Paving the Way for Quicker, Safer Discharges After Brain Surgery

Donato Pacione, MD.
Donato Pacione, MD.

Rushing back to the emergency room in the days after surgery is a traumatic experience, no matter how minor the reason. The fear is especially pronounced when that surgery involves a patient’s brain. 

“From a psychological standpoint, oftentimes the only thing [patients] end up remembering is that time they had to go back to the ER—even if the surgery was successful and everything went great,” said Donato Pacione, MD, a neurosurgeon and director of quality assurance for the Department of Neurosurgery at NYU Langone Health. “That hangs over them.” 

That anxiety-inducing visit—likely for easily fixable issues like taking medication incorrectly—can also spell trouble for the hospital, which is working hard to free up beds and resources in an often-overcrowded ER, Dr. Pacione added.  

But it turns out preventing such disruptions can be as simple as streamlining communication between doctor and patient. 

At NYU Langone Health, the number of patients readmitted to the ER after cranial surgery has dropped by more than half, from 6.9 percent to only 2.8 percent. This welcome change follows a new protocol introduced during Dr. Pacione’s project with United Hospital Fund and Greater New York Hospital Association’s Clinical Quality Fellowship Program. 

Dr. Pacione credits the drop to an overhaul of how and when patients were given information. 

“In the past, they got discharge instructions when they were getting ready to leave, and sometimes they didn’t understand some things,” said Dr. Pacione. He explained that patients are now shown discharge instructions before they go into surgery and are given a telehealth call on their first day home. “Doing this [new protocol], we all got together and said, ‘Okay, what are the things we really want to make sure we convey to them?’” 

The dip in readmission numbers is even more impressive when considering that Dr. Pacione’s project didn’t aim to tackle readmission directly. In fact, Dr. Pacione had expected readmissions might tick up while he focused on addressing another important factor in a patient’s recovery—how soon they can go home. 

Known as the Enhanced Recovery After Cranial Surgery (ERACS) pathway, the new post-surgery protocol Dr. Pacione introduced aimed to let patients leave the hospital in two days instead of the average four-day stay for craniotomies. It successfully brought the length of stay to an average of 1.8 days, a major win for both the hospital’s efficiency and patient experience. 

“Ever since COVID, we’ve obviously dealt with these surges of patient movement through the hospital, so freeing up those beds early has made a significant impact,” Dr. Pacione said. “[And] patients have obviously been happy about being able to go home earlier.”  

The new pathway relied largely on existing improvements to anesthesia practices and a recent switch from opiates to Tylenol, both of which meant patients could emerge from surgery and start physical therapy or other recovery steps earlier than before. Dr. Pacione had noticed that despite these improvements, doctors had still been waiting until the morning after an afternoon surgery to start mobilizing their patients, instead of starting that evening. 

“Nothing happened for that patient for 24 hours [after surgery],” Dr. Pacione said. “We felt like we could get ahead of that.” 

But perhaps the most important factor in the new pathway’s success was a deep dive into hospital data to show staff that reducing the length of stay could be done safely. The research found that complications requiring repeat surgery occurred in less than 2 percent of craniotomy patients, and, in cases when it did, the bleed happened within 36 hours of surgery. 

Since Dr. Pacione’s project, the ERACS pathway has expanded to NYU Langone’s Long Island hospital for craniotomy patients and has been used for other types of surgery, including lumbar spine procedures and endoscopic pituitary surgery. 

Its success also gained such attention that Dr. Pacione was tapped to evaluate all the hospital’s surgical subspecialties and look for areas where processes can be more streamlined.  

That review might not have happened if not for the Clinical Quality Fellowship Program, according to Dr. Pacione, who said it led him to consider his project with a hospital-wide lens. 

“Having people I could bounce ideas off of from nursing, from administration, from social work—it really helped me think about it in different perspectives,” he said. “If I was trying to embark on something like this before the fellowship, [that’s] something I would not have thought of.” 

Started in 2009, the 15-month Clinical Quality Fellowship Program has trained nearly 300 mid-career physicians, nurses, and physician assistants from over 50 health care facilities in the New York metropolitan area to become quality improvement and patient safety leaders in their organizations.