Article Text
Abstract
Paediatric patients often present with symptoms of respiratory illnesses in the weeks leading up to surgery. Current or recent illness can increase the risk of experiencing perioperative respiratory complications. Ideally, children with recent illnesses should be identified before coming to the hospital to determine the safest course of action. We recognised that our system lacked a standardised process for documenting preoperative respiratory illness during the preoperative phone call. The global aim of this quality improvement initiative was to decrease paediatric perioperative respiratory adverse events. The SMART Aim (Specific, Measurable, Achievable, Relevant and Time-bound) was to increase the percentage of patients with standardised documentation of preoperative respiratory illness from 0% to 90% by 1 March 2023. Implementation of a standardised preoperative illness questionnaire increased standardised illness documentation from 0% to 95%. Nurses quickly adopted this intervention and easily integrated it into their routine workflow. Clinical leaders elected to implement the intervention electronically across all three operating room (OR) locations (main OR, satellite location and procedure centre). Future implementation of additional standardised preoperative processes will be needed to improve the global aim of decreasing perioperative respiratory complications.
- Paediatrics
- Anaesthesia
- Quality improvement
- Surgery
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Paediatric perioperative respiratory adverse events (PRAEs) are common1 and can lead to increased length of hospitalisation, escalation of care, worsened patient outcomes and higher costs.2 As children commonly present with acute respiratory illnesses that increase PRAE risk, illnesses should be identified before admission to determine the safest action. This initiative aimed to decrease paediatric PRAEs using quality improvement (QI) methodology. The SMART Aim (Specific, Measurable, Achievable, Relevant and Time-bound) was to increase the percentage of patients with standardised respiratory illness documentation from 0% to 90% by 1 March 2023.
Our free-standing academic paediatric medical centre performs over 40 000 anaesthetic cases annually in multiple locations (main operating room (OR), satellite and non-OR locations). The QI team included a nurse practitioner (NP), preoperative nurses (registered nurses, RNs), nurse managers, anaesthesiologists, a surgeon, a quality specialist and an electronic health record (EHR) analyst. The team determined that standardised processes for PRAE reduction were needed, and a key driver diagram (KDD) was developed (figure 1).
Process observations revealed inadequate recent illness documentation during the preoperative phone call two business days before procedure. While there was a script to facilitate questions, there was no standardised questionnaire to document required elements for recent illness-related decision-making, creating redundant workflows, including calling families again for additional information and/or searching for missing illness data in the EHR. Missing recent illness information led to day-of-surgery cancellations, frustrated families and pressure to proceed with cases that should have been rescheduled. Thus, our first intervention was to develop and test standardised preoperative illness phone call questions (based on questions experienced anaesthesiologists ask on day of surgery).
In the main OR, we ran five Plan Do Study Act (PDSA) cycles with seven staff members (RNs, NPs, anaesthesiologists) to trial and optimise an initial algorithm and standardised form for preoperative illness-related questions. Feedback indicated that the algorithm would be difficult to integrate into the existing workflow and documentation process. Therefore, we created a paper version of an EHR flow sheet (figure 2). Once department leaders approved the form, we conducted four PDSAs in the outpatient procedure centre. The procedure centre was chosen (vs main OR) because the smaller environment/patient volume allowed all nurses (8 RNs/day) to participate and made it feasible to manually review all patient charts. This trial proceeded for 7 weeks. A total of 53% (n=49) of paper forms were returned and 93–100% (median=95%, n=156) of patients with ill symptoms were captured. After successfully trialling the paper form in three surgery locations (main, satellite location, procedure centre) with positive qualitative feedback, the electronic standardised form was integrated into the EHR. After implementation, we collected quantitative data from the procedure centre for direct comparison with our prior paper data. Quantitative data collection across all locations was not feasible due to the need for manual chart review for every patient presenting for surgery.
In 6 weeks following implementation, the electronic form was used for 98% (n=62) of patients with ill symptoms and captured 81–96% (median=92%, n=372) of key decision-making elements. After reviewing and discussing missing elements with team members, we noted that some form elements were not always required to determine surgery cancellation (eg, influenza pre-elective procedure, chronic respiratory symptoms at baseline). While the EHR build was less intuitive than the paper form for some elements, iterative improvements ensured all components could be documented.
The standardised electronic preoperative respiratory illness questionnaire increased the percentage of patients with documentation of respiratory illness from 0% to 90% by 1 March 2023. This form provided a standardised method to gather information about recent illness information and created an effective, sustainable method of documentation that is still being used. However, surgery cancellation decisions are complex and multifactorial (eg, age, elective vs urgent case, medical history, type of surgery, recent surgery cancellation, time since the illness, severity of illness). Cancellation guidelines exist, but currently, each case requires an NP review and, when indicated, a surgeon and anaesthesiologist to determine the safest course of action. If providers determine it is reasonable to proceed, risks/benefits are explained to the family, who decides whether to proceed with elective surgery. Future work is needed to standardise the surgery cancellation process.
Decreasing respiratory complications is challenging. Additional process standardisation will allow methodical testing and change implementation. As outlined in the KDD, future process standardisation could include implementation of a validated respiratory risk score (eg, COLDS score)3 and standardised interventions to decrease risk (eg, preoperative intravenous line placement, albuterol administration, anxiolytic premedication in at-risk patients). Collaboration with national and international organisations will support widespread validation and adoption of standardised processes.
Ethics statements
Patient consent for publication
Ethics approval
The Cincinnati Children's Hospital IRB reviewed the study. This study was designated as 'not human subjects'.
Footnotes
Contributors AVW: study conception and design; acquisition, analysis and interpretation of data; drafting and revising the manuscript; final approval of the manuscript; accountable for all aspects of this work. SR, NTGT, JB, DWB: study conception and design; acquisition, analysis and interpretation of data; revising the manuscript; final approval of the manuscript.
Funding This project was funded with internal funds only.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.