Unplanned returns to the operating room: a quality improvement methodology for the comparison of institutional outcomes to national benchmarks.

OBJECTIVE: Unplanned returns to the operating room (RORs) constitute an important quality metric in surgical practice. In this study, the authors present a methodology to compare a department's unplanned ROR rates with national benchmarks in the context of large-scale quality of care surveillance. METHODS: The authors identified unplanned RORs within 30 days from the initial surgery at their institution during the period 2014-2018 using an institutional documentation platform that facilitates the collection of reoperation information by providers in the clinical setting. They divided the procedures into 28 groups by Current Procedural Terminology and International Classification of Diseases, 9th and 10th Revision codes. They estimated national benchmarks of unplanned RORs for these procedure groups via querying the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) registry during the period 2014-2018. Finally, they numerically assessed the unplanned ROR rates at their institution compared with those calculated from the ACS NSQIP registry. RESULTS: Using the above methodology, the authors were able to classify 12,575 of the cases performed in their department during the period of interest, including 6037 (48%) cranial cases and 6538 (52%) spinal or peripheral nerve cases. Among those, 161 (1.3%) presented with complications that required an unplanned ROR within 30 days from the initial surgery. The respective cumulative unplanned ROR rate in the ACS NSQIP registry during the same timeframe was 3.6%. Among 15 categories of cranial procedures, the cumulative unplanned ROR rate was 1.3% in the authors' department and 5.6% in the ACS NSQIP registry. Among 13 categories of spinal and peripheral nerve procedures, the cumulative unplanned ROR rate was 1.3% in the authors' department and 2.8% in the ACS NSQIP registry. Unplanned ROR rates at the authors' institution were lower than the national average for each of the 28 procedure groups of interest. Yearly analysis of institutional ROR rates for the five most commonly performed procedures showed lower reoperation rates compared with the national benchmarks. CONCLUSIONS: Using an institutional documentation tool and a widely available national database, the authors developed a reproducible and standardized method of comparing their department's outcomes with national benchmarks per procedure subgroup. This methodology accommodates longitudinal quality surveillance across the different subspecialties in a neurosurgical department and may illuminate potential shortcomings of care delivery in the future.

Positive impact of the pandemic: the effect of post-COVID-19 virtual visit implementation on departmental efficiency and patient satisfaction in a quaternary care center.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has significantly changed clinical practice across US healthcare. Increased adoption of telemedicine has emerged as an alternative to in-person contact for patient-physician interactions. The aim of this study was to analyze the impact of telemedicine on workflow and care delivery from January 2019 to December 2021 in a neurosurgical department at a quaternary care center. METHODS: Prospectively captured data on clinic appointment utilization, duration, and outcomes were queried. Visits were divided into in-person visits and telemedicine appointments, categorized as follow-up visits of previously surgically treated patients, internal consultations, new patient visits, and early postoperative returns after surgery. Appointment volume was compared pre- and postpandemic using March 2020 as the pandemic onset. Clinical efficiency was measured by time to appointment, rate of on-time appointments, proportion of appointments resulting in surgical intervention (surgical yield), and patient-reported satisfaction, the latter measured as the proportion of patients indicating "high likelihood to recommend practice." RESULTS: A total of 54,562 visits occurred, most commonly for follow-up for previously operated patients (51.8%), internal new patient referrals (24.5%), and external new patient referrals (19.8%). Total visit volume was stable pre- to postpandemic (1521.3 vs 1512, p = 0.917). However, in-person visits significantly decreased (1517/month vs 1220/month, p < 0.001), with a nadir in April 2020, while telemedicine appointment utilization increased significantly (0.3% vs 19.1% of all visits). Telemedicine utilization remained stable throughout the 1st calendar year following the pandemic. Telemedicine appointments were associated with shorter time to appointment than in-person visits both before and after the pandemic onset (0-5 days from appointment request: 60% vs 33% vs 29.8%, p < 0.001). Patients had on-time appointments in 87% of telemedicine encounters. Notably, telemedicine appointments resulted in surgery in 31.8% of internal consultations or new patient visits, a significantly lower rate than that for in-person visits (51.8%). After the widespread integration of telemedicine, patient satisfaction for all visits was higher than before the pandemic onset (85.9% vs 88.5%, p = 0.027). CONCLUSIONS: Telemedicine use significantly increased following the pandemic onset, compensating for observed decreases in face-to-face visits. Utilization rates have remained stable, suggesting effective integration, and delays between referrals and appointments were lower than for in-person visits. Importantly, telemedicine integration was not associated with a decrease in overall patient satisfaction, although telemedicine appointments had a lower surgical yield. These data suggest that telemedicine smoothened the impact of the pandemic on clinical workflow and helped to maintain continuity and quality of outpatient care.

Initiation of a Robotic Program in Spinal Surgery: Experience at a Three-Site Medical Center.

OBJECTIVE: To highlight the early experience of implementing a robotic spine surgery program at a three-site medical center, evaluating the impact of increasing experience on the operative time and number of procedures performed. PATIENTS AND METHODS: A retrospective chart review of patients undergoing robotic screw placement between September 4, 2018, and October 16, 2019, was conducted. Baseline characteristics as well as intraoperative and post-operative outcomes were obtained. RESULTS: For a total of 77 patients, the mean age (SD) was 55.7 years (11.5) and 49.4% (n=38) were female. A total of 402 screws were placed (384 pedicle screws, 18 cortical screws) using robotic guidance with a median of two operative levels (interquartile range [IQR], 1 to 2). Median (IQR) estimated blood loss was 100 mL (50 to 200 mL) and the median (IQR) operative time was 224 minutes (193 to 307 minutes). With accrual of surgical experience, operative time declined significantly (R=-0.39; P<.001) whereas the number of procedures performed per week increased (R=0.30; P=.05) throughout the study period. Median (IQR) length of hospital stay following surgery was 2 days (IQR, 2 to 3 days). There were two screws requiring revision intraoperatively. No postoperative revisions were required, and no complications were encountered related to screw placement. CONCLUSION: Early experience at our institution using a spinal robot has demonstrated no requirement for postoperative screw revisions and no complications related to screw malposition. The increased operative times were reduced as the frequency of procedures increased. Moreover, procedural times diminished over a short period with a weekly increasing number of procedures.