Initial Assessment of the Risk Assessment and Prediction Tool in a Heterogeneous Neurosurgical Patient Population.

BACKGROUND: Bundled care payments are increasingly being explored for neurosurgical interventions. In this setting, skilled nursing facility (SNF) is less desirable from a cost perspective than discharge to home, underscoring the need for better preoperative prediction of postoperative disposition. OBJECTIVE: To assess the capability of the Risk Assessment and Prediction Tool (RAPT) and other preoperative variables to determine expected disposition prior to surgery in a heterogeneous neurosurgical cohort, through observational study. METHODS: Patients aged 50 yr or more undergoing elective neurosurgery were enrolled from June 2016 to February 2017 (n = 623). Logistic regression was used to identify preoperative characteristics predictive of discharge disposition. Results from multivariate analysis were used to create novel grading scales for the prediction of discharge disposition that were subsequently compared to the RAPT Score using Receiver Operating Characteristic analysis. RESULTS: Higher RAPT Score significantly predicted home disposition (P < .001). Age 65 and greater, dichotomized RAPT walk score, and spinal surgery below L2 were independent predictors of SNF discharge in multivariate analysis. A grading scale utilizing these variables had superior discriminatory power between SNF and home/rehab discharge when compared with RAPT score alone (P = .004). CONCLUSION: Our analysis identified age, lower lumbar/lumbosacral surgery, and RAPT walk score as independent predictors of discharge to SNF, and demonstrated superior predictive power compared with the total RAPT Score when combined in a novel grading scale. These tools may identify patients who may benefit from expedited discharge to subacute care facilities and decrease inpatient hospital resource utilization following surgery.

The Benefits of Implementing an Early Mobility Protocol in Postoperative Neurosurgical Spine Patients.

: Background: Despite the known benefits of early postsurgical mobility, there are no clear recommendations on early mobility among uncomplicated postoperative neurosurgical spine patients. PURPOSE: The purpose of this quality improvement initiative was to establish an NP-led early mobility protocol to reduce uncomplicated postsurgical spine patients' length of stay (LOS) in the hospital and eliminate the variability of postsurgical care. A secondary objective was to educate and empower nursing staff to initiate the early mobility protocol independently and incorporate it in their practice to improve patient care. METHODS: Two neurosurgery NPs led an interprofessional team to develop the early mobility protocol. Team members provided preadmission preoperative education to communicate the necessity for early mobility and provide information about the protocol. New nursing guidelines called for patient mobility on the day of surgery, within six hours of arrival on the medical-surgical unit. Nurses were empowered to get patients out of bed independently, without a physical therapy consultation; they also removed urinary catheters and discontinued IV opioids when patients' status permitted. RESULTS: Over a one-year period, implementation of the protocol resulted in a nine-hour reduction in LOS per hospitalization in neurosurgical spine patients who underwent lumbar laminectomies. The protocol also allowed nurses more autonomy in patient care and was a catalyst for patient involvement in their postoperative mobility. Given the success of the protocol, it is being replicated by other surgical services throughout the organization. CONCLUSIONS: This low-cost, high-reward initiative aligns with the strategic plan of the organization and ensures that high-quality, patient-centered care remains the priority. NPs in other institutions can modify this protocol to promote postoperative mobility in their organizations.