Efficacy of a Computer-Based Reminder System (SAM) for the Timely Initiation of Intra-Operative Epidural Infusions
May 2nd, 2015Western Anesthesia Residents Conference
Aalap C. Shah, MD CA3Department of Anesthesiology & Pain Medicine
University of Washington Medical Center
IntroductionTo improve postoperative pain in select
surgeries, pre-operative epidural catheters should ideally be used starting at the beginning of surgery.
Regional anesthesia reduces:◦postoperative acute hyperalgesia1,2 ◦Surgery-induced pain sensitization2,3
◦Opioid-induced hyperalgesia3
◦Chronic pain3,4
Introduction
Decreased PACU Complications◦Post-Operative Pulmonary Complications (POPC)5
◦Myocardial Infarction6
◦Post-Operative Nausea/Vomiting (PONV)1
Improved Pain Control◦VAS Scores1
◦Opioid-sparing effects1
Decreased PACU LOS◦Med / Surg Inpatient Floor Admission Criteria
[UWMC]
REGIONAL ANESTHESIA BENEFITS (CONT’D)
Review of surgical schedule by the Regional Attending the day before
Reg. or Room team meets with patient on DOS Verbal consent IV placed
Finalize schedule with RIC
Prepare epidural tray
Apply monitors Position patient Time-out w/ RN +/-
midazolam/fentanyl
Epidural Placements
Contraindications?- Anticoagulation
(labs, Rx)
- Pt. refusalCase cancellation?
Successful placement?
Off pathway
Off pathway
Pt. need TEP/LEP?
Off pathway
Yes
No Yes
Yes
No
No
UWMC Regional Team Workflow (I)
Room team sets up epidural infusionbetween procedure start and PACU
Attending/resident
review epidural
plan after procedure
start
Pain service notified &Note in ORCA+/- CORES
Reg/Room
team call, reminder
- Pharmacy checks queue periodically
- Infusion prepared- +/- OR team
contacted
Pharmacy call,
reminder
Infusion ordered
?
Infusion in OR?
Box/pump + tubing available?
Attending/facilitator
contacted to bring box to
OR
Attending/resident review initiation plan Epidural
started?
To PACU, + running epidural+/- boluses+/- rate changes, ~hypotensive events
PACU nurse waits for pt. to wake up
APS notified for pain control
To PACU w/o running epidural
YesYes
Yes
Yes
No
No
No No
New:
UWMC Regional Team Workflow (II)
MethodsI. STUDY DESIGN
◦Originated as QI project after co-resident discussion (Regional and Acute Pain Teams)
◦ Intervention: Process Workflow Improvements Package (11/1/14)
Creation Of Electronic Anesthesia Information System Reminder[Smart Anesthesia Manager (SAM)]
Improvement Of Epidural Infusion Ordering Processing Times Shortening Of Infusion Delivery Time To Operating Theaters Consolidation Of Epidural Infusion Equipment Supply Locations Increased Frequency Of Equipment Stocking Initiation Of Educational Meetings For All Involved Staff Placement Of Reminder Posters
Methods
I. STUDY DESIGN
◦Pre- / Post-Implementation Comparison Pre-Implementation: 9/22/14 – 10/30/14 Post-Implementation: 11/1/14 – 12/11/14
◦ Inclusion Criteria: All patients receiving pre-operative epidural
catheters prior to elective surgery
◦Exclusion Criteria: OB (C-Section) patients
MethodsI. STUDY DESIGN
Data Collection- Nursing Survey Forms- Microsoft AMALGA
II. EPIDURAL SAM REMINDER
Methods – Process Improvements
SCOAP 1: Revised Time-out note Checkbox to indicate “Epidural Infusion ordered for postoperative pain
management
Methods – Process Improvements
Epidural Infusion List (the choice)
II. EPIDURAL SAM REMINDER (CONT’D)
Methods – Process Improvements
Prompts every 24 min IF no epidural infusion has been started after infusion has been documented in SCOAP step 1 (Docusys)
II. EPIDURAL SAM REMINDER (CONT’D)
Methods – Process Improvements
The messages are stopped if either an epidural infusion has been started or if the provider documents that epidural initiation is contraindicated.
II. EPIDURAL SAM REMINDER (CONT’D)
Methods – Process ImprovementsII. PHARMACY WORKFLOW PROCESS IMPROVEMENTS
Pharmacy will: Check their queue at 0800 Calling into the room when the solution is ready (definitely for first-start
cases)
Regional Resident / First-case start provider: Placing orders latest in by 0745 Informs the Acute Pain Service
ROOM residents are responsible for: Calling regional team if no order is in ORCA by the time surgical incision is
made Calling pharmacy to remind them about infusion for all cases EXCEPT
first-start cases.
Methods – Process ImprovementsIII. OTHER WORKFLOW IMPROVEMENTS
ResultsI. DEMOGRAPHICS (PRE VS. POST)
Results
Pre And Intra-operative Epidural Infusion Start Rates Infusion NOT started
Infusion Started
P
Pre-intervention
13 27 (67.5%)
Post-intervention
8 48 (85.7%) 0.045
II. INITIATION RATES (PRE VS. POST)
ResultsIII. SMART ANESTHESIA MANAGER - COMPLIANCE (Data collection 12/31/14)
◦334 / 1322 elective cases answered the SAM prompt (i.e. Pre-Op Epidural Placed?) (25.3%)
◦302 NO, 32 YES All 32 started intraoperative (i.e. timely) epidural infusions (Infusion
Started) (100%) Elapsed time (35.4 +/- 34.2 min)
◦60 cases with epidural (YES) but SAM prompt ignored 39 / 60 cases started intraoperative (i.e. timely) epidural infusions
(Infusion Started) (65.0%) Elapsed time (58.5 +/- 45.3 min)
SAM Answered vs. SAM Ignored Initiation Rates and Elapsed Time100% vs 65.0% (p <.001)35.4 +/- 34.2 min vs. 58.5 +/- 45.3 min (p=.10)
Results
Pain Scores PACU Pain
Scoren Infusion NOT Started
(N=40)
n Infusion Started (N=56)
p
Maximum 15 7.2 +/- 4.0 (10) 32 5.7 +/- 3.6 (6) 0.027
Sign-out 17 4.5 +/- 2.5 (5) 49 3.0 +/- 2.3 (3) 0.023
IV. PAIN SCORES (BY INFUSION STATUS)
Results
Reasons Why Epidural Infusion Was Not Started during Surgery
n
Intermittent Boluses Of Lidocaine Were Given (Provider Preference)
6
Epidural Infusion Did Not Arrive In Time From Pharmacy / Case Ended Earlier Than Expected
5
Epidural Infusion Order Was Not Placed / Initiated With Pharmacy
2
Intraoperative Hypotension (Anesthesia Team Decision)
1
Surgeon Request 1
V. EXPLANATIONS FOR UNINITIATED EPIDURAL INFUSIONS
DiscussionWorkflow improvements (pharmacy,
equipment and electronic alerts) resulted in a ~20% increase in timely initiation of epidurals.
AIMS epidural documentation had poor compliance, but near real-time notifications to initiate epidural infusions were modestly effective
Epidural initiation coincided with a mild decrease in PACU patient-reported pain scores.
Future DirectionsPROBLEMS WITH PAIN SCORES AS OUTCOME MEASURES PACU RN bias (i.e. patients without active epidural infusions get
higher scores, vice versa) Patient-subjective – influenced by patient’s level of awareness at
time of report Confounders
◦ Adjunctive pain medications (opioids used to bring pain scores down prior to floor transfer
◦ Timing of pain scores – before or after epidural or IV opioid bolus is given◦ Chronic pain / pain risk factors
Future DirectionsIRB-approved retrospective study◦ Intervention: Process Workflow Improvements
Package (11/1/14)◦Pre- / Post-Implementation Comparison
Pre-Implementation: 10/1/12 – 9/30/14 Post-Implementation: 10/1/14 – 9/30/15
◦N=2199 proceduresOpioid Consumption (Intra-, Post-Operative)Adjust for Pain Risk FactorsAdjust for “split” patients (i.e. Epidural + Post-
Op PCA)
Future DirectionsPRE-IMPLEMENTATION RESULTS
◦ N=2199 procedures 1238 (56.3%) infusions started during surgery
◦ First, Last (Signout) and MAX Pain Scores (n=1889)
◦ Opioid Consumption, PONV and Pain Risk Factors Analyses Pending
AcknowledgementsBala Nair, PhD, Research Associate ProfessorLaurent Bollag, MD Assistant ProfessorMichelle McGauvran, MD CA2 Anesthesiology ResidentShue-Fang Newman Software EngineerKaren Domino, MD PhD ProfessorCharles Spiekerman, PhD Statistician,
Institute for Translational Health Sciences (ITHS)
References1. Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Wu CL (2003). "Efficacy of
postoperative epidural analgesia: a meta-analysis". JAMA 290 (18): 2455–63. doi:10.1001/jama.290.18.2455. PMID 14612482.
2. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;367:1618-25.
3. Rivat C, Bollag L, Richebe P. Mechanisms of regional anaesthesia protection against hyperalgesia and pain chronicization. Current opinion in anaesthesiology 2013.
4. Andreae MH, Andreae DA. Local anaesthetics and regional anaesthesia for preventing chronic pain after surgery. The Cochrane database of systematic reviews 2012;10:CD007105.
5. Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, Angelillo IF, Mosteller F (1998). "The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials". Anesth Analg 86 (3): 598–612. doi:10.1097/00000539-199803000-00032. PMID 9495424.
6. ^ Beattie WS, Badner NH, Choi P (2001). "Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis". Anesth Analg 93 (4): 853–8.
7. Nair BG, Peterson GN, Schwid HA. Electronic reminders to improve timely antibiotic doses. Anesthesia and analgesia 2011;113:1284.
Thank You!
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