Implementation of an Epidural Rounding Reminder in the Electronic Medical Record Improves Performance of Standardized Patient Assessments during Labor

Abstract

Background Poorly functioning labor epidural catheters lead to pain and dissatisfaction. Regular catheter assessment ensures timely identification of malfunction and may improve safety by facilitating rapid and successful conversion to general anesthesia for emergency cesarean. Informatics-based systems encourage standardization of care to identify epidural malfunctions earlier.

Objectives This article demonstrates that visual epidural rounding reminder display on an electronic patient board would alert clinicians to elapsed time and decrease mean time between assessments.

Methods As a quality initiative, we implemented an epidural rounding reminder on our obstetric patient board. The reminder indicated the number of elapsed minutes since placement or last patient assessment. We retrospectively reviewed labor epidural charts 3 months prior to and 5 months following reminder implementation, with a 4-week washout period. The primary outcome was mean time between documented epidural assessments, with secondary outcomes including maximum time between assessments, total number of assessments during labor, catheter replacement rates, and patient satisfaction. Unadjusted comparisons between pre- and postimplementation groups were conducted using Wilcoxon's rank-sum and Pearson's chi-square tests, as appropriate. A test for equal variances was conducted for time between assessment outcomes.

Results Following implementation, mean time between assessments decreased from a median of 173 (interquartile range [IQR]: 53, 314) to 100 (IQR: 74, 125) minutes (p <0.001), and maximum time between assessments decreased from median 330 (IQR: 60, 542) to 162 (IQR: 125, 212) minutes (p < 0.001). Total number of evaluations during labor increased from 3 (IQR: 2, 4) to 5 (IQR: 3, 7; p < 0.001). Decreased variance in mean and maximum time between assessments was noted following reminder implementation (p < 0.001). Epidural replacement rates decreased from 14 to 5% postimplementation (p < 0.001). Patient satisfaction was unchanged.

Conclusion Implementation of an informatics-based solution can promote standardization of care. A simple epidural rounding reminder prompted clinicians to perform more frequent labor epidural assessments. In the future, these process improvements must be linked to improvements in patient experiences and outcomes.

Keywords

anesthesiology - epidural - labor analgesia - neuraxial analgesia - obstetrics/gynecology

Background and Significance

Epidural analgesia is the most effective method to reduce labor pain and is considered the safest anesthetic method for cesarean delivery following a failed labor course.[1] [2] Poorly functioning labor epidural catheters can lead to uncontrolled pain, with deleterious effects on patient experience and satisfaction.[3] [4] Additionally, poorly functioning catheters place patients at risk of conversion to general anesthesia for intrapartum cesarean delivery, with the incidence of failed conversion as high as 20%.[5] General anesthesia for cesarean delivery increases the risk of maternal complications including surgical site infection, venous thromboembolism, uncontrolled postoperative pain, and poorer neonatal outcomes.[6] [7] [8]

Given these implications on patient birth experience and safety, timely identification of catheter malfunction during labor may reduce the occurrence of these negative outcomes. To ensure timely recognition, the Society for Obstetric Anesthesia and Perinatology recommends “regular assessment of labor analgesia effectiveness,” or rounding on patients with epidurals at regular intervals to assess dermatome block level as well as patient pain scores.[9] On a busy labor floor, where direct communication and task delegation among anesthesia team members can prove challenging, informatics-based systems to ensure consistency of care may ultimately improve patients' experiences.[10] Our aim was to evaluate the efficacy of an epidural rounding reminder, which visually displayed the number of elapsed minutes since epidural placement or last patient assessment, in ensuring timely assessment of patients with labor epidural catheters.

Objectives

As part of a quality initiative, we implemented an epidural rounding reminder to the labor and delivery patient display board on August 12, 2020. The reminder indicated the number of elapsed minutes since epidural placement or the last documented patient assessment and was visible only to the obstetric anesthesia team. Our goal was to encourage patient assessment every 120 minutes—an expectation that was in place prior to the reminder's implementation based on the Society for Obstetric Anesthesia and Perinatology Center of Excellence Criteria. We hypothesized that the implementation of an epidural rounding reminder on our electronic labor and delivery patient board would decrease the mean time between assessments.

Methods

Following Institutional Review Board approval (protocol no.: 210043), a retrospective review was conducted of labor epidural charts at Vanderbilt University Medical Center, a tertiary referral center in Nashville, Tennessee with approximately 4,800 deliveries per year. Obstetric anesthesia services are provided by a team of residents, certified registered nurse anesthetists, student nurse anesthetists, obstetric anesthesiology fellows, and attending anesthesiologists, with 4 to 6 working team members per shift. Data on patient demographics, labor epidural procedures and assessments, and patient satisfaction were collected during the 3-month period prior to and 5-month period following epidural rounding reminder implementation, with a 4-week washout period. Patients with no documented assessments were excluded from the primary analysis. No other exclusion criteria were applied. While we initially planned to collect data for 3 months pre- and postimplementation, delays in data collection allowed us to include additional months in the postperiod to demonstrate more sustained change. Data were extracted electronically from the medical record, where labor epidural assessments were documented using custom-built assessment templates ([Supplemental Material A], available in the online version). The assessment template is completed by obstetric anesthesia team members to document each patient assessment, with a pain score of 0 documented if the patient is noted to be asleep during the assessment.

For each included patient, multiple assessments could be documented, thus each individual patient's data was summarized by both a mean and maximum time between assessments, counting epidural placement as the first assessment. The primary outcome was the median of those individual patient mean times within the pre- versus postimplementation time periods. Secondary outcomes included median of individual maximum times between assessments, median of individual total number of assessments during labor, catheter replacement rates, and median patient satisfaction scores, comparing pre- versus post-time periods. Satisfaction scores were assessed on postpartum day 1 using a 10-point numeric rating scale, with 1 representing lowest satisfaction and 10 representing highest satisfaction. Patients with no documented assessments were excluded because the primary outcome could not be calculated; however, a post hoc sensitivity analysis was conducted in which total anesthesia time was substituted for both mean and maximum time between assessments for all patients with no documented assessments. Unadjusted comparisons between pre- and postimplementation groups were conducted using Wilcoxon rank-sum and Pearson's chi-square tests for continuous and categorical data, as appropriate. The Fligner–Killeen test for homogeneity of variances pre- and postimplementation was conducted for mean and maximum time between assessments. All statistical analyses were conducted using R statistical software ( https://www.R-project.org/ ).[11]

Results

A total of 1,496 patients were included in the final analysis, 307 patients in the preimplementation period and 1,189 subjects in the postimplementation period ([Fig. 1]). Fewer patients were examined in the preimplementation period due to fewer months included, fewer deliveries per month, and a greater number of subjects excluded due to no assessments being documented. Only 32% of subjects (307/993) with a labor neuraxial analgesia record had at least one documented assessment prior to the epidural rounding reminder, whereas that number increased to 66% (1,189/1,811) postimplementation. Baseline characteristics were generally similar between groups; however, combined spinal-epidural was more commonly used in the postimplementation period, and total anesthesia time was longer preimplementation ([Table 1]).

Fig. 1 Patient flow diagram.

Table 1 Baseline characteristics

	Preimplementation (n = 307)	Postimplementation (n = 1,189)	Overall (n = 1,496)
Age (y)	28 [24, 32]	29 [25, 33]	29 [24, 33]
Race
White	197 (67%)	705 (63%)	902 (64%)
Black	53 (18%)	198 (18%)	251 (18%)
Other	45 (15%)	208 (19%)	253 (18%)
Missing	12 (4%)	78 (7%)	90 (6%)
Ethnicity
Hispanic or Latino	50 (17%)	214 (19%)	264 (18%)
Not Hispanic	251 (83%)	934 (81%)	1,185 (82%)
Missing	6 (2%)	41 (3%)	47 (3%)
Gravidity	1 [1, 3]	2 [1, 3]	2 [1, 3]
Parity	0 [0, 1]	0 [0, 1]	0 [0, 1]
ASA class
I or II	224 (73%)	838 (72%)	1,062 (72%)
III and above	83 (27%)	321 (28%)	404 (28%)
Missing	0 (0%)	30 (3%)	30 (2%)
Analgesia type
Epidural	205 (67%)	622 (52%)	827 (55%)
Combined spinal-epidural	94 (31%)	528 (44%)	622 (42%)
Other/missing	8 (3%)	39 (3%)	47 (3%)
Total anesthesia time (min)	681 [401, 1,032]	492 [294, 800]	524 [313, 855]

Abbreviation: ASA, American Society of Anesthesiologists.

Note: Data are presented as median [interquartile range] or n (%).

Following implementation, mean time between assessments decreased from a median of 173 (interquartile range [IQR]: 53, 314) to 100 (IQR: 74, 125) minutes (p < 0.001), and maximum time between assessments decreased from a median of 330 (IQR: 60, 542) to 162 (IQR: 125, 212) minutes (p < 0.001; [Table 2]). [Fig. 2] visually depicts this significant decline in both mean (A) and maximum (B) time between assessments, as well as the decrease in variability among patients, which was confirmed using the Fligner–Killeen test for homogeneity of variances (p < 0.001). Due to more frequent assessments, total number of patient evaluations during labor increased from 3 (IQR: 2, 4) to 5 (IQR: 3, 7) (p < 0.001). Labor epidural catheter replacement rates decreased from 14 to 5% pre- versus postimplementation (p < 0.001). Patient satisfaction scores were not statistically significantly different between the two time periods (median 10 [IQR: 9, 10] vs. 10 [IQR: 10, 10] pre- vs. postimplementation).

Fig. 2 Plot of mean times between assessments (A) and maximum times between assessments (B) showing preimplementation (left) versus postimplementation (right) with a 4-week washout period around the implementation date of August 12, 2020. Each point represents the mean or maximum time for a single patient. Test for homogeneity of variances pre- and postimplementation demonstrated p < 0.001 for both mean and maximum time between assessments.

Table 2 Comparison of primary and secondary outcomes between pre- and post-epidural rounding reminder implementation periods

	Preimplementation (n = 307)	Postimplementation (n = 1,189)	p-value
Mean time between assessments (min)	173 [53, 314]	100 [74, 125]	<0.001
Maximum time between assessments (min)	330 [60, 542]	162 [125, 212]	<0.001
Total number of assessments	3 [2, 4]	5 [3, 7]	<0.001
Neuraxial catheter replacement required	42 (14%)	62 (5%)	<0.001
Patient satisfaction (0–10 scale)	10 [9, 10]	10 [10, 10]	0.007

Note: Data are presented as median [interquartile range] or n (%). p-Values calculated using the Wilcoxon rank-sum test for continuous variables and the Pearson's chi-square test for categorical variables.

In a post hoc sensitivity analysis including those patients who were previously excluded due to no documented assessments (with mean and maximum time between assessments set to total anesthesia time), results were largely unchanged. Mean time between assessments decreased from a median of 173 (102, 355) minutes to 103 (82, 128) minutes (p < 0.001), and maximum time between assessments decreased from a median of 212 (107, 441) to 141 (101, 196) minutes (p < 0.001) in the postimplementation period. Labor epidural catheter replacement rates remained lower in the postimplementation period (7 vs. 4%; p < 0.001), and patient satisfaction remained unchanged (10 [9, 10] vs. 10 [10, 10]; p = 0.11).

Discussion

We demonstrate the implementation of an informatics-based solution to encourage adherence to national society recommendations for standardized labor epidural assessments. A simple rounding reminder provided a visual cue to clinicians to perform more frequent and regular pain assessments of laboring patients with an epidural catheter. This change in physician behavior was associated with fewer catheter replacements during labor. While more frequent assessments could have plausibly resulted in more frequent replacements as more nonfunctioning catheters were recognized, we hypothesize that this decrease in replacements stems from successful and timely troubleshooting of inadequate catheters prior to need for catheter replacement. There was no statistically significant effect on patient satisfaction scores. However, high baseline scores (median: 10/10) make it difficult to detect further improvement, and we were underpowered to detect this difference.

Clinical decision support (CDS) is an important aspect of electronic medical record (EMR) functionality which greatly contributes to the safety, efficiency, and value that EMRs provide to health care institutions.[12] [13] By thoughtful evaluation of current practices, providers can identify valuable uses of CDS in countless workflows.[14] Our rounding reminder exemplifies a patient-specific relevant data display, one of the 53 types of front-end CDS tools defined by Wright et al in their CDS taxonomy.[15] This type of CDS can be highly effective, as prior work has shown that timely and well-designed displays of salient information can assist with clinical task completion and make work easier for clinicians.[16] Furthermore, in developing the reminder, we also considered the “Commandments for Effective Clinical Decision Support” set out by Bates et al.[17] This intervention epitomizes the commandment that “simple interventions work best” and also recognizes the importance of delivering needed information in real time and within the user's workflow.

In designing this intervention as a quality improvement initiative on our labor and delivery unit, we also utilized published guidance from The Centers for Medicare and Medicaid Services on how to conduct performance improvement projects.[18] In this document, corrective actions to change a system are categorized as strong, intermediate, and weak, and we intentionally avoided weaker actions such as team training or creating a new policy to facilitate our desired outcome of more frequent epidural assessments. On the contrary, we utilized only intermediate to strong actions, including software enhancement, enhanced documentation, and standardized processes. Based on this, our likelihood of sustained improvement is greatly increased. It must be mentioned, however, that these change management strategies were unique to our practice environment, in which a large anesthesia team of four- to six-members staff the labor and delivery unit 24 hours a day. It is likely that a significant barrier to timely epidural assessments in this setting was lack of communication between team members as to when assessments were due to occur, and this barrier was overcome using the reminder system. This intervention would probably be less effective in alternate practice settings where, for example, a single covering provider may neglect to perform frequent evaluations due to competing higher priority tasks. In this setting, our reminder system may prove useful but would likely require additional workflow adaptations such as assessments completed by bedside nurses.

Despite the intentional development and deployment of this CDS system and the positive results, our findings should be considered in the context of several limitations. Most importantly, our study compared a 3-month period preintervention to a 5-month period postintervention, thus we cannot exclude the possibility that other confounders over this time period contributed to the improvements measured in epidural assessment times and catheter replacement rates. Other variables, especially those that are difficult to measure such as organizational culture and attitudes toward epidural assessments, may have changed throughout the study period and impacted our results. Of the factors measured, total anesthesia time was shorter and frequency of combined spinal-epidural use was higher in the postimplementation period, with no other obvious baseline differences. If anything, shorter labors in the postimplementation period strengthen the finding of a greater number of assessments performed; however, shorter labors may also be an alternative explanation for lower catheter replacement rates. Assessment interval expectations for combined spinal-epidurals were the same as for all other neuraxial techniques. Additionally, given our primary outcome of mean time between assessments, we initially excluded patients who did not receive any assessments. While uneven exclusion in pre- versus postimplementation periods could have introduced bias, results of a post hoc sensitivity analysis including all patients showed similar results. Importantly, the proportion of patients receiving at least one assessment during labor increased between the two periods, adding credence to the assertion that the epidural rounding reminder influenced provider behavior. Finally, we used assessment documentation time as a surrogate for assessment time, which could have introduced inaccuracies in the calculated mean and maximum time between assessments. We believe that these discrepancies would be minimal and rare, given that our team members are trained to retroactively document assessments to the time at which they occurred.

Conclusion

In conclusion, through the implementation of a simple, pragmatic epidural rounding reminder on our labor and delivery patient board, we have demonstrated a positive effect on clinician behavior, encouraging more frequent assessment of patients with labor epidural catheters. In the future, it will be important to link these process improvements to improvements in patient experiences and outcomes.

Clinical Relevance Statement

The deployment of an epidural rounding reminder exemplifies how informatics and clinical decision support can standardize otherwise variable processes. This study demonstrates a decreased mean time between labor epidural catheter assessments, with the postimplementation time between assessments more closely approximating the national society recommendation of 120 minutes. Given the relatively minor technical requirements and simple implementation process, this solution can be widely adopted in centers hoping to standardize obstetric care, with the potential to further study the effectiveness of the intervention and downstream patient outcomes in diverse patient populations.

Multiple-Choice Questions

1. Which of the following outcomes is associated with the implementation of an epidural rounding reminder to alert clinicians to the need for labor epidural catheter assessment?

   • Decreased mean time between assessments

   • Decreased maximum time between assessment

   • Improved patient satisfaction scores

   • a & b

   • All of the above

   Correct Answer: The correct answer is option d. Decreased mean and maximum time between assessments were demonstrated following implementation of an epidural rounding reminder. Patient satisfaction scores were not significantly different between groups.

2. Which of the following is true regarding epidural replacement rates following implementation of an epidural rounding reminder alert?

   • Replacement rates decreased, likely because patients were more likely to report pain.

   • Replacement rates decreased, likely because malfunctioning catheters were recognized in a timely manner and actively managed.

   • Replacement rates increased, likely because patients were more likely to report pain.

   • Replacement rates increased, likely because malfunctioning catheters were recognized in a timely manner and actively managed.

   Correct Answer: The correct answer is option b. Following implementation of an epidural rounding reminder, epidural replacement rates decreased. While more frequent assessments could have plausibly resulted in more frequent replacements as more nonfunctioning catheters were recognized, it is hypothesized that this decrease in replacements stems from successful and timely troubleshooting of inadequate catheters prior to need for catheter replacement.

Conflict of Interest

None declared.

Protection of Human and Animal Subjects

This quality improvement study was determined to be exempt by the Human Research Protections Program of the sponsoring institution.

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Publication History

Received: 03 October 2022

Accepted: 09 January 2023

Accepted Manuscript online:
12 January 2023

Article published online:
22 March 2023