Towards the development of an enhanced recovery after surgery protocol for elective spine surgery

Abstract

Patients who receive spine surgery are subject to significant pain and disability following surgery. Following surgery, length of stay (LoS) is mutually problematic for patients and healthcare systems alike, as each day in hospital increases a patient’s risk for adverse events and also represents significant financial burden for healthcare systems. Enhanced recovery after surgery (ERAS) protocols have been shown to be able to reduce LoS without increasing patient risk for re-admission to hospital. While ERAS protocols are well established in many surgical fields, ERAS is relatively novel in spine. This dissertation used a mixed methods approach to develop an ERAS protocol for elective spine surgery at the QEII hospital in Halifax, Nova Scotia. A protocol was developed alongside an expert in enhanced recovery and stakeholders who provide care for spine surgery patients. Following this, a systematic review was performed to examine the efficacy of ERAS in spine, observing a reduction in LoS by 1 day after implementing an ERAS protocol. However, most studies included were subject to serious risk of bias due to confounding. Locally, we wanted to identify what factors most frequently prevent spine surgery patients from being discharged from hospital. Issues related to mobilization, urinary retention and pain management were the most common reasons patients remained in hospital. By targeting these issues through an ERAS protocol, LoS could be reduced. Lastly, patient education was studied through both a qualitative approach with patients with lived experience with surgery, as well as through a review of the literature and throughout Canada to identify how other surgical sites provide spine ERAS education. A series of discussion groups covered how education could optimally be provided. Patients reported a strong preference for personalized education, however, were open to a multimodal approach to education delivery due to the difficulty of providing personalized education. In the literature, few studies elucidated what ERAS education entailed, or how it was even provided. In Canada, only the Vancouver General Hospital was identified to have a spine ERAS program and used a multimodal approach to education. They provided education via online booklets and in person classroom-style sessions.