Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Adult Intensive Care Unit, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong.
Anaesthesia. 2018 Sep;73(9):1067-1078. doi: 10.1111/anae.14326. Epub 2018 Jul 4.
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.
新斯的明拮抗肌松作用的不适当剂量与术后肺部并发症有关。我们评估了一项针对优化新斯的明拮抗神经肌肉阻滞药物使用的质量改进计划对术后肺部并发症、成本和住院时间的影响。质量改进计划包括：减少可用的新斯的明等分剂量大小；认知辅助工具；教育组成部分；以及在给予新斯的明之前记录四成肌颤搐测量值的术中记录的财务激励。我们对我们的质量改进研究中获得的数据进行了预先指定的分析。在倾向匹配队列中进行了额外的分析。采用中断时间序列设计来区分干预措施和反事实情况。我们分析了 2015 年连续进行的 12025 例手术病例。在干预前的 2937 例病例中，有 220 例（7.5%）发生术后肺部并发症，在干预后的 9088 例病例中，有 568 例（6.3%）发生术后肺部并发症。调整后的回归分析显示，术后肺部并发症的风险显著降低（OR 0.73（95%CI 0.61-0.88）；p = 0.001），成本降低（发病率比 0.95（95%CI 0.93-0.97）；p < 0.001），住院时间缩短（发病率比 0.91（95%CI 0.87-0.94）；p < 0.001）。在实施质量改进计划后，在倾向匹配样本（每组 2936 例）和中断时间序列分析（每组 27202 例）中的分析证实了这一发现。我们的数据表明，当地的、多方面的质量改进计划可以提高术中神经肌肉阻滞剂使用的质量，从而降低术后肺部并发症的发生率。
