Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of An Evidence Based Clinical Care Pathway

SPINE An International Journal for the study of the spine Publish Ahead of Print
DOI : 10.1097/BRS.0000000000001703
Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients with Implementation
of an Evidence Based Clinical Care Pathway
Alison Bradywood RN, Farrokh Farrokhi MD , Barbara Williams PhD, Mark Kowalczyk BS, C.
Craig Blackmore MD MPH
All authors: Virginia Mason Medical Center, Seattle, WA
Corresponding author contact info:

Dr. Farrokh Farrokhi
925 Seneca St.
Mailstop: X7-NS
Seattle, WA 98101
206-223-7525 x.11893
farrokhfarrokhi@virginiamason.org
Acknowledgement: August 25, 2015

1st Revise: January 16, 2016
2nd Revise: March 13, 2016
Accept: April 23, 2016
The manuscript submitted does not contain information about medical device(s)/drug(s).
No funds were received in support of this work.
Relevant financial activities outside the submitted work: royalties.
Copyright 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited
Abstract
Study design: Quality improvement with before and after evaluation of the intervention.
Objective: To improve lumbar spine post-operative care and quality outcomes through a series of
Lean quality improvement events designed to address root causes of error and variation.
Summary of Background Data: Lumbar spine fusion procedures are common, but highly variable in
process of care, outcomes, and cost.
Methods: We implemented a standardized lumbar spine fusion clinical care pathway through a series
of Lean quality improvement events. The pathway included: 1) an evidence based electronic orderset;
2) a patient visual tool; and 3) multidisciplinary communication, and was designed to delineate
expectations for patients, staff and providers. To evaluate the effectiveness of the intervention, we
performed a quality improvement study with before and after evaluation of consecutive patients from
January 2012 to September 2014. Outcomes were hospital length of stay and quality measures before
and after the April 1, 2013 intervention. Data were analyzed with chi-square and t-tests for before and
after comparisons, and were explored graphically for temporal trends with statistical process control
charts.
Results: Our study population was 458 patients (mean 65 years, 65% female). Length of stay
decreased from 3.9 to 3.4 days, a difference of 0.5 days (CI 0.3, 0.8, p<.001). Discharge disposition
also improved with 75% (183/244) being discharged to home post-intervention, versus 64% (136/214)
pre-intervention (p=0.002). Urinary catheter removal also improved (p=0.003). Patient satisfaction
scores were not significantly changed.
Conclusions: Applying Lean methods to produce standardized clinical pathways is an effective way
of improving quality and reducing waste for lumbar spine fusion patients. We believe quality
improvements of this type are valuable for all spine patients, to provide best care outcomes at lowest
cost.
Key Words: clinical care pathway; spine fusion; Lean; quality improvement; length of stay; bundled
care; pathway; outcomes; standard care; ordersets
Level of Evidence: 4
Introduction
Lumbar fusion surgery has increased markedly over the last decade from 46 to 80 procedures per
100,000 persons per year [1]. Average charges have doubled from a decade ago, now $80,000 to
$112,000 [2]. Variability in surgical practice is extensive [3]. Though length of stay (LOS) in lumbar
fusion patients has decreased from 4.87 days in 2001 to 3.99 days in 2010 [1], wide variation persists
across the United States [4].
Clinical care pathways are procedure-specific tools designed to standardize care to create an optimal
regimen of care tailored to a specific institution [5]. They have been shown to reduce health care
costs, improve quality, and increase hospital efficiency [5, 6, 7, 8, 9]. While there is a paucity of
literature related to spine fusion, total joint replacement evidence has shown reductions in LOS,
hospital costs, and complications, while improving or maintaining patient outcomes [5].
At Virginia Mason, as at other institutions, lumbar fusion length of stay was variable and exceeded
national and regional averages. Across providers, there was variability in adherence to evidence based
practices, with corresponding lack of standard sequencing in nursing care and physical/occupational
therapy. Engagement of patients and families was incomplete with absence of clear expectations
regarding peri-operative progress. Because of these factors, and an institutional priority to grow the
spine service line, lumbar fusion care was targeted for improvement by administration and providers
alike.
To address these quality concerns, we developed and implemented a lumbar fusion clinical care
pathway based both on evidence review to guide standardization of care, and on defined expectations
for patients, providers, nurses and therapists. To our knowledge, no prior work has been published
using our methodology of combining Lean process improvement, Experience-Based Design (EBD),
and evidence based practice. The objective of this study was to assess the effect of this clinical care
pathway on length of stay, quality outcomes, and patient satisfaction.
Materials and Methods
This investigation was performed as a quality improvement project and with waiver from the
Institutional Review Board. The setting was the Neurosurgery Department in a 336 bed, acute care
hospital in the Pacific Northwest with a team including the neuroscience nursing staff, inpatient
physical and occupational therapists, neurosurgeons, orthopedic spine surgeons and physician
assistants.
Using our institutional adaptation of Lean [see Appendix] manufacturing techniques [10][11], and
with support from institutional Lean coaches, the team initiated a structured four part process to create
a lumbar fusion clinical care pathway: (1) understanding the current state of care through Value
Stream Mapping (VSM) and staff and patient surveys, (2) identification of best practices through
evidence based literature review supplemented with content expert consensus (3) development of an
ideal future state that included a flow map detailing the sequencing of providers and processes, and (4)
implementation through a Lean Rapid Process Improvement Workshop (RPIW) [12]. Lean refers to
the improvement of care processes through systematic identification of what is adding value to a
process and decreasing waste (all that does not add value) [10]. Value stream maps are a component
of Lean where care processes are mapped out in sequence, usually with identification of specific
inputs and personnel at each step. Value stream maps are also used to visually depict any waste (often
shown as a cloudburst), which can then be targeted for quality improvement [10]. Finally, RPIWs are
structured five day quality improvement events, where representatives of the various personnel
involved in a specific value steam focus on addressing specified wastes to improve the process [12].
The entire lumbar fusion process extended from approximately 2 months prior to the RPIW (February
1, 2013) to full implementation by the end of September, 2013.
Prior to the intervention, we observed the actual process of care for lumbar fusion patients, and
mapped these to a VSM, delineating the major steps of the care experience from admission through
discharge (Figure 1). On this VSM we also identified variability and care deficiencies, highlighted as
cloudbursts, which were then evaluated using root cause analysis. Root cause analysis approaches
under Lean included asking why 5 times and Ishikawa fishbone diagrams. Additionally, to
understand and incorporate the patient experience into our care process, we surveyed 2 patients, 3
physician assistants and 15 nurses using EBD [13, 14]. EBD is a method to incorporate the patient and
staff experience into health care redesign using qualitative methods to identify touch points in the care
process that have high emotional content. This touch points have strong influence on the overall
patient experience, but are not always intuitive. Identification of negative emotion touch points
enabled targeting of improvement efforts, and may therefore contribute to patient-centered care
improvement [13, 14]. Primary patient concerns identified through EBD in our work included: postoperative pain management, hand-overs between physicians, nurses and physical/occupational
therapists, patient/family uncertainty regarding the care plan, and discharge planning and readiness.
Second, we performed a targeted structured literature review by all 8 spine surgeons (including
neurosurgery and orthopedic surgery). Relevant journal articles and consensus guidelines were
identified by the lead spine surgeon in collaboration with the medical librarians. These were then
distributed to all spine surgeons who in consensus identified a single set of evidence based practice
standards for pain management, bracing and post-operative imaging. This early involvement of the
surgeons enhanced their engagement through highlighting the variability in the current state.
Third, the team created an ideal VSM for sequencing of work needed to improve both patient
experience and hospital-based quality metrics. This process identified care that was unsynchronized
leading to delays. Development of this future state set up the improvement team to efficiently
address the gaps.
Fourth, the future state clinical care pathway was implemented through a one week Lean RPIW. The
multidisciplinary RPIW team, comprised of a physical therapist, staff nurse, clinic-based nurse
educator, neurosurgeon, two physician assistants, and nursing director, developed approaches to
achieve and sustain the desired clinical care pathway. Additional stakeholders were consulted
throughout the week to test ideas and provide feedback.
The RPIW identified and addressed three key elements:

1) Electronic order sets: Order sets were built within the electronic medical record (EMR) to
encourage evidence based practice, simplify the providers work, and reduce care variability. The
order set provided sequencing for all multidisciplinary care during the hospitalization, including postoperative care, medications, mobility and therapy expectations, bracing protocols, and standardized
patient education. For example, post-operative radiographs (a cause of delay in care) were rescheduled
just prior to discharge rather than on post-operative day (POD) 1, to serve as baseline comparison
imaging in the event of suspected hardware failure or pseudoarthrosis [15, 16]. The order sets were
also designed to eliminate medications associated with delirium and established nurse driven
protocols (i.e. early fluid bolus administration initiated by nurses at identification of hypotension,
medications for promotion of bowel function, early management of nausea). Because poor pain
management may be directly related to longer lengths of stay [17] and peri-operative pain
management was a patient concern identified through EBD, we developed built into the order sets
evidence based standardized pre-operative multimodal analgesics including gabapentin,
acetaminophen, and NSAIDs, with early discontinuation of IV opioids [18, 19, 20, 21].
2) Patient Pathway: To improve patient and family engagement, we developed a patient poster with
clearly define milestones and expectations for the hospitalization, mirroring the protocols defined in
the EMR order set (Figure 2). This specifically addressed the concerns reflected in the survey
regarding pain management, patient education and discharge planning. Designed with feedback from
patients and families, the tool was intended to decrease anxiety in both patients and staff and
encourage further mobilization with lower narcotic use. The diagrams were placed in the patient
rooms on admission and reviewed by both nursing and therapy staff throughout the post-operative
stay.
3) Multidisciplinary Communication: Daily multidisciplinary rounding with providers and nursing

was implemented to reinforce the clinical pathway, and discuss and correct challenges preventing
patient progression. Rounds also focused more on discharge planning to hopefully facilitate smoother
transitions between the hospital and post-acute setting, and increase staff comfort in addressing patient
and family concerns. A single provider pager was instituted in an attempt to eliminate delays in care.
In summary, these three key improvements from the RPIW were designed to align care with evidence
based practice, standardize sequence interventions to improve efficiency in the patient pathway to
recovery poster (figure 2), address patient-centeredness in care through improved communication and
align expectations among provider, staff and patients. Most importantly, the improvements targeted
known challenges to lumbar fusion post-operative care (e.g. pain, mobility, and hypotension) to allow
for partnering with the patient/family in mutually establishing goals of care.
Study of the intervention
To assess the clinical care pathway, we performed a before and after evaluation of both length of stay
and quality outcomes (e.g. discharge disposition, pain, falls) for consecutive lumbar fusion patients
from January 2012 to September 2014. Five hundred eighty five cases were identified based on ICD9
codes for lumbar fusion, including spinal canal exploration (03.09), excision intervertebral
diskectomy (80.51), and lumbar fusions (81.05-81.08). All patient charts were reviewed to confirm
eligibility. Patients who underwent concomitant cervical or thoracic spine procedures (N=10),
emergent procedures (N=1), complex fusions or fusions of more than six levels (N=77), who received
surgery due to spinal tumor (N=1), revision or re-fusion (N=26), or fracture (N=3) were excluded,
leaving a final study size of 458 surgeries. Data was extracted retrospectively from the electronic
medical record by one of two reviewers. Chart reviewers were an experienced nursing director (AB)
and research scientist (BW), with 10% of charts reviewed independently by both for assessment of
inter-observer reliability.
Quality care process metrics included discharge disposition, urinary catheter removal, and postoperative day 1 and 2 pain levels. Urinary catheter removal was successful if removed anytime
between the end of surgery and 0700 on POD 2, based on the Centers for Disease Control definition
of Catheter associated urinary tract infection [22]. Hospital readmissions were within 30-days of
discharge for any reason. Post-operative pain levels were determined from earliest patient reported
pain levels (patient self-reported 0-10 scale) after 0700 on POD 1 and POD 2. Surgery minutes were
the time from incision to close while case minutes were measured from the patient entering to
departing from the operating room. Patient satisfaction metrics were five patient questions from a
standardized national mail survey administered post discharge by a third party vendor (Press Ganey,
South Bend, IN) as part of the hospital patient experience survey. Each question had a 5-point Likert
scale ranging from very poor to very good.
April 1, 2013 was defined as the intervention date for before and after comparison, as this was when
the initial implementation occurred. However, this date is conservative, as the intervention was not
fully implemented until end of September 2013, delaying the full effect of the program. Data before
and after the intervention was analyzed using chi square for proportions, t-test for means of
continuous variables, and Wilcoxon rank-sum for median LOS. We also performed a secondary
analysis of length of stay and discharge disposition using multiple regression to adjust for
comorbidities, age, and gender. Fisher exact test was used for contingency tables with small sample
size. In addition, the length of stay data was assessed before and after the intervention using statistical
process control charts [23]. Inter-observer agreement was assessed using the kappa statistic. Statistical
analysis was performed on STATA 12.0 (Stata Corp. College Station, TX).
Results
There were 458 lumbar spine surgery patients who met inclusion criteria. Mean age was 64 years, and
65% were female. There were no significant differences in patient demographics, comorbidities or
primary diagnoses before and after the intervention (Table 1).
Data inter-reviewer agreement on outcomes assessed from chart review was excellent [24], with
kappa for urinary catheter removal of 0.88, for pain on post-operative day 1 of 0.86, and for pain on
post-operative day 2 of 0.90.
Overall, following the lumbar fusion clinical care pathway intervention, the mean length of stay
decreased from 3.9 to 3.4 days, a difference of 0.5 days (CI .3,.8, p<.001). The change in median
length of stay also improved significantly from 4 days to 3 days (Wilcoxon rank-sum p<.001); the
range for both before and after groups was 1-11 days. We also observed significant improvements in
patient disposition post discharge (Table 2), with 75% (183/244) being discharged to home, versus
64%, (136/214) prior to the intervention (p=0.002). Statistical process control charts confirmed a
significant decrease in length of stay between pre-intervention (prior to April 1, 2013) to postintervention (October 1, 2013 and after) with transition during the implementation period April 1 to
September 30, 2013. (Figure 3). There was high variability in the data, but no consistent temporal
trend prior to the intervention. The length of stay was also unchanged or decreased across all 8
surgeons while increased disposition to home was seen in 7 of 8 surgeons. There was no significant
difference in comorbidities (coronary artery disease, congestive heart failure, chronic obstructive
pulmonary disease, diabetes, hypertension, and obesity), in age, or in gender before and after the
intervention (Table 2). After adjustment for age, gender, and comorbidities in multiple regression
analysis, the difference in length of stay associated with the intervention was slightly greater at a
decrease of 0.7 days (95% CI: 0.4-1.0 days, p<.001). The effect size for discharge disposition was also
slightly increased when adjusted for age, gender, and comorbidities (data not shown).
We also noted significant improvements in Foley urinary catheter removal by 0700 POD 2 (p=0.003)
(Table 2). In addition, patient falls were statistically unchanged (from 2/214 to 0/244, p=.22), with a
low number of events decreasing study power. Among other outcomes, thirty day readmission rates
were few and unchanged; 11 (5%) patients prior to the intervention and 6 (2%) following the
intervention (p=.13) were readmitted. Only one additional patient had an emergency department visit
(with no readmission) within 30 days of discharge. Pain scores on POD 1 and 2, as well as surgery
and case minutes were not significantly changed (Table 2). Other patient safety indicators were rare.
Of the 458 surgical patients, only two patients had a patient safety indicator (one perioperative
pulmonary embolism and one iatrogenic pneumothorax).
Response rate for patient satisfaction data was 40% (85/214) prior to the intervention, and 41%
(102/244) after. No statistically significant differences were observed for any questions (Table 2).
Importantly, despite our focus on earlier discharge and mobility, we identified no significant detriment
in overall hospital recommendation, pain control or readiness for discharge, though statistical power
was low.
Discussion
In this project, we demonstrate decreased LOS and improved quality outcomes with lumbar fusion
surgery following the implementation of a provider and patient focused clinical care pathway.
Evidence based best practices were identified and then implemented via standardized EMR order sets,
and the patient experience of care was targeted through better accord on patient expectations using a
visible pathway, and through multidisciplinary communication. These three interventions aimed to
address a number of care delivery challenges in the post-operative period: proactive pain
management, mitigation of deliriogenic medications, nursing orders to quickly manage nausea, bowel
function and hypotension, clear standards around brace use, and promotion of early mobility with both
nursing and physical therapy. The involvement of the patient/family early in their care through
implementing the pathway poster also helped to share expectations for progress and address concerns
early in the hospital course.
Clinical care pathways have previously been shown to reduce health care costs and improve quality in
orthopedic patient populations [5, 6]. Prior publications note complexity in heterogeneous lumbar
spine patient populations and similar challenges with providers within large hospital systems. While
many previous studies have needed to homogenize the populations to show impact of interventions,
the use of a clinical care pathway was associated with improved outcomes despite the population
heterogeneity. We addressed communication between providers around clinical practices through
provider discussion and analysis of evidence, thereby enabling collaborative establishment of best
practices in the absence of strong evidence.
A major component of the clinical care pathway was standardized peri-operative multimodal
analgesia and judicious use of postoperative opioids. Evidence over the last decade demonstrates that
overuse of narcotics can increase complications, decrease mobility, and through overdose, increase
mortality [25]. Through evidence based order sets, we were able standardize decreased administration
of narcotics and other deliriogenic medications, without affecting postoperative pain levels or patient
perceptions related to their overall pain management. Importantly, we also improved sequencing in
rehabilitative efforts including nursing mobility, physical, and occupational therapy, supporting
reduction in length of stay and skilled nursing disposition. Despite concern that earlier discharge
might be associated with decrease in patient satisfaction, no downward trend was noted.
Critical to our work was the institutional adoption of the Virginia Mason Production System. This
management approach, adapted from the Lean Toyota Production System, encompasses quality
improvement tools with a supportive institutional culture and committed leadership [11]. Though not
universally present in US health care systems, such approaches have been increasingly adopted by
health systems throughout the world. These Lean systems reorganize the resources available in any
hospital to eliminate redundancy, waiting times and non-evidence based care, and should be readily
transferable to other clinical care settings with appropriate engagement of team members, regardless
of the local quality improvement approach. Other institutions use Lean, IHI and other methods which
may also be effective in other settings. The keys we identified were leveraging a multidisciplinary
team to examine evidence based practice and implement process improvement tools that withstand
human factors, making the improvement work part of the work flow.
The limitations of this study include the lack of both a contemporaneous control group and
randomization of patients to the intervention. Statistical process control charts enable identification of
underlying temporal trends in outcomes, but do not allow exclusion of all other factors that may
contribute to the results. Also, this is a single center study, which may limit generalizability. Different
institutions may identify different underlying causes of challenges in care of lumbar spine fusion
patients, with correspondingly different interventions. Further, decreases in LOS from quality
improvements may be smaller in magnitude if the baseline LOS is already short. However, the
overall approach we employ should still be relevant. In addition, we are only able to look at outcomes
in total, and are not able to segregate out any effects related to each specific component of the
intervention. In addition, one component of our intervention, the patient poster, maybe dependent on
language and health literacy, which varies among different populations. Finally, the general patient
satisfaction questions we used may be relatively insensitive to small changes, supporting the need for
better patient reported outcomes. It should also be noted that quality improvement requires time
commitment, in our case an entire week for all members of the RPIW team (including the
neurosurgeon lead), plus time for preparation and post-event implementation.
Despite these limitations, we may have underestimated the effect of the intervention. For the primary
analysis, we elected to be conservative, and considered the time before versus after the start of the
intervention on April 1, 2013. However, the intervention extended through August, 2013, and
comparison of outcomes at the conclusion of implementation to baseline would demonstrate greater
effect, as suggested on the statistical process control chart (Figure 3).
Standardizing care and quickly impacting quality indicators in lumbar spine populations will be
increasingly relevant as payers continue to move towards bundled care models and hospitals are
penalized for complications and hospital acquired conditions. Additionally, patients are increasingly
aware of publicly reported quality measures and are seeking out centers of excellence that are proven
to demonstrate both quality and appropriateness of care. Future studies should continue to correlate
length of stay and quality metrics within the diverse lumbar spine populations to identify additional
opportunities to improve the patient care experience and increase efficacy of hospital-based resources.
In addition, indications for spinal fusion procedures remains controversial, and quality improvement
should focus on insuring appropriate selection of patients for these procedures.
In conclusion we identified significant benefits in length of stay and quality outcomes associated with
a clinical care pathway for lumbar fusion. We believe the approach we describe with standardizing
care by incorporating these pathways is generalizable to both other patient populations and care
environments. This methodology is feasible and effective to standardize multidisciplinary care and
likely contributes to improved care for all lumbar fusion spine patients.
Appendix
Value Stream Map (VSM): A component of Lean where care processes are mapped out in sequence,
usually with identification of specific inputs and personnel at each step. Value stream maps are also
used to visually depict any waste (often shown as a cloudburst), which can then be targeted for quality
improvement.
Lean: the improvement of care processes through systematic identification of what is adding value to
a process and decreasing waste (all that does not add value)
Rapid Process Improvement Workshop (RPIW): Structured five day quality improvement events,
where representatives of the various personnel involved in a specific value steam focus on addressing
specified wastes to improve the process
Experience-Based Design (EBD): A method to incorporate the patient and staff experience into
health care redesign using qualitative methods to identify touch points in the care process that have
high emotional content and have a strong influence on the overall patient experience. Identification of
negative emotion touch points enabled targeting of improvement efforts, and may therefore contribute
to patient-centered care improvement
Clinical Care Pathway: procedure-specific tools designed to standardize care across institutions
which have been shown to reduce health care costs, improve quality, and increase hospital efficiency
in some organizations.
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Figure 1. Major
M
steps of the lumbbar fusion paatient care experience
e
ffrom admisssion throughh discharge
prior to thee interventioon. The clooudbursts reppresent the care challennges that cann be addresssed.
Figure 2. Lumbar fusiion Recoverry Pathway.
Figure 3. Statistical
S
prrocess contrrol chart of llength of staay for lumbar fusion paatients. The
implementtation of thee clinical carre pathway was from A
April to Septtember 20133. VSM-Vallue Stream
Map, RPIW
W-Rapid Prrocess Improovement Woorkshop
Table 1. Patient and surgery descriptives, by hospital admission before or after April 2013.
Total
Before
On or after
April 1, 2013
April 1, 2013
N=458
N= 214
N= 244
Sig P
Patient Characteristics
Age mean, SD
64 (11)
64 (11)
64 (11)
.99
Female, %
296 (65)
131 (61)
165 (68)
.15
42 (9)
24 (11)
18 (7)
.16
CHF, %
12 (3)
8 (4)
4 (2)
.16
COPD, %
15 (3)
6 (3)
9 (4)
.60
Diabetes, %
HTN, %
16 (3)
221 (48)
5 (2)
103 (48)
11 (5)
118 (48)
.21
.96
Obese, %
54 (12)
21 (10)
33 (13)
.22
Comorbidities
CAD, %
Principal diagnosis
.59
738.4 Spondylolisthesis, %
724.02 Spinal stenosis, %
287 (63)
66 (14)
137 (64)
27 (13)
150 (61)
39 (16)
Other
105 (23)
50 (23)
55 (23)
Hospitalization
Principle Description (ICD9)
.21
Lumbar/lumbosac fus post

(81.08)
Lumbar/lumbosac fus lat
(81.07)
Other
223 (49)
113 (53)
110 (45)
150 (33)
62 (29)
88 (36)
85 (18)
39 (18)
46 (19)
Surgery minutes mean, SD
153 (59)
156 (61)
151 (57)
.37
Case minutes mean, SD
212 (65)
216 (68)
209 (62)
.24
Table 2. Surgery outcomes, by hospital admission before or after April 2013.

Outcomes
Total
LOS days mean, SD
3.6 (1.5)
Before
April 1, 2013
3.9 (1.5)
On or after
April 1, 2013
3.4 (1.5)
LOS >= 4 days, %

Discharge
202 (44)
117 (55)
85 (35)
to home, %
319 (70)
136 (64)
183 (75)
to SNF, %
69 (15)
39 (18)
30 (12)
other, %
Foley out by Day 2, %
70 (15)
375 (82)
39 (18)
164 (77)
31 (13)
211 (87)
.003
Day 1 pain <= 5, %
313 (68)
146 (68)
167 (68)
.96
Day 2 pain <= 5, %
280 (61)
129 (60)
151 (62)
.73
Surgery minutes mean, SD

Case minutes mean, SD
153 (59)
212 (65)
156 (61)
216 (68)
151 (57)
209 (62)
.37
.24
Readmit within 30 days, %
17 (4)
11 (5)
6 (2)
.13
Patient satisfaction is good

or very good (%)
Recommend hospital
n=187
n=85
n=102
161 (90)
75 (90)
86 (91)
.97
Nurses kept you informed
163 (91)
75 (89)
88 (93)
.43
Patient included in decision

making
Pain controlled
Ready for discharge
151 (87)
69 (86)
82 (87)
.85
162 (89)
162 (88)
74 (89)
75 (90)
88 (88)
87 (86)
.81
.38
<.001
<.001
.002

Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of An Evidence Based Clinical Care Pathway

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Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of An Evidence Based Clinical Care Pathway

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SPINE An International Journal for the study of the spine Publish Ahead of Print

Corresponding author contact info:

Acknowledgement: August 25, 2015

Materials and Methods

The RPIW identified and addressed three key elements:

3) Multidisciplinary Communication: Daily multidisciplinary rounding with providers and nursing

Study of the intervention

Figure 2. Lumbar fusiion Recoverry Pathway.

Lumbar/lumbosac fus post

Surgery minutes mean, SD

Case minutes mean, SD

Table 2. Surgery outcomes, by hospital admission before or after April 2013.

LOS days mean, SD

LOS >= 4 days, %

Day 1 pain <= 5, %

Day 2 pain <= 5, %

Surgery minutes mean, SD

Readmit within 30 days, %

Patient satisfaction is good

Nurses kept you informed

Patient included in decision

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