Reducing postoperative pain in children undergoing strabismus surgery: From bundle implementation to clinical decision support tools.

BACKGROUND: Postoperative pain is a significant cause of morbidity in pediatric anesthesia, which can result in delayed discharge and unplanned hospital admission. Children undergoing strabismus surgery are known to be a particularly high-risk group for postoperative pain. AIM: The aim of this project was to reduce the incidence of moderate to severe postoperative pain by 25% over a period of 12 months in children undergoing strabismus surgery. METHODS: This was a multidisciplinary quality improvement project using the Institute for Healthcare Improvement model for improvement and iterative Plan-Do-Study-Act cycles. Baseline data from one hundred patients were collected retrospectively from patient records. Subsequently, iterative interventions introduced comprised: a perioperative bundle (comprising preoperative acetaminophen, intraoperative dexamethasone and ketorolac, a long-acting opioid, and two anti-emetics), email reminders, dissemination of results at departmental rounds, and an intraoperative clinical decision aide. Postoperative pain data were collected as an outcome measure, and length of stay in PACU was monitored as a balancing measure. Statistical process control charts were constructed to monitor bundle compliance and incidence of postoperative pain in the postanesthesia care unit. RESULTS: Postoperative pain and bundle compliance data were collected for 1127 children in total. Baseline mean monthly incidence of moderate to severe postoperative pain was 47.3%. By the conclusion of this project, the incidence of postoperative pain decreased to 21%. Concurrently, mean bundle compliance increased to 78.7%. Mean length of PACU stay for baseline audit patients was 72.5 min compared with 70 min for patients after the introduction of the strabismus macro (November 2018-April 2019, n 91) (mean difference, 2.5; 95% CI, -3.86 to 8.86; P = .439). CONCLUSION: Through the implementation and adoption of an evidence-based bundle of care, we successfully decreased the incidence of moderate to severe postoperative pain for children undergoing strabismus repair. We demonstrated that combining nudge theory with QI methodology can be an effective means of delivering positive results in quality improvement projects.

A 4 year quality improvement initiative reducing post-operative nausea and vomiting in children undergoing strabismus surgery at a quaternary paediatric hospital.

BACKGROUND: Post-operative nausea and vomiting is a significant cause of morbidity in pediatric anesthesia. As well as patient discomfort, post-operative nausea and vomiting can also result in dehydration, delayed discharge and unplanned hospital admission. Children undergoing strabismus surgery are known to be a particularly high risk group for post-operative nausea and vomiting. AIMS: The aim of this project was to reduce post-operative nausea and vomiting by 50% over a period of 12 months. METHODS: This was a single centre retrospective observational study, with prospective observational follow up. A driver diagram was constructed and smart aim established. The Plan-Do-Study-Act method of quality improvement was used for this project. Benchmark data from one hundred patients was collected retrospectively from patient records. After this, interventions were introduced and serial data was prospectively collected. Statistical process control charts were constructed to monitor percentage bundle compliance and incidence of post-operative nausea and vomiting in the post anesthetic care unit. RESULTS: Post-operative nausea and vomiting data was collected for 1079 children in total. Baseline incidence of post-operative nausea and vomiting was 18%. After 4 years this was reduced to 4.72%. At the conclusion of the project there was no significant difference over the previous six months between the incidence of post-operative nausea and vomiting in the strabismus population and the general post anesthetic care unit population. CONCLUSION: Using quality improvement methodology, we were able to sustainably reduce the incidence of post-operative nausea and vomiting for children undergoing strabismus repair. We demonstrated using an evidence based therapeutic bundle can reduce incidence of post-operative nausea and vomiting in the high risk surgical strabismus population to a level comparable to the average post-operative nausea and vomiting incidence in our post anesthetic care unit population.

Knowledge translation and process improvement interventions increased pain assessment documentation in a large quaternary paediatric post-anaesthesia care unit.

BACKGROUND: Due to inadequate pain assessment documentation in our paediatric post-anaesthetic care unit (PACU), we were unable to monitor pain intensity, and target factors contributing to moderate and severe postoperative pain in children. The purpose of this study was to improve pain assessment documentation in PACU through a process improvement intervention and knowledge translation (KT) strategy. The study was set in a PACU within a large university affiliated paediatric hospital. Participants included PACU and Acute Pain Service nursing staff, administrative staff and anaesthesiologists. METHODS: The Plan-Do-Study-Act method of quality improvement was used. Benchmark data were obtained by chart review of 99 patient medical records prior to interventions. Data included pain assessment documentation (pain intensity score, use of validated pain intensity measure) during PACU stay. Repeat chart audit took place at 4, 5 and 6 months after the intervention. INTERVENTION: Key informant interviews were conducted to identify barriers to pain assessment documentation. A process improvement was implemented whereby the PACU flowsheets were modified to facilitate pain assessment documentation. KT strategy was implemented to increase awareness of pain assessment documentation and to provide the knowledge, skill and judgement to support this practice. The KT strategy was directed at PACU nursing staff and comprised education outreach (educational meetings for PACU nurses, discussions at daily huddles), reminders (screensavers, bedside posters, email reminders) and feedback of audit results. RESULTS: The proportion of charts that included at least one documented pain assessment was 69%. After intervention, pain assessment documentation increased to >90% at 4 and 5 months, respectively, and to 100% after 6 months. CONCLUSION: After implementing process improvement and KT interventions, pain assessment documentation improved. Additional work is needed in several key areas, specifically monitoring moderate to severe pain, in order to target factors contributing to significant postoperative pain in children.