Jump to comment:

• Building on feedback to maximise quality improvement
  Dean A Cowie
  Published on: 14 September 2018

• Published on: 14 September 2018

  Building on feedback to maximise quality improvement

  • Dean A Cowie, Staff Anaesthetist Austin Health, Melbourne

  Optimising the quality of recovery following anaesthesia, with a focus on both physiological and emotional wellbeing, is an important goal for anaesthesia quality improvement.(1) I was interested to read the paper by Collyer and colleagues(2) which reports an reduction in the incidence of nausea, hypothermia, significant pain and unplanned admission from the relatively simple intervention of audit followed by individual performance feedback which included a comparison to the departmental averages. It is commendable that they have chosen issues in anaesthesia recovery aligned with NICE quality standards and indicators,(3) and which are both important and common, so that even a small change in outcome will have a significant impact on healthcare.
  A continuous observational study of outcome provides the best information to highlight opportunities for improvement, although data collection can be onerous. The improvements reported have the potential to reduce indirect costs of hospitalisation and variation in practice standards. This study includes metrics which are of interest to both patients and providers. No doubt this contributed to the high level of acceptance and engagement reported in the survey of participants. The inclusion of a wide variety of patients both in- and out of hours and the use of a custom data recording instrument is likely to have increased the validity of the findings.
  However, there are a number of issues with the reliability of the...

  Show More

  Optimising the quality of recovery following anaesthesia, with a focus on both physiological and emotional wellbeing, is an important goal for anaesthesia quality improvement.(1) I was interested to read the paper by Collyer and colleagues(2) which reports an reduction in the incidence of nausea, hypothermia, significant pain and unplanned admission from the relatively simple intervention of audit followed by individual performance feedback which included a comparison to the departmental averages. It is commendable that they have chosen issues in anaesthesia recovery aligned with NICE quality standards and indicators,(3) and which are both important and common, so that even a small change in outcome will have a significant impact on healthcare.
  A continuous observational study of outcome provides the best information to highlight opportunities for improvement, although data collection can be onerous. The improvements reported have the potential to reduce indirect costs of hospitalisation and variation in practice standards. This study includes metrics which are of interest to both patients and providers. No doubt this contributed to the high level of acceptance and engagement reported in the survey of participants. The inclusion of a wide variety of patients both in- and out of hours and the use of a custom data recording instrument is likely to have increased the validity of the findings.
  However, there are a number of issues with the reliability of the study which may impact on the conclusions drawn by the authors. As stated in the paper, there was no data collected regarding management processes and so the improvement in patient outcomes may not relate to the audit and feedback process. This could be tested by having a control group which was audited but which did not receive feedback. A recent study using audit and feedback as a behavioural change strategy failed to find a difference in intraoperative temperature management between the intervention groups and the control group.(4) By contrast this study showed rates of improvement between 9.6 and 30% which are higher than expected for an intervention of this type.(5)
  One source of bias could have been explored in the operative time and anaesthesia category data collected as part of the study. A reduction in the use of prefilled morphine syringes was reported and other factors which could contribute to a fall in measured outcomes may have become evident, such as an increase in regional anaesthesia rates or shorter anaesthesia times. These may represent the evolution of patient care over the duration of the study.(6) Another factor which may confound the results is that outcome data was not collected for around one eighth of eligible patients. Since a failure to enter data could be expected to occur more often in complicated patients requiring a lot of attention from the recovery nurse, it would be helpful to report whether the patients left out were different in their baseline characteristics and whether the rate of missing data was the same throughout the study. Finally, although the data has been collected prospectively the duration of collection was not pre-planned. The graphs provided show steady improvement for some outcomes, however data in figure 1 suggests that rate of unexpected admissions varied significantly.
  While the results of this study are encouraging, the use of other quality improvement strategies have the potential to achieve sustained and reliable results. One option is to measure and report on processes which lead to the outcomes of interest, such as whether practitioners follow established anti-emetic guidelines.(7) Although not an aim of this study by design, process improvement can be brought about by the use of education, clinical practice guidelines, cognitive aids and process mapping. This would facilitate the implementation of a complete quality improvement cycle process, with measured outcomes driving process change. The study period could also be extended beyond the immediate recovery period to capture other outcomes which would be of interest and use to practitioners, patients and the hospitals. Additional meaningful sources would include medical records, administrative databases and patient satisfaction surveys.

  References
  1. Myles PS. Measuring quality of recovery in perioperative clinical trials. Curr Opin Anaesthesiol. 2018;31(4):396-401.
  2. Collyer T, Robertson M, Lawton T, Rothwell A. Comparative performance reports in anaesthesia: impact on clinical outcomes and acceptability to clinicians. BMJ Open Qual. 2018;7(3):e000338.
  3. National Institute for Haelth and Care Excellence. Standards and indicators. 2018 [3/9/2018]. Available from: https://www.nice.org.uk/standards-and-indicators.
  4. Boet S, Bryson GL, Taljaard M, Pigford AA, McIsaac DI, Brehaut J, et al. Effect of audit and feedback on physicians' intraoperative temperature management and patient outcomes: a three-arm cluster randomized-controlled trial comparing benchmarked and ranked feedback. Can J Anaesth. 2018.
  5. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012(6):CD000259.
  6. Lin CJ, Williams BA. Postoperative nausea and vomiting in ambulatory regional anesthesia. Int Anesthesiol Clin. 2011;49(4):134-43.
  7. Kolanek B, Svartz L, Robin F, Boutin F, Beylacq L, Lasserre A, et al. Management program decreases postoperative nausea and vomiting in high-risk and in general surgical patients: a quality improvement cycle. Minerva Anestesiol. 2014;80(3):337-46.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top