Clinical quality indicators are being used worldwide as a tool to identify healthcare improvement opportunities and to measure the efficacy of a specific intervention.1 By definition, quality indicators are specific and measurable elements of practice that can be used to assess the quality of care.2 They are usually derived from case studies, scientific evidence, retrospective reviews of medical records, routine information sources or surveillance systems.3 We chose premature epidural catheter termination as a quality indicator because previous audits in the literature4,5 and observations in our hospital indicated that this is an issue that required measures for improvement. In addition to being relevant, cost and easy applicability are also important for any quality assessment tool in developing countries like ours.
Epidural analgesia is a widely used technique for the management of postoperative pain relief. It provides better dynamic pain relief than other conventional methods of pain control, but interaction and cooperation between the acute pain team, surgical team, nursing staff and the patient is necessary for epidural care in the postoperative period. The epidural analgesia failure rate leading to insufficient dynamic pain relief6 is 30–50%. The epidural analgesia technique is associated with several complications, including premature epidural catheter dislodgement, disconnection, local anaesthetic toxicity, postdural puncture headache, epidural abscess and haematoma that require urgent attention.
Premature epidural catheter termination is a common but preventable cause of epidural analgesia failure with an incidence of 5.7–13%.4,5 This not only denies patients the benefits of continuous epidural analgesia but also presents with an added risk of infection and bleeding in patients receiving heparin.
The Acute Pain Service (APS) team at the Aga Khan University Hospital, Karachi, started this project in 2004 with the aim of reducing the incidence of premature epidural termination, and most of the remedial measures were taken during 2005.
The present prospective audit was conducted by the APS at the Aga Khan University Hospital, Karachi, from January 2004 to December 2007. Epidural catheters were placed while patients were still in the operating room and later continued as infusions in the recovery room and surgical wards. All patients with an epidural catheter were included in this audit except those patients with epidurals placed for chronic pain and thoracotomy patients, as these cases were managed by other teams and not by the APS. Premature epidural catheter termination was defined as accidental catheter dislodgement from the epidural space for any reason and disconnection or breakage of the catheter leading to its removal because of fear of infection. We usually continue epidural infusion for 24–48 h after surgery and any decision about discontinuation is taken by the APS consultant during the morning ward round. Epidural analgesia discontinuation earlier than the planned time was also considered as premature epidural termination.
Mishandling of a catheter was defined as noncompliance with the existing policy of epidural catheter handling by nursing staff, anaesthetists and surgeons. The responsible person for premature epidural catheter termination was also assigned on the basis of noncompliance with the epidural care policy. Excessive movement by the patient due to agitation or confusion was also considered as a factor for premature termination. In addition, consideration was also given to the method of securing the epidural catheter on the back and the filter on the chest wall. Both ends of the epidural catheter were also defined and monitored. The patient end of the catheter was defined as the distal end, which was inserted in the epidural space and secured on the back with Opsite, whereas the other end was called the filter end of the catheter, which was secured with a Luer lock connector.
All patients were seen by an anaesthesia resident preoperatively and epidural analgesia was explained to them. The epidural catheters were inserted by an experienced anaesthesiologist in the operating room, with the patient in a sitting position. Routinely, the distal end of the catheter was inserted 3–5 cm into the epidural space. The proximal end was connected to a Luer lock connector and a bacterial filter. The catheter was then secured to the back of the patient at the insertion site using an Opsite dressing. Owing to the high incidence of premature termination, we started using an epidural Lockit clamp as a remedial measure in 2005 before applying a transparent Opsite dressing. A Mefix dressing was used for fixing the epidural filter on the anterior chest wall7 and on the back above the Opsite dressing. Once in the recovery room, nursing staff recorded assessments of patient pain scores and level of motor block. The site of epidural insertion was inspected for any leakage or pullout. This monitoring continued in the surgical wards, where the acute pain team also visited these patients at least twice a day.
The process of quality indicators was started after receiving an incident form or verbal complaint regarding epidural catheter-related issues from nursing staff, the acute pain resident, the acute pain nurse, the patient or relatives. The acute pain resident and nurse began the investigation process by visiting the place of the incident. In addition, a predesigned pro forma was completted by the APS resident, which included relevant questions regarding the cause of the incident, the place of the incident, the person responsible for the incident and any suggestions that person might have for remedial measures to avoid such an incident in the future. On the basis of these suggestions, certain quality improvement measures were adopted, including counselling of the person responsible, group teaching and reinforcement of epidural care policy. Feedback was also provided to the primary anaesthetist about the progress of epidural analgesia. Documentation of the epidural care checklist became mandatory for the acute pain resident. Initially, premature epidural termination began as a departmental quality indicator, but later it became a hospital quality indicator in 2006.
Educational methods used during the period included lecture sessions for nurses and residents, hands-on teaching methods for residents and daily discussions with the acute pain nurse and resident. The acute pain nurse met twice a month for an interactive session with ward nurses in the presence of the resident. The APS published an information booklet on epidural infusion for medical staff, containing information on epidural analgesia, its advantages and disadvantages, possible complications and algorithms to deal with these complications. This booklet is available in all surgical wards as a reference and for troubleshooting. We also published a patient information booklet in English and local (Urdu) language. All incidents of premature epidural termination were shared with nursing staff every 3 months and feedback given to the primary anaesthetist. The acute pain nurse collected and kept all the incident forms.
Data were entered in Statistical Package for Social Sciences 16.0 (SPSS Inc., Chicago, Illinois, USA) and analysed at the end of the study period. Frequencies with percentages were obtained for demographics and other characteristics. Fisher's exact test was used to determine the relationship between the type of surgery and other parameters such as the reason for the incident, the disconnection site, the responsible person and the timing of the incident. Exact P values are reported and a P value less than 0.05 is treated as significant. A χ2 test for goodness of fit test was used to assess the homogeneity of the incidence at different time points. A χ2 test for the linear trend was used to assess the trend of the incidence in different years.
A total of 2035 epidural infusions were managed by the APS during a 4-year period between January 2004 and December 2007. Sixty-nine (3.39%) epidural catheters were removed prematurely during this study period (Table 1). The demographics and general characteristics are reported in Table 2. Five patients were excluded from the study owing to nonavailability of the complete record.
The incidence of premature epidural catheter removal was 5.59% in 2004, which was reduced in 2005, 2006 and 2007 to 2.25, 3.81 and 1.98%, respectively. Forty-eight per cent of premature catheter terminations occurred within 24 h of epidural catheter insertion.
The main reason for premature epidural catheter termination was mishandling of the catheter and filter (64%). The surgical ward nurse was responsible for premature catheter termination in the majority of cases (70.3%), whereas five cases (7.8%) were due to miscellaneous causes (Table 3). These miscellaneous causes included mishandling by the physiotherapist (3%) and the primary anaesthetist (3%), who did not tighten the Luer lock connector, and one catheter had a manufacturing fault in which the Leur lock connector was unable to hold the catheter despite tightening. Thirty-nine (61%) epidural catheters were removed by the APS team owing to fear of infection following disconnection at the filter end of the catheter (n = 35), after catheter breakage (n = 1) or disconnection between the infusion tubing and the filter (n = 3). Premature epidural catheter termination did not lead to any bleeding or infection-related complication in our audit.
The reason for the incident (P = 0.532), disconnection site (P = 0.293), responsible person (P = 0.521) and timing of the incident (P = 0.221) did not show any significant association with the type of surgery. The association between the incident and its occurrence during working hours and out of office hours was significantly high (P = 0.003). The trend of the incidence for different years (2004–2007) was also assessed and found to be significant (P = 0.00005).
Quality indicators have been used successfully as a screening tool8 to identify problem areas, measure the efficacy of a specific intervention and provide information about individual practices and implementation of policies. They are most powerful when used as a mechanism of improving the system of care rather than judging performance. Audits and feedback9 are an integral part of healthcare quality indicators, which can help in improving the quality of care provided to the patient. The choice of indicator depends on its importance in terms of impact on health and policy-making and also the patient's safety. In addition, the indicator needs to be scientifically sound, which means that it must have acceptability, feasibility, face validity, content validity and reliability.
The risk of premature epidural termination cannot be entirely eliminated but certainly it can be minimized. This type of approach helps in finding the cause of the adverse incident, to learn from the incident, to target resources and to implement strategies to minimize the adverse consequences.10 About 15% of epidural analgesia failures are due to technical problems causing dislodgement and disconnections of the epidural catheter.11 The dislodgement rate increases with the length of treatment. In addition, premature catheter dislodgement has an added risk of compromising patients' safety by putting them at risk of epidural abscess and haematoma. We started this as a departmental indicator, but later it was included in the list of hospital quality indicators. At that time, we concentrated all our efforts on one quality indicator because choosing several indicators has shown a decline in quality in other areas.9 By making it a hospital quality indicator, we were able to create awareness among surgeons and nursing staff about the importance of epidural care during the perioperative period. Audits were shared with the nurses on a quarterly basis and feedback provided to the primary anaesthetist who had inserted the epidural catheter. The immediate cause of the incident and causative factors were recorded. Investigations proceeded in a supportive manner and concentrated on what went wrong and how to minimize adverse consequences in the future.
Disconnection of the catheter at the Luer lock connector was noticed in 54% of patients. Although reconnection is possible if the internal fluid column remains stable,12 for the patient's safety the catheter should be considered contaminated and discontinued as bupivacaine and fentanyl provide good culture media for bacterial growth.12 A change in design or early recognition of an equipment fault is also important as one of the incidents was related to equipment failure wherein, despite the use of the proper technique, the resident was unable to secure the catheter in the Luer lock connector.
Various means of securing the catheter have been described in the literature to minimize the chances of accidental epidural catheter pullout and disconnection. These include the use of Steri-Strips, clear adhesive dressing, benzoin tincture, Lockit,13 or several types of tapes (paper, cloth, plastic) and a tunnelling technique. Although we did not adopt a tunnelling technique in our service, it has been used in postoperative pain patients, particularly in thoracotomy and obese patients. Subcutaneous tunnelling is beneficial in reducing clinically significant movement of the catheter in the epidural space, but its usefulness in reducing dislodgement at either end of the catheter still needs to be confirmed.14 Transparent dressings help in identification of dislodgement15 and fluid collection, which is associated with catheter migration.5 Another method that might protect against disconnection is to make a loop in the epidural catheter and tape it to filter, which protects the junction of the filter and the catheter from any force.16 In 2005, we changed our practice and started using a Lockit epidural catheter clamp along with clear adhesive dressing, and some consultants also made a catheter loop and taped it to the filter. Another change was to secure the catheter on the back and the epidural filter on the anterior chest wall with a Mefix dressing. These changes along with continuous education of medical staff and patients helped us in reducing the incidence.
Studies have proven the safety of epidural management in surgical wards.17 Nursing staff play a vital role in the care of epidural infusions on the surgical wards. Attention is required, particularly during a position change from supine to sitting and out of the bed and into a chair. In addition, the surgical ward nurse and acute pain team are supposed to make sure that the filter is secured on the chest wall and the dressing on the back is properly covering the insertion site and there is no soakage or fluid collection. Our audit clearly shows the importance of continuous education for nurses in the management of epidural analgesia. Educational methods used by the APS included publication of a booklet on epidural care for medical staff, development of a nursing assessment chart, monthly classes, workshops, an annual symposium and feedback on the day of any untoward incident. Although there has been a significant improvement over the years in the knowledge and attitude of nurses, we probably need to involve them in decision-making18 as well in reducing the incidence further. Understandably, a significant number of incidents (P = 0.003) occurred after 5.00 p.m. and during the weekend owing to the fact that out of office hours are longer and there is less coverage by paramedical staff. This highlights implies the importance of the same vigilance and coverage being provided during odd hours.
Our experience clearly shows the importance and feasibility of using a quality indicator in improving healthcare quality in a developing country. Epidural catheter pullout as a quality indicator has been helpful in identifying the problem, creating awareness about the importance of a multidisciplinary approach and quantifying the overall quality of care. It was also helpful in showing the improvement, once remedial measures such as change in practice, continuous efforts to teach medical staff and reinforcement of well defined techniques of securing an epidural catheter were applied.
The authors thank Ms Riffat Aamir (acute pain nurse) for technical support in data collection and maintenance and Dr Iqbal Azam, assistant professor CHS, for statistical support.
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Keywords:© 2010 European Society of Anaesthesiology
developing country; epidural; quality indicator