3. Results
Our goal of reducing the number of post-Induction sedated LPs by 50% in
pediatric ALL patients was met. During the three-month post-intervention
period from 10/1/20 to 12/31/20, 37 out of 77 post-Induction LPs were
performed with sedation (48.1%) compared to 59 out of 59 (100%) in the
same patient group one year earlier (10/1/19 to 12/31/19) (Fig. 1).
Inclusive of Induction LPs, the total number of LPs in the
post-intervention period was 91. Additional patient information is shown
in Table 1.
Process maps developed for both techniques demonstrated that unsedated
LPs provided a more streamlined approach, involving 42 total steps
instead of 53, and 6 non value-added steps versus 16. Similarly,
observations of clinic visits for patients receiving sedated or
unsedated LPs revealed substantial differences in clinic visit duration.
Six sedated LP visits and five unsedated LP visits were observed.
Clinical time (visit time related directly to patient care, excluding
wait and transportation times) was, on average, more than twice as long
(169 minutes compared to 83 minutes) for patients receiving sedated LPs
instead of unsedated, primarily related to involvement of the anesthesia
team (evaluation and recovery).
An additional factor related to optimizing the LP process for both the
institution and for patients is the cancelling of sedated procedures.
During the post-intervention period, 30% of scheduled sedated LPs were
cancelled for reasons such as NPO violations, positive COVID-19 tests,
and viral upper respiratory infections. Patients receiving unsedated LPs
were not tested for COVID-19 and were able to proceed with their
procedures if symptoms of mild respiratory infection were present.
Analysis of CSF characteristics obtained from LPs during the
post-intervention period revealed a higher incidence of blood in the CSF
(>500 RBCs) for unsedated procedures (5/43, 11.6%) as
compared to sedated procedures (0/48, 0%) (Fig. 2). There were no
failed LPs in either group.
Surveys were provided to 19 patients who received both types of LPs, and
16 were returned (response rate 84.2%). Patient and guardian
preferences for unsedated vs sedated LPs (evaluated on a 0 to 10 scale,
10 indicating a strong preference for unsedated LPs) showed a mean
response of 9.3 for guardians and 8.5 for patients (Fig. 3). 43% of
guardians and 33% of patients indicated that COVID-19 testing
requirements did not play a significant role in their responses (Fig.
4), suggesting that some might choose to continue with unsedated LPs
even if COVID-19 testing was not required.
Finally, costs were approximated by comparing the overall charges to
patients for sedated and unsedated LPs, and by assessing the cumulative
opportunity cost of cancelled LPs. The average overall charges to a
pediatric patient with ALL at the University of Iowa for a clinic visit
involving a sedated LP, inclusive of labs, medications, involvement of
the anesthesia team and use of recovery rooms, total $10,620.85
(average obtained from 6 observed sedated LPs). For a visit with an
unsedated LP, the average overall charges total $4,884.69 (average
obtained from 5 observed unsedated LPs). This results in a cost
reduction of $5,736.16 per procedure. Extrapolating the total number of
LPs performed during our post-intervention window, 91, to an entire
year, provides an estimate of 364 LPs per year. If 50% of these are
performed unsedated, there is an approximate health care expenditure
reduction of $1,043,981 to pediatric patients with ALL per year. During
the post-intervention period, 21 sedated LPs were cancelled. The average
usage time of sedated procedure and recovery rooms per sedated LP was
determined to be 91 minutes, and the total charges, including anesthesia
team and recovery rooms, approximately $15,392.54. Extrapolating these
numbers results in an opportunity cost of 128 hours and $1,290,000 per
year to our institution.