Prioritisation of quality indicators for elective perioperative care: a Delphi consensus.

BACKGROUND: A systematic review of the peer-reviewed and grey literature previously identified over 1200 perioperative structure and process quality indicators. We undertook a Delphi consensus process with the aim of creating a concise list of indicators that experts deemed most important for assessing quality in perioperative care. METHODS: A basic Delphi consensus was completed using an online survey which was distributed to surgeons, anaesthetists, nurses, physicians and lay representatives. Participants were asked to prioritise the indicators in order of importance (high, medium or low) to be included for collection in a national perioperative quality improvement programme. RESULTS: One hundred and thirty-seven indicators were included in the first iteration of the Delphi consensus (91 structure and 48 process indicators). Sixty-three experts agreed to participate and the consensus was completed in five rounds. Ninety-five indicators were agreed as high priority: 65 structural and 30 process indicators. CONCLUSION: The Delphi consensus process was able to reduce the number of recommended indicators to only a modest extent. Further work to evaluate the practicalities of routinely collecting such a comprehensive list of quality indicators is now required.

Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review.

BACKGROUND: Care bundles are small sets of evidence-based recommendations, designed to support the implementation of evidence-based best clinical practice. However, there is variation in the design and implementation of care bundles, which may impact on the fidelity of delivery and subsequently their clinical effectiveness. METHODS: A scoping review was carried out using the Arksey and O'Malley framework to identify the literature reporting on the design, implementation and evaluation of care bundles. The Embase, CINAHL, Cochrane and Ovid MEDLINE databases were searched for manuscripts published between 2001 and November 2017; hand-searching of references and citations was also undertaken. Data were initially assessed using a quality assessment tool, the Downs and Black checklist, prior to further analysis and narrative synthesis. Implementation strategies were classified using the Expert Recommendations for Implementing Change (ERIC) criteria. RESULTS: Twenty-eight thousand six hundred ninety-two publications were screened and 348 articles retrieved in full text. Ninety-nine peer-reviewed quantitative publications were included for data extraction. These consisted of one randomised crossover trial, one randomised cluster trial, one case-control study, 20 prospective cohort studies and 76 non-parallel cohort studies. Twenty-three percent of studies were classified as poor based on Downs and Black checklist, and reporting of implementation strategies lacked structure. Negative associations were found between the number of elements in a bundle and compliance (Spearman's rho = - 0.47, non-parallel cohort and - 0.65, prospective cohort studies), and between the complexity of elements and compliance (p < 0.001, chi-squared = 23.05). Implementation strategies associated with improved compliance included evaluative and iterative approaches, development of stakeholder relationships and education and training strategies. CONCLUSION: Care bundles with a small number of simple elements have better compliance rates. Standardised reporting of implementation strategies may help to implement care bundles into clinical practice with high fidelity. TRIAL REGISTRATION: This review was registered on the PROSPERO database: CRD 42015029963 in December 2015.

Perioperative structure and process quality and safety indicators: a systematic review.

BACKGROUND: Clinical indicators assess healthcare structures, processes, and outcomes. While used widely, the exact number and level of scientific evidence of these indicators remains unclear. The aim of this study was to evaluate the number, type, and evidence base of clinical process and structure indicators currently available for quality and safety measurement in perioperative care. METHODS: We performed a systematic review searching Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Google Scholar, and System for Information in Grey Literature in Europe databases for English language human studies in adults (age >18) published in the past 10 years (January 2005-January 2016). We also included professional and governmental body publications and guidelines describing the development, validation, and use of structure and process indicators in perioperative care. RESULTS: We identified 43 860 journal articles and 43 relevant indicator program publications. From these, we identified a total of 1282 clinical indicators, split into structure (36%, n=463) and process indicators (64%, n=819). The dimensions of quality most frequently addressed were effectiveness (38%, n=475) and patient safety (29%, n=363). The majority of indicators (53%, n=675) did not have a level of evidence ascribed in their literature. Patient-centred metrics accounted for the fewest published clinical indicators. CONCLUSIONS: Despite widespread use, the majority of clinical indicators are not based on a strong level of scientific evidence. There may be scope in setting standards for the development and validation process of clinical indicators. Most indicators focus on the effectiveness, safety, and efficiency of care. PROSPERO DATABASE: CRD4201501277.

Topical lidocaine patch 5% for acute postoperative pain control.

A 39-year-old para 3 woman presented for elective caesarean section (lower segment caesarean section (LSCS)) for breech presentation. The patient had a strong history of atopy and anaphylaxis to paracetamol, codeine, penicillin and latex. The patient was asthmatic, triggered by aspirin. Epidural anaesthesia was unsuccessful and LSCS was carried out under spinal anaesthesia. Postoperatively the patient was unwilling to take analgesic medication due to fear of an allergic reaction. Three 5% lidocaine patches were applied to the wound for postoperative analgesia. This reduced the patient's visual analogue scale pain score from 10/10 to 5/10 at rest and 10/10 to 7/10 with movement. Transcutaneous electrical nerve stimulation was added and this improved associated back pain, reducing the pain further to 2/10. This is the first description of lignocaine patch 5% for postoperative LSCS pain. It is suggested that this method of delivery of local anaesthetic, which is easy to apply and has minimal side effects, should be considered not as a sole agent but as part of a multimodal technique to address postoperative LSCS pain.