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Quality improvement project: adapting an electronic medical record system to improve quality measures reporting in obstetric anesthesia
Abstract Number: S-53
Abstract Type: Original Research
Background: Quality measures for regional anesthesia in obstetrics include unintended dural puncture and failed block(1). Previous large scale studies have estimated adverse events of neuraxial anesthesia in obstetrics(2,3). These include minor complications such as dural puncture, venous puncture, paresthesias, and epidural failure/catheter replacement. Local practice data must be complete and accurate so that a practice can compare their rates of adverse events to national norms. We initiated a quality improvement (QI) project that compared our current medical record system with an automated electronic medical record (EMR) system to evaluate several regional anesthesia quality measures.
Methods: Medical records(paper and EMR) were reviewed for completeness for the following six measures over a ten day period in patients who had a lumbar epidural placed: unintended dural puncture, presence of blood in the epidural catheter, paresthesia reported during block placement, epidural failure requiring replacement/use of a second anesthetic, presence of documented sensory levels during the anesthetic, and patient satisfaction. Our study intervention placed separate questions into the EMR corresponding to each of the six quality measures. The EMR program was also changed to mandate completion of all six questions before the case could be closed in the EMR. Ten days of records were reviewed after the intervention.
Results: Records for 79 patients were reviewed; 36 patients pre-intervention and 43 patients post-intervention. Pre-intervention, gaps in documentation for the quality measures were significant, with missing or unknown responses as follows: paresthesias 14%, blood in catheter 8%, dural puncture 11%, epidural replacement 97%, bilateral sensory levels 31%, and patient satisfaction 64%. The rate decreased to zero for all six quality measures once the mandatory EMR system was instituted. Rates of adverse outcomes could not be compared because of the large amount of missing data pre-intervention.
Discussion: The QI intervention eliminated documentation deficiencies. Adapting the EMR has allowed us to track quality measures related to neuraxial anesthesia. As a result of this study, we now have real-time notification of each patient not satisfied with her epidural and investigate each failure prior to patient discharge. Limitations include using some quality markers that may, or may not be, important for optimal patient care.
1. Anesthesia Quality Institute. http://www.aqihq.org/qualitymeasurementtools.aspx May 11, 2013. Accessed January, 2014.
2. Paech MJ, Godkin R, Webster S. Complications of obstetric epidural analgesia and anaesthesia: a prospective analysis of 10,995 cases. Int. J. Obstet. Anesth. 1998;7:5–11.
3. Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. Int. J. Obstet. Anesth. 2004;13:227–233.