Background There is a paucity of literature regarding the implementation of enhanced recovery after surgery (ERAS) protocols for open lumbar spine fusions. We implemented an ERAS program for 1–2-level lumbar spine fusion surgery and identified areas that might benefit from perioperative interventions to improve patient satisfaction and outcomes. Methods This institutionally approved quality improvement (QI) ERAS program for lumbar spine fusion was designed for all neurosurgical patients 18 years and older scheduled for 1 or 2 level primary lumbar fusions. The ERAS bundle contained elements such as multimodal analgesia including preoperative oral acetaminophen and gabapentin, postoperative early mobilization and physical therapy, and a prophylactic multimodal antiemetic regimen to decrease postoperative nausea and vomiting. No fluid management or hemodynamic parameters were included. Pre-ERAS and post-ERAS data were compared with regard to potential confounders, compliance with the ERAS bundle, and postoperative outcomes. Results A total of 230 patients were included from October 2013 to May 2017. The pre-ERAS phase consisted of 123 patients, 11 patients during the transition period, and 96 serving as post-ERAS patients. The pre-ERAS and post-ERAS groups had comparable demographics and comorbidities. Compliance with preoperative and intraoperative medication interventions was relatively good (~ 80%). Compliance with postoperative elements such as early physical therapy, early mobilization, and early removal of the urinary catheter was poor with no significant improvement in post-ERAS patients. There was no significant change in the amount of short-acting opioids used, but there was a decrease in the use of long-acting opioids in the post-ERAS phase (14.6 to 5.2%, p = 0.025). Post-ERAS patients required fewer rescue antiemetic medications in the recovery room compared to pre-ERAS patients (40 to 24%). There was no significant difference in postoperative pain scores or hospital length of stay between the two groups. Conclusions Implementing an ERAS bundle for 1–2-level lumbar fusion had minimal effect in decreasing length of stay, but a significant decrease in postoperative opioid and rescue antiemetic use. This ERAS bundle showed mixed results likely secondary to poor ERAS protocol compliance. Going forward, this QI project will look to improve post-operative ERAS implementation to improve patient outcomes.

Most current awake craniotomy techniques utilize unnecessarily complicated airway management, and cause discomfort to the patients during the awake phase of the surgery. Our manuscript is written to discuss the neurosurgical and anesthetic techniques that we have developed to optimize awake craniotomy techniques at Stony Brook University Medical Center. We used the frameless Brainlab TM skull-mounted array for stereotactic navigation. Rigid fixation of the skull was avoided. General anesthesia with established airway was used during the ''asleep" phase of the surgery. Following the removal of the bone flap and the opening of the dura, the patients were woken up, and the established airway was removed. Cortical mapping was performed to establish a safe entry zone for tumor removal. While the tumors were being removed, we continued motor examination and casual conversation with the patients to ensure safety. Patients were sedated during the remaining phase of the surgery until skin closure. No patient exhibited any neurological deficits or adverse anesthesia outcomes during the postoperative period. The protocol we developed avoids rigid skull fixation and emphasizes flexible intraoperative planning, thereby maximizing patient and physician comfort while allowing for successful tumor resection.

Background and Purpose: Several years ago, an excel spreadsheet was created to improve real time communication about stroke core measure compliance to all the inpatient units. This daily spreadsheet was sent to the nursing leadership to be shared with the nurse or MD to ensure the stroke orders were carried out and patient education provided. The process to review each chart daily for compliance with the core measures, enter it into the spreadsheet, send it to the nursing leadership daily took approximately 3 hours or more a day. This was not an efficient use of time. We decided to create an electronic dashboard that would extract all of the stroke core measure information from the electronic patient record automatically, eliminating manual abstraction, thus making the process more efficient while allowing effective communication throughout the organization. Methods: Our IT department, working alongside our Stroke Care Team, developed data extraction processes pertinent to Stroke Core Measures to allow for an hourly extraction into a Tableau dashboard. This software allows for logic to be applied to the various elements to evaluate the successful completion of each core measure for patients currently admitted to our institution for Stroke-related diagnoses and conditions. Results: The key stake holders for each unit review the dashboard which is refreshed hourly to identify areas that have not met the measure. After the review, the leadership implements a plan to improve attainment for these measures. The dashboard has also allowed for correction of documentation in real time but has limitations because it depends on the data within the electronic medical record and the programing to extract that data. The team communicates with our IT department to correct the issues with the data displayed in tableau. Conclusions: The tableau dashboard is an effective and efficient tool providing a snapshot of the current attainment of the primary and comprehensive stroke core measures. The implementation of this dashboard has increased awareness of the stroke core measure compliance and has improved communication among the clinical staff.