Reduced time to imaging, length of stay, and hospital charges following implementation of a novel postoperative pathway for craniotomy

Abstract

Objective: The authors created a postoperative postanesthesia care unit (PACU) pathway to bypass routine intensive care unit (ICU) admissions of patients undergoing routine craniotomies, to improve ICU resource utilization and reduce overall hospital costs and lengths of stay while maintaining quality of care and patient satisfaction. In the present study, the authors evaluated this novel PACU-to-floor clinical pathway for a subset of patients undergoing craniotomy with a case time under 5 hours and blood loss under 500 ml.

Methods: A single-institution retrospective cohort study was performed to compare 202 patients enrolled in the PACU-to-floor pathway and 193 historical controls who would have met pathway inclusion criteria. The pathway cohort consisted of all adult supratentorial brain tumor cases from the second half of January 2021 to the end of January 2022 that met the study inclusion criteria. Control cases were selected from the beginning of January 2020 to halfway through January 2021. The authors also discuss common themes of similar previously published pathways and the logistical and clinical barriers overcome for successful PACU pathway implementation.

Results: Pathway enrollees had a median age of 61 years (IQR 49-69 years) and 53% were female. Age, sex, pathology, and American Society of Anesthesiologists physical status distributions were similar between pathway and control patients (p > 0.05). Most of the pathway cases (96%) were performed on weekdays, and 31% had start times before noon. Nineteen percent of pathway patients had 30-day readmissions, most frequently for headache (16%) and syncope (10%), whereas 18% of control patients had 30-day readmissions (p = 0.897). The average time to MRI was 6 hours faster for pathway patients (p < 0.001) and the time to inpatient physical therapy and/or occupational therapy evaluation was 4.1 hours faster (p = 0.046). The average total length of stay was 0.7 days shorter for pathway patients (p = 0.02). A home discharge occurred in 86% of pathway cases compared to 81% of controls (p = 0.225). The average total hospitalization charges were $13,448 lower for pathway patients, representing a 7.4% decrease (p = 0.0012, adjusted model). Seven pathway cases were escalated to the ICU postoperatively because of attending physician preference (2 cases), agitation (1 case), and new postoperative neurological deficits (4 cases), resulting in a 96.5% rate of successful discharge from the pathway. In bypassing the ICU, critical care resource utilization was improved by releasing 0.95 ICU days per patient, or 185 ICU days across the cohort.

Conclusions: The featured PACU-to-floor pathway reduces the stay of postoperative craniotomy patients and does not increase the risk of early hospital readmission.

Keywords: craniotomy; neurosurgery outcomes; postoperative pathway; tumor.

FIG. 1.

Boxplots of time to MRI (A), time to first postoperative visit by PT and/or OT (B), LOS (C), and total hospital charges (D) for patients in the PACU pathway versus historical controls. *p < 0.05; ****p < 0.0001.

FIG. 2.

A: Boxplots of LOS, time to first postoperative MRI, and time to first postoperative PT and/or OT evaluation for PACU patients and historical controls, separated by operative start time of day. B: Boxplot of total hospital charges for pathway patients and historical controls, separated by operative start time of day. C: Boxplots of LOS, time to first postoperative MRI, and time to first postoperative PT and/or OT evaluation for PACU patients and historical controls, separated by weekday versus weekend operative dates. D: Boxplots of total hospital charges for PACU patients and historical controls, separated by weekday versus weekend operative dates. ns = not significant. *p < 0.05; ****p < 0.0001.

FIG. 3.

Discharge disposition (A) and readmission after 30 days of initial discharge (B) in PACU pathway and control cohorts. AMA = discharge against medical advice; SNF = skilled nursing facility.

FIG. 4.

Patient and operative characteristics associated with unfavorable outcomes in PACU pathway and control patients. Significance indicated by red outlining (p < 0.05).