Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review.

The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.

Attribution: whose complication is it?

BACKGROUND: To improve quality, programs such as accountable care organizations need to determine the part of the health care system most "responsible" for a complication. This is referred to as attribution. This provides a framework to compare physicians for patients and third-party payers. Traditionally, the attribution of complications has been to the admitting physician. This may misidentify the physician "responsible" for the complication. This is especially difficult in trauma patients who have multiple providers. We hypothesized that the current mechanism for attributing complications in trauma patients is inadequate and will need to be modernized. METHODS: All trauma admissions during a 12-month period were reviewed. Patients with single-system trauma were excluded. We reviewed our trauma database for mechanism of injury, complications, and readmissions. The trauma director and the medical director of our accountable care organizations reviewed all complications and attributed them to the appropriate health care provider. These were compared with the hospital decisions using the traditional definition. RESULTS: The trauma service had 1,526 admissions. After exclusions, 1,019 patients were reviewed. One hundred twenty-five complications occurred in 73 patients. Using the traditional definition, the acute care surgery service was assigned all 125 complications. Using the trauma director and medical director method, the neurosurgical attending accounted for 36% (45 of 125) of complications. The acute care surgery attending was responsible for 34% (43 of 125) of complications, and orthopedic surgery was identified as the causative factor in 22% (27 of 125). The remaining 8% (10 of 125) were attributed to various other services. Seven patients had unexpected readmissions. Most (6 of 7) of these were related to orthopedics. CONCLUSION: Hospital complications are now being assigned to individual surgeons. Which physician is responsible for each complication will be a controversial matter. Without a critical review process with physician input, up to two thirds of complications could be attributed incorrectly. The attribution process needs to be refined. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

What's the hold up? Factors contributing to delays in discharge of trauma patients after medical clearance.

BACKGROUND: One area of potential savings in healthcare spending is the identification of nonmedical delays in discharge. The purpose of this study was to identify factors associated with discharge delays. METHODS: All patients admitted to our trauma center over a 1-year period with a social work consult were retrospectively evaluated to identify delays in discharge after medical clearance. RESULTS: Over half of our patients experienced a delay in discharge. Age was not associated with delay in discharge. Higher injury severity score, intensive care unit admission, and hospital length of stay greater than 1 week were all associated with increased delays in discharge. Other factors such as disposition to a rehabilitation/nursing facility and mechanism of injury were also associated with a nonmedical delay. CONCLUSIONS: We have identified nonmedical factors associated with delays in discharge. Strategies using these data could be used to improve discharge planning and may help decrease healthcare costs.