An Enhanced Recovery Program for Same Day Spine Surgery
Background/Introduction: In recent years, there has been a growing trend for surgical patients to be discharged home on the same day. Not only does this lead to decreased hospital costs, but it allows patients to recover in the comfort of their home. Evidence suggests that some spine procedures can be safely performed on a same day basis. Postoperative urinary retention (POUR), postoperative nausea and vomiting (PONV), and uncontrolled pain were common causes of in-patient admission following “same day spine” surgery at our institution. We therefore formed an anesthesiologist led multidisciplinary team that created an evidence-based Same Day Spine Surgery enhanced recovery protocol in an effort to reduce PONV, reduce POUR, improve pain control, and increase same day discharge rate.
Methods: Following institutional review board approval of this expedited chart review, 23 adult patients scheduled for single or double level lumbar laminectomy, single or double level lumbar discectomy, single or double level anterior cervical discectomy and fusion were included in our pilot protocol. 23 age matched controls were used for comparison. All patients were ≥18 years of age and had a Morphine Equivalent Daily Dose (MEDD) < 50. One orthopedic-spine physician at the Beaumont Royal Oak campus was included in this protocol. Outcome measures included quantitative assessments of the incidence of POUR (defined as patient discomfort or palpable bladder with a bladder scan volume > 600 mL), PONV (defined as reported nausea or anti-emetic rescue required in PACU), the recording of IV narcotic medications required in PACU, and success at same-day discharge. Protocol components included pre-operative education, multimodal analgesia, goal directed perioperative fluid management, and neuromuscular blocking agent reversal with sugammadex. All patients attended the B-Ready Clinic, a pre-surgical education clinic comprised of a multidisciplinary team that is focused on preparing patients and their families for a successful recovery. One week postoperatively, patients were called and patient reported outcome measures were collected.
Results: Our results show an 21.7% decrease in PONV, 17.4% decrease in POUR, 8.7% decrease in the use of IV narcotics in the PACU, and a 43.5% increase in the same day discharge rate. In our protocolized patients, 3 of the 23 protocolized developed PONV whereas 8 of the 23 control patients had PONV. None of the protocolized patients experienced POUR whereas 4 of the 23 control patients developed POUR. 11 of the 23 protocolized patients required IV pain medications in the PACU, and 13 of the 23 control patients required IV pain medications in the PACU. 22 of the 23 protocolized patients were discharged same day whereas 12 of the 23 control patients were discharged the same day.
Conclusion: Results from our pilot program show a decrease in PONV, decrease in POUR, decrease in IV narcotic use, and an increase in the same day discharge rate. While our sample size is small, applied on a larger scale, our protocol could lead to improvements in quality, safety, satisfaction, and cost.
Lepczyk L, Toma B, Haddad M, Schmidt, Park, Fayne R, Soto R. An enhanced recovery program for same day spine surgery. ASER Meeting, Scottsdale, AZ, September 11-14, 2019; ASA Meeting Abstracts, Orlando, FL, October 2019.