Enhanced Perioperative Care for Major Spine Surgery

Armagan Dagal, MD, FRCA, MHA; Carlo Bellabarba, MD; Richard Bransford, MD; Fangyi Zhang, MD; Randall M. Chesnut, MD, FCCM, FACS; Grant E. O'Keefe, MD, MPH; David R. Wright, BM, FRCA; Timothy H. Dellit, MD; Ian Painter, PhD; Michael J. Souter, MB, ChB, DA, FRCA, FNCS


Spine. 2019;44(13):959-966. 

In This Article

Abstract and Introduction


Study Design: The enhanced perioperative care (EPOC) program is an institutional quality improvement initiative. We used a historically controlled study design to evaluate patients who underwent major spine surgery before and after the implementation of the EPOC program.

Objective: To determine whether multidisciplinary EPOC program was associated with an improvement in clinical and financial outcomes for elective adult major spine surgery patients.

Summary of Background Data: The enhanced recovery after surgery (ERAS) programs successfully implemented in hip and knee replacement surgeries, and improved clinical outcomes and patient satisfaction.

Methods: We compared 183 subjects in traditional care (TRDC) group to 267 intervention period (EPOC) in a single academic quaternary spine surgery referral center. One hundred eight subjects in no pathway (NOPW) care group was also examined to exclude if the observed changes between the EPOC and TRDC groups might be due to concurrent changes in practice or population over the same time period. Our primary outcome variables were hospital and intensive care unit lengths of stay and the secondary outcomes were postoperative complications, 30-day hospital readmission and cost.

Results: In this highly complex patient population, we observed a reduction in mean hospital length of stay (HLOS) between TRDC versus EPOC groups (8.2 vs. 6.1 d, standard deviation SD = 6.3 vs. 3.6, P < 0.001) and intensive care unit length of stay (ILOS) (3.1 vs. 1.9 d, SD = 4.7 vs. 1.4, P = 0.01). The number (rate) of postoperative intensive care unit (ICU) admissions was higher for the TRDC n = 109 (60%) than the EPOC n = 129 (48%) (P = 0.02). There was no difference in postoperative complications and 30-day hospital readmissions. The EPOC spine program was associated with significant average cost reduction—$62,429 to $53,355 (P < 0.00).

Conclusion: The EPOC program has made a clinically relevant contribution to institutional efforts to improve patient outcomes and value. We observed a reduction in HLOS, ILOS, costs, and variability.

Level of Evidence: 3


Harborview Medical Center's Enhanced Peri-Operative Care (EPOC) program is a multidisciplinary quality improvement initiative to optimize the hospital course of surgical patients to improve outcomes, reduce complications, and cost. The EPOC care pathways accentuate the importance of coordinated, timely, and specialized clinical care of the hospitalized patient. The EPOC program aims to create standardization in care delivery and reduction in unnecessary variation, while allowing for individualized care through appropriate preoperative assessment, optimization, and advanced planning.[1] The EPOC program can be consequently seen as a local platform for the implementation of initiatives such as enhanced recovery after surgery (ERAS). ERAS is an established evidence-based approach designed to accelerate recovery from surgery. It helps to reduce the surgical stress response and unnecessary variability through consistent delivery of evidence-based care in every patient. Since it was first reported in 1997, the ERAS concept has been successfully applied to many surgical disciplines.[2–7]

Longitudinal trends in spine surgery indicate an increasing frequency and cost associated with degenerative spine disease care, coupled with changing patient demographics.[8,9] Chronic opioid use and aging population with increasing medical complexity leads to significant cause of long-term disability, hospitalization, and utilization of social and health care services, producing a major economic burden upon health care resources.[10–18] Diminished functional reserves and inadequately managed chronic disease states further delay recovery, increasing the risk of surgical complications, and frequency of readmissions from complex spinal reconstruction procedures.[19–21]

At our institution, before the introduction of the EPOC spine pathway, traditional care delivery was highly variable. Patients were fasted from midnight on the day of surgery and had delayed oral intake postoperatively. Patient management was at the discretion of the surgical and anesthesia providers. Perioperative multimodal analgesia was not routine. Intraoperative fluid administration was based on observation of blood loss and changes in hemodynamics and urine output. Early mobilization, feeding and urinary catheter removal were unscheduled and unusual occurrences. Patients were distributed to available beds around the hospital. There was lack of consensus on management, education, and a variable approach to documentation (Figure 1).

Figure 1.

Mean hospital length of stay. EPOC indicates enhanced perioperative care; HLOS, hospital length of stay; TRDC, traditional care.

The successful application of ERAS programs to high volume orthopedic surgeries such as hip and knee replacements, has already provided evidence of both improved clinical outcomes and patient satisfaction.[22–28] Therefore, we identified major spine surgery patients as ideal candidates for the application of coordinated care pathways targeted at restoration of function.

To our knowledge, our study is the first description of the application of multidisciplinary enhanced perioperative care pathways to major elective spine surgery. The purpose of this study was to determine whether our EPOC program was associated with a clinical and financial improvement in elective adult major spine surgery patient outcomes.