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Reducing the general anaesthesia rate for emergency caesarean section through implementing a multidisciplinary quality improvement approach
Abstract Number: S5B-6
Abstract Type: Original Research
General anaesthesia (GA) in the obstetric population is associated with increased morbidity and mortality and lower patient satisfaction. Our unit serves a high-risk heterogeneous population of parturients. This provided us with motivation to reduce our GA rate, although our baseline levels were within the accepted UK standards, set by the Royal College of Anaesthetists (below 15% for emergency CS). Here we explain how we used a sustained multidisciplinary quality improvement methodology over a five year period to halve the rate of GA for emergency CS in our unit from 10.7% to 5.6%.
From 2013 to 2017, we used electronic patient records, enabling fast real-time data analysis for quality assurance and improvement. Quality indicators were tracked and discussed regularly in joint obstetric, anaesthetic and midwifery forums. We monitored the rates of GA administered for CS, as well as indications and complications. We also analysed the mode of anaesthesia for all CS classified as Category 1 and the type of epidural top up mix used. We used a multipronged approach for improvement. We introduced a faster-onset epidural mix for top-ups, enabling more emergency CS to be done under epidural. We altered training to emphasise the need for regular review and better communication regarding epidural analgesia to recognise sub-optimal epidural placement. Our obstetric colleagues tackled the high baseline rate of Category 1 CS (19% in 2013) by intensive training and casenote review, and we introduced multidisciplinary in-situ simulation training to improve teamworking and communication across specialties.
During the 5 year period, the rate of GA administered for emergency CS decreased from 10.7% to 5.6% (RR 0.53, 95% CI 0.40-0.71, p<0.0001). Over this period, there was a near four-fold reduction (19.1% to 5.7%) in the percentage of CS being classified as Category 1. We observed an increasing trend of using faster-onset epidural mixture (lidocaine, adrenaline and fentanyl) for Category 1 CS (from 4.7% to 42.8%). The conversion rate to GA from failed epidural top-up dropped from 5.0% to 1.1%. Complications including difficult or failed intubation remained constant at about 3%.
We found that we were able to reduce our failure rate for epidural top-up by 80% by better anticipation of poorly-working epidurals and the introduction of a rapid-onset top-up mix. However, the main driver for our reduction in GA rate was that obstetricians rectified a tendency to incorrectly categorise the urgency of emergency CS. The choice of anaesthesia for emergency CS is influenced by a range of factors involving the complexities of teamworking and communication between members of the delivery suite team. Cohesive interdisciplinary teamworking on the ground and at management level alongside a collaborative approach between obstetric and anaesthetic departments towards clinical governance has the potential to improve anaesthetic outcomes.