Our next abstract, which will be presented by Jennifer Viner, NP, Pathway for Emitting ICU Level of Care Following Craniotomy for Resection of Supratetorial Brain Tumors. The author block is Michael McDermott, Joseph Osorio, Michael Safie, and Stephen McGill. Thank you. Thank you for the opportunity for being here today to present our work that we have underway at UCSF. Essentially, it's a program that we've developed that is bypassing services of the neurointensive care unit following craniotomy surgery in patients with safe, predictable post-operative courses. So, I am the recipient of an internal grant at UCSF known as the Caring Wisely Grant, and this is a fund that aims to support frontline providers at reducing direct health care costs. So, I have carried this grant for the last year. So, the background to the problem is that, historically, the culture at UCSF has been that all post-operative craniotomy patients would board in the neuro-ICU post-operatively. They would spend one night there before going to a lower level of care, typically the next day. And the problem with that is that this mandatory ICU placement creates a bottleneck within our system. In turn, a domino effect on throughput of cases, often causing OR delays and sometimes cancellations. So, very unhappy neurosurgeons. This was all in the context of a growing disparity of patient acuity within our ICU, where I could have a very well post-operative tumor patient eating a hamburger on their cell phone, complaining about noise across the hall from an organ donor patient who has already suffered brain death waiting to go for organ harvest, or a very sick subarachnoid hemorrhage patient in vasospasm on triple pressers, intubated. So, things just didn't match within our ICU. We also built a new children's hospital, Mission Bay, and that opened up 20 beds for a neurotransitional care unit to expand. So, things kind of happened at the same time in 2016. So, we proposed a solution to trial sending certain post-operative craniotomy patients from the operating room instead to the PACU, and then once they met the standard discharge criteria from PACU, go to this new neurotransitional care unit. The only difference in level of monitoring would be instead of having hourly neurochecks and vital signs, it would be done on an every two-hour basis. The patients would still be maintained on telemetry and continuous pulse oximetry, and that would be the only change. So, just a flow chart of the historical practice, and then with the new practice. We've branded this program internally as the Safe Transitions Pathway Program, and you might see the acronym STP throughout the presentation. It's just the name of the program internally. So, we thought that the advantages would be, well, for the patient first all, they'd have a more restful environment, they'd be able to mobilize sooner, have their family members stay at the bedside for that first night, which always created a lot of stress, there'd be less delays in care, they wouldn't be waiting to transfer out of the ICU, and there would be less disruptions because of improved sleep, privacy, and maybe even an ability to reduce delirium risk. And the value was very apparent right away. We know at our institution the cost differential between an ICU bed and a transitional care unit bed is $1,500 per day. And then there's also that priceless cost of being able to admit a very sick patient from the community because they had access to an ICU bed at our institution. We thought that this would improve the throughput and maybe even improve patient and nurse satisfaction because these nurses were getting boarded with a lot of medicine patients. That was the problem. So, on the left is an example of a typical neuro-ICU bed at UCSF. Pretty standard, very sterile environment, separated by closing glass doors, so not a lot of privacy, nurse right outside the room. And then on the right is the neuro-transitional care unit bed. It's an actual room with a door that opens and closes, a bathroom in the room, room for a pull-out chair for the family member to sleep, a sleep chair. And then there is a monitor in the room, but it doesn't beep in the room. It beeps at the central nursing station so the patients aren't disrupted with the constant noise. So, Dr. McDermott is the attending surgeon that I work for. He's a senior cranial neurosurgeon and I'm his nurse practitioner. And starting in August 2016, we developed a set of selection criteria to enroll patients. And we started off by putting through very simple, conservative, small, convexity, meningioma patients. And very quickly, he became very excited with the program and started putting through some more complicated patients, which is why you'll see a very large glioma down below. But all of the tumors were supratentorial in location. They all had a very short OR time of less than five hours, minimal blood loss, age ranges were anywhere from 29 years old to 75 years old, and they were all discharged home between post-up day one and four, with the majority of them going home on post-up day two. Here's a basic timeline of the work that we've done to date. Since that initial pilot in August, we had buy-in from other cranial surgeons, so now we're also doing other procedures like Chiari decompression, microvascular decompression, with this same workflow. Because we have this Caring Wisely grant, we take priority with IT builds, and that's been a big success in propelling the work forward. A lot of moving pieces to get a program like this up and running, a lot of people involved along the way, communication being really important. For the first many patients, we told them that this was a different model that we were trying. We were very honest with them, and we had to work really hard to prepare the nurses to accept these patients sooner in their level of care. So for the transitional care unit nurses, making them feel very confident, reinforcing neuro-education with them. Our PACU nurses, although they had always had shunt patients come to them and pituitary tumors come to them, they were still nervous about the program initially. So we spent a lot of time working with them and educating them. We had to develop workflows specific to all the team members. So for the surgeons, so they remember how to book the case. The residents, so they remember how to order the standard post-operative orders for them. And our nurse practitioners were critical to advocate for the program. We prepared the patients also by developing some pamphlets that illustrated a day-by-day of what they'll expect. The EPIC systems were really instrumental to keep things flowing on a day-to-day basis. And unfortunately at this time, everyone in the hospital is still reliant on me sending a weekly email of all the patients coming through, because it's still not a standard workflow at our hospital. We're in the process of changing. But things are coming along nicely now. We're tracking patient satisfaction, nurse satisfaction, outcomes, including length of stay, cost, and any adverse outcomes. This is an example of a poster in our clinician's room when the surgeon's booking a case. He or she is prompted of the eligibility criteria. If someone hasn't participated yet, we recommend they be a little bit more conservative until they're comfortable with the program. So a supratentorial tumor or Chiari microvascular decompression or arachnoid cyst decompression. They might want to start off small with a tumor less than three centimeters, a relatively young patient, less than 65, and an anticipated OR course that is straightforward. No major medical problems that would warrant ICU. And if at any time along the continuum they change their mind, we fully support that and tell them you can change your mind at any time and revert back to the traditional pathway of ICU. This is a group shot of our team. The nurse practitioners have been great because they've been rounding in the PACU, making a big presence on the transitional care unit. So the nurses feel very supported with this program. They know who to call. So historically we rarely would go to the PACU, but now we have a very big presence there to support. An example of posters floating around the PACU, the transitional care unit, really branding this new program so people have awareness of it. And on the right is an example of an OR visibility screen that shows in real time where the intended post-operative destination is now for every patient. That was a very important build because unfortunately we did have one case that didn't go through the pathway simply because the surgeon forgot warning of and then everyone else forgot based on the email I had previously sent out. So this was a really good help. And every institution will have their little nuances of how to make something like this work. These are some examples of the pamphlets that we've created and it supports the patient's expectation. Most specifically we tell them that we expect they're going to go home on post-update two. So that's been very helpful to set that expectation up front. We continue to grow our numbers month to month. The April numbers are a little shy because they didn't capture this week's discharges, but we continue to grow upward of 14-15 cases a month now. So to date our measurement, we've had 87 patients, actually more 91 with this week, go through the pathway successfully. Majority of them being supratentorial tumors of either glioma, metastases, or meningiomas, but also a fair holding in Chiari decompressions and microvascular decompressions. The others might be a biopsy for a brain abscess, open crani for biopsy, something like that. Of all the eligible patients just based off of procedure code and age, we think that right now we're putting through about 20 percent of eligible patients through this new pathway. And as more surgeons are buying in, we're going to see a rise in this. I've highlighted our shortcomings. The three cancellations, one because the team forgot the day of to put them through, one because there was an intraoperative complication. So although they had been booked to go through the pathway, it got canceled intraop. One because of Chiari decompression was taking longer in the OR to perform, so the surgeon canceled that one as well. And then in one tumor patient, the patient had bradycardia triggered from nausea and vomiting, secondary to the anesthetic. And so while they were on the transitional care unit, we actually did escalate them, but to a cardiac ICU to be paced. So it wasn't a neurological problem, it was a cardiac monitoring reason that they escalated in care. So measurement, we've reduced post-operative length of stay by more than a quarter of a day. We've saved the medical center at this time now, it's actually more than a hundred ICU days because when we calculated it, it turns out the patients weren't just spending that first night in the ICU. On average, they were spending 1.13 days in the ICU. And just of note, these patients are spending on average about an hour and a half in the PACU before going to the transitional care unit. This is our money slide. We only have the first two quarters of the fiscal year highlighted right now, but we've already saved the medical center more than $130,000 in direct costs per case. And it's astronomical, it's actually been a 25% reduction per case from just under $20,000 to just over $15,000. And these numbers actually fluctuate, we've seen better savings with our tumor patients. The Chiari patients don't necessarily go home sooner, but they're still, you know, opening up ICU beds and it's still probably the right thing to do. A lot of lessons learned. Culture change is very slow. Executive leadership is critical. This is a team approach between many different levels of nursing and physicians and IT, bed control. IT modifications, although we can envision them easily, they're not always possible to create or they take time to build. You require the ongoing participation of your key stakeholders. And in order to sustain this type of a program, you really need to build a consensus now over a new norm. This week in JNS Focus, we have our first article that will be printed and it's going to highlight those very, very first steps that we took in order to create that pilot and get everyone in the institution on board. I'm expecting within the next few months we'll have a follow-up article with that first year of all of the numbers and looking forward to seeing what that's going to be. A big team, a lot of moving parts, a lot of people helping, particularly my attending neurosurgeon Dr. McDermott. You know, everyone refers to him as having been the guinea pig in doing this because he took that risk of it being his patients to go through. Our nurse practitioners have been the best advocates for the program and then this Caring Wisely team who are really, you know, behind the scenes helping with all the data collection and analytics have been really helpful. That's it. Any questions? Thank you.

UCSF

Safe Transitions Pathway Program

ICU bed bottlenecks

patient satisfaction

procedure outcomes