Perioperative Quality Improvement Research Articles

Launching a Geriatric Surgery Center: Recommendations from the Society for Perioperative Assessment and Quality Improvement.

To prepare for the increasing numbers of older adults undergoing surgery, the American College of Surgeons (ACS) has recently launched the Geriatric Surgery Verification Program with the goal of encouraging the creation of centers of geriatric surgery. Meanwhile, the Society for Perioperative Assessment and Quality Improvement (SPAQI) has published recommendations for the preoperative management of frailty, which state that teams should actively screen for frailty before surgery and that pathways, including geriatric comanagement, shared decision-making, and multimodal prehabilitation, should be embedded in routine care to help improve patient outcomes. Both SPAQI and the ACS advocate for a multidisciplinary approach to improve the value of care for older adults undergoing surgery. However, the best way to implement geriatric services in the surgical setting is yet to be determined. In this statement, we will describe the SPAQI recommendations for launching a geriatric surgery center and the process by which its value should be assessed over time.

Perceptions of opioid use and prescribing habits in oncologic surgery: A survey of the society of surgical oncology membership.

The objective of this study was to assess current perceptions surrounding opioid prescribing in surgical oncology to inform perioperative quality improvement initiatives. After the Society of Surgical Oncology (SSO) approval, a survey was distributed to its membership. Five sample procedures were used to assess provider perceptions and prescribing habits. Data were summarized and compared by self-reported demographics. One hundred and seventy-five participants completed the survey: 149 (85%) faculty, 24 (14%) trainees, and 2 (1%) advanced practice providers. Most participants (76%) practiced in academic programs and 21% practiced in non-US locations. Few differences were identified based on clinical role, academic rank, or practice years. Compared with non-US providers, US providers expected higher pain scores at discharge, recommended greater opioid prescriptions, and estimated more days of opioid use for almost every procedure. More non-US providers believed discharge opioids should not be distributed to patients who are opioid-free in their last 24 inpatient hours (80% vs 50%, P = .001). All providers ranked education as "very important" for reducing opioid prescriptions. Compared with their international counterparts, US surgical oncology providers expected greater opioid needs and recommended higher prescription numbers. Educating providers on multimodal opioid-sparing bundles, accelerated weaning protocols, and standardized discharge prescribing habits could have a positive impact the US opioid epidemic.

Postoperative Utilization of Oral Nutrition Supplements in Surgical Patients in US Hospitals.

Postoperative nutrition delivery is essential to surgical recovery; unfortunately, postoperative dietary intake is often poor. Recent surgical guidelines recommend use of oral nutritional supplements (ONS) to improve nutrition delivery. Our aim was to examine prevalence of coded ONS use over time and coded malnutrition rates in postoperative patients. The Premier Healthcare Database (PHD) was queried for postoperative patients found to have charges for ONS between 2008-2014. ONS use identified via charge codes. Descriptive statistics utilized to examine prevalence of malnutrition and ONS utilization. Multilevel, multivariable logistic regression models were fit to examine factors associated with ONS use. A total of 2,823,532 surgical encounters were identified in PHD in 172 hospitals utilizing ONS charge codes. ONS-receiving patients were 72% Caucasian, 65% Medicare patients with mean age of 66 ± 16.5 years. Compared with patients not receiving ONS, ONS patients had higher van Walraven severity scores (7.3 ± 7.8 vs 2.3 ± 5.6, P < .001) with greater comorbidities. Overall coded malnutrition prevalence was 4.3%. Coded malnutrition diagnosis increased from 4.4% to 5.2% during study period. Only 15% of malnourished patients received ONS. Individual hospital practice explained much of variation in early postoperative ONS use. In this large surgical population, inpatient ONS use is most common in older, Caucasian, Medicare patients with high comorbidity burden. Despite increased malnutrition during study period, observed ONS prescription rate did not increase. Our data indicate current ONS utilization in surgical patients, even coded with malnutrition, is limited and is a critical perioperative quality improvement opportunity.

Prioritisation of quality indicators for elective perioperative care: a Delphi consensus

BackgroundA systematic review of the peer-reviewed and grey literature previously identified over 1200 perioperative structure and process quality indicators. We undertook a Delphi consensus process with the aim of creating a concise list of indicators that experts deemed most important for assessing quality in perioperative careMethodsA basic Delphi consensus was completed using an online survey which was distributed to surgeons, anaesthetists, nurses, physicians and lay representatives. Participants were asked to prioritise the indicators in order of importance (high, medium or low) to be included for collection in a national perioperative quality improvement programme.ResultsOne hundred and thirty-seven indicators were included in the first iteration of the Delphi consensus (91 structure and 48 process indicators). Sixty-three experts agreed to participate and the consensus was completed in five rounds. Ninety-five indicators were agreed as high priority: 65 structural and 30 process indicators.ConclusionThe Delphi consensus process was able to reduce the number of recommended indicators to only a modest extent. Further work to evaluate the practicalities of routinely collecting such a comprehensive list of quality indicators is now required.

Using Time-Driven Activity-Based Costing to Demonstrate Value in Perioperative Care: Recommendations and Reviewfrom the Society for Perioperative Assessment and Quality Improvement (SPAQI).

A shift in healthcare payment models from volume toward value-based incentives will require deliberate input into systems development from both perioperative clinicians and administrators to ensure appropriate recognition of the value of all services provided-particularly ones that are not reimbursable in current fee-for-service payment models. Time-driven activity-based costing (TDABC) methodology identifies cost drivers and reduces inaccurate costing based on siloed budgets. Inaccurate costing also results from the fact that current costing methods use charges and there has been tremendous cost shifting throughout health care. High cost, high variability processes can be identified for process improvement. As payment models inevitably evolve towards value-based metrics, it will be critical to knowledgably participate in the coordination of these changes. This document provides 8 practical Recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI) aimed at outlining the principles of TDABC, creating process maps for patient workflows, understanding payment structures, establishing physician alignment across service lines to create integrated practice units to facilitate development of evidence-based pathways for specific patient risk groups, establishing consistent care delivery, minimizing variability between physicians and departments, utilizing data analytics and information technology tools to track progress and obtain actionable data, and using TDABC to create costing transparency.

Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation.

Smokers are at increased risk for surgical complications. Despite the known benefits of smoking cessation, many perioperative health care providers do not routinely provide smoking cessation interventions. The variation in delivery of perioperative smoking cessation interventions may be due to limited high-level evidence for whether smoking cessation interventions used in the general population are effective and feasible in the surgical population, as well as the challenges and barriers to implementation of interventions. Yet smoking is a potentially modifiable risk factor for improving short- and long-term patient outcomes. The purpose of the Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation is to present recommendations based on current scientific evidence in surgical patients. These statements address questions regarding the timing and intensity of interventions, roles of perioperative health care providers, and behavioral and pharmacological interventions. Barriers and strategies to overcome challenges surrounding implementation of interventions and future areas of research are identified. These statements are based on the current state of knowledge and its interpretation by a multidisciplinary group of experts at the time of publication.

Leadership of Perioperative Quality Improvement Council

Leadership of Perioperative Quality Improvement Council

Same-Day Surgery for Mastectomy Patients in Alberta: A Perioperative Care Pathway and Quality Improvement Initiative.

Same-day surgery (SDS) following mastectomy is safe and well accepted. Overnight admission in patients fit for discharge is an inefficient use of health resources. In response to a national review highlighting SDS following mastectomy at 1.4% in Alberta, a perioperative pathway was conceived. The pathway was implemented across Alberta at 13 hospitals beginning in 2016. A steering committee was assembled, and clinical and administrative leads at each site were identified. Opportunities along the patient care experience whereby action could be taken to promote uptake of SDS were identified. Provincially branded support materials including presentations, order sets, and standard operating procedures were developed. Nurse educators provided in-service teaching such as standardized drain care and discharge teaching. Educational booklets, group classes, and online resources were developed for patients and families. An audit of SDS rates, unscheduled return to the emergency department (ED), and readmission rates was reported to teams quarterly, allowing for iterative modifications. Patient-reported experience measures (PREMs) were collected. SDS following mastectomy increased from 1.7 to 47.8%, releasing an estimated 831 bed days per year. No differences in unexpected return to the ED or readmission to hospital existed between SDS patients and those admitted overnight. A total of 102 patients completed the PREM survey, of whom 90% felt "excellent or good" with the plan to go home, how to care for themselves once home, and who to contact should issues arise. Implementation of a provincial perioperative pathway improved uptake of SDS following mastectomy and demonstrated favorable PREMs.

Qualitative process evaluation of the Perioperative Quality Improvement Programme (PQIP): study protocol

IntroductionThe Perioperative Quality Improvement Programme (PQIP) is designed to measure complications after major elective surgery and improve these through feedback of data to clinicians. Previous research suggests that despite the...

Perioperative Quality Initiative consensus statement on postoperative blood pressure, risk and outcomes for elective surgery

BackgroundPostoperative hypotension and hypertension are frequent events associated with increased risk of adverse outcomes. However, proper assessment and management is often poorly understood. As a part of the PeriOperative Quality Improvement (POQI) 3 workgroup meeting, we developed a consensus document addressing this topic. The target population includes adult, non-cardiac surgical patients in the postoperative phase outside of the ICU. MethodsA modified Delphi technique was used, evaluating papers published in MEDLINE examining postoperative blood pressure monitoring, management, and outcomes. Practice recommendations were developed in line with National Institute for Health and Care Excellence guidelines. ResultsConsensus recommendations were that (i) there is evidence of harm associated with postoperative systolic arterial pressure <90 mm Hg; (ii) for patients with preoperative hypertension, the threshold at which harm occurs may be higher than a systolic arterial pressure of 90 mm Hg; (iii) there is insufficient evidence to precisely define the level of postoperative hypertension above which harm will occur; (iv) a greater frequency of postoperative blood pressure measurement is likely to identify risk of harm and clinical deterioration earlier; and (v) there is evidence of harm from withholding beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors in the postoperative period. ConclusionsDespite evidence of associations with postoperative hypotension or hypertension with worse postoperative outcome, further research is needed to define the optimal levels at which intervention is beneficial, to identify the best methods and timing of postoperative blood pressure measurement, and to refine the management of long-term antihypertensive treatment in the postoperative phase.

Near Miss in Intraoperative Magnetic Resonance Imaging: A Case for In Situ Simulation.

Introduction:Pediatric patients in intraoperative magnetic resonance imaging (iMRI) settings are at high risk for morbidity should an adverse event occur. We describe an experience in the iMRI scanner where no harm occurred, yet revealed an opportunity to improve the safety of patients utilizing the iMRI. The perioperative quality improvement team, resuscitation team, and radiology nurse leadership collaborated to understand the process better through in situ simulation.Methods:After a problem analysis, the team planned an in situ, high-fidelity simulation with predefined learning objectives to identify previously overlooked opportunities for improvement. The iMRI simulation had unique considerations, including the use of a magnetic resonance imaging (MRI)-compatible mannequin and ensuring participants' safety. Audiovisual equipment was placed in strategic locations to record the MRI and operating room (OR) segments of the simulation, and trained health-care simulation experts provided debriefing.Results:After completion of the iMRI simulation, the quality improvement team solicited feedback from participants and reviewed the video-recorded simulation. Several opportunities for improvement surrounding staff responsibilities and unique aspects of the iMRI environment were identified.Conclusions:iMRI in situ simulation has not been previously described. It presents unique challenges given the integration of personnel from OR and radiology environments, anesthetized patients, and risks from the high-powered MRI magnet. Other institutions utilizing hybrid ORs with iMRI may consider conducting in situ simulations using the described methods.

Society for Perioperative Assessment and Quality Improvement Reply to “American Society of Enhanced Recovery

Society for Perioperative Assessment and Quality Improvement Reply to “American Society of Enhanced Recovery

The Perioperative Quality Improvement Programme

How is the programme improving surgical care and how can you get involved?

A Review of peri-operative quality improvement programmes and their effect on post-operative pulmonary complication rates

A Review of peri-operative quality improvement programmes and their effect on post-operative pulmonary complication rates

Safety Stop: A Valuable Addition to the Pediatric Universal Protocol

The World Health Organization (WHO) guidelines and Joint Commission requirements state that the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ must be performed just prior to incision. A mock Joint Commission survey at one institution revealed that the time-out was performed prior to preparation and draping (P&D) of the patient, not afterward, representing both a patient and regulatory risk. The multidisciplinary perioperative quality improvement team at a freestanding, quaternary care, academic pediatric hospital led the development of a new time-out process. An enhanced pediatric Universal Protocol, which included a new component, the safety stop, was created. The safety stop occurred just prior to P&D of the patient, and the time-out was performed just prior to incision, aligning with WHO recommendations. After electronic correspondence and several perioperative leadership meetings, the enhanced pediatric Universal Protocol was initiated. Compliance audits were performed to demonstrate comprehensive adoption. In seven operating room locations, 60 audits were completed in four weeks, with 96.7% (58/60) demonstrating compliance with the new policy. During a subsequent Joint Commission accreditation survey, the enhanced pediatric Universal Protocol with inclusion of the safety stop was highlighted as a leading practice. Although initially it was believed that moving the time-out from prior to P&D to just prior to incision would be a simple solution, flow mapping the complete time-out process identified significant risk of wrong-site or wrong-patient surgery with this solution. This risk was exacerbated by the small body size of pediatric patients being obscured by draping on a typical operating room table.

Recommendations for Preoperative Management of Frailty from the Society for Perioperative Assessment and Quality Improvement (SPAQI)

Frailty is an age-related, multi-dimensional state of decreased physiologic reserve that results in diminished resiliency and increased vulnerability to stressors. It has proven to be an excellent predictor of unfavorable health outcomes in the older surgical population. There is agreement in recommending that a frailty evaluation should be part of the preoperative assessment in the elderly. However, the consensus is still building with regards to how it should affect perioperative care. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in the fields of gerontology, anesthesiology and preoperative assessment to outline practical steps for clinicians to assess and address frailty in elderly patients who require elective intermediate or high risk surgery. These recommendations summarize evidence-based principles of measuring and screening for frailty, as well as basic interventions that can help improve patient outcomes.

The Perioperative Quality Improvement Programme: improving outcomesd.

The Perioperative Quality Improvement Programme: improving outcomesd.

Quality improvement in perioperative medicine: driving the revolution.

Perioperative medicine and quality improvement are both emerging fields with the potential to contribute to safer and more reliable care for surgical patients. One key component has been the evolution of the national audit project programme. This article describes the current state of quality improvement within perioperative medicine, the evolution of the national audit project programme and the effects it has produced on the quality of patient care. The article also highlights opportunities for health-care professionals to engage with this innovative area of medicine.

Using the WHO Surgical Safety Checklist to Direct Perioperative Quality Improvement at a Surgical Hospital in Cambodia: The Importance of Objective Confirmation of Process Completion

BackgroundThe WHO surgical safety checklist (SSC) is known to prevent postoperative complications; however, strategies for effective implementation are unclear. In addition to cultural and organizational barriers faced by high-income countries, resource-constrained settings face scarcity of durable and consumable goods. We used the SSC to better understand barriers to improvement at a trauma hospital in Battambang, Cambodia.MethodsWe introduced the SSC and trained data collectors to observe surgical staff performing the checklist. Members of the research team observed cases and data collection. After 3 months, we modified the data collection tool to focus on infection prevention and elicit more accurate responses.ResultsOver 16 months we recorded data on 695 operations (304 cases using the first tool and 391 cases with the modified tool). The first tool identified five items as being in high compliance, which were then excluded from further assessment. Two items—instrument sterility confirmation and sponge counting—were identified as being misinterpreted by the data collectors’ tool. These items were reworded to capture objective assessment of task completion. Confirmation of instrument sterility was initially never performed but rectified to >95% compliance; sponge counting and prophylactic antibiotic administration were consistently underperformed.ConclusionsStaff complied with communication elements of the SSC and quickly adopted process improvements. The wording of our data collection tool affected interpretation of compliance with standards. Material resources are not the primary barrier to checklist implementation in this setting, and future work should focus on clarification of protocols and objective confirmation of tasks.

The American College of Surgeons Children's Surgery Verification and Quality Improvement Program: implications for anesthesiologists.

The Task Force for Children's Surgical Care, an ad-hoc multidisciplinary group of invited leaders in pediatric perioperative medicine, was assembled in May 2012 to consider approaches to optimize delivery of children's surgical care in today's competitive national healthcare environment. Over the subsequent 3 years, with support from the American College of Surgeons (ACS) and Children's Hospital Association (CHA), the group established principles regarding perioperative resource standards, quality improvement and safety processes, data collection, and verification that were used to develop an ACS-sponsored Children's Surgery Verification and Quality Improvement Program (ACS CSV). The voluntary ACS CSV was officially launched in January 2017 and more than 125 pediatric surgical programs have expressed interest in verification. ACS CSV-verified programs have specific requirements for pediatric anesthesia leadership, resources, and the availability of pediatric anesthesiologists or anesthesiologists with pediatric expertise to care for infants and young children. The present review outlines the history of the ACS CSV, key elements of the program, and the standards specific to pediatric anesthesiology. As with the pediatric trauma programs initiated more than 40 years ago, this program has the potential to significantly improve surgical care for infants and children in the United States and Canada.