Download For patient selection criteria please refer to: http://www

The OSU Wexner Medical Center: Spine Clinical Pathway
Pre-Admit
Pre-Procedure
Page 1 of 4
Peri-Op
Day of Surgery
POD 1
POD 3
POD 2






Desired Patient
Outcomes







Testing completed, results obtained
by scheduled OR time
Patient verbalizes understanding of
patient education manual
Personalized risk reduction plan
Patient attends Joint Camp
Patient discontinues all forms of
tobacco at least 30-days preoperatively




Pain control < 5 on pain scale
O2 SAT ≥ 92%
Breath sounds clear
DVT mechanical prophylaxis pump
in place (SCD)
Patient tolerates position changes
Skin integrity
Neurovascular function intact
Intraoperative / intraprocedure
blood glucose target: 140-180
mg/dl.











Pain control < 5 on pain scale
O2 SAT ≥ 92%
Family aware of care progression
for hospitalization
Voids within 8 hours after urinary
catheter removed
Has active bowel sounds
Tolerates sitting in chair for 30 min.
Verbalizes understanding of
teaching
No signs/symptoms of DVT/PE
Skin integrity
Neurovascular intact
VS stable











Pain control < 5 on pain scale
O2 SAT ≥ 92%
Has active bowel sounds
Voids without difficulty within 8
hours of urinary catheter removal
Ambulates safely with assistance
and assistive devices on level
surface
No signs/symptoms of DVT/PE
Skin integrity
Neurovascular function intact
No signs/symptoms of hematoma
Hemovac removed 24-48 hours
post-op
Disposition to be determined













Assessments




Medical history
o Indication(s) for procedure
o Allergies and adverse
medication reactions
o Current medications
including prescriptions, overthe-counter, and herbal and
dietary supplements
o Medical Problems, including
current status. Pay special
attention to sleep apnea risk,
abnormal airway, recent
stroke or heart attack and
intravascular stents
o Factors that increase
infection risk (e.g., skin
disease, diabetes mellitus,
malnutrition, smoking)
o Thorough evaluation of
issues relevant to the
planned procedure and
anesthesia
Physical
o Height, weight, and body
mass index (BMI)
o Vital signs (blood pressure,
pulse, respiratory rate)
o Cardiovascular
o Pulmonary
o Neurologic
o Other findings pertinent to
the patient and the
procedure
See OSUWMC Preoperative
Testing and Medication
Management for Non-Cardiac
Surgery
o Document ASA class, as it is
a robust predictor of
perioperative complications.
Screen patient for tobacco use
Screen patients for OSA risk by
using the STOP-Bang or STOP
Questionnaire







Surgical site marking
o Rectify consent with surgical
site
Interim H&P
Surgical time out
Post-procedure sign out
Assess patients for VTE risk factors






VS every hour for 3 hours; Then
every 4 hours for 48 hours;
Progress to every 8 hours and prn
(dorsalis pedis and posterior tibialis
pulse, sensation, color/temp)
Maintain cardiac monitoring/
telemetry 24 hours post-op. Cardiac
monitoring /telemetry after 24 hours
must be re-evaluated by physician.
Neuro/Vascular extremity checks q
4 h and prn
Assess coccyx, bony prominences
for redness every 8 hours and prn
I&O every 8 hours
Head to toe
Actively warm patients
intraoperatively (temperature >
36ºC or 96.8ºF.)
Check blood glucose immediately
upon arrival to PACU or
Postprocedure holding area and
hourly thereafter while blood
glucose is in acceptable range





VS q 4 h
Maintain cardiac monitoring/
telemetry 24 hours post-op. Cardiac
monitoring /telemetry after 24 hours
must be re-evaluated by physician.
Neuro/Vascular q shift and prn
Assess coccyx, bony prominences
for redness q shift and prn
I&O q shift




VS q shift if stable
Neuro/Vascular q shift and prn
Assess coccyx, bony prominences
for redness q shift and prn
I&O q shift; DC when hemovac, IV
and Foley catheter removed 2448hrs.



Pain control < 5 on pain scale
Has active bowel sounds
Coccyx without redness
Independently performs bed
transfer (supine to sitting)
Ambulates safely with assistance
and assistive devices on level
surface
No signs/symptoms of DVT/PE
Able to administer anticoagulation
therapy if applicable
Voids without difficulty
Describes spine precautions
Skin integrity
Neurovascular function intact
Ascends/descends 4 stairs safely
with assistive devices
Independently performs ADL with
assistive devices
Independently performs home
exercise program
Aware of anticoagulation therapies
and signs/ symptoms of infection
Discharge
VS q shift
Neuro/Vascular extremity checks q
shift and p.r.n.
Assess coccyx, bony prominences
for redness q shift and PRN
The OSU Wexner Medical Center: Spine Clinical Pathway
Pre-Admit
Pre-Procedure
Page 2 of 4
Peri-Op
Day of Surgery
POD 1
POD 3
POD 2
o





Consults/Tests


If patient is high risk for OSA,
refer to sleep clinic if time
permits.
o If patient has previously
been diagnosed with OSA
then instruct patient to bring
in CPAP and prescription for
CPAP pressure levels at
time of surgery. If patient not
using CPAP or does not
have machine yet, instruct
patient to bring in
prescription for CPAP
pressure levels
Anesthesiology
Hospital Medicine
Dental Clearance
Check HbA1C -if patient is known
or suspected to have diabetes, and
if not available within the last 30
days
Recommended testing:
o CBC, PT, PTT (within 6
weeks)
o T&S for 1 unit PRBC (within
30-days)
o Chem6 (within 6-weeks)
o UA (within 6-weeks)
o MRSA (within 6-weeks)
o Coags (within 6-weeks)
o CXR (within one year)
o ECG (within 6-moenths)
o T&C (within 30-days)
Hip X-ray (unless previously done)
EKG if indicated








Pre-op glucose
hCG (when appropriate)
Laboratory and diagnostic tests are
not routinely necessary unless
there is a specific patient or
procedural indication.







Medications and
IV Therapy





Before stopping antiplatelet
therapy, even temporarily in a
patient with an arterial stent,
follow the guideline. If you are
uncertain about how to instruct the
patient, then consult the Ross
Clinical Specialty Pharmacists the
OPAC / PREOP Clinic
Discontinue non-physician
prescribed aspirin and all other
NSAIDs two weeks before surgery
Prophylactic antibiotics
Empiric mupirocin (pending
MRSA/MSSA screen)
CHG scrub (PM before procedure &
AM of surgery)
Sage cloth
Provide tobacco cessation
pharmacological treatment








Chloraprep
See OSUWMC Prevention of
Surgical Site Infections (SSIs)
with Antimicrobial Prophylaxis
guideline for specific peri-op
medication recommendations prior
to surgery.
Postpone elective procedures until
the patient completes a full course
of antiplatelet therapy if patient
discontinued antiplatelet therapy
inappropriately.









Hospital Medicine
PT
OT
Social Services as needed
Respiratory
o Have positive airway pressure
(CPAP or BiPAP) available
when appropriate, based on
clinical judgment. Adjust O2 sat
to maintain baseline levels.
o Note: Patient’s previously
prescribed pressure levels may
need to be increased if
receiving narcotics.
Hgb/hct, coags, CMP large fusion
case post-op
Discharge planning
Microdecompression,
microdiscectomy
IV pain meds for break through pain
ACDF, multilevel decompression
with or without fusion
PCA
IV; as ordered
Oral analgesic
Antipruritic prn for itching
Tylenol every 4 hours and prn for
HA or temperature > 101.5F
DVT / PE prophylaxis must be
administered within 24 hours of
surgical end-time, unless
documented contraindication.
Antibiotic
Antiemetic prn for nausea
AAOC prn
Stool softener/LOC
Prior to an invasive/surgical
procedure consult the surgeon/
proceduralist about the need to
order or hold antithrombotics
If blood glucose is not in acceptable
range, follow table in Perioperative
/ Periprocedure Glucose
Management guideline for blood
glucose correction
Resume full antiplatelet therapy as
soon as hemostasis is achieved
Appropriate VTE pharmacological
thromboprophylaxis options include:
o Heparin 5,000 Units SQ
EVERY 8 HOURS























Hospital Medicine
PT
OT
CBC, Chem7, Mag, Phos, BMP
PT/PTT/INR if indicated
No labs for ACDF,
microdecompression,
microdiscectomy unless indicated
Upright radiographs if
instrumentation placed
Discharge planning
Discontinue PCA 24-48 hours
IV ; DC if p.o. intake is adequate –
convert to saline well
Antibiotic as ordered last dose
before 24 hours surgery end time
IV pain meds for break through pain
Oral analgesic prn
Antipruritic prn for itching
Hypnotic h.s. prn sleep
Tylenol q 4 h prn for HA or
temperature > 101.5F
DVT prophylaxis/SCDs
continuously while patient not
ambulatory or until discharge
Anticoagulant
Antiemetic prn for nausea
AAOC prn
Stool softener/LOC
Discontinue prophylactic antibiotics
within 24 hours of surgery, except
for ECMO, VAD and transplant
recipients within 48 hrs.
Appropriate VTE pharmacological
thromboprophylaxis options include:
o Heparin 5,000 Units SQ
EVERY 8 HOURS
(PREFERRED AGENT)
Enoxaparin 40 mg SQ DAILY
(avoid if CrCl < 30 mL/min)
o Enoxaparin 40 mg SQ EVERY
12 HOURS - for obese patients
(BMI > 40) - avoid if CrCl < 30
mL/mi







Hospital Medicine
PT
OT
CBC, Chem7, Mag, Phos, BMP
PT/PTT/INR if indicated
Upright radiographs if
instrumentation placed
Discharge planning

Remove perineural prior to
discharge

Convert IV to saline well if p.o.
intake is adequate
Oral analgesic prn
IV pain meds for break through pain
Antipruritic prn for itching
Hypnotic h.s prn sleep
DVT prophylaxis/SCDs
continuously while patient not
ambulatory or until discharge
Anticoagulant
Antiemetic prn for nausea
AAOC prn
Stool softener/LOC
Tylenol q 4 h prn for HA or
temperature > 101.5F



























Hospital Medicine
PT
OT
CBC, Chem7, BMP
PT, INR, Coag if indicated
Upright radiographs if
instrumentation placed
Discharge planning
D/C saline well
Oral analgesic
IV pain meds for break through pain
Antipruritic prn for itching
Tylenol q 4 h prn for HA or
temperature > 101.5F
DVT prophylaxis/SCDs
continuously while patient not
ambulatory or until discharge
Antiemetic prn for nausea
Routine post-op meds
AAOC prn
Stool softener/LOC
The OSU Wexner Medical Center: Spine Clinical Pathway
Pre-Admit
Pre-Procedure
Page 3 of 4
Peri-Op
Day of Surgery
o
POD 1
(PREFERRED AGENT)
Enoxaparin 40 mg SQ DAILY
(avoid if CrCl < 30 mL/min)
Enoxaparin 40 mg SQ EVERY
12 HOURS - for obese patients
(BMI > 40) - avoid if CrCl < 30
mL/min

Nutrition
Activity



NPO after midnight prior to surgery
Take instructed medications with
sip of water
Up ad lib

Preadmission diet as tolerated









°
Bed rest, HOB 0-30
Turn q2 hours
Ankle pumps 10X per hour prn
while awake
Spine precautions
Orthosis, if indicated















Other Treatments
and
Interventions

Consents obtained


POD 3
POD 2
O2 per NC
IS, C&DB every hour while awake



ACDF, microdecompression,
microdiscectomy
Preadmission diet
Multilevel decompression with or
without fusion
NPO until flatus
If flatus, advance diet slowly as
tolerated

Begin ADL training
Turn q2 hours
Wt bearing as tolerated, spine
precautions
Orthosis, if indicated
OOB to chair tid 30 min. per PT
Gait training with walker, as
tolerated


O2 per NC
D/C if O2 SAT ≥ 92%
IS and C&DB qh while awake
Foley catheter to straight drain; D/C
24-48hrs post-op
Bladder scan prn inability to void
Straight cath q 6h if unable to void
Hemovac, E-vac; empty q shift and
prn
Sterile technique if dressing change
required
Appropriate VTE mechanical
prophylaxis:
o Ambulation when patient is
stable
o Use Sequential Compression
device in addition to drug
therapy or if drug therapy
contraindication is
documented
Maintain continuous pulse ox 24
hours post IV opiates. Pulse ox
after 24 hours must be reevaluated by physician.
Maintain cardiac monitor / telemetry
24 hours post-op. Cardiac monitor /
telemetry after 24 hours must be reevaluated by physician.
Consider the following information
for discontinuation of pulse oximetry
/ telemetry for patients with OSA or
at risk:
o Blood pressure within 10-20%
of baseline
o Heart rate within 10-20% of
baseline
o Not receiving sedative
mediations (e.g. opioids,
antiemetics, anxiolytics)
o Oxygen saturation > 92% on

















ACDF, microdecompression,
microdiscectomy
Preadmission diet
Multilevel decompression with or
without fusion
NPO until flatus
If flatus, advance diet slowly as
tolerated
Turn q2 hours
Wt bearing as tolerated, spine
precautions
Orthosis, if indicated
OOB to chair tid 30 min. per PT
Gait training with walker, as
tolerated
D/C O2
D/C Foley catheter 24-48hrs
Straight cath q 6 h and prn if unable
to void
Hemovac, E-vac; empty q shift and
prn
Bladder scan prn inability to void,
rectal as indicated
Straight cath q 6h if unable to void
Dressing change q day prn
D/C hemovac if drng  50cc per
shift if ordered lumbar and 30cc
per shift if ordered cervical
Turn q2 hours
Appropriate VTE mechanical
prophylaxis:
o Ambulation when patient is
stable
o Use Sequential Compression
device in addition to drug
therapy or if drug therapy
contraindication is documented

Preadmission diet


Safe transfer with assistance
Verbally explain car transfer
techniques
Progresses transfer and gait
training
Maintain weight bearing status,
spine precautions
Stair climbing per PT
Perform home exercise program






Dressing q day and prn
Appropriate VTE mechanical
prophylaxis:
o Ambulation when patient is
stable
o Use Sequential Compression
device in addition to drug
therapy or if drug therapy
contraindication is documented
The OSU Wexner Medical Center: Spine Clinical Pathway
Pre-Admit
Pre-Procedure
Page 4 of 4
Peri-Op
Day of Surgery
POD 1
o




Teaching


Discharge
Planning


Patient education handouts
Explanation of patient education
materials
Questions answered
Health Care Worker (HCW) must
document education provided in
IHIS
Provide the patient specific written
instructions about continuing or
holding and resuming antiplatelet
therapy
Educate patients on need to
discontinue tobacco use
Discuss post-op plans, LOS, wound
care and follow-up
Assess equipment needs/family
supports
POD 3
POD 2
room air or baseline O2 while
sleeping
RASS and/or MEWS Score
not indicating sedation or
hyperactivity. Agitation and
somnolence are equivalent
indicators of inadequate
ventilation.










Review spine precautions
Pain scale (protocol)
Review IS, C&DB
Review ankle pumps
Reinforce patient care guide
information
Discuss unit rules with family
Evaluate emotional and behavioral
responses
Document Key






Initiate spine precautions
Reinforce pain management
Reinforce pulmonary toilet
Reinforce patient education manual



Educate spine precautions
Educate wound care teaching
including signs/symptoms of
infection
Educate patient education manual






Quality Measures
Average Length of Stay
Post-op PE/DVT rate
Post-op Infection Rate




Discharge planning
Identify support system and home
needs
Initiate COC if needed


Discharge planning
Continue to update COC as needed



Reinforce spine precautions
Wound care including
signs/symptoms of infection
Instruct on and reinforce home
exercise program/spine handout
Review discharge Instructions
Maintain nocturnal CPAP; if
requiring continuous CPAP,
consider other causes (fluid
overload, over-sedation).
Observe OSA Care (if applicable)
o Consider follow-up with Sleep
Clinic.
o Provide patient and family with
OSA education
Discharge planning completed
COC completed
Pt home/ECF/Rehab
AAOC – antacid of choice
LOC – laxative of choice
C&DB – cough and deep breathing
Order Sets/ Tools


Progress note templates in IHIS
IHIS OS: pending
Disclaimer: Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center (OSUWMC) are standards that are intended to
provide general guidance to clinicians. Patient choice and clinician judgment must remain central to the selection of diagnostic tests and therapy. OSUWMC’s
guidelines and algorithms are reviewed periodically for consistency with new evidence; however, new developments may not be represented.
Related Policies/Procedures








OSUWMC Guide to Cervical Spine Trauma
OSUWMC Guide to Thoracolumbar Spine Trauma
OSUWMC Management of Obstructive Sleep Apnea (OSA)
OSUWMC Deep Venous Thrombosis (DVT): Prevention
OSUWMC Prevention of Surgical Site Infections (SSIs) with Antimicrobial Prophylaxis
OSUWMC Managing Antiplatelet Therapy in Patients with Stents Around the Time of Surgery and Procedures
OSUWMC Tobacco Cessation
OSUWMC Perioperative / Periprocedure Glucose Management
Authors


Elizabeth Yu, MD
Safdar Khan, MD
Pathway Approved
March 26, 2014. First Edition.
.
Copyright © 2014. The Ohio State University. No part of this publication may be reproduced in any form without permission in writing from The Ohio State
University Wexner Medical Center