Keywords
anesthesiology - epidural - labor analgesia - neuraxial analgesia - obstetrics/gynecology
Background and Significance
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
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
Multiple-Choice Questions
-
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.
-
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.
