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DeVries Z, Nucci N, Smit K, Tice A, Romeo J, Jarvis JG. Determining the factors associated with a prolonged length of stay for adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion in a single-payer health care system: are these factors different than those in the United States? Spine Deform 2024; 12:133-139. [PMID: 37672201 DOI: 10.1007/s43390-023-00750-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/02/2023] [Indexed: 09/07/2023]
Abstract
INTRODUCTION Rapid recovery pathways (RRP) for adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion (PSIF) have been shown to be successful in reducing hospital length of stay (LOS). Although the majority of patients are discharged within 3 days, some patients require longer hospital admission. Previous studies in the United States have identified predictors of prolonged LOS for this patient population. The goal of this project was to determine if these predictors are the same for Canadian scoliosis patients and to identify those features which are different under this single-payer system. METHODS A RRP for scoliosis surgery was implemented in March 2015 at a single, tertiary referral children's hospital in Canada. Previously identified features, along with numerous other patient factors, were collected. Spearman correlations were used to determine the factors most associated with hospital LOS and those factors were used in a multivariable regression model. RESULTS A total of 161 patients were included in the analysis. Of the previously identified patient factors, only receiving a peri-operative transfusion was found to be significant (ρ = 0.24; p = 0.002). None of the other pre-identified variables were found to be significantly correlated with LOS. Variables not previously examined that were found to be significantly correlated with hospital LOS included ASA status (ρ = 0.19, p = 0.046), fusion involving both the thoracic and lumbar spine (ρ = 0.18, p = 0.025), and receiving celecoxib on post-operative day 1 (ρ = - 0.16; p = 0.038). The features that had the greatest association with LOS through multivariable regression was receiving a blood transfusion (B = 0.48; 95%CI 0.096-0.89; p = 0.017). CONCLUSIONS In this study, we found that many of the features found to be significantly correlated with prolonged hospital LOS in the United States are not transferable to the Canadian healthcare system. This is important for the Canadian, and other surgeons in a single-payer system, in order to identify pre-operative or immediate post-operative factors that may extend patient LOS following PSIF and plan resources accordingly. LEVEL OF EVIDENCE III; therapeutic.
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Affiliation(s)
- Zachary DeVries
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Nicholas Nucci
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Kevin Smit
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Andrew Tice
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Jessica Romeo
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - James G Jarvis
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
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Lebel DE, Machida M, Koucheki R, Campbell F, Bath N, Koyle M, Ruskin D, Levin D, Brennenstuhl S, Stinson J. Utilization of individual components of enhanced recovery after surgery (ERAS) protocol improves post-operative outcomes in adolescent idiopathic scoliosis: a blueprint for progressive adoption of ERAS. Spine Deform 2023; 11:1117-1125. [PMID: 37233951 PMCID: PMC10425294 DOI: 10.1007/s43390-023-00706-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 05/13/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE Enhanced recovery after surgery [ERAS] is an approach for standardization of perioperative care aimed at improving patient outcomes. The primary aim of this study was to determine if length of stay (LOS) differed by protocol type (ERAS vs. non-ERAS [N-ERAS]) in patients undergoing surgery for adolescent idiopathic scoliosis (AIS). METHODS A retrospective cohort study was conducted. Patient characteristics were collected and compared between groups. Differences in LOS were assessed using regression adjusting for age, sex, BMI, pre-surgical Cobb angle, levels fused and year of surgery. RESULTS Fifty nine ERAS patients were compared to 81 N-ERAS patients. Patients were comparable in their baseline characteristics. Median LOS was 3 days (IQR = 3-4) for the ERAS group, compared to 5 days (IQR = 4-5) for the N-ERAS group (p < 0.001). The ERAS group had a significantly lower adjusted rate of stay (RR = 0.75; 95% CI = 0.62-0.92). The ERAS group had significantly lower average pain on post-operative days 0 (least-squares-mean [LSM] 2.66 vs. 4.41, p < 0.001), POD1 (LSM 3.12 vs. 4.48, p < 0.001) and POD5 (LSM 2.84 vs. 4.42, p = 0.035). The ERAS group had lower opioid consumption (p < 0.001). LOS was predicted by the number of protocol elements received; those receiving two (RR = 1.54 95% CI = 1.05-2.24), one (RR = 1.49; 95% CI = 1.09-2.03) or none (RR = 1.60, 95% CI = 1.21-2.13) had significantly longer rates of stay than those receiving all four. CONCLUSION Adoption of modified ERAS-based protocol for patients undergoing PSF for AIS led to significant reduction in LOS, average pain scores, and opioid consumption.
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Affiliation(s)
- David E Lebel
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada.
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
| | - Masayoshi Machida
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Robert Koucheki
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Fiona Campbell
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Natasha Bath
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Martin Koyle
- Division of Urology, The Hospital for Sick Children, Toronto, Canada
| | - Danielle Ruskin
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - David Levin
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Sarah Brennenstuhl
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jennifer Stinson
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
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Contartese D, Salamanna F, Brogini S, Martikos K, Griffoni C, Ricci A, Visani A, Fini M, Gasbarrini A. Fast-track protocols for patients undergoing spine surgery: a systematic review. BMC Musculoskelet Disord 2023; 24:57. [PMID: 36683022 PMCID: PMC9869597 DOI: 10.1186/s12891-022-06123-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 12/29/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND CONTEXT Fast-track is an evidence-based multidisciplinary strategy for pre-, intra-, and postoperative management of patients during major surgery. To date, fast-track has not been recognized or accepted in all surgical areas, particularly in orthopedic spine surgery where it still represents a relatively new paradigm. PURPOSE The aim of this review was provided an evidenced-based assessment of specific interventions, measurement, and associated outcomes linked to enhanced recovery pathways in spine surgery field. METHODS We conducted a systematic review in three databases from February 2012 to August 2022 to assess the pre-, intra-, and postoperative key elements and the clinical evidence of fast-track protocols as well as specific interventions and associated outcomes, in patients undergoing to spine surgery. RESULTS We included 57 full-text articles of which most were retrospective. Most common fast-track elements included patient's education, multimodal analgesia, thrombo- and antibiotic prophylaxis, tranexamic acid use, urinary catheter and drainage removal within 24 hours after surgery, and early mobilization and nutrition. All studies demonstrated that these interventions were able to reduce patients' length of stay (LOS) and opioid use. Comparative studies between fast-track and non-fast-track protocols also showed improved pain scores without increasing complication or readmission rates, thus improving patient's satisfaction and functional recovery. CONCLUSIONS According to the review results, fast-track seems to be a successful tool to reduce LOS, accelerate return of function, minimize postoperative pain, and save costs in spine surgery. However, current studies are mainly on degenerative spine diseases and largely restricted to retrospective studies with non-randomized data, thus multicenter randomized trials comparing fast-track outcomes and implementation are mandatory to confirm its benefit in spine surgery.
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Affiliation(s)
- Deyanira Contartese
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Francesca Salamanna
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Silvia Brogini
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Konstantinos Martikos
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cristiana Griffoni
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Ricci
- grid.419038.70000 0001 2154 6641Anesthesia-resuscitation and Intensive care, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andrea Visani
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Milena Fini
- grid.419038.70000 0001 2154 6641Scientific Direction, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Gasbarrini
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Comparison of interventions and outcomes of enhanced recovery after surgery: a systematic review and meta-analysis of 2456 adolescent idiopathic scoliosis cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3457-3472. [PMID: 34524513 DOI: 10.1007/s00586-021-06984-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 05/30/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this meta-analysis and systematic review is to compare the methodology and evaluate the efficacy of Enhanced recovery after Spine Surgery (ERAS) for adolescent idiopathic scoliosis (AIS) and to compare the outcomes with traditional discharge (TD) pathways. METHODS Using major databases, a systematic search was performed. Studies comparing the implementation of ERAS or ERAS-like and TD pathways in patients with AIS were identified. Data regarding methodology and outcomes were collected and analyzed. RESULTS Fourteen studies (n = 2456) were included, comprising 1081 TD and 1375 ERAS or ERAS-like patients. Average age of patients was 14.6 ± 0.4 years. Surgical duration was on average 35.6 min shorter for the ERAS group compared to TD cohort ([2.8, 68.3], p = 0.03), and blood loss was 112.3 milliliters less ([102.4, 122.2], p < 0.00001). ERAS group reached first ambulation 29.6 h earlier ([11.2, 48.0], p-0.002), patient-controlled-analgesia (PCA) discontinuation 0.53 day earlier ([0.4, 0.6], p < 0.00001), urinary catheter discontinuation 0.5 day earlier ([0.4, 0.6], p < 0.00001), and length-of-stay (LOS) was 1.6 days shorter ([1.4, 1.8], p < 0.00001). Rates of complications and 30-day-readmission-to-hospital were similar between both groups. Pain scores were significantly lower for ERAS group on days 0 through 2 post-operatively. CONCLUSIONS Use of ERAS after AIS is safe and effective, decreasing surgical duration and blood loss. ERAS methodology effectively focused on reducing time to first ambulation, PCA discontinuation, and urinary catheter removal. Outcomes showed significantly decreased LOS without a significant increase in complications. There should be efforts to incorporate ERAS in AIS surgery. Further studies are necessary to assess patient satisfaction. LEVEL OF EVIDENCE III Meta-analysis of Level 3 studies.
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Gadiya AD, Koch JEJ, Patel MS, Shafafy M, Grevitt MP, Quraishi NA. Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review. Spine Deform 2021; 9:893-904. [PMID: 33725329 PMCID: PMC8270839 DOI: 10.1007/s43390-021-00310-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/13/2021] [Indexed: 12/28/2022]
Abstract
STUDY DESIGN A systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS. OBJECTIVE To systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS. ERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published. METHODS A systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with < 5 patients were excluded. Length of stay (LOS), complication and readmission rates were used as outcome measures. Statistical analysis was done using the random effects model. RESULTS Of a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p < 0.00001). There was no significant difference in the complication (p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy. CONCLUSION This systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Akshay D. Gadiya
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Jonathan E. J. Koch
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Mohammed Shakil Patel
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Masood Shafafy
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Michael P. Grevitt
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Nasir A. Quraishi
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
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