Implementation of a new strategy to improve the peri‐operative management of neuromuscular blockade and its effects on postoperative pulmonary complications

Implementation of a new strategy to improve the peri‐operative management of neuromuscular blockade and its effects on postoperative pulmonary complications

Summary Inappropriate dosing of neostigmine for antagonism of neuromuscular blockade has been associated with postoperative pulmonary complications. We evaluated the effects of a quality improvement initiative tailored to optimise the use of neostigmine in antagonising neuromuscular blockade on post...

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Bibliographic Details
Published in:Anaesthesia Vol. 73; no. 9; pp. 1067 - 1078
Main Authors: Rudolph, M. I., Chitilian, H. V., Ng, P. Y., Timm, F. P., Agarwala, A. V., Doney, A. B., Ramachandran, S. K., Houle, T. T., Eikermann, M.
Format: Journal Article
Language:English
Published: England Blackwell Publishing Ltd 01-09-2018
Subjects:
Cognitive ability
Complications
Data processing
Incidence
Intervention
Neostigmine
neostigmine: dose rationale
neuromuscular block: assessment
patient care
Quality
Quality control
quality measures
Regression analysis
Surgery
Time series
neuromuscular block: assessment
neostigmine: dose rationale
patient care
quality measures
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Summary:Summary Inappropriate dosing of neostigmine for antagonism of neuromuscular blockade has been associated with postoperative pulmonary complications. We evaluated the effects of a quality improvement initiative tailored to optimise the use of neostigmine in antagonising neuromuscular blockade on postoperative pulmonary complications, costs and duration of hospital stay. The quality improvement initiative consisted of: a reduction in available neostigmine aliquot sizes; a cognitive aid; an educational component; and a financial incentive for the intra‐operative documentation of train‐of‐four measurement before administration of neostigmine. We conducted a pre‐specified analysis of data obtained in our quality improvement study. Additional analyses were conducted in a propensity‐matched cohort. An interrupted time series design was used to discriminate between the intervention and a counterfactual scenario. We analysed 12,025 consecutive surgical cases performed in 2015. Postoperative pulmonary complications occurred in 220 (7.5%) of 2937 cases pre‐intervention and 568 (6.3%) of 9088 cases post‐intervention. Adjusted regression analyses showed significantly a lower risk of postoperative pulmonary complications (OR 0.73 (95%CI 0.61–0.88); p = 0.001), lower costs (incidence rate ratio 0.95 (95%CI 0.93–0.97); p < 0.001) and shorter duration of hospital stay (incidence rate ratio 0.91 (95%CI 0.87–0.94); p < 0.001) after implementation of the quality improvement initiative. Analyses in a propensity‐matched sample (n = 2936 per group) and interrupted time series analysis (n = 27,202 cases) confirmed the findings. Our data show that a local, multifaceted quality improvement initiative can enhance the quality of intra‐operative neuromuscular blocking agent utilisation, thereby reducing the incidence of postoperative pulmonary complications.
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content type line 23
ISSN:0003-2409
1365-2044
DOI:10.1111/anae.14326