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!