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Implementation of a new strategy to improve the peri‐operative management of neuromuscular blockade and its effects on postoperative pulmonary complications
Author(s) -
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.
Publication year - 2018
Publication title -
anaesthesia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.839
H-Index - 117
eISSN - 1365-2044
pISSN - 0003-2409
DOI - 10.1111/anae.14326
Subject(s) - medicine , neostigmine , propensity score matching , dosing , anesthesia , incidence (geometry) , cohort , quality management , surgery , operations management , management system , physics , optics , economics
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.