Next presentation is by Sheena Weaver, Cost Savings Associated with the Introduction of a Standard Perioperative Protocol for Endoscopic Transploidal Pituitary Surgery, a Cost-Benefit Analysis. Good afternoon. I'm Sheena Weaver, and I represent a large, multidisciplinary group focused on efficiency, patient flow, patient safety, and cost savings at Vanderbilt University Medical Center. And I do not have any financial disclosures. The initial patient group that we focused on were pituitary patients undergoing endoscopic transploidal surgery. Six months prior to rollout of a standardized pathway, we determined key issues leading to inefficient processes using a root cause analysis, as you can see here in this fishbone diagram. Some of the areas of focus were in the preoperative clinic, and we worked on establishing standardized patient teaching forms, as well as standardizing patient expectations regarding length of stay and discharge processes. We also worked on standardized preoperative order sets, standard anesthetic management, as well as postoperative clinical management. We performed value stream mapping exercises illustrating current state and future state processes. Here you can see an illustration of our future state process in which we break down the patient's perioperative journey into distinct phases, preop, intraop, and then the postoperative days. Our most important outcome measures were ICU resource utilization and hospital length of stay. We compared 134 patients in the 21 months prior to rollout to 117 patients post rollout and found that their case mix index, which is basically the acuity of the patients, did not differ between groups. In the pre-rollout phase, the protocol was to admit all patients to the ICU postoperatively. But what we tried to do was reduce ICU resource utilization and so post rollout, we actually were able to drop that ICU utilization to only about 13% of our patients. And of note, all the patients that went to the floor immediately postoperatively, none of them bounced back to the ICU. Our mean ICU length of stay was 2.8 days pre-rollout and that dropped to less than one day post rollout. And then our mean hospital length of stay or our resource length of stay was dropped by a day. All of these were statistically significant. We also focused on the mean number of labs drawn per patient. And we were able to reduce those by almost five labs per patient. This has contributed to the cost savings as well. Our total variable costs, both intraoperatively and postoperatively, were more than $4,400 per patient. And you can see below what some of the variable direct costs might actually look like. These are basically expenses that we can control either by using less of something or maybe using something that costs less. So to further break down our cost savings, as I said, the average cost savings per patient was more than $4,400. You can see here that almost 50% of these savings come from the fact that these patients no longer were admitted to the ICU postoperatively. So you see here we have ICU room and board and then the critical care professional fees making up about 50% of our cost savings. Some of these other cost savings can be explained such as here our intraoperative professional fees most likely are linked to the fact that we no longer routinely place arterial lines on these patients. Our chargeable and nonchargeable fees may stem from the fact that we no longer routinely place Foley catheters in our patients intraoperatively. And then here you can see the inpatient professional fees. Those are most likely linked to the fact that the endocrinologist does not actually see the patient for that additional day. So again, a lot of the changes that we made are linked to quite a bit of cost savings. If you want to annualize our reduction in resource utilization, say we average about 100 patients per year in this patient population, we would save greater than $440,000. We would return almost 140 inpatient bed days to the hospital and almost 200 ICU bed days. And again, we had a pretty significant reduction in the avoidable laboratory tests that we were drawing on the patients. Although we were very pleased to see that our average length of stay was 40% lower than the national average before we even started, which has been stagnant for the prior several years, we were excited to see that we could reduce it even further by applying this standardized pathway. In summary, although there is room for improvement in efficiency and cost savings for this particular patient subpopulation nationwide, application of a standardized multidisciplinary perioperative pathway can be successful. We've shown that we can improve efficiency and avoid ICU resource utilization without compromising patient safety. Preliminarily, we were able to show that we've seen no significant change in our readmission data nor in our complication data. Overall, we're very pleased with our results and thankful to have such a collegial group working on the betterment of patient care. Thank you. Actually, we've caught up a little, so we have time for a question. Perfect. May you? I guess. So the major costs associated with pituitary surgery are whether or not you develop CSF leak or diabetes insipidus. What were your rates for each of those in your cohort study? So we don't have that data quite yet. We actually had the unfortunate transition of an entire electronic health record between pre and post rollout. And so we're currently trying to look through two different systems to try and kind of coordinate that data. So until you can robustly show that you can manage those issues under your new paradigm, you really haven't shown it. So that still needs to be done. Right. I agree. Any other questions? Okay.

cost-benefit analysis

perioperative protocol

endoscopic transsphenoidal pituitary surgery

ICU resource utilization

length of stay