Dr Neha Singal and Dr Manoj Sharma develop a database for reviewing the quality performance of anaesthetists at the medium-sized district general hospital Luton and Dunstable hospital in the UK.
Background
The NHS Next Stage Review report ‘High Quality Care for All’ aims to make organisations accountable for quality through a focus on the measurement and reporting of quality indicators representing safety, effectiveness, and patient experience. [1] Anaesthetic services are no exception to the requirements. Clinical indicators are increasingly developed and promoted by professional organisations and government agencies as measures of quality and performance. Guy Haller et al identified 108 key performance indicators out of a big systemic review of the published articles. [5]
Perioperative mortality and serious morbidity has decreased significantly over the past 50 years, which is also influenced by a range of patient and surgical factors. The quality of anaesthetic care can be more directly assessed in the immediate postoperative period, in which the patient’s experience of recovery is closely linked to the quality of the anaesthetic. Two of the most important dimensions of quality of recovery in the postoperative period are postoperative nausea and vomiting (PONV) and postoperative pain. [2] PONV and incisional pain during recovery has a strong negative influence on patient satisfaction and are among the most undesirable complications from the patient’s point of view. [2]
From: Using quality indicators in anaesthesia: feeding back data to improve care Br J Anaesth. 2012;109(1):80-91. doi:10.1093/bja/aes173
It was a challenge to develop a database for reviewing the quality performance of anaesthetists at a medium-sized district general hospital such as Luton and Dunstable hospital. Metrics collected during the immediate post-anaesthetic recovery period, such as patient temperature, patient-reported quality of recovery, pain and nausea provide potentially useful information for the anaesthetist, yet this information is not routinely fed back. [4] Reviews of the effects of feeding back performance data to healthcare providers suggest that this may result in small to moderate positive effects upon outcomes and professional practice, with stronger effects where feedback is integrated within a broader quality improvement strategy. [4] Aside from the importance patients place upon experience of the immediate post-operative period, these also represent important anaesthetic quality indicators for the attending anaesthetist. The quality indicators generate data representing variation in an underlying parameter of the care process (plus measurement error). It is central that this data is turned into useful actionable information, which can be feedback to the frontline clinician to effectively support quality improvement in anaesthesia.
Methods
Key Performance indicator (KPI) dashboard was created at Luton & Dunstable University Hospital, Luton. It involved team of theatre nurses, recovery nurses and IT department. The anaesthetists were not involved in feeding the data at any level to remove the bias. Evidence from literature and most practically useful quality performance indicators for anaesthetist were decided by a group of consultant anaesthetists. It was advised to adopt a continuous quality monitoring approach, which is backed by quarterly feedbacks. The data was collected by PACU nurses against the following metrics: (i) temperature upon arrival in recovery (in accordance with NICE guidelines), (ii) patient-reported PONV (iii) patient-reported pain scale score and (vi) patient overall satisfaction during their peri-operative journey. We collected data from 3000 patients over three months (April, May, June 2019) as analysed on excel sheets using Pivot charts. The results were presented to the perioperative care providers in clinical governance meeting.
Results
There were a total of 2912 patients admitted in recovery after either elective or emergency theatres in Luton and Dunstable Hospital in a period extending from 1 April, 2018 to 31 June,2018. The result showed that 70 per cent (2154) patient experienced no or minimal pain (verbal pain score: 0,1,2) immediately after anaesthetic while 13 per cent (386) experienced mild pain (pain score: 3,4), 11 per cent (350) had moderate pain (pain score: 5,6,7) and 6 per cent (171) experienced severe pain (pain score: 8,9,10) immediately after anaesthetic in PACU. The pain modality was further analysed in 18 different surgical specialities. It was found that the patients waking up after gynaecological procedures, general surgery, which includes bariatric procedures, and breast surgeries experienced more than average pain. With gynaecological surgeries, 25 per cent (54) experiencing moderate to severe pain. Similarly, 32 per cent (136) and 21 per cent (24) patients experienced moderate to severe pain while recovering after general surgery and breast procedures respectively. While trauma and orthopaedic patients experienced less pain than average with 15 per cent (112) of patients complaining of moderate to severe pain immediately after anaesthetic.
The results for nausea and vomiting in PACU showed that 90 per cent (2656) patient experienced no or minimal nausea, 7 per cent (209) experienced mild discomfort, 2 per cent (65) had moderate and another 1 per cent (20) experienced severe discomfort due to nausea vomiting while recovering immediately after anaesthetic. There was not much difference noted in the incidence in different surgical specialties.
The peri-operative temperature management was achieved as per AAGBI guidelines in almost 87 per cent (2567) patients and the rest 13 per cent (391) experienced cold while in PACU. There was no significant difference in temperature management between different surgical specialties.
The questionnaire before discharge to recovery confirmed that 98 per cent (2840) of patients were satisfied with the care received, 2 per cent (60) patients weren’t sure and another two patients were not satisfied with the care. The main cause for concern for patients who were not sure or not satisfied was long waiting times or too much rush in the hospital.
Conclusion
There is no agreed standard for quality indicators for anaesthetists. In a literature search we found more than 100 indicators, which can be used to assess quality performance of anaesthetists. In practical terms immediate post operative outcome are probably best quality indicators in anaesthesia. We recommend it should be regularly monitored and fed back to all individual anaesthetists and the staff involved in the peri-operative care of the patient. Our short local experience clearly showed that it’s a useful tool for reflecting on anaesthetic practice and may be included for appraisal and revalidation evidence.
Future actions
The monitoring of quality performance indicators would be an ongoing process associated with quarterly data analysis and presented to peri-operative care providers. The result would be fed back to the system aiming to bring about positive changes. In future, we would also aim to feedback to individual anaesthetists anonymously, which can be a useful for improving their practice and quality of care they provide.
Conflict of interest: None to declare
References:
- Department of Health. High Quality Care for All: NHS Next Stage Review Final Report. London: Department of Health, 2008
- Macario A. Which clinical Anaesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999; 89: 652
- Hysong S, Best R, Pugh J. Audit and feedback and clinical practice guideline adherence: making feedback actionable. Implement Sci 2006; 1: 9
- J Benn, Arnold G BJA: Using quality indicators in Anaesthesia: feeding back data to improve care, British Journal of Anaesthesia, Volume 109, Issue 1, 1 July 2012, Pages 80–91
- Guy Haller et all, Quality and Safety Indicators in Anesthesia, A Systematic Review Anesthesiology 2009; 110:1158–75
Authors
Dr Neha Singal1, Dr Manoj Sharma2
- Clinical Fellow, Anaesthetics, Luton and Dunstable university Hospital, Luton, UK
- Consultant Anaesthetist, Luton and Dunstable University Hospital, Luton, UK.
Correspondence: Dr Manoj Sharma (Email id: manoj.sharma2@ldh.nhs.uk)
