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Quality Assurance Project

DR. MOHD FAIZAL NIZAM MOHD FOZI

DR. NOOR AZLIN AABDULLAH

DR. MOHAMMAD AZIZUDDIN FAHMI NORDIN

KUP. WAN KHAZANAH BT WAN LAILA

SN.SITI FAZLINA BT CHE ALLI

PT. NOR HASMAARNIZA BINTI HASSAN

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TOWARDS MINIMIZING PAIN POST ELECTIVE CAESAREAN SECTION RECEIVING INTRATHECAL ANALGESIA IN HOSPITAL KEMAMAN

Anesthesiology Department, Hospital Kemaman

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Problem Identification�

  1. Delay interval time between elective cases.
  2. High incidence of Postdural Puncture Headache (PDPH) in O&G cases.
  3. High incidence of pain in Elective LSCS patient post intrathecal analgesia.
  4. High incidence of unplanned Intensive Care Unit (ICU) admission post elective case surgery.
  5. High incidence of cancellation of elective cases after pre-op assessment.

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  • Caesarean section is the most common procedure in all hospitals, amounting to 420 cases in Hospital Kemaman last year. However pain post LSCS is one of the significant problems in Hospital Kemaman.

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  • This can cause distress to patient, delay ambulation, prolong hospital stay and increase morbidity and mortality to patient.

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  • It could be due to inadequate analgesia, lack of knowledge, improper explanation by anesthetist and misjudgment by the patient.

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  • Thus, our aim is to identify the cause and determine the remedial action in order to improve our quality of service to achieve pain free hospital as implemented by Ministry of Health (MOH) since 2011.

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Problem Statement

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Introduction

  • Pain is generally considered unavoidable especially in Lower Segment Caesarean Section (LSCS). However, with modern drugs and techniques, there are many simple ways of relieving pain. Unfortunately pain is often not well managed in most hospitals.

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  • Analgesia after LSCS is important because postpartum women with pain have difficulty in mobility which can increase the morbidity and mortality. A good postoperative analgesia can help hasten rehabilitation, improve patient satisfaction and reduce hospital stay.

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Definition

  • Intrathecal is the route of administring drug into anatomic space, which is the subarachnoid space.
  • Pain can be assessed with few techniques but in caesarean section we commonly use numerical rating scale from 0 -10.
    • 0 : no pain
    • 1-3 : mild pain
    • 4-6 : moderate pain
    • 7-10 : severe pain

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(NIPC, National Initiative Pain Control)

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Unbearable pain

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Literature review

  • Study done by Francisco et al. in Brazil shows 62% out of 130 patients experienced moderate to severe pain at 6 to 24 hours post LSCS after receiving intrathecal morphine (ITM).

Francisco et al., Acta Paul Enferm 2009; 22(6):741-7

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  • The higher dose of ITM, the better pain control; or the ITM combined with supplemental analgesia achieve better pain control.

Dahl JB, Jeppesen IS, Jorgensen H, et al, Anesthesiology, 1999; 91:1919-1927

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  • Inadequately managed pain can lead to adverse physical and psychological outcomes such as reduced patient mobility, resulting in complications such as deep vein thrombosis, pulmonary embolus, and pneumonia that can increase morbidity and mortality.

Apfelbaum JL, Chen C, Mehta S, et al. Postoperative pain experience: results from a national survey suggesting postoperative pain continues to be undermanaged. Anesth Analg. 2003;97:534–40.

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Key measures

General Objective

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To reduce rate of unbearable pain post Caesarean section receiving intrathecal analgesia in Hospital Kemaman

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Specific Objectives

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  1. To verify the incidence of pain post Caesarean section receiving intrathecal analgesia
  2. To identify factors which may contribute to the above problem
  3. To recommend & implement proper remedial measures
  4. To evaluate the effectiveness of remedial measures

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Indicators

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No. of patient with pain score ≥ 4 post ELLSCS

receiving intrathecal analgesia

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No. of total patients undergo ELLSCS receiving

intrathecal analgesia

Standards

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Percentage of patient experience unbearable pain post ELLSCS <10%. Based on Key Performance Indicator (KPI) for Anesthesiology Department Hospital Kemaman with consensus Head of Department

Key measures

X 100

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Inclusion Criteria

All parturients undergo ELLSCS receiving intrathecal analgesia in Hospital Kemaman

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Exclusion criteria

    • Failed spinal or patchy block, convert to GA
    • Mentally challenged patient
    • Language barrier
    • Critically ill patient with ASA III - IV

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Key measures

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FIT FOR INTRATHECAL

GA

Induction of anesthesia

Preoperative assessment & discussion with specialist

Process of Good Care

Recovery & APS review

Patient for Cesarean Section

Supplemental Analgesia

Need resuscitation/ stabilization

NO

NO

YES

Case notification

Reassessment

Receiving patient in OT

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BIL

PROCESS

CRITERIA

ACTUAL

STANDARD

1

Case Notification

All cases ELLSCS must notify to anesthetic doctors within 24hours before operation.

100%

100%

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2

Preoperative assessment

History

  • Age, gravida/para, POG
  • Antenatal complication/ past surgical history
  • Anemic/ URTI symptoms

Examination

  • General examination
  • Respiratory & Cardiovascular
  • Mallampati, TMD, neck movement

100%

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​

​

​

​

​

​

100%

​

​

​

​

​

​

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Explanation regarding technique of anesthesia by using poster, booklet and pamphlet

Premedication: Aspiration prophylaxis

Discussion with Anesthesiologist

26%

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100%

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Model of Good Care

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BIL

PROCESS

CRITERIA

ACTUAL

STANDARD

3

Receiving patient in OT

Follow Safe Surgery Safe Life (SSL) protocol

-reviewed patient check list in details

100%

100%

4

Reassessment

Re-assessment of patient prior operation

-if patient not fit for intrathecal (IT) anesthesia, operation will be proceed under GA

100%

100%

5

Induction by anesthetic doctors

  • Experienced Medical officer >1 year
  • Appropriate equipment

100%

100%

  • Correct drugs and dosage according to patient height and weight following Obstetric Anesthesia Guideline/ Protocol
  • Technique: Intrathecal Anesthesia

60%

100%

Model of Good Care

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BIL

PROCESS

CRITERIA

ACTUAL

STANDARD

6

Supplemental Analgesia

All parturient will be given

  • Supp Paracetamol or Supp Voren or both to optimize post operative pain

40%

100%

7

Recovery

Vital sign monitoring every 5 minutes

Good pain assessment technique by using numerical rating scale.

Discharge patient from OT with pain score <4

35%

100%

8

Reassessment by APS Team

Reassess PS after 6H post operation

Good pain assessment technique by using numerical rating scale

Adequate analgesia in ward

Encourage early ambulation

60%

100%

Model of Good Care

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  • Re-evaluation study done yearly
    • January 2016 – May 2016
    • May 2017- August 2017

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3 Phases of Our Study

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Process of Gathering Information

PHASE I STUDY

Study design

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Cross-Sectional study

Randomly Sampling Technique

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All parturients undergo ELLSCS in Hospital Kemaman

From November to December 2014

Total 55 cases

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Questionnaires method

Done in postnatal ward

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Result (Verification study)

ABNA

25%

18/55 cases

TOTAL ELLSCS PER YEAR (2014): 220 CASES

55 cases =25% from total ELLSCS/YEAR

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High incidence of pain in ELLSCS patient post intrathecal analgesia

Improper pain assessment

Improper case management

Anxious patient

Improper pre-operative assessment

misconception

Inexperience receiving intrathecal analgesia

Not comply with protocol

Inexperience medical officer

Inadequate drug (single mode)

Lack of knowledge regarding procedure

Lack of knowledge among staffs

Under usage of pain assessment tools

Inadequate practice/ experience

Causes and Effect Diagram

Analysis study conducted in January and February 2015 to verify the possible factors involved.

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Analysis

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      • 2 sets of questionnaire were constructed and distributed
        • For patient undergo ELLSCS (before induction)
        • For all staff in operation theater including medical officer and paramedic.

Analysis

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Analysis

Percentage

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Analysis

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NO

RISK FACTORS

% (PREREMEDIAL)

1

Patient misconception

76

2

Improper pre-operative assessment

74

3

Under usage of pain scale assessment tool

65

4

Inadequate practice pain assessment

40

5

Inadequate drugs (single mode)

60

6

Not comply to obstetric anaesthesia protocol

40

7

Competency among the staffs

70

Interpretations

  • Conclusions of Phase I Study
  • There was a significant misconception by the patient regarding intrathecal anesthesia that could be due to

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  • inadequate explanation given by anesthetic doctors during preoperative assessment that representing 76% and 74% respectively.

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  • Under usage of pain scale as assessment tool also is give significant factors, because it is essential to assess level of pain that patient experience.

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  • Inadequate drug given and not comply to obstetric protocol also contribute to this matter that can reduced the effectiveness pain control.

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Problem

Remedial measure

Description/ diagram

1. Inadequate

drug

1.1 Obstetric Anesthesia Protocol

  • Cooperate standardizing protocol in giving acute drug and dose

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1.2 Multimodal drug approach

  • Given supplemental analgesia: SUPP PCM/SUPP VOREN

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1.3 Passover Session

  • Done among all medical officer and specialist daily to emphasize the implementation of protocol.

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Strategies of Change

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Problem

Remedial measure

Description/ diagram

2. Improper pain assessment

2.1 Bedside teaching

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  • Done periodically
  • Targeting mainly all nurses at recovery bay and antenatal ward.
  • Guided the nurses for correct pain assessment technique and tools

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​

​

​

​

​

​

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Strategies of Change

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Problem

Remedial measure

Description/ diagram

2. Improper pain assessment

2.2 Continuous Medical Education (CME)

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  • Done periodically to all staff to abreast new protocol, technique and drug regarding intrathecal analgesia

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Strategies of Change

Date

Persons involved

19/3/15

Medical Officer

23/7/15

Paramedic

7/12/15

Houseman and paramedic

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Problem

Remedial measure

Description/ diagram

3. Inadequate explanation

3.1 Educational material

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  1. Pamphlet
  2. Booklet
  3. Poster

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  • Provide information regarding intrathecal anesthesia

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Strategies of Change

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Problem

Remedial measure

Description/ diagram

3. Inadequate explanation

3.2 Educational Talk

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1. Obstetric ward

2. Obstetric Clinic

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  • Early exposure to all parturient
  • Enhance patient knowledge

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Strategies of Change

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Method

Person involved

Time frame

Method of supervision

Obstetric Anesthesia protocol and guideline

Specialists, MOs and paramedic

6months

List of names of staff involved, checked periodically

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Bedside Teachings

Doctors and nurses at HKM

3 months

List of names of staff involved, checked periodically

CMEs department

Specialists, MOs, HOs and paramedic in OT

6 months

List of names of participants, checked periodically

Educational Talk with parturient

MOs, Paramedic and parturients in postnatal ward and O&GClinic

3 months

List of names of participants, checked periodically

Posters

MOs and paramedic

6 months

Given to postnatal ward and Anesthesia Clinic for reference

Pamphlet

All parturients

3 months

Given to all patients that will undergo LSCS

Monitoring of Remedies

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Process of Gathering Information

PHASE II STUDY

Study design

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Cross-Sectional study

Randomly Sampling Technique

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All parturients undergo ELLSCS in Hospital Kemaman

From May to June 2015

Total 55 cases

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Questionnaires method

Done in postnatal ward

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Effect of Changes

Percentage

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Effect of Changes

Percentage

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Effect of Changes

PRE-REMEDIAL

POST-REMEDIAL

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ABNA

Effect of Changes

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  • Inadequate practice and under usage of assessment tools still need improvement.
  • There is still medical officer not comply with new protocol and need for reinforcement/checklist, because it is the crucial part of pain control to tackle this problem

Effect of Changes (why not achieved?)

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Problem

Remedial measure

Description/ diagram

Inadequate drug

  1. Obstetric Anesthesia Protocol
  2. Multimodal drug approach
  3. Passover Session
  4. Amendment of APS FORM
  5. For reinforcement of the protocol

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Improper pain assessment

  1. Bedside teaching
  2. Continues medical education (CME)

3. APS Workshop

  • To emphasis the usage of assessment tool and practice

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​

​

​

​

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Strategies of Change

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Process of Gathering Information

PHASE III STUDY (re-evaluation)

Study design

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Cross-Sectional study

Randomly Sampling Technique

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All parturient undergo ELLSCS in Hospital Kemaman

Carried out in

    • January to May 2016 (55 cases)
    • May to August 2017(55 cases)

Total 110 cases

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Questionnaires method

Done in postnatal ward

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Effect of Changes

Percentage

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Effect of Changes

Percentage

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Effect of Changes

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Effect of Changes (Achievement)

  • Reevaluation carried out in January to May 2016 and May to August 2017, involving 55 samples showed marked improvement in the percentage of reduction pain post operation, from 15% to 6%.

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ABNA

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What we have learnt..

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1. All staff easily to perform their work with the presence of new simplified guideline and protocol for better outcome of the patient and easily to assess as references.

Effect of Changes

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What we have learnt..

2. This study also give benefit to all patient by the evidence of patient satisfaction as below.

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Effect of Changes

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3. This study also help in reducing the admission cost for the patient with good pain control. It also help for patient early ambulation and further can reduce the length of stay in the ward.

Item

Patient with good pain control

Patient with poor pain control

Warded

RM 3 x 4 = 12

RM 3 x 5 = 15

Laboratory

RM 10

RM 18

Investigation (CTG)

RM 10

RM 10

Operation

RM 100

RM 100

Medication (post operation)

RM 1.40

RM 50.80

TOTAL

RM 133.40

RM 193.8

Effect of Changes

Comparison between admission’s cost

TOTAL SAVING PER YEAR: RM 15,100 (250cases/year)

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4. Multimodal drug approach instead of single drug approach just by adding Supp PCM and Supp Voren which is cheap and less invasive but it can give better outcome for patient. We reinforcement this method by amendment of APS form as a checklist.

Effect of Changes

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  • To re-inforce the remedial measures such as the use of educational material and proper pain score assessment tool
  • To organize more frequent CME, bedside teaching and educational talk we aim to broaden these to hospital level.
  • To prepare further study and implementation of these remedial measures in other surgical fields such as gynecology, orthopedics and surgical case.
  • To promote the implementation of these remedial measures to other health care level such as district hospital and health clinic.
  • To organize a program to educate Kemaman community regarding spinal anesthesia during Hospital Kemaman open day.

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The Next Step

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  • Francisco et al., Acta Paul Enferm 2009; 22(6):741-7
  • Dahl JB, Jeppesen IS, Jorgensen H, et al, Anesthesiology, 1999; 91:1919-1927
  • Apfelbaum JL, Chen C, Mehta S, et al. Postoperative pain experience: results from a national survey suggesting postoperative pain continues to be undermanaged. Anesth Analg. 2003;97:534–40
  • Obstetric Anesthesia and Analgesia, Practical issue by YK Can, Alex Sia, Stephen Gatt.
  • Pain Free Hospital Manual, Malaysia Minitry Of Health.
  • 5th edition Clinical Anesthesiology by Murgan & Mikhail
  • Concise Anatomy forAnesthesiology, Andreas G Erdmann

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References

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Questionnaire

APPENDIX

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THANK YOU…….