Abstract No. 447 Quality improvement: creation and sustainability of an enhanced recovery after procedure initiative for hepatic microwave ablation

Abstract

Listen

Translate article

The purpose of this quality improvement project (QI) was to establish a novel and sustainable enhanced recovery after procedure (ERAP) pathway utilizing a computerized physician order entry (CPOE) set to improve periprocedural pain for patients undergoing hepatic microwave ablation (MWA). An enhanced recovery after procedure (ERAP) pathway was formulated and included evidence-based interventions shown to decrease periprocedural procedural pain. These included pre-procedure analgesics (PA): acetaminophen, celecoxib, oxycodone as well as preprocedure bilateral paravertebral blocks (PVB). A dedicated regional anesthesia team from the OR was recruited to perform the PVB. The pathway was implemented in October 2017. IR fellows, nurses, and anesthesia providers were educated with lectures on acute pain management. Initially, daily email reminders were sent for PA and PVB. Subsequently, the CPOE order set was developed for IR physician use, which included choices and recommendations for PAs. This was implemented in June 2018, and emails stopped. Acute pain management lectures were given to incoming IR fellows. A QI retrospective cohort analysis was then conducted from May 2016 through March 2020 on over 300 consecutive patients undergoing CT-guided liver microwave ablations (MWA). Adherence to PA and PVB performance was compared prior to ERAP (May 2016-September 2017) and after ERAP (October 2017 - March 2020). Initial goals were that 80% of eligible patients would receive at least 1 PA, and 50%of eligible patients would receive PVB. Process control charts were utilized to analyze month to month compliance to the ERAP pathway. Statistical process control charts demonstrated that after initiation of the ERAP protocol PA administration increased from 12% to 93%, and PVB increased from 15% to 78% on average from May 2016 to March 2020. After implementation of the CPOE order set and discontinuation of daily email reminders, there was a sustained adherence to utilizing the ERAP protocol over time with month-to-month adherence of > 80% for PA and > 50% for PVB (eligible patients). Acute pain management programs such as ERAP are a viable option for many patients presenting to IR for microwave ablations as well as for other painful ablative procedures. This initiative represents stresses that education and CPOE are effective elements to facilitate implementation of and adherence to ERAP pathways.