Implementation of an Epidural Rounding Reminder in the Electronic Medical Record Improves Performance of Standardized Patient Assessments during Labor

Abstract

Background Poorly functioning labor epidural catheters lead to pain and dissatisfaction. Regular catheter assessment ensures timely identification of malfunction and may improve safety by facilitating rapid and successful conversion to general anesthesia for emergency cesarean. Informatics-based systems encourage standardization of care to identify epidural malfunctions earlier.

Objectives This article demonstrates that visual epidural rounding reminder display on an electronic patient board would alert clinicians to elapsed time and decrease mean time between assessments.

Methods As a quality initiative, we implemented an epidural rounding reminder on our obstetric patient board. The reminder indicated the number of elapsed minutes since placement or last patient assessment. We retrospectively reviewed labor epidural charts 3 months prior to and 5 months following reminder implementation, with a 4-week washout period. The primary outcome was mean time between documented epidural assessments, with secondary outcomes including maximum time between assessments, total number of assessments during labor, catheter replacement rates, and patient satisfaction. Unadjusted comparisons between pre- and postimplementation groups were conducted using Wilcoxon's rank-sum and Pearson's chi-square tests, as appropriate. A test for equal variances was conducted for time between assessment outcomes.

Results Following implementation, mean time between assessments decreased from a median of 173 (interquartile range [IQR]: 53, 314) to 100 (IQR: 74, 125) minutes (p <0.001), and maximum time between assessments decreased from median 330 (IQR: 60, 542) to 162 (IQR: 125, 212) minutes (p < 0.001). Total number of evaluations during labor increased from 3 (IQR: 2, 4) to 5 (IQR: 3, 7; p < 0.001). Decreased variance in mean and maximum time between assessments was noted following reminder implementation (p < 0.001). Epidural replacement rates decreased from 14 to 5% postimplementation (p < 0.001). Patient satisfaction was unchanged.

Conclusion Implementation of an informatics-based solution can promote standardization of care. A simple epidural rounding reminder prompted clinicians to perform more frequent labor epidural assessments. In the future, these process improvements must be linked to improvements in patient experiences and outcomes.

Keywords

anesthesiology - epidural - labor analgesia - neuraxial analgesia - obstetrics/gynecology

Protection of Human and Animal Subjects

This quality improvement study was determined to be exempt by the Human Research Protections Program of the sponsoring institution.

Publikationsverlauf

Eingereicht: 03. Oktober 2022

Angenommen: 09. Januar 2023

Accepted Manuscript online:
12. Januar 2023

Artikel online veröffentlicht:
22. März 2023

• References

• 1 Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev 2018; 5 (05) CD000331
• 2 Mhyre JM, Sultan P. General anesthesia for cesarean delivery: occasionally essential but best avoided. Anesthesiology 2019; 130 (06) 864-866
• 3 Yurashevich M, Carvalho B, Butwick AJ, Ando K, Flood PD. Determinants of women's dissatisfaction with anaesthesia care in labour and delivery. Anaesthesia 2019; 74 (09) 1112-1120
• 4 Tan DJA, Sultana R, Han NLR, Sia ATH, Sng BL. Investigating determinants for patient satisfaction in women receiving epidural analgesia for labour pain: a retrospective cohort study. BMC Anesthesiol 2018; 18 (01) 50
• 5 Mankowitz SK, Gonzalez Fiol A, Smiley R. Failure to extend epidural labor analgesia for cesarean delivery anesthesia: a focused review. Anesth Analg 2016; 123 (05) 1174-1180
• 6 Guglielminotti J, Landau R, Li G. Adverse events and factors associated with potentially avoidable use of general anesthesia in cesarean deliveries. Anesthesiology 2019; 130 (06) 912-922
• 7 Palmer E, Ciechanowicz S, Reeve A, Harris S, Wong DJN, Sultan P. Operating room-to-incision interval and neonatal outcome in emergency caesarean section: a retrospective 5-year cohort study. Anaesthesia 2018; 73 (07) 825-831
• 8 Tsen LC, Bateman BT. Anesthesia for cesarean delivery. In: Chestnut DH, Wong CA, Tsen LC, et al, eds. Chestnut's Obstetric Anesthesia Principles and Practice. 6th ed. Philadelphia, PA: Elsevier; 2020: 568-626
• 9 Carvalho B, Mhyre JM. Centers of excellence for anesthesia care of obstetric patients. Anesth Analg 2019; 128 (05) 844-846
• 10 Urban MK, Chiu T, Wolfe S, Magid S. Electronic ordering system improves postoperative pain management after total knee or hip arthroplasty. Appl Clin Inform 2015; 6 (03) 591-599
• 11 R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing; 2020. Accessed November 5, 2020, at: https://www.R-project.org/
• 12 Garg AX, Adhikari NK, McDonald H. et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005; 293 (10) 1223-1238
• 13 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330 (7494): 765
• 14 Raban MZ, Baysari MT, Jorgensen ML, Tariq A, Georgiou A, Westbrook JI. Unmet needs for transdermal patch management in electronic medication administration records: an analysis of data from 66 aged care facilities. Appl Clin Inform 2020; 11 (05) 812-820
• 15 Wright A, Sittig DF, Ash JS. et al. Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems. J Am Med Inform Assoc 2011; 18 (03) 232-242
• 16 Pamplin J, Nemeth CP, Serio-Melvin ML. et al. Improving clinician decisions and communication in critical care using novel information technology. Mil Med 2020; 185 (1-2): e254-e261
• 17 Bates DW, Kuperman GJ, Wang S. et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003; 10 (06) 523-530
• 18 Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects. (PIPs). Centers for Medicare and Medicaid Services. Accessed January 27, 2023, at: https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/guidanceforrca.pdf