four patients were shadowed through the existing process to see where improvements could be made. All MDT members were encouraged to attend the monthly SLERP meetings. A DVD made by members of the Spinal MDT explaining the SLERP pathway was shown to over 800 Hospital employees as part of a Trust-wide leadership programme.