RESUMEN
OBJECTIVES: To determine adherence of perioperative knee/hip arthroplasties and hip fracture repairs to the American Pain Society (APS) guideline recommendations for perioperative pain control. One secondary objective was to perform an internal quality audit on the use of enhanced recovery after surgery (ERAS) protocols; another secondary objective was to design an evidence-based, multi-modal perioperative quick-order menu (if warranted). DESIGN/PATIENTS: A retrospective quality improvement (QI) review of uncomplicated knee/hip replacement and hip fracture repairs from January 2018 through March 2018. SETTING: West Palm Beach Veterans Affairs Medical Center (WPB VAMC) including acute care, subacute rehabilitation, and outpatient setting. MAIN OUTCOME MEASURE: Analgesic use in the perioperative setting via electronic health record review. RESULTS: Forty-seven patients were retrospectively reviewed. Perioperative multi-modal analgesia was used in 85% of patients. Eighty-seven percent were discharged on multi-modal analgesia. There was a 67% response rate to the internal quality audit on ERAS protocol usage from the orthopedic team. CONCLUSION: A retrospective QI review completed approximately two years after APS guideline publication showed that compliance with these recommendations for multi-modal analgesia (consisting of the use of at least two medication classes) at the WPB VAMC in the postoperative setting for knee/hip arthroplasties and hip fracture repairs was 85%. This indicated potential for improvement in achieving a pharmacologic multimodal and ERAS intervention. The authors developed an evidence-based quick-order menu to further reinforce adherence to the APS perioperative guidelines.
Asunto(s)
Analgesia , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Veteranos , Humanos , Estudios Retrospectivos , Estados UnidosRESUMEN
OBJECTIVES: The purpose of this quality improvement (QI) project was to improve the overall process of implementing continuous subcutaneous infusion of opioids (CSCIOs) at the West Palm Beach Veterans Affairs Medical Center and characterize their use in the hospice unit. METHODS: A retrospective chart review from July 2014 to August 2017 was conducted to identify patients who had received CSCIO. Results were analyzed with descriptive statistics.The business philosphy, LEAN methodology "The 5 Whys" was utilized to identify the root causes for delayed infusion timeliness and corrections were implemented by August 2018. Follow-up retrospective time study completed from September 2018 to February 2019. RESULTS: Of the 107 patients identified, 7 were excluded and 100 were reviewed. The mean age was 73 years, 94% male, and 86% Caucasian. A total of 55 veterans received morphine with an average final infusion rate of 2.5 mg/h. A total of 45 Veterans received hydromorphone with a final infusion rate of 1.3 mg/h. The average infusion duration until death was 5 days. Pharmacy verified 94 (94%) orders and nursing verified 55 (55%) orders within 1 hour (gold standard). Sixteen (16%) patients received CSCIO within 1 hour. The 5 Whys identified nursing order verification and pharmacy lack of visual STAT order notification for priority as the potential sources for infusion timeliness improvement. The follow-up time study confirmed improvement in pharmacy delivery time from 29% to 75% on time. CONCLUSION: Pharmacist-led intervention directed to improve CSCIO processes in an inpatient hospice unit utilizing LEAN QI methodology increased timeliness of pharmacy CSCIO delivery.