Safe Transitions Pathway in Neurological Surgery

From the 2018 HVPAA National Conference

Jennifer Viner (UCSF), Aldea Meary-miller (UCSF)


Most craniotomy patients board in the neuro-intensive care unit (NICU) their first night after surgery then transfer to the floor. These patients are clinically well, with uncomplicated post-operative courses and are anticipated to be discharged home post-operatively after two days. Some of these patients can bypass the NICU.


1. Design a safe transitions pathway (STP) to bypass the NICU after lower risk craniotomies.

2. Reduce direct cost per case for eligible procedures $23,100 per case in fiscal year 2017 to $17,575 per case for fiscal year 2018.

3. Reduce post-operative length of stay, increase nursing satisfaction, increase patient satisfaction, and improve NICU bed availability.


We identified a population of lower risk patients with potential for direct post-operative admission to the transitional care unit rather than the NICU. This includes simple supra-tentorial brain tumors (meningiomas, metastases, gliomas), Chiari decompression, microvascular decompression, and arachnoid cyst decompression. Nursing education supports the care of new patient populations in all locations along the care pathway: operating room, post-anesthesia care unit, and the neuro-transitional care unit.  Physician engagement in workflow redesign ensured program awareness and buy-in, as well as the creation of dedicated order sets in the electronic health record. Patient engagement includes ongoing experience surveys and a pamphlet describing the surgical pathway (see attachment).


Since July 1 2017, 55 patients have received care through the STP. This includes 5 microvascular decompressions, 11 chiari malformations, and 39 tumors.

In the first half of fiscal year 2018, cases in the STP demonstrated $4,925 in direct cost savings per case when compared to cases eligible for STP but undergoing usual care with NICU admission. The average length of stay was 0.23 days shorter in the STP group than non-STP cases.


Some patients undergoing craniotomy do not require ICU care post-operatively. Workflow redesign in standardized pathways can lead to significant value improvement.

Implications for the Patient

Interdisciplinary pathways with appropriate engagement of nurses, physicians, and patients can ensure safe transitions in neurosurgery and has implications for other surgical populations whose care needs may be met in transitional care units at lower cost to the health system.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog