Cost-effectiveness development for the postoperative care of craniotomy patients: a safe transitions pathway in neurological surgery.

OBJECTIVE The authors' institution is in the top 5th percentile for hospital cost in the nation, and the neurointensive care unit (NICU) is one of the costliest units. The NICU is more expensive than other units because of lower staff/patient ratio and because of the equipment necessary to monitor patient care. The cost differential between the NICU and Neuro transitional care unit (NTCU) is $1504 per day. The goal of this study was to evaluate and to pilot a program to improve efficiency and lower cost by modifying the postoperative care of patients who have undergone a craniotomy, sending them to the NTCU as opposed to the NICU. Implementation of the pilot will expand and utilize neurosurgery beds available on the NTCU and reduce the burden on NICU beds for critically ill patient admissions. METHODS Ten patients who underwent craniotomy to treat supratentorial brain tumors were included. Prior to implementation of the pilot, inclusion criteria were designed for patient selection. Patients included were less than 65 years of age, had no comorbid conditions requiring postoperative intensive care unit (ICU) care, had a supratentorial meningioma less than 3 cm in size, had no intraoperative events, had routine extubation, and underwent surgery lasting fewer than 5 hours and had blood loss less than 500 ml. The Safe Transitions Pathway (STP) was started in August 2016. RESULTS Ten tumor patients have utilized the STP (5 convexity meningiomas, 2 metastatic tumors, 3 gliomas). Patients' ages ranged from 29 to 75 years (median 49 years; an exception to the age limit of 65 years was made for one 75-year-old patient). Discharge from the hospital averaged 2.2 days postoperative, with 1 discharged on postoperative day (POD) 1, 7 discharged on POD 2, 1 discharged on POD 3, and 1 discharged on POD 4. Preliminary data indicate that quality and safety for patients following the STP (moving from the operating room [OR] to the neuro transitional care unit [OR-NTCU]) are no different from those of patients following the traditional OR-NICU pathway. No patients required escalation in level of nursing care, and there were no readmissions. This group has been followed for greater than 1 month, and there were no morbidities. CONCLUSIONS The STP is a new and efficient pathway for the postoperative care of neurosurgery patients. The STP has reduced hospital cost by $22,560 for the first 10 patients, and there were no morbidities. Since this pilot, the authors have expanded the pathway to include other surgical cases and now routinely schedule craniotomy patients for the (OR-NTCU) pathway. The potential cost reduction in one year could reach $500,000 if we reach our potential of 20 patients per month.

A program utilizing community pharmacists to improve diabetes education in the Kingdom of Saudi Arabia.

OBJECTIVE: The aim of this program was to demonstrate that retail community pharmacists could successfully recruit, engage and counsel people with diabetes by serving as a trusted source of diabetes information. We evaluated the outcomes of this clinical program in preparation for a wider roll out. METHODS: Joslin Diabetes Center collaborated with Nahdi Medical Company, a large retail pharmacy chain in Saudi Arabia, to offer a 'Let's Talk About Diabetes' (LTAD) program. LTAD consists of four 1: 1 counselling sessions, approximately 20 min each, scheduled over a 2-4 month period with a focus on medications, lab results, glucose monitoring and doctor visits. Twenty-five pharmacists completed diabetes education certification and intensive on-site training to deliver the LTAD program. RESULTS: The 25 program pharmacists in 11 locations enrolled 2639 individual customers into the program. Of these, 1582 participated in at least one session and 1137 (71.9%) participated in at least one LTAD session and completed follow-up surveys. There were 380 customers with paired HbA1C results which demonstrated a reduction from 8.50% (69 mmol/mol) to 7.32% (56 mmol/mol) (P < 0.001). There were improvements in diabetes awareness, attitudes towards diabetes and medication adherence. CONCLUSION: The evaluation of this community program suggests that a pharmacy-led diabetes education program is feasible in Saudi Arabia.

UC Care Check-A Postoperative Neurosurgery Operating Room Checklist: An Interrupted Time Series Study.

BACKGROUND: The effectiveness of neurosurgical operating room (OR) checklists to improve communication, safety attitudes, and clinical outcomes is uncertain. PURPOSE: To develop, implement, and evaluate a post-operative neurosurgery operating room checklist. METHODS: Four large academic medical centers participated in this study. We developed an evidence-based checklist to be performed at the end of every adult-planned or emergent surgery in which all team members pause to discuss key elements of the case. We used a prospective interrupted time series study design to assess trends in clinical and cost outcomes. Safety attitudes and communication among OR providers were also assessed. RESULTS: There were 11,447 neurosurgical patients in the preintervention and 10,973 in the postintervention periods. After implementation, survey respondents perceived that postoperative checklists were regularly performed, important issues were communicated at the end of each case, and patient safety was consistently reinforced. Observed to expected (O/E) overall mortality rates remained less than one, and 30-day readmission rate, length of stay index, direct cost index, and perioperative venous thromboembolism and hematoma rates remained unchanged as a result of checklist implementation. CONCLUSION: A neurosurgical checklist can improve OR team communication; however, improvements in safety attitudes, clinical outcomes, and health system costs were not observed.

A Safe Transitions Pathway for post-craniotomy neurological surgery patients: high-value care that bypasses the intensive care unit.

OBJECTIVE: High-value medical care is described as care that leads to excellent patient outcomes, high patient satisfaction, and efficient costs. Neurosurgical care in particular can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. The authors developed a "Safe Transitions Pathway" (STP) model in which select patients went to the postanesthesia care unit (PACU) and then the neuro-transitional care unit (NTCU) rather than being directly admitted to the neurosciences intensive care unit (ICU) following a craniotomy. They sought to evaluate the clinical and financial outcomes as well as the impact on the patient experience for patients who participated in the STP and bypassed the ICU level of care. METHODS: Patients were enrolled during the 2018 fiscal year (FY18; July 1, 2017, through June 30, 2018). The electronic medical record was reviewed for clinical information and the hospital cost accounting record was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impressions of the hospital stay and of the recovery pathway. RESULTS: No patients who proceeded to the NTCU postoperatively were upgraded to the ICU level of care postoperatively. There were no deaths in the STP group, and no patients required a return to the operating room during their hospitalization (95% CI 0%-3.9%). There was a trend toward fewer 30-day readmissions in the STP patients than in the standard pathway patients (1.2% [95% CI 0.0%-6.8%] vs 5.1% [95% CI 2.5%-9.1%], p = 0.058). The mean number of ICU days saved per case was 1.20. The average postprocedure length of stay was reduced by 0.25 days for STP patients. Actual FY18 direct cost savings from 94 patients who went through the STP was $422,128. CONCLUSIONS: Length of stay, direct cost per case, and ICU days were significantly less after the adoption of the STP, and ICU bed utilization was freed for acute admissions and transfers. There were no substantial complications or adverse patient outcomes in the STP group.

The Impact of Unmet Communication and Education Needs on Neurosurgical Patient and Caregiver Experiences of Care: A Qualitative Exploratory Analysis.

OBJECTIVE: To describe neurosurgical patient and caregiver perceptions of provider communication, the impact of patient education, and their understanding of information given to them throughout the neurosurgical care trajectory. METHODS: We organized focus groups composed of patients who had been hospitalized on the neurosurgical service at 5 urban academic tertiary referral hospitals within a large university health system, along with the patients' caregivers. During focus groups, we used semistructured questions to answer the study questions. Content analysis was used to analyze the data. RESULTS: Forty-three patients and caregivers took part in 5 focus groups. In total we identified 12 coding categories (or topics) that were associated with patient and family information needs. Despite the fact all patients were receiving care within the same health system, often with the same care team and clinical environments, their experiences often could not have been more different. We found stark variations in how patients and caregivers described the quality of communication and patient education they received that affected their satisfaction. Satisfied patients and caregivers generally felt well informed and reported good understanding of the clinical care plan throughout the perioperative course, whereas dissatisfied patients struggled with unanswered questions, unmet information needs, and a sense of confusion throughout their care experience. CONCLUSIONS: Our study describes several unmet needs, finds inconsistencies in how information is delivered and a lack of patient-centered and caregiver-centered approaches to communication. Neurosurgery groups should identify unmet needs at their institution and implement strategies and interventions to improve the patient and caregiver experience.

Caring Wisely: A Program to Support Frontline Clinicians and Staff in Improving Healthcare Delivery and Reducing Costs.

We describe a program called "Caring Wisely"®, developed by the University of California, San Francisco's (UCSF), Center for Healthcare Value, to increase the value of services provided at UCSF Health. The overarching goal of the Caring Wisely® program is to catalyze and advance delivery system redesign and innovations that reduce costs, enhance healthcare quality, and improve health outcomes. The program is designed to engage frontline clinicians and staff-aided by experienced implementation scientists-to develop and implement interventions specifically designed to address overuse, underuse, or misuse of services. Financial savings of the program are intended to cover the program costs. The theoretical underpinnings for the design of the Caring Wisely® program emphasize the importance of stakeholder engagement, behavior change theory, market (target audience) segmentation, and process measurement and feedback. The Caring Wisely® program provides an institutional model for using crowdsourcing to identify "hot spot" areas of low-value care, inefficiency and waste, and for implementing robust interventions to address these areas.

Changing Operating Room Culture: Implementation of a Postoperative Debrief and Improved Safety Culture.

BACKGROUND: Patient safety is foundational to neurosurgical care. Postprocedural "debrief" checklists have been proposed to improve patient safety, but data about their use in neurosurgery are limited. Here, we implemented an initiative to routinely perform postoperative debriefs and evaluated the impact of debriefing on operating room (OR) safety culture. METHODS: A 10-question safety attitude questionnaire (SAQ) was sent to neurosurgical OR staff at a major academic medical center before and 18 months after the implementation of a postoperative debriefing initiative. Rates of debrief compliance and changes in attitudes before and after the survey were evaluated. The survey used a Likert scale and analyzed with standard statistical methods. RESULTS: After the debrief initiative, the rate of debriefing increased from 51% to 86% of cases for the neurosurgery service. Baseline SAQ responses found that neurosurgeons had a more favorable perception of OR safety than did anesthesiologists and nurses. After implementation of the postoperative debriefing process, perceptions of OR safety significantly improved for neurosurgeons, anesthesiologists, and nurses. Furthermore, the disparity between nurses and surgeons was no longer significant. After debrief implementation, neurosurgical OR staff had improved perceptions of patient safety compared with surgical services that did not commonly perform debriefing. Debriefing identified OR efficiency concerns in 26.9% of cases, and prevention of potential adverse events/near misses was reported in 8% of cases. CONCLUSIONS: Postoperative debriefing can be effectively introduced into the OR and improves the safety culture after implementation. Debriefing is an effective tool to identify OR inefficiencies and potential adverse events.

The impact of a patient education bundle on neurosurgery patient satisfaction.

BACKGROUND: As reimbursements and hospital/physician performance become ever more reliant on Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) and other quality metrics, physicians are increasingly incentivized to improve patient satisfaction. METHODS: A faculty and resident team at the University of California, San Francisco (UCSF) Department of Neurological Surgery developed and implemented a Patient Education Bundle. This consisted of two parts: The first was preoperative expectation letters (designed to inform patients of what to expect before, during, and after their hospitalization for a neurosurgical procedure); the second was a trifold brochure with names, photographs, and specialty/training information about the attending surgeons, resident physicians, and nurse practitioners on the neurosurgical service. We assessed patient satisfaction, as measured by HCAHPS scores and a brief survey tailored to our specific intervention, both before and after our Patient Education Bundle intervention. RESULTS: Prior to our intervention, 74.6% of patients responded that the MD always explained information in a way that was easy to understand. After our intervention, 78.7% of patients responded that the MD always explained information in a way that was easy to understand. "Neurosurgery Patient Satisfaction survey" results showed that 83% remembered receiving the preoperative letter; of those received the letter, 93% found the letter helpful; and 100% thought that the letter should be continued. CONCLUSION: Although effects were modest, we believe that patient education strategies, as modeled in our bundle, can improve patients' hospital experiences and have a positive impact on physician performance scores and hospital ratings.