Essay on Quality Indicators of Anesthesia

A quality indicator, as described by Boulkedid et al. (2011), is measures, systems or processes set in place to gauge the level of performance and service provision in the health care sector. These indicators entirely base on pieces of evidence collected in the course of service provision. These evidence-based approaches are useful in the identification and assessment of the variations in service quality at both outpatient and inpatient levels (Isaac, Zaslavsky, Cleary & Landon, 2010). Generally, these quality indicators are split into four: Prevention, Inpatient, Patient Safety and pediatric (Farquhar, 2008).

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Prevention indicators outline the various measures implemented to reduce the probability of hospitalization for a patient capable of treatment on an outpatient basis. Prevention indicators also encompass ambulatory services, which are instrumental preventing further development of complications and severe ailments through early interventions (Farquhar, 2008). Inpatient quality indicators are a measure of the care quality given to patients while under health facility precautions. Inpatient quality indicators assess patient mortality, level of utilization and adherence to the set procedures to avoid situations of misuse, underuse and overuse (Glance, Osler, Mukamel & Dick, 2008). These safety indicators focus on identifying complications that are somewhat preventable but that have arisen from the patient being under the care of the hospital (Indicators, 2006). Lastly, the pediatric indicators assess the level of care given to young children below the age of seventeen.

The discovery of anesthesia revolutionized the practice of surgery. The use of anesthesia made surgery safer and less discomforting to the patient (Fradin, 1996). However, like any other conventional medicine, the use of anesthesia brought with it hazards that still result in patient mortality and morbidity to date (Metzner & Domino, 2010). Although the field of anesthesia is experiencing considerable changes, more actions are still necessary to ensure the patients receive the highest quality of service. In South Africa, over one million surgeries take place yearly, making it necessary to put measures in place that ensure that safety and quality standards are up to the required standards and patients receive utmost care. In the earlier years, the key indicators of quality and safety were the rate of patient mortality and morbidity. However, this has changed in the recent years since advancements in technology have led to better anesthetics and administration practices. A more comprehensive approach is therefore required, one that is capable of incorporating the various quality and safety indicators and provide the necessary guidelines for the implementation of these indicators.

In South Africa, there is little data on safety and quality from the health sector, private and public alike. As a result, stakeholders in the healthcare industry are still dependent on reviews of patient morbidity and mortality as well as incidence reports. These are rather ambiguous and do not provide the necessary perspective of the safety and quality issues surrounding South African anesthetics. The scenario has led to unchecked levels of preventable patient mortality cases. According to Haller et al. (2009), quality indicators mostly focus on the preoperative, perioperative and post-operative care which require a more established framework for quality assessment.

According to the research done by Donabedian (Benn, Arnold, Wei, Riley & Aleva, 2012), there exists a clear distinction between the process, structure and outcome brought about by the proximity or relationship that one particular variable has concerning the desired outcome. However, it is still quite difficult to identify a single routine to assess the quality of anesthesia, mostly due to the close relationship of anesthetics, surgeons and other proceduralists involved in the perioperative process (Peden, 2012). According to the review of quality indicators by Haller et al. (2009), the data currently collected by health care providers does not have the adequate sensitivity required to conduct a conclusive analysis of the levels of quality and safety of anesthetics practices. According to Haller et al. (2009), previous research literature identify a total of 108 anesthetics quality indicators, half of which look specifically at anesthesia itself and the other half at the care given to patients in the surgical rooms as well as in post-operative recovery wards.

Notably, patient mortality significantly declined over the past decades, to such an extent where patient death due to anesthesia becomes a clear indicator of poor quality in anesthesia application (Dripps, Lamont & Eckenhoff, 1961). Several researches attribute this to the rare occurrence of anesthesia-related deaths in modern health care set-ups. Furthermore, the deaths that do occur during surgery or after surgery occur due to factors that are absolutely out of the control of the anesthetist (Lienhart, Auroy, Pequignot, Benhamou, Warszawski, Bovet & Jougla, 2006). Indeed, anesthesia is revolutionizing the way surgery is carried out in modern times as well as improving the overall safety in healthcare provision. With the high number of surgeries performed annually, the adoption of quality and health-safety indicators will ensure that the number of complication and death that occur during and after surgery remain relatively minimal.

The quality of anesthetic care given to patients is assessed more accurately and directly during the post-operative period (Goodman, 2016), which differs significantly from the perioperative period influenced by surgical, patient and anesthetic factors. During this postoperative period, the patients rate of recovery closely associates with the selected anesthetic, analgesic and anti-emetic techniques (Nett, 2010). Determining the quality, in this case, is rather challenging since such considerations as patient satisfaction and experience during recovery are abstract in comparison to mortality rates (Fung & Cohen, 1998).

The most suitable approach, therefore, would be to gauge patient satisfaction with anesthesia practices through the development of questionnaires. Once preparation is complete, the questionnaires are provided to post-operative patients and the results taken through a systematic process of validation and assessment to determine the outcome. According to Myles et al. (2000), a scale, also known as a Quality of Recovery (QoR) scale, is used to measure the postoperative outcomes but with the added benefit of patient input. The scale measures the physiological effects that may include: Nausea, altered bowel functions and physical pain and mental awareness factors such as understanding of simple instruction. The scores can also be inclusive of factors such as time spent at the hospital, the surgery itself, general well-being and even gender. A positive QoR score indicates good anesthetic practice.

Postoperative quality indicators are often implemented, on a regular basis, by the staff. Measurements such as body temperature at time of admission and time spent at recovery are the determinants of a patients postoperative experience (Idvall, Hamrin, Sjostrom & Unosson, 2001). Recently, two postoperative conditions have become key to the recovery process; these are: postoperative vomiting and nausea abbreviated to PONV and postoperative pain. PONV, as well as post-operative pain, are key quality indicators because they are the most unpleasant to patients under care (Jorgensen et al., 2001). Postoperative experience is of utmost importance to patients and care, therefore, is taken while assessing and quantifying pain (Apfelbaum, Chen, Mehta & Gan, 2003). Although there are other established means of gauging postoperative pain; behavioral, visual and verbal scales still remain in common use today (Imani, 2011). The information obtained from these investigations are used to determine quality by the anesthetist and determine the necessary medication to better the patients experience.

Patient safety indicator development is a study that was conducted by (Emond, Stienen, Wollersheim, Bloo, Westert, Boermester, Pols, Calsbeek and wolf, 2015). The main objective of the study was to further improve quality and safety of both perioperative and postoperative care. The method adopted by Emond et al. (2015) was the Modified Delphi method. At the end of the study, a total of 11 perioperative Patient safety indicators formulated with of intent of application in the improvement, assessment and improvement of the quality accorded to perioperative patients.

The RAND-modified Delphi method is a systematic procedure that brings together opinions from experts and evidence gathered using the scientific methods (Hsu & Sandford, 2007). The fact that this approach can merge the above-mentioned items makes it the most suitable for patient safety indicator development. The study, therefore, was conducted based on this method and consisted of two phases. The first phase involved the development and testing of both pre and perioperative procedures. The second phase involved the addition of testing of postoperative processes.

The first step of phase one is to identify the main recommendations from the already existing guidelines. The recommendations are then rated formally by an established panel of experts drawn from different organizations. After formal rating, the results are then processed and analyzed using the RAND-modified Delphi procedure (Boulkedid, Abdoul, Loustau, Sibony & Alberti, 2011), which was prior to the results discussion by a select panel to decide on the recommendations that best satisfied the criteria. The suitable recommendations are then merged to form patient safety indicators. The PSIs consisted of both numerators and denominators, determined by the number of patients who adhere to the guidelines and the number of patients to whom the guidelines are applicable. Finally, after outlining all the patient safety indicators and perioperative care process, a pilot testing commences in both academic and teaching hospital environments to assess the compatibility of the quality criteria to the current practice.

References

Apfelbaum, J. L., Chen, C., Mehta, S. S. & Gan, T. J. (2003). Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia & Analgesia, 97(2), 534-540.

Benn, J., Arnold, G., Wei, I., Riley, C. & Aleva, F. (2012). Using Quality Indicators in Anesthesia. Br J Anesth. 109 (1): 80-91

Boulkedid, R., Abdoul, H., Loustau, M., Sibony, O. & Alberti, C. (2011). Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PloS One, 6(6), e20476.

Dripps, R. D., Lamont, A. & Eckenhoff, J. E. (1961). The role of anesthesia in surgical mortality. Jama, 178(3), 261-266.

Emond, Y.E., Stienen, J. J., Wollersheim, H.C., Bloo, G. J., Damen, J., Westert, G.P., Boermeester, M. A. Pols., Calsbeek, H. & Wolff, A. P. (2015). Development and measurement of perioperative patient safety indicators. British Journal of Anaethesia. Doi: 10.1093/bja/aeu561

Fradin, D. B. (1996). " We Have Conquered Pain": The Discovery of Anesthesia. MK McElderry Books.

Fung, D. & Cohen, M. M. (1998). Measuring patient satisfaction with anesthesia care: A review of current methodology. Anesthesia & Analgesia, 87(5), 1089-1098.

Glance, L. G., Osler, T. M., Mukamel, D. B. & Dick, A. W. (2008). The impact of the present-on-admission indicator on hospital quality measurement: Experience with the Agency for Healthcare Research and Quality (AHRQ) I...