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From the Department of Anaesthesia, Vancouver General Hospital, Vancouver, British Columbia, Canada.
Address correspondence to: Dr. Himat Vaghadia, Department of Anaesthesia (JPP 2449) Vancouver General Hospital, 855 West 12th Avenue, Vancouver, British Columbia V5Z 4E3, Canada. Phone: 604-875-4575; Fax: 604- 875-5209; E-mail: hvaghadi{at}vanhosp.bc.ca
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Abstract |
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Methods: After institutional approval, we conducted a prospective quality assurance audit in a cohort of 462 consecutive outpatients. A measurement tool was developed using information from previous literature. Data recorded included demographics, type of surgery and anesthesia, duration of stay in the postanesthetic care unit (PACU) and any adverse events in the PACU. The effect of ethnicity on the above was also examined.
Results: The demographics and practice profiles of our unit were comparable to other units. The mean duration of stay in the PACU was 91 ± 55.3 min and is twice as long as other units. The incidence of hypotension, hypothermia and excessive pain in the PACU were higher compared to other centres. The incidence of other adverse events was comparable to that reported by other centres. O2 supplementation was required more frequently in Caucasians (23% vs 9%; P <0.05) and postoperative bleeding occurred more frequently in Asiatics (46% vs 27%; P <0.05).
Conclusion: A mini-audit was found to be helpful in assessing and monitoring quality of care and in identifying areas where improvements could be made.
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Introduction |
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The objective of this study was to develop and implement a mini-audit for the rapid assessment and monitoring of quality in the postanesthetic care unit (PACU) of a busy outpatient unit. A secondary objective was to determine whether such an audit could be useful in evaluating the impact of ethnicity on the PACU complications because it was our clinical impression that ethnicity appeared to be an important factor in the development of adverse events.
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Methods |
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Patients attending this unit are admitted routinely to the preoperative area 90 min prior to the scheduled operation. IV access is secured and an infusion of 0.9% saline is commenced. All patients receive 975 mg acetaminophen po and depending on the type of surgery, diclofenac po/pr may be given also. Patients walk to the appropriate operating room and anesthesia is induced with propofol iv or sevoflurane by inhalation. Anesthesia is maintained with O2/N2O and either sevoflurane/isoflurane or a propofol infusion. If required, intraoperative opiates are used including fentanyl, alfentanil, sufentanil, morphine and meperidine. At the discretion of the attending anesthesiologist, routine antiemetic treatment (metoclopramide 10 mg, dolansetron 20–50 mg or perphenazine 1–2 mg) is administered either preoperatively or on emergence from anesthesia. Regional anesthetic techniques are employed based on patient's preference and medical condition as well as anesthesiologist's preference. The most common regional techniques employed are spinal anesthesia, iv regional anesthesia, popliteal block, ankle block, and axillary block. Monitored anesthesia techniques consist of local anesthetic infiltration and sedation with adjuvants such as midazolam, opioids and propofol.
Patients are then transferred to the PACU where a minimum of three sets of physiological measurements (heart rate, respiratory rate, O2 saturation, non-invasive blood pressure and sedation scores) are taken at 15-min intervals. If indicated, aural temperature and capillary glucose are recorded. On fulfilling the unit's discharge criteria, patients are discharged from the centre. The criteria for discharge from the PACU are: 1) alert and oriented; 2) stable vital signs; 3) complete recovery of neuraxial block; 4) control of pain with oral analgesia; 5) control of postoperative nausea and vomiting (PONV); and 6) absence of surgical bleeding.
We studied prospectively the postoperative course of patients attending the SDU of Vancouver General Hospital. The design of the study was ‘occurrence screening’ over a two-week period in November 1998, during which all 462 patients admitted consecutively to the PACU were evaluated. Institutional Ethics Committee approval was obtained but since this was an observational study with no deviation from standard care, written consent was not required.
Several meetings were held to determine which items were to be included and to develop guidelines for inclusion of variables. The data collection tool had to be paper based, short (single sheet, double sided) and have enough space to allow hand written commentary. Strict definition of variables was used to ensure strict adherence and uniformity. All definitions, unless specified, were consistent with previous studies.1,3 Data were collected by one anesthesiologist in the PACU to minimize inter observer variability. After development of a prototype form, it was tested for two days in the PACU before adoption. Preoperative information recorded consisted of date, time, hospital ID, age, weight, sex, ASA class, ethnicity, type of operation and anesthesia. The PACU information recorded consisted of total time in the PACU, respiratory rate (normal, <10, >10•min–1), SpO2 on room air (<94%, >94%), O2 requirement for SpO2<94% on room air (none, nasal prongs, O2 mask), intubated on transfer to the PACU (yes, no), intubated in the PACU (yes, no), occurrence of respiratory complications,3 blood pressure (normal, low,3 high,3) heart rate [normal, low (<50 beats•min–1), high (>120 beats•min–1)], occurrence of cardiovascular complications as defined in previous studies,3 temperature [normal, low,3 high (>38°C skin, or 38.5°C aural)], neurological status,3 nausea/vomiting,3 pain control (comfortable, required treatment, number of nursing visits for pain treatment), bleeding in the PACU (none, <200 mL, >200 mL), renal/metabolic abnormalities,3 any other complications and whether a return to the operating room occurred.
Data were analyzed with SPSS (version 4.0). Descriptive statistics of the demographic data were calculated and a comparison was made between the Asiatic and Caucasian populations. Student's t test was used for continuous variables and the Chi square test for categorical variables. A P value <0.05 was considered statistically significant.
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Results |
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). Most procedures were performed under general anesthesia. Details of methods of anesthesia and types of surgery are shown in Table II. The mean length of stay (± SD) in the PACU was 91 ± 55 min.
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Hypertension occurred in 8.7% of patients and hypotension in 21.4% while in the PACU. Bradycardia occurred in 29.9% while 0.4% of patients developed tachycardia. No patient developed evidence of myocardial ischemia, infarction or arrest. Dysrhythmias occurred in only 0.2 % of patients.
Aural temperature was measured in 36.1% of patients. This was within normal range in 92% of these patients, the remaining patients having a temperature of <36°C. No patient developed hyperthermia. A majority (99.8%) of patients were conscious/drowsy on admission to the PACU while one patient (0.2%) was unconscious for <15 min.
PONV was present in 6.5% of patients and 3.7% of all patients received antiemetic medication in the PACU. Thirty-seven percent of patients described their pain as unbearable while 63% were comfortable. Analgesia was required in 54.5% of patients. One postoperative nursing visit for pain was required in 27.9%, while 8, 6.9, 4.3 and 3.9% of patients required two, three, four and five visits respectively (Figure).
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Subgroup analysis showed that 24% of patients were of Asiatic origin and 76% were Caucasian. There was no difference between the groups with respect to age and weight. Ninety percent of Asiatics received general anesthesia compared to 83% of Caucasians. The mean length of stay in the PACU was 101 ± 61 min for Asiatics and 90 ± 55 min for Caucasians. There was a higher requirement for O2 supplementation in Caucasians patients (23%) compared to Asiatics (9%, P <0.05). There was a higher frequency of bleeding amongst Asiatic patients (46%) compared to Caucasian patients (27%, P <0.05). Bleeding was 200 mL in all patients in the study.
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Discussion |
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Demographic data indicate the type of practice profile of the unit and are helpful in inter-institutional comparisons and for monitoring change in practice over time. The age, ASA class, and surgery type in our unit are comparable to other Canadian outpatient units.4 Anesthetic practice has not changed over the last decade and most outpatients continue to receive general anesthesia.4 This is in keeping with the heavy demands of a busy unit and the need to maintain efficiency. More patients arrive in the PACU between 12:00–17:43 hr than before 12:00 hr. Since the unit closes at 19:00 hr, the shortest amount of recovery time available was approximately 2.2 hr. Since there were no admissions to hospital, it is reasonable to assume that there is enough time for recovery and discharge of patients in the unit provided that the last operation is finished by 17:43 hr at the latest.
Duration of stay in the PACU is an interesting measure of anesthetic quality – a short stay suggestive of a rapid, uneventful recovery without complications. The mean duration of the PACU stay for our unit was 91 ± 55 min. This compares with the PACU times of 104 ± 31min in units not using fast-track eligibility criteria5 (ability to achieve the PACU discharge criteria) and 40 ± 13 min reported by other units using fast-track criteria to abbreviate the duration of the PACU stay.6,7 This suggests that implementation of fast-track eligibility criteria in our day unit would result in improved efficiency of the PACU. An audit such as this, by providing objective information, will help in facilitating a change in behaviour in our unit.
Respiratory problems identified were: bradypnea (2.4%), SpO2<94% (0.4%), and bronchospasm (0.4%). These compare favourably with a 4.3% respiratory complication rate reported in 6914 outpatients4 and a 0.8% incidence of bronchospasm and 0.9% incidence of hypoxia reported in 96,107 hospital patients (mixed outpatient and inpatient database).2 Supplemental oxygenation use was 19% and is probably a reflection of patients' physical status, type of anesthetic, sea level location of Vancouver and surgery. The number of patients arriving to the PACU with an LMA (2.6%) or ETT (1.7%) is low and reflects variability in anesthetic practice and patient type.
Cardiovascular problems identified were: hypotension (21%), hypertension (8.7%), bradycardia (30%), tachycardia (0.4%) and dysrhythmias (0.2%). In previous studies,4 the incidence of hypotension in the PACU in outpatients was 0.2% and of hypertension was 0.1%. In hospital patients,2 the incidences of hypotension, hypertension, bradycardia and dysrhythmia were 7%, 2.9%, 2.4% and 1.8% respectively. In a previous report we identified hypotension due to poor hydration as a significant problem in our day unit and an important contributory factor to hospital admission.8 Even though liberalization in fasting criteria (clear fluids up to three hours before surgery) has occurred in our unit, it appears not to have lowered the incidence of hypotension. A study by Yogendran et al. has shown that aggressive hydration with isotonic electrolyte solutions (20 mL•kg–1) results in a lower incidence of complications such as dizziness due to hypotension and inadequate hydration.9 Implementation of, and voluntary compliance with, such a regimen may be useful in reducing the incidence of hypotension and would seem warranted in our unit.
Hypothermia was diagnosed in 8.4% of patients in our day unit. This was a higher rate than found in two other studies of 6,914 outpatients4 and 96,107 hospital patients2 (0.1% and 0.3% respectively). It would be unreasonable financially to apply warming devices to all our outpatients. A less expensive solution would be to raise the ambient temperature in the operating room and the PACU and consider warming devices for longer cases and in those patients more likely to develop hypothermia (for example, elderly patients receiving spinal anesthesia).
The incidence of PONV in our patients was 6.5% and compares favourably with incidences of 7.2% and 2.7% in other institutions.4,10 On the other hand, 37% of our patients described their pain as unbearable compared to reports of 6.2% in other units.10 The mean number of nursing visits for pain was 1.2 ± 1.8 and 45% of patients did not require any visit for pain management. One postoperative nursing visit for pain was required in 27.9% of patients, while 8, 6.9, 4.3 and 3.9% of patients required two, three, four and five visits respectively (Figure
). Since pain is an important factor contributing to unanticipated admission after ambulatory surgery, it seems reasonable to address this finding aggressively.11 In some outpatient facilities that rely exclusively on opioids for analgesia, 40% of patients report moderate to severe pain.12 Michaeloliakou et al. showed that a multimodal approach to pain treatment consisting of opioids, NSAIDs and local anesthesia, allowed more painful procedures to be performed on an outpatient basis with a low risk of PONV.13 It is also important to note that patients continue to express a strong desire to avoid outcomes such as pain and vomiting.15 Anesthesiologists should therefore pay special attention to ensure that the incidence of these adverse events is as low as possible.15
One surprising finding of our study was that Asiatic patients bled more than Caucasian patients did whereas supplemental oxygen was required more frequently in Caucasian patients. Preliminary reports seem to suggest that ethnicity may be an important factor in the development of adverse events.14 However, our results need to be substantiated by other centres before specific recommendations can be made on these interesting findings.
In summary, in a mini-audit of a cohort of 462 outpatients, we showed that, whereas the overall quality of care was acceptable, there were specific areas where improvements in quality could be made. The incidence of hypotension, hypothermia and pain was higher than that reported from other centres. Mini-audits may help to improve quality of care in areas not previously identified when it does not meet established bench marks.15
Revision received May 23, 2001. Accepted for publication April 11, 2001.
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2
Bothner U, Georgieff M, Schwilk B. Building a large-scale perioperative anaesthesia outcome-tracking database: methodology, implementation, and experiences from one provider within the German quality project. Br J Anaesth 2000; 85: 271–80.
3
Cohen MM, Duncan PG, Tweed WA, et al. The Canadian four-centre study of anaesthetic outcomes: I. Description of methods and populations. Can J Anaesth 1992; 39: 420–9.
4
Duncan PG, Cohen MM, Tweed WA, et al. The Canadian four-centre study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice? Can J Anaesth 1992; 39: 440–8.
5
Mulroy MF, Larkin KL, Hodgson PS, Helman JD, Pollock JE, Liu SS. A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy. Anesth Analg 2000; 91: 860–4.
6 Song D, Joshi GP, White PF. Fast-track eligibility after ambulatory anesthesia: a comparison of desflurane, sevoflurane, and propofol. Anesth Analg 1998; 86: 267–73.[Abstract]
7
Song D, Greilich NB, White PF, Watcha MF, Tongier WK. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000; 91: 876–81.
8
Fancourt-Smith PF, Hornstein J, Jenkins LC. Hospital admissions from the surgical day care centre of Vancouver General Hospital 1977–1987. Can J Anaesth 1990; 37: 699–704.
9 Yogendran S, Asokumar B, Cheng DCH, Chung F. A prospective randomized double-blinded study of the effect of intravenous fluid therapy on adverse outcomes on outpatient surgery. Anesth Analg 1995; 80: 682–6.[Abstract]
10
Chung F, Mezei G, Tong D. Adverse events in ambulatory surgery. A comparison between elderly and younger patients. Can J Anesth 1999; 46: 309–21.
11
Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery – a prospective study. Can J Anaesth 1998; 45: 612–9.
12
Beauregard L, Pomp A, Choinière M. Severity and impact of pain after day-surgery. Can J Anaesth 1998; 45: 304–11.
13 Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996; 82: 44–51.[Abstract]
14 Glass PSA, Jamerson BD, Colopy M, et al. Is there a difference in adverse events during general anesthesia based on gender, age, or ethnic group? Anesth Analg 1998; 86: S169 (abstract).
15
Vaghadia H. Outpatient anesthesia. Some aging perspectives: advice from a caterpillar (Editorial). Can J Anesth 1999; 46: 305–8.
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