Evaluation of early postoperative intravenous opioid rescue as a novel quality measure in patients who receive thoracic epidural analgesia: a retrospective cohort analysis and prospective performance improvement intervention.
Efficiency metrics
Perioperative analgesia
Quality improvement
Regional anesthesia
Thoracic epidural analgesia
Journal
BMC anesthesiology
ISSN: 1471-2253
Titre abrégé: BMC Anesthesiol
Pays: England
ID NLM: 100968535
Informations de publication
Date de publication:
19 04 2021
19 04 2021
Historique:
received:
25
09
2020
accepted:
31
03
2021
entrez:
20
4
2021
pubmed:
21
4
2021
medline:
6
1
2022
Statut:
epublish
Résumé
In this study, we explored the utility of intravenous opioid rescue analgesia in the post anesthesia care unit (PACU-OpResc) as a single marker of thoracic epidural analgesia (TEA) failure and evaluated the resource implications and quality improvement applications of this measure. We performed a retrospective analysis of all TEA placements over a three-year period at a single academic medical center in Boston, Massachusetts. The study exposure was PACU-OpResc. Primary outcome was PACU length of stay (LOS). Secondary outcomes included reasons for delayed PACU discharge and intraoperative hypotension. The analyses were adjusted for confounding variables including patient comorbidities, surgical complexity, intraoperative intravenous opioids, chronic opioid use and local anesthetic bolus through TEA catheter. Post analysis chart review was conducted to determine the positive predictive value (PPV) of PACU-OpResc for inadequate TEA. As a first Plan-Do-Study-Act cycle, we then introduced a checkbox for documentation of a sensory level check after TEA placement. Post implementation data was collected for 7 months. PACU-OpResc was required by 211 (22.1%) patients who received preoperative TEA, was associated with longer PACU LOS (incidence rate ratio 1.20, 95% CI:1.07-1.34, p = 0.001) and delayed discharge due to inadequate pain control (odds ratio 5.15, 95% CI 3.51-7.57, p < 0.001). PACU-OpResc had a PPV of 76.3 and 60.4% for re-evaluation and manipulation of the TEA catheter in PACU, respectively. Following implementation of a checkbox, average monthly compliance with documented sensory level check after TEA placement was noted to be 39.7%. During this time, a reduction of 8.2% in the rate of PACU-OpResc was observed. This study demonstrates that PACU-OpResc can be used as a quality assurance measure or surrogate for TEA efficacy, to track performance and monitor innovation efforts aimed at improving analgesia, such as our intervention to facilitate sensory level checks and reduced PACU-OpResc. not applicable.
Sections du résumé
BACKGROUND
In this study, we explored the utility of intravenous opioid rescue analgesia in the post anesthesia care unit (PACU-OpResc) as a single marker of thoracic epidural analgesia (TEA) failure and evaluated the resource implications and quality improvement applications of this measure.
METHODS
We performed a retrospective analysis of all TEA placements over a three-year period at a single academic medical center in Boston, Massachusetts. The study exposure was PACU-OpResc. Primary outcome was PACU length of stay (LOS). Secondary outcomes included reasons for delayed PACU discharge and intraoperative hypotension. The analyses were adjusted for confounding variables including patient comorbidities, surgical complexity, intraoperative intravenous opioids, chronic opioid use and local anesthetic bolus through TEA catheter. Post analysis chart review was conducted to determine the positive predictive value (PPV) of PACU-OpResc for inadequate TEA. As a first Plan-Do-Study-Act cycle, we then introduced a checkbox for documentation of a sensory level check after TEA placement. Post implementation data was collected for 7 months.
RESULTS
PACU-OpResc was required by 211 (22.1%) patients who received preoperative TEA, was associated with longer PACU LOS (incidence rate ratio 1.20, 95% CI:1.07-1.34, p = 0.001) and delayed discharge due to inadequate pain control (odds ratio 5.15, 95% CI 3.51-7.57, p < 0.001). PACU-OpResc had a PPV of 76.3 and 60.4% for re-evaluation and manipulation of the TEA catheter in PACU, respectively. Following implementation of a checkbox, average monthly compliance with documented sensory level check after TEA placement was noted to be 39.7%. During this time, a reduction of 8.2% in the rate of PACU-OpResc was observed.
CONCLUSIONS
This study demonstrates that PACU-OpResc can be used as a quality assurance measure or surrogate for TEA efficacy, to track performance and monitor innovation efforts aimed at improving analgesia, such as our intervention to facilitate sensory level checks and reduced PACU-OpResc.
TRIAL REGISTRATION
not applicable.
Identifiants
pubmed: 33874890
doi: 10.1186/s12871-021-01332-7
pii: 10.1186/s12871-021-01332-7
pmc: PMC8054410
doi:
Substances chimiques
Analgesics, Opioid
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
120Références
BMJ Qual Saf. 2016 Dec;25(12):986-992
pubmed: 26369893
J Anesth. 2017 Aug;31(4):494-501
pubmed: 28185011
Best Pract Res Clin Anaesthesiol. 2017 Dec;31(4):547-560
pubmed: 29739543
Anesthesiol Clin. 2015 Mar;33(1):65-78
pubmed: 25701929
Int J Obstet Anesth. 2013 Nov;22(4):310-5
pubmed: 23932551
Acta Anaesthesiol Scand. 2010 Jul;54(6):761-3
pubmed: 20039845
J Anesth. 2006;20(4):290-9
pubmed: 17072694
J Clin Epidemiol. 2008 Apr;61(4):344-9
pubmed: 18313558
Br J Anaesth. 2012 Aug;109(2):144-54
pubmed: 22735301
Cochrane Database Syst Rev. 2016 Jan 05;(1):CD005059
pubmed: 26731032
Anesth Analg. 2017 Nov;125(5):1784-1792
pubmed: 29049123
JAMA. 2003 Nov 12;290(18):2455-63
pubmed: 14612482
Br J Anaesth. 2010 Mar;104(3):292-7
pubmed: 20124282
Reg Anesth Pain Med. 2016 May-Jun;41(3):309-13
pubmed: 27035462
Reg Anesth Pain Med. 1999 Nov-Dec;24(6):499-505
pubmed: 10588551
J Thorac Dis. 2018 Mar;10(3):1998-2004
pubmed: 29707356
Front Med (Lausanne). 2018 Apr 09;5:93
pubmed: 29686989
Anesthesiology. 2013 Jun;118(6):1276-85
pubmed: 23571640
Anesth Analg. 2017 Nov;125(5):1667-1674
pubmed: 29049112
BMC Anesthesiol. 2015 Jan 21;15:5
pubmed: 25971251
Reg Anesth Pain Med. 2017 Sep/Oct;42(5):649-651
pubmed: 28727584
Anesth Analg. 2016 Dec;123(6):1591-1602
pubmed: 27870743
Anesth Analg. 2019 May;128(5):953-961
pubmed: 30138173
Perioper Med (Lond). 2014 Nov 26;3(1):10
pubmed: 25485103