151. Factors causing delay in discharge in patients eligible for ambulatory lumbar fusion surgery

Abstract

<h3>BACKGROUND CONTEXT</h3> Assessing postoperative system inefficiencies and implementing process-improvement measures are vital to increase the feasibility of ambulatory lumbar fusion. <h3>PURPOSE</h3> Primary objective was to identify patients who would have been eligible for same-day discharge following minimally invasive elective lumbar fusion and then analyze the limiting factors in their postoperative pathway that led to a delay in discharge. Secondary objective was to assess if patient characteristics and operative variables had an impact on postoperative parameters influencing discharge. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of prospectively collected data. <h3>PATIENT SAMPLE</h3> Consecutive patients undergoing primary single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative conditions of the lumbar spine who would have been eligible for ambulatory lumbar fusion. <h3>OUTCOME MEASURES</h3> Postoperative in-hospital variables including 1) length of stay (LOS), 2) time in post-anesthesia recovery unit (PACU), 3) alertness check, neurological exam and pain scores at 3 hours and 6 hours, 4) type of analgesia, 5) time to physical therapy (PT) visit and clearance, 6) reasons for PT non-clearance, 7) time to per-oral (PO) intake, 8) time to voiding, 9) time to readiness for discharge, and 10) complications. <h3>METHODS</h3> Eligibility criteria for ambulatory lumbar fusion and discharge criteria were determined a priori based on a review of the literature and the authors' experience. Preoperative, surgical and postoperative in-hospital data were analyzed. Time taken to meet each discharge criterion was calculated. Time of discharge readiness was taken as the point when the patient had fulfilled all the criteria. The percentage of patients meeting each discharge criterion at 3 hours and 6 hours post-surgery was calculated. Correlation and regression analyses were performed to study the effect of postoperative variables on LOS. Multiple linear and logistic regression analyses were performed to study the effect of preoperative and operative variables on postoperative parameters influencing discharge. <h3>RESULTS</h3> A total of 71 patients were included of which only 4% were discharged on the same day. Most (69%) patients were discharged on postoperative day one. PT clearance, voiding and PO intake were the last-met discharge criterion in 93%, 6% and 1% of patients respectively. A total of 66% of patients did not get a PT evaluation on the day of surgery. Intravenous (IV) opioids for pain control (average of 2 doses) were required for 76% of patients. Less than 60% of patients had adequate pain control at 3 hours and 6 hours after the surgery. Orthostatic intolerance was seen in 27% of patients. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analyses showed that postoperative variables (time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at 3 hours) had a significant effect on LOS. There was no effect of preoperative and operative variables on postoperative parameters influencing discharge. <h3>CONCLUSIONS</h3> Unavailability of PT, orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge in patients eligible for ambulatory lumbar fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.