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Anesth Analg. 2019 May;128(5):953-961. doi: 10.1213/ANE.0000000000003742.

Process Optimization and Digital Quality Improvement to Enhance Timely Initiation of Epidural Infusions and Postoperative Pain Control.

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From the Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington.
Institute for Translational Health Sciences (ITHS), University of Washington, Seattle, Washington.



Although intraoperative epidural analgesia improves postoperative pain control, a recent quality improvement project demonstrated that only 59% of epidural infusions are started in the operating room before patient arrival in the postanesthesia care unit. We evaluated the combined effect of process and digital quality improvement efforts on provider compliance with starting continuous epidural infusions during surgery.


In October 2014, we instituted 2 process improvement initiatives: (1) an electronic order queue to assist the operating room pharmacy with infusate preparation; and (2) a designated workspace for the storage of equipment related to epidural catheter placement and drug infusion delivery. In addition, we implemented a digital quality improvement initiative, an Anesthesia Information Management System-mediated clinical decision support, to prompt anesthesia providers to start and document epidural infusions in pertinent patients. We assessed anesthesia provider compliance with epidural infusion initiation in the operating room and postoperative pain-related outcomes before (PRE: October 1, 2012 to September 31, 2014) and after (POST: January 1, 2015 to December 31, 2016) implementation of the quality improvement initiatives.


Compliance with starting intraoperative epidural infusions was 59% in the PRE group and 85% in the POST group. After adjustment for confounders and preintervention time trends, segmented regression analysis demonstrated a statistically significant increase in compliance with the intervention in the POST phase (odds ratio, 2.78; 95% confidence interval, 1.73-4.49; P < .001). In the PRE and POST groups, cumulative postoperative intravenous opioid use (geometric mean) was 62 and 34 mg oral morphine equivalents, respectively. A segmented regression analysis did not demonstrate a statistically significant difference (P = .38) after adjustment for preintervention time trends.


Process workflow optimization along with Anesthesia Information Management System-mediated digital quality improvement efforts increased compliance to intraoperative epidural infusion initiation. Adjusted for preintervention time trends, these findings coincided with a statistically insignificant decrease in postoperative opioid use in the postanesthesia care unit during the POST phase.

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