TABLE 2.
Results of selective protocols and care pathways designed to bypass overnight admission to the ICU
| Authors & Year | Methodology | No. of Cases (focus of study) | Pathway Criteria | Protocol | ICU Time Reduction per Patient (days) | LOS Reduction (days) | ICU Admissions/Transfers | Cost Savings per Patient | Pathway Readmission | Comparison Group | Comparison Findings |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Present study | Retro cohort | 202 (adult brain tumor resection) | Supratentorial craniotomy for brain tumor/SDH, infratentorial craniotomy for CM/MVD, op time <5 hrs, EBL <500 ml | 4-hr obs in PACU w/ neurological checks q hr, then transfer to floor | 0.95 | 0.7 | 3.4% | $13,448 | 19% (30-day, includes ER visits) | Historical controls | Decreased time to MRI, time to PT, LOS, & hospital charges for pathway |
| Vallejo et al., 202211 | Single-surgeon prospective cohort | 37 (adult brain tumor resection) | supratentorial brain tumor <4 cm, op time <3 hrs, EBL <300 ml, start time before 8:30 am | 3-hr obs in PACU, then MRI, then 3-hr ICU monitoring, then PT evaluation, then discharge | - | - | 0.0% (14.0% admitted to floor) | - | 11% | - | - |
| Young et al.,20216 | Case control | 94 (adult brain tumor resection, MVD, & CM) | Age <65 yrs, supratentorial craniotomy for brain tumor <3 cm, infratentorial craniotomy for CM/MVD, case length <6 hrs, EBL <500 ml | 4-hr obs in PACU w/ neurological checks q 2 hrs, then transfer to floor | 1 | 0.25 | 0.0% | $4,000 | 1% (30-day) | Concurrent patients | Decreased LOS & hospital charges for pathway |
| Laan et al., 202027 | Retro cohort | 109 (adult brain tumor resection) | Su supratentorial craniotomy for brain tumor, op time <6 hrs | Routine admission to ward unless surgery >6 hrs or significant cardiopulmonary comorbidities | 0.2 | 1.0 | 24.0% | €1,953 | Historical controls | Decreased ICU LOS, periop complications, & hospital charges for pathway | |
| Mirza et al.,201 828 | Retro cohort | 355 (adult & pediatric brain tumor resection) | Supratentorial craniotomy for intraaxial brain tumor | 2- to 4-hr obs in PACU, then transfer to floor | - | - | 0.1% | - | - | - | - |
| Florman et al., 20175 | Retro cohort | 200 (adult brain tumor resection & biopsy) | Supratentorial craniotomy for brain tumor | 4-hr obs in PACU w/ transfer to floor | - | 4.0 | 2.5% | - | - | Concurrent patients | Decreased LOS & increased likelihood of discharge home for pathway |
| Venkatraghavan et al., 20167 | Single-surgeon retro cohort | 198 (adult brain tumor resection) | Supratentorial craniotomy for brain tumor, op time <4 hrs, caregiver ability overnight w/in 1 hr of hospital | 2-hr obs in PACU, CT scan 4 hrs postop, 2-hr obs in day surgery unit | - | - | 0.0% (11.6% admitted to floor) | - | 3% | - | - |
| Bui et al., 201129 | Retro cohort | 394 (adult brain tumor resection & biopsy, ventriculostomy, & vascular lesion management) | Supra- & infratentorial brain tumor, pituitary tumors, hydrocephalus treated w/ETV | 2- to 3-hr obs in PACU, then 6-hr obs on floor w/ neurological & vital sign checks q hr, then routine floor care | - | 2.9 | 13% (2% planned, 11% unplanned) | - | - | - | - |
| Boulton & Bernstein, 200830 | Single-surgeon retro cohort | 145 (adult brain tumor resection) | Supratentorial craniotomy fo r intraaxial brain tumor | RoRoutine admission to PACU w/ plan for discharge home PODO | - | - | - | - | - | - | - |
| Beauregard & Friedman, 20034 | Single-sugeon retro cohort | 132 (adult brain tumor resection & TN) | Su supra- & infratentorial brain tumor, pituitary tumors, TN | Routine floor admission | - | 3.3 | - | $4,026 | - | Concurrent patients of other attending surgeons | Decreased LOS & hospital charges for pathway |
| Gabel et al.,201631 | Retro cohort | 61 (pediatric brain tumor resection) | Susupra- & infratentorial craniotomy for brain tumor | Routine floor admission | - | - | 9.8% | - | - | - | - |
CM = Chiari malformation; ER = emergency room; ETV = endoscopic third ventriculostomy; MVD = microvascular decompression; obs = observation; POD = postoperative day; q = every; retro = retrospective; SDH = subdural hematoma; TN = trigeminal neuralgia.