Subarachnoid Hemorrhage "Fast Track": A Health Economics and Health Care Redesign Approach for Early Selected Hospital Discharge

Christina I Collins; Tasneem F Hasan; Lesia H Mooney; Jessica L Talbot; Amanda L Fouraker; Katherine F Nelson; MaryAnn Ohanian; Stephanie L Bonnett; Rabih G Tawk; Lisa M Nordan; David O Hodge; Robert S Kaplan; Benjamin L Thiemann; Meredith Karney; William D Freeman

doi:10.1016/j.mayocpiqo.2020.04.001

Subarachnoid Hemorrhage "Fast Track": A Health Economics and Health Care Redesign Approach for Early Selected Hospital Discharge

Mayo Clin Proc Innov Qual Outcomes. 2020 Jun 5;4(3):238-248. doi: 10.1016/j.mayocpiqo.2020.04.001. eCollection 2020 Jun.

Authors

Christina I Collins¹, Tasneem F Hasan¹, Lesia H Mooney², Jessica L Talbot³, Amanda L Fouraker³, Katherine F Nelson⁴, MaryAnn Ohanian⁵, Stephanie L Bonnett⁶, Rabih G Tawk¹, Lisa M Nordan⁷, David O Hodge⁸, Robert S Kaplan⁹, Benjamin L Thiemann¹⁰, Meredith Karney¹¹, William D Freeman^{1

3

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Affiliations

¹ Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
² Department of Nursing, Mayo Clinic, Jacksonville, FL.
³ Department of Neurology, Mayo Clinic, Jacksonville, FL.
⁴ Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, FL.
⁵ Department of Radiology, Mayo Clinic, Jacksonville, FL.
⁶ Department of Radiology, Ultrasound, Mayo Clinic, Jacksonville, FL.
⁷ Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL.
⁸ Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL.
⁹ Accounting and Management, Harvard Business School, Boston, MA.
¹⁰ Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL.
¹¹ Center for Medical Interoperability, Nashville, TN.
¹² Department of Critical Care and Multidisciplinary Program, Mayo Clinic, Jacksonville, FL.

Abstract

Objective: To determine whether earlier hospital discharge is feasible and safe in selected patients with subarachnoid hemorrhage (SAH) using an outpatient "fast-track" protocol.

Patients and methods: We conducted a prospective quality improvement cohort study with the primary feasibility end point of patients with SAH deemed safe for discharge by treating team consensus. All patients received detailed education and outpatient transcranial Doppler monitoring; caregivers could contact the on-call team 24-7. Primary safety end points were adverse events after discharge and hospital readmission.

Results: From January 1, 2010, to January 1, 2015, our center had 377 SAH diagnoses, of which 200 were included in the final cohort, 36 qualifying for fast-track early discharge. The 30-day readmission rate for fast-track patients was 11.0% (4 of 36) compared with 11.4% (18 of 164) for non-fast-track patients. The rate of delayed cerebral ischemia and stroke was 3% (1 of 36) in the fast-track group vs 25.0% (41 of 164) for the non-fast-track group. Adverse events occurred in 11.0% (4 of 36) of the fast-track group compared with 26.0% (43 of 164) in the non-fast-track group. The mean length of stay was reduced 60% from 15 days to 6.6 days in the fast-track group.

Conclusion: Although our fast-track group was relatively small, data suggested early feasibility and safety in a carefully selected group of patients with SAH. Direct and indirect financial benefits of early discharge over a 5-year period were an estimated savings at least $864,000 in overall costs. A comparative effectiveness study is planned to replicate and validate these results using a larger multicenter design.

Keywords: DCI, delayed cerebral ischemia; ICU, intensive care unit; LOS, length of stay; MCA, middle cerebral artery; QI, quality improvement; SAH, subarachnoid hemorrhage; TCD, transcranial Doppler ultrasonography; TDABC, time-driven activity-based cost; WFNS, World Federation of Neurological Surgeons; mFS, modified Fisher scale.