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Process Optimization and Digital Quality Improvement to Enhance Timely Initiation of Epidural Infusions and Postoperative Pain Control

Shah, Aalap C., MD*; Nair, Bala G., PhD*; Spiekerman, Charles F., PhD; Bollag, Laurent A., MD*

doi: 10.1213/ANE.0000000000003742
Healthcare Economics, Policy, and Organization: Original Clinical Research Report

BACKGROUND: Although intraoperative epidural analgesia improves postoperative pain control, a recent quality improvement project demonstrated that only 59% of epidural infusions are started in the operating room before patient arrival in the postanesthesia care unit. We evaluated the combined effect of process and digital quality improvement efforts on provider compliance with starting continuous epidural infusions during surgery.

METHODS: In October 2014, we instituted 2 process improvement initiatives: (1) an electronic order queue to assist the operating room pharmacy with infusate preparation; and (2) a designated workspace for the storage of equipment related to epidural catheter placement and drug infusion delivery. In addition, we implemented a digital quality improvement initiative, an Anesthesia Information Management System–mediated clinical decision support, to prompt anesthesia providers to start and document epidural infusions in pertinent patients. We assessed anesthesia provider compliance with epidural infusion initiation in the operating room and postoperative pain-related outcomes before (PRE: October 1, 2012 to September 31, 2014) and after (POST: January 1, 2015 to December 31, 2016) implementation of the quality improvement initiatives.

RESULTS: Compliance with starting intraoperative epidural infusions was 59% in the PRE group and 85% in the POST group. After adjustment for confounders and preintervention time trends, segmented regression analysis demonstrated a statistically significant increase in compliance with the intervention in the POST phase (odds ratio, 2.78; 95% confidence interval, 1.73–4.49; P < .001). In the PRE and POST groups, cumulative postoperative intravenous opioid use (geometric mean) was 62 and 34 mg oral morphine equivalents, respectively. A segmented regression analysis did not demonstrate a statistically significant difference (P = .38) after adjustment for preintervention time trends.

CONCLUSIONS: Process workflow optimization along with Anesthesia Information Management System–mediated digital quality improvement efforts increased compliance to intraoperative epidural infusion initiation. Adjusted for preintervention time trends, these findings coincided with a statistically insignificant decrease in postoperative opioid use in the postanesthesia care unit during the POST phase.

From the *Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington

Institute for Translational Health Sciences (ITHS), University of Washington, Seattle, Washington.

Published ahead of print 20 July 2018.

A. C. Shah is currently affiliated with the Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California.

Accepted for publication July 20, 2018.

Funding: The Institute for Translational Health Sciences (ITHS) at University of Washington, Seattle, WA, provided statistical support for this project. ITHS is funded by Grant UL1TR000423 from the National Institutes of Health (NIH) National Center for Advancing Translational Sciences through the Clinical and Translational Sciences Awards Program (CTSA). For more information, please visit

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

This report was previously presented, in part, at the 2015 meeting of the Society for Technology in Anesthesia, Phoenix, AZ, January 8, 2015.

Reprints will not be available from the authors.

Address correspondence to Aalap C. Shah, MD, Department of Anesthesiology, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048. Address e-mail to

© 2019 International Anesthesia Research Society
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