Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis

This QI project was conducted at a 540-bed, freestanding, tertiary children’s hospital. Project patients were defined as nonambulatory patients with neuromuscular scoliosis planning for their primary orthopedic spinal corrective surgery (either PSF or GRP), beginning in October 2017. Nonambulation was defined as requiring mobility assistance outside of the home setting, similar to the Gross Motor Function Classification System Level IV or V¹⁰  classifications for patients with cerebral palsy. Patients were identified on the basis of their preoperative orthopedic clinic visits, at the discretion of the orthopedic surgeon or APP. After surgery, the patients were admitted to the PICU on postoperative day (POD) 0. Once returning to a stable respiratory status on home ventilatory support, patients were transferred out of the ICU to 1 of 2 other units for continued postoperative inpatient care. Patients were excluded if they required cardiac ICU during their postoperative admission or if they required a staged surgical process for their primary correction. Otherwise, all nonambulatory NMS patients admitted after their primary scoliosis correction surgery participated in the project.

For all scoliosis patients, after spinal surgery, once transferred out of the ICU, they were admitted to and maintained on the orthopedic service through their remaining inpatient postoperative period. The Division of Hospital Medicine (HM) had an automatic comanagement agreement with the Division of Pediatric Orthopedic Surgery for all postoperative scoliosis surgery patients admitted to the hospital.¹¹  The agreement did not include any outpatient perioperative management. HM provided collaborative clinical care with orthopedics, sharing patient care responsibility and accountability. Twice daily, orthopedics and HM huddled with other subspecialists to discuss shared patients, including NMS patients, yet rounded independently on each patient.

This project, with its QI framework, aimed to improve the quality of care locally, not to create generalizable knowledge as defined by research. Therefore, it was not human subjects research, and our institutional review board leadership has shared that such work does not require their review.

Our interdisciplinary team included representatives from orthopedics (surgeons, APP), HM (hospitalist), pain management (anesthesiologist, APP), gastroenterology (gastroenterologist), critical care (intensivist, APP), pulmonary (pulmonologist, APP), physical therapy, nutritional therapy (clinical dietician), respiratory therapy, patient services (nursing), a QI specialist, and a quality and transformation analysist. Team members remained constant throughout the project and were chosen from subspecialties that consistently provide clinical care for postoperative NMS patients. Clinicians who cared for each patient were not predetermined, clinical schedules were not altered on the basis of pending NMS admissions, and surgery schedulers were unaware of anticipated clinician schedules. When schedules aligned, project team members provided direct clinical postoperative care for NMS patients.

The project had 3 phases of study: pretesting, testing, sustain. The pretesting phase reviewed existing processes, collected baseline data, and created an education plan to introduce the NMS pathway. Using the newly created NMS pathway as a clinical guide, all 2015 NMS patients meeting the above inclusion criteria were retrospectively analyzed as baseline data. Patients in 2015 were chosen to decrease any confounding factors because a similar pathway project for idiopathic scoliosis patients started in 2016 (Supplemental Fig 5). No significant changes in surgical technique or postoperative pain management occurred between 2015 and the start of our testing phase. The testing phase, October 2017 to December 2018, was the most active, with multiple plan–do–study–act cycles. Testing of the NMS pathway started on the individual patient level, modifying orders and reviewing failures for each patient. As familiarity with the NMS pathway increased, analysis of patient compliance moved to a monthly basis. After 15 months of active improvement in the testing phase, the project transitioned to sustain phase in January 2019 for an additional 12 months. During this final phase, no active improvement occurred; instead, we observed the performance of the system with quarterly patient LOS and compliance analysis.

We used The Improvement Guide’s approach throughout our project.¹²  The team developed 6 key drivers for successful implementation of the NMS pathway.¹²  Key drivers guided the development of interventions, which were tested and refined through sequential plan-do-study-act cycles.¹²  (Fig 1).

Our multidisciplinary team reviewed the current idiopathic scoliosis PSF perioperative pathway. Using a modified Delphi method based on published evidence and expert opinion (where evidence lacked), the team adapted the idiopathic scoliosis pathway to the medical complexity of NMS patients to approve a finalized NMS pathway (Fig 2). Once established, the orthopedic nurses shared the key components of the NMS pathway with patients and their caregivers during a preoperative spine education class and in a perioperative spine booklet. Preoperative patient/caregiver education focused on early mobilization, pain control, and discharge goals.

The final NMS pathway included 10 to 38 different measures, based on each patient’s clinical complexity, in 5 different areas of care from surgery to hospital discharge: activity, respiratory, pain management, intake, and output. Pain management, intake, and output were further divided into 2 parallel arms and each patient was expected to follow 1 of the 2 arms for these care areas, depending on whether the patient’s surgery was PSF or growing rod placement, whether >50% of their nutrition derived from tube feeds or oral feeds, and whether the patient had a home bowel regimen or not, respectively (Fig 2).

When creating the project team, focus on interdisciplinary collaboration and accountability was paramount. The NMS population’s medical complexity requires care coordination from multiple clinical care providers; recruiting an influential representative from each group allowed customization of education efforts, clear communication of pathway implementations, and focused adaptations. Similarly, during monthly failure analysis, each team member was held accountable for the performance of their respective service line.

Robust education about the NMS pathway preceded testing, then continued intermittently during the testing phase. The training occurred throughout the institution, across the 3 different inpatient units (including ICU), and among all typical consultants. Each team member provided education to their respective area and each educational platform was customized based on team member and audience needs. Rotating providers (eg, orthopedic residents) received in-person education of the NMS pathways on day 1 of their rotation by permanent providers. Some examples of provider-specific education included required online modules, in-person NMS pathway review by team stakeholders, weekly e-mail reminders highlighting upcoming patients, and quarterly subspecialty discussions of project successes and failures. Standardized education platforms were not required, although templated education modules and communication options were shared with the team.

During the testing and sustain phases, the team’s initial perception to pathway noncompliance was a lapse in the previously mentioned NMS pathway education. When compliance failures were observed in real-time, appropriate educational adjustments occurred to improve pathway compliance; for example, modifying educational modalities or employing just-in-time education for affected providers. If a failure was recognized after discharge, team members spoke directly with the providers associated with the recent patient encounter to address any educational lapses regarding the NMS pathway’s expectations, to identify the failure’s root cause, and to obtain general project feedback.

Parents or caregivers of children with complex medical conditions, including those with NMS, are experts in their child’s medical needs, with the ability to manage acute and chronic symptoms simultaneously.^13,14  When these patients require hospitalization, parents or caregivers relinquish their child’s medical management to inpatient providers, despite the preference for increased participation.^13,14  Strong bidirectional communication with the medical providers regarding care planning is often cited as crucial to decreasing parents or caregiver anxiety and improving patient care.^13,14  With this goal in mind, our team developed a discharge checklist to reflect the discharge readiness expected with NMS patients (Supplemental Fig 6). The checklist was posted in the patient’s room after transfer from the ICU. Twice-daily review of the checklist at multidisciplinary huddles focused on safe discharge planning. In patient rooms, daily review by HM and nursing engaged parents or caregivers as active participants in patient recovery.

Parents or caregivers of all hospitalized children, regardless of medical complexity, report enhanced discharge preparedness after comprehensive written and verbal discharge education.¹⁵  To ease the hospital-to-home transition for our NMS patients, we modified scoliosis discharge instructions to reinforce the NMS pathway’s goals and enhance postdischarge contingency planning. The instructions were verbally reviewed by nursing and the orthopedic APP with parents or caregivers at discharge.

The primary outcome measure was hospitalized LOS after spinal surgery, recorded as distinct integers of calendar overnight stays, undifferentiated by time of discharge. Although statistical difference in LOS among the PSF and GRP groups was observed in the pretesting phase (longer LOS with PSF), both groups were analyzed together because of the small volumes per phase. If a patient required inpatient rehabilitation for continued postsurgical recovery, the calculated LOS ended on the date of transfer to rehabilitation.

Our process measure was the percentage of total pathway compliance per patient, with the numerator being the total pathway components successfully achieved for a patient and the denominator being the total possible components for that patient. As consistent with a complex medical population, each patient had unique postoperative clinical requirements, and we tailored the expected outcomes (the denominator) to the personalized medical needs (Fig 2). Some component measurements leveraged successfully integrated components in the institution’s perioperative culture. For example, achieving success in the respiratory care area required only that lung recruitment was initiated by POD 3. Similarly, processes to reduce venous thromboembolism were already embedded in orthopedic perioperative culture, so their steps were not tracked as expected outcomes for this project. We tracked compliance through a standardized retrospective electronic medical chart review in Research Electronic Data Capture.¹⁶ 

Our balancing measure was total 30-day readmissions to our institution per patient for each phase, using retrospective chart review.

The 3 phases were analyzed for patient characteristics (including primary diagnosis, surgery type, home feeding regimen, and home bowel regimen) and a nonparametric analysis of variance was performed. Statistical Analysis System version 9.4 was used for all statistical analyses. Outcome and process measures were both evaluated using statistical process control charts and established rules were employed to detect special cause variation.^17,18  Individual NMS pathway components (activity, respiratory, pain management, intake, output) were analyzed as a percentage of compliance for the project phase, using Statistical Analysis System generalized linear mixed model procedure.

Total NMS patients who had scoliosis surgery for the 3 phases were pretesting, 51, testing, 71, and sustain, 67. Nonambulatory patients with NMS who received their primary, nonstaged scoliosis surgical repair were pretesting, 23, testing, 26, and sustain, 22. In all phases, 2 surgeons performed nearly 80% of surgeries and most surgeries were PSF. For patient characteristics, nonparametric analysis of variance resulted in no significant difference during the 3 phases. Cerebral palsy was the prevalent primary diagnosis, tube-fed nutrition and oral nutrition were similar in frequency, and the majority had an existing home bowel regimen (Table 1).

The pretesting mean LOS was 8.0 (95% confidence interval [CI], 5.1–10.9) days before implementation of the NMS pathway. Seven months into the testing phase, we observed SPC special cause variation with a shift in our mean LOS down to 5.3 (95% CI, 4.4–6.2) (Fig 3). Also, a decrease in postoperative LOS variability was confirmed by a decrease in the interquartile range from the 5 days in the pretesting phase to 2 days in the combined testing and sustain phases.

For the process measure, the project noted significant increase of the mean by 24% (95% CI, 16–32) from 60% (95% CI, 54–65) pretesting to 84% (95% CI, 78–91) testing. During the sustain phase, a decline in compliance occurred, causing the mean percentage to decrease from 84% to 68% (95% CI, 62–74) (Fig 4).

Analysis of variance for percentage compliance of the 5 NMS pathway individual components showed statistical improvement for output from pretesting to testing. Although not meeting statistical improvement with 95% CI overlap, pain management increased in percentages with each phase transition, but the improvements did not meet statistical significance. Similarly, activity and intake saw percentage improvements from pretesting to testing but overlaps in 95% CI remained. Respiratory remained at 100% through all phases (Table 1).

During the sustain phase, 83% of pain management failures were incomplete transition to all enteral pain medications by POD 3. Lack of enteral intake on POD 0 was 56% of intake sustain failures. For output sustain failures, 17% were secondary to urinary retention and 78% as a result of medication refusal on POD 1 or 2 given presumed patient intolerance to the bowel medication’s enteral formulations. Activity, highly reliant on medical record documentation, failed as POD 1 or 2 mobility was not documented on 73% of sustain patients.

Readmission numbers were determined 40 days from discharge because 2 patients required readmission for surgically related reasons 35 to 40 days after discharge. Rates remained stable throughout each phase (Table 1) and were less than the 2012 national rate of 6.83%.¹⁹  In the testing phase, readmission reasons included aspiration pneumonia and a wound infection. Readmissions during the sustain phase included aspiration pneumonia, opioid-induced constipation, and wound infection.

This project successfully used QI methodology to test and implement a standardized clinical care pathway for nonambulatory NMS patients after primary spinal correction, resulting in decreased mean LOS and LOS variability. Despite the unique and complex medical needs of each NMS patient, a pathway for clinical standardization is both possible and effective for improving clinical care, with input from parents or caregivers. The work also demonstrated that multidisciplinary collaboration and engagement helps ensure sustainability in a freestanding, tertiary children’s hospital.

This project provided multiple key learnings and strengths, warranting discussion. Decreasing postoperative clinical variability tends to shorten postoperative recovery for our most medically complex patients.²⁰  The small population size was an impactful feature of our project, allowing for near real-time provider feedback. Pathways can be created and yield positive patient care outcomes, even in the absence of strong evidence-based recommendations. Maintaining multidisciplinary collaboration and accountability is key to success, especially in a project involving different organizational facets.

A recent publication by Flectcher et al advocated that, “As certain patients appear more likely to require longer hospitalizations and are at a higher risk for complications, focusing resources on optimizing and standardizing care of these patients may result in improved outcomes.”²⁰  This work supports their findings, particularly regarding decreased LOS variability. Before this project, the NMS patients at our institution who required the longest LOS after spinal surgery were presumed to have a higher degree of medical complexity. Instead, perhaps those patients were simply more vulnerable to previous provider inconsistencies and variability in postoperative medical care. By decreasing clinical irregularities, provider focus is now on individual deviations in expected recovery, allowing earlier recognition of necessary clinical intervention(s). The results may not illuminate which fundamental factor or group of factors resulted in LOS improvement, yet they demonstrate that clinical standardization likely plays a positive role for NMS patients’ postoperative recovery.

The small annual population size of the project was unique for a pathway standardization project, yet ultimately contributed to the project’s successes. Communication among providers was simplified with a small population size. During the testing phase’s monthly patient evaluations, lapses in NMS pathway compliance were recognized within hours to days, allowing for a heightened focus on individual patient progress. As each patient interacted with numerous clinical areas and subspecialty care providers, nimble and adaptive changes were simplified from the smaller patient population.

At our institution, each NMS postoperative patient interacts with multiple subspecialists during hospital recovery, making collaboration a key component to a patient’s clinical success. During our project, the diverse opinions and expertise of our team were equally valued through regular in-person meetings. This culture of open collaboration undoubtedly drove the success of our project by focusing on the “human side of change;” for example, consistently gathering input from all providers, staff, and parents/caregivers.¹² 

Our complex postoperative NMS pathway evolved partly from other successful QI projects. Previous quality work with the orthopedic department optimized urinary retention prevention, venous thrombosis embolism prevention,²¹  and postoperative lung recruitment.²²  Before the NMS pathway, these projects were applied to all postoperative inpatient orthopedic patients, including complex medical patients such as our NMS population. The successes of these endeavors incorporated easily into the NMS pathway because they were already established in orthopedic clinical culture. Similarly, a project that promoted early mobilization in critical care patients allowed for easy adoption of our POD 1 physical therapy efforts.²³  The success of our overall NMS pathway was increased by the successes of previous collective QI work (Supplemental Fig 5).

Fulbrook and Mooney stress that “individual components of each care bundle should be … based on strong science; usually level 1 or 2 research.”⁸  Unfortunately, postoperative care for NMS patients has minimal data or evidence-based practices and this project frequently relied upon expert-based opinions to design the NMS pathway (Fig 2). Evidence-based care remains critical in medicine and should direct efforts, where available. However, if lacking, we must not delay in addressing known clinical care gaps; using the best resources available, monitoring each step closely, and maintaining a patient-focused perspective to care.

The knowledge from our project has spread to other areas within our institution. Orthopedic pelvic surgery for complex medical patients now uses a similar accelerated and enhanced postoperative pathway approach, and 2 new institutional guidelines were derived from our work: (1) postoperative respiratory management of neuromuscular patients, and (2) neuromuscular spine surgery postoperative pain management. We also shared our results and information with other surgical groups, helping to educate colleagues who care for similar patient populations.

Sustainability of any successful QI work is challenging.^24,25  The sustainability plan included onboarding and continued employee education programs, updated NMS pathway documents, modified electronic medical record admission order sets, and updated guidelines for postoperative respiratory and acute pain support. LOS and NMS pathway compliance data were reviewed with the project team quarterly during the sustain phase, filling education gaps when necessary. This project demonstrated that sustainability is possible with robust integration of the process and adaptation of previous clinical successes.

Limitations to our work did exist, particularly in a few main areas: the small patient population, individualized clinical needs of each patient, low level of reliability for some measures, and the possibility of inaccurate balancing measure data. Working with approximately 20 patients a year was difficult to establish patterns of care, despite the benefits noted above. Similarly, although the patients shared a similar diagnosis, each patient had a unique set of clinical needs within the NMS pathway. Generalizability among the patients was challenging to determine based on these variabilities. Regarding the level of reliability for our measures, some of our measures relied on inconsistent written documentation of events (eg, out-of-bed mobility on POD 1 or POD 2), whereas others were dependent on collaborative decision-making with the patient’s parent or caregiver (eg, advancing enteral feeds). Unfortunately, we were unable to increase the level of reliability for such measures, perhaps diminishing their ability for success. For our balancing measure, we only reviewed patients admitted to our institution, perhaps missing readmissions which occurred outside of our immediate referral area.

As noted earlier, GRP patients had significantly shorter LOS during the pretesting phase and, therefore, the potential to negatively affect project results. However, during each project phase, PSF patients greatly outnumbered GRP patients (Table 1). Theoretically, this discrepancy in surgical type could negatively impact the project’s LOS; however, LOS was still significantly decreased in both the testing and sustain phases (Fig 3).

This multidisciplinary quality improvement project demonstrated that a standardized clinical care pathway can successfully decrease LOS after major orthopedic surgery for NMS pediatric patients. Given the success of this project, reviewing the applicability of NMS pathway principles to the postoperative care of other medically complex pediatric populations is warranted. Conversely, the observed lack of statistical improvement in certain NMS pathway clinical care areas could prompt future investigations into NMS perioperative recovery, such as considering if pathway components should be weighed equally for influence characteristics or if different measurement parameters or different components need consideration.

We thank the staff and providers from the Department of Pediatric Orthopaedics, the Division of Hospital Medicine, the Division of Pain Management, the PICU, the Surgical Short Stay Unit, and the Transitional Care Center for their constant support and dedication to our neuromuscular patient population.