Optimum Care: Implementation of Quality Assurance Benchmarks for Pituitary Surgery

Introduction: Quality improvement in a particular sector of medicine requires standardization of protocols and adherence to those protocols. Our goal was to introduce a protocol for pituitary surgery, which would mandate the achievement of certain standards in the preoperative, intraoperative, and postoperative periods.

Methods: We introduced a standardized protocol into our pituitary surgery program and measured our own adherence to each parameter. The preoperative part of the protocol mandated a prolactin level screen, an adrenal insufficiency (AI) screen via cortisol levels, and a thyroid insufficiency (TI) screen via free T4 levels. The intraoperative protocol included the SCIP measures and intraoperative stress dose steroids, when appropriate. The postoperative protocol was focused on DVT prophylaxis.

Results: After 8 months of implementation, 39 patients with pituitary adenomas were subject to the new protocol. Our adherence to the criteria set forth was 94.8% for prolactin screening, 97.4% for AI screening, 97.4% for TI screening, 100% for SCIP measures, 100% for intraoperative stress dose steroids when indicated for AI, and 100% for postoperative DVT prophylaxis. The lower adherence rates were seen in the early stage of the protocol implementation and improved to 100% across all aspects with time. One patient did not complete the required labs due to an insurance denial, which took place before the protocol was implemented. In one Cushing’s disease patient, the prolactin level was not measured during the endocrinologic workup.

Conclusions: We demonstrated a successful implementation of a set of quality assurance measures into our practice of pituitary surgery. Quality improvement protocols require a learning curve and multiple system-wide adaptations.