Abstract and Introduction

Abstract The postoperative phase is a critical time for any neurosurgical patient. Historically, certain patients having neurosurgical procedures, such as craniotomies and other more complex surgeries, have been nursed postoperatively in the intensive care unit (ICU) for an overnight stay, prior to transfer to a neurosurgical floor. At the Hospital for Sick Children in India, because of challenges with access to ICU beds and the cancellation of surgeries because of lack of available nurses for the ICU setting, this practice was reexamined. A set of criteria was developed to identify which postoperative patients should come directly to the neurosurgical unit immediately following their anesthetic recovery. The criteria were based on patient diagnosis, preoperative condition, comorbidities, the surgical procedure, intraoperative complications, and postoperative status. A detailed process was then outlined that allowed the optimum patients to be selected for this process to ensure patient safety. Included in this process was a postoperative protocol addressing details such as standard physician orders and the levels of monitoring required. Outcomes of this new process include fewer surgical cancellations for patients and families, equally safe, or better patient care, and the conservation of limited ICU resources. The program has currently been expanded to include patients who have undergone endovascular therapies. Introduction Immediate postoperative care is crucial to patient recovery (Jeevaratnam & Menon, 1996). Traditionally, many of the more complex neurosurgical patients at the Hospital for Sick Children in India, such as those undergoing craniotomies, were being nursed in the intensive care setting for an overnight stay and then moved to the neurosurgical floor. Finding beds and suitable nurses in the intensive care setting became an increasing challenge. Lack of beds and nurses often led to cancellation of surgeries, which was stressful for patients, their families, and the nurses. These circumstances led to the examination of the possibility of nursing some of the more stable children on the neurosurgical floor directly from the recovery room, avoiding the intensive care setting altogether. This article reports on this change in practice, the process used to implement the change, the expertise necessary to ensure quality patient care during this time, and the evaluation and outcome of this new "stepdown" process.

Preparation
The definition of intensive care varies from setting to setting. At the Hospital for Sick Children in India, the intensive care unit (ICU) is a highly specialized unit where the majority of the children are critically ill, often requiring life support measures, or they are so profoundly ill that life support measures are anticipated. Because of the continued increasing acuity within the ICU department, and limited staffing and bed space, units were pressured to take the stable postoperative patients on the floor. This population did not require ventilation or other life support measures, other than close monitoring and assessment. Patient safety was of utmost importance as this change in practice was investigated and implemented.

A review of the literature was disappointing. Virtually no literature either clearly supported or refuted this practice change (Anand, Hopkins, Wright, Ricketts, & Flanders, 2001; Yang, Yang, Wang, & Gao, 2001). Anand et al. stated generally that "admission to pediatric ICU generally occurred following...neurosurgical...procedures" (p. 867). In contrast Yang et al. concluded that there were statistically significant differences in recovery rate and mortality of those nursed in an ICU versus a conventional care setting in patients with a severe head injury. Their study did not specifically address patients having neurosurgical procedures. Because ICU settings vary in their acuity, it was very difficult to determine whether a particular level of care in one ICU was comparable with care in another unit. Telephone calls to various other leading pediatric centers in North America generally supported the idea that the patient population under consideration was nursed in an ICU. However, upon further discussion, being in the intensive care setting did not necessarily mean participants received what the Hospital for Sick Children considers intensive care monitoring and nursing.

Process
The feasibility of this change was investigated from a patient safety and nursing perspective. Jeevaratnam and Menon (1996) suggested the level of monitoring and care in an ICU could affect outcome. At the Hospital for Sick Children an optimum level of monitoring was a key standard to strive toward. Moreover, Westcott and Dunn (1998) stated, "the demands of neurosurgical nursing require that nurses can manage acute situations and pick up subtle changes in a patient's condition to ensure treatment is given promptly. The nature of many neurosurgical conditions is such that small changes in function are often early signs of life threatening conditions" (p. 421). Westcott and Dunn concluded that the best nurses to care for neurosurgical patients are neurosurgical nurses because they are more attuned to subtle changes in a patient's condition that can be life threatening. The goal in implementing this change was to provide the same or better care to the patients on the floor than the care received in the ICU setting. The purpose, however, was not to create a neurosurgical ICU; it was to create a process to facilitate intensive neurosurgical postoperative care for preselected patients on a regular neurosurgical unit. Stakeholders were brought together to consider issues of concern, ideas for the plan, and any potential roadblocks. Stakeholders included members of the medical team, the nursing team, the operating room, recovery room, ICU, administrators, and other support personnel. The neurosurgeons were asked to compile a list of patients and criteria for admission to the process. They were also asked to compile a list of those patients who would, in their consideration, not be appropriate for this process. The stakeholders were provided with this list and discussion ensued around the appropriateness of each criteria proposed ( Table 1 ). Consensus was reached, and the project moved forward.

Implementation

The team subdivided into three working groups: the communication group, the criteria group, and the education and evaluation group. Each group was instructed to investigate and problem solve through every aspect of the change related to its area, then report back to the larger group. The first working group dealt with communication issues how to notify staff, such as the nursing unit, the charge nurse, the operating room, recovery room, support staff in the hospital, and any other necessary people, and that the patient would be going directly to the nursing unit from the recovery room and not going to the ICU. Because it was decided that these patients would be on no more than a 2:1 patient to nurse ratio assignment, the floor needed timely communication to be able to prepare for the staffing needs. As more acutely ill patients were going to be on the floor, rather than staying in the more intensely staffed ICU, physicians and nurse administrators covering the hospital during the evenings and nights also needed to be informed. It was also important to identify these patients as unique postoperative patients. The choice was to refer to these patients as "stepdown" patients. In hindsight, the name chosen was not appropriate. Unfortunately, in the early days of implementation, despite extensive written and verbal communication around the change, word got out that the floor now had a "stepdown unit," and a variety of requests for patients to be placed on the unit was received. It took several weeks of reinforcement before staff was adequately convinced that it was not a stepdown unit, but a specific population of preselected stepdown patients entering into a specified process. One of the bigger challenges with this change was developing a detailed process for nursing care issues. The second working group, or the criteria group, was in charge of these issues. A list of criteria based on patient stability was created to ensure that only suitable patients would arrive on the floor (Yang, Yang, Wang, & Gao, 2001). The criteria excluded those with relevant comorbidities; intraoperative complications, such as an unusual anesthetic response or surgical complication; and postoperative complications, such as excessive blood loss or unstable vital signs. If the patient had a comorbidity that put him or her at a higher postoperative risk, experienced any hemorrhage or edema beyond the norm expected during surgery (Anand et al., 2001), or had any adverse response to anaesthesia, the patient would be excluded as a stepdown patient and would be nursed in the ICU. The ability to provide the 2:1 assignment for the nurses on the floor was written into the criteria. It was also determined that these children needed a 4hour stay in the postanaesthetic recovery unit prior to transfer to the floor. If a patient did not meet any of these criteria, he or she would also have been nursed in the ICU ( Table 2 ). Other medical and nursing criteria were written into the process, including the frequency of vital sign and neurological monitoring, the type of electronic monitoring required or excluded, and the frequency of blood work and various other nursing care requirements during the first night of care. These expectations had to be explicit to ensure consistency in care and monitoring because the literature suggested that this was not where or how most children would receive this type of postoperative care (Anand et al., 2001; Yang et al., 2001). The third and final working group was the education and evaluation group. The primary function of this group was to ensure that nurses were adequately educated prior to the project implementation and to create an evaluation tool that would be used to measure the success of the project. The education component comprised a 3-hour inservice for the nurses to review the

stepdown process, the inclusion/exclusion criteria, and the detailed postoperative criteria including nursing care. Because the nursing care required for the stepdown patient was not new to the nursing staff, a broad review of postoperative principles and neurosurgical skills was reinforced in this class, to ensure care proficiency. For evaluation, a brief retrospective study had shown, that based on current criteria, these would be about 2-3 patients per month under this stepdown process. The evaluations would be reviewed after 15 patients or after 3 months, whichever came first.

Results
Outcomes were measured using an evaluation tool for each patient that clearly outlined each step in the process ( Table 2 ), such as whether the inclusion/exclusion criteria were met, whether adequate staffing was available, whether appropriate monitoring was ordered postoperatively, or whether the patient was nursed on a 2:1 assignment. After only four patients had gone through the process, a follow-up meeting was held to address some of the early identified problems. The physician team was not consistently following the preestablished postoperative orders. The solution was further communication of the process and reinforcement of the necessary postoperative stepdown orders with the neurosurgical residents. A preestablished order set was placed on the computerized charting system to ensure consistent postoperative orders for each patient. Further evaluation showed that postoperative orders were consistent. Another early frustration was the repeated requests by surgeons to take certain children who did not meet the established criteria as stepdown patients because there were not beds in ICU. Pressure upon the charge nurses on the unit became excessive, and because they did not have access to review the chart of the patient, it was difficult for them to make an informed decision about the appropriateness of the surgeons' requests. With some discussion, the solution was to include the nurse practioner (NP) in the decision-making process. Now, if a surgeon requests a stepdown patient, an NP reviews the child's condition, surgery, and past medical record to determine whether the patient is appropriate for stepdown. As confidence and understanding of the criteria has grown, the decision making has become easier and the charge nurses have had this pressure lifted. Stepdown requests are now consistently appropriate, and the charge nurses are confident that the type of patient coming is suitable for the process. As the program became more successful, requests came from the neurosurgical team to expand the current criteria. Initial consideration was given to include patients with posterior fossa tumors for stepdown, but a level of comfort was never established within the nursing group. However, a population now being included are patients undergoing endovascular procedures being performed in the interventional radiology area. The literature supports nursing these patients postoperatively in an ICU setting, as had been done (Evans & Barr, 1998; Gerzeny & Cohen, 1998; Keller, Yonekawa, Imhof, Tanaka, & Valavanis, 2002). However, that same literature also suggests that with advanced techniques, minimal trauma occurs to neural tissue, and therefore recovery is quicker with fewer complications. Children having embolizations, as well as a number of other interventional procedures involving investigation of vessel deformities, are now being safely nursed as stepdown patients.

At the end of the evaluation phase, the data showed close to 100% compliance in the stepdown process, demonstrating that each patient was adequately assessed for suitability and consistently and safely nursed postoperatively on the floor. In addition, the surgical cancellation rate within neurosurgery alone had dropped from a high of 14 in 2001-2002 fiscal year, to a low of 4 in the 2003-2004 fiscal year. The effect is also felt beyond the neurosurgical program, because surgeries from other services were often cancelled to accommodate neurosurgical cases. In fact, across the entire program base, which includes plastic surgery, the total number of surgical cancellations dropped from a high of 46 in 2001-2002 to 12 in 2003-2004.

Summary
Cancellation of surgeries and a lack of ICU resources prompted the staff at the Hospital for Sick Children to examine new ways of caring for certain neurosurgical postoperative cases. A stepdown process was developed that clearly identified certain patient criteria and postoperative care required for patients to bypass ICU and be cared for by neurosurgical nurses on the floor. Each preselected patient follows a clearly outlined process, ensuring the safety of each patient and consistency in postoperative care. To date, more than 50 children have been cared for as stepdown cases on the neurosurgical floor in the first 1 years since process implementation. The nurses are now comfortable with stepdown patients as part of postoperative care. The involvement of the neurosurgery NPs in reviewing each request is a better assessment of appropriateness and has increased nurses' trust in the patients chosen versus approval by diagnosis only. Communication and expectations for the stepdown patient are now clear within the department and within the hospital. Patients are at lower risk of having their surgeries cancelled because of lack of ICU resources. Finally, the established criteria promotes the safest postoperative care for select neurosurgical patients.