Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts.
Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts.
JAMA Otolaryngol Head Neck Surg. 2019 Apr 1;145(4):321-327. doi: 10.1001/jamaoto.2018.4348.
Health care organizations are complex and evolving systems. To date, longitudinal evaluation to ensure the sustainability of quality improvement (QI) initiatives has been missing from the otolaryngology literature. We sought to reassess perioperative management of laryngotracheal reconstruction, which requires adequate sedation.
Using principles of continuous QI, the objectives of this study were to (1) describe step-by-step methods to sustain QI efforts and (2) revisit a series of process, outcome, and balance measures for sedation weaning management following implementation of a new electronic health record (EHR).
DESIGN, SETTING, AND PARTICIPANTS: A standardized sedation weaning protocol was previously developed and instituted in February 2013. To address healthcare system-wide changes, a 7-step, Institute for Healthcare Improvement methodology was used to reevaluate a series of measures comparing a previous postweaning group (2013-2014; 13 patients) and current post-EHR group (2016; 11 patients). We conducted a focus group review of these 24 patients.
The primary outcome measure was length of sedation weaning. Secondary outcome, process, and balance measures included total length of sedation, absence of standardized wean document, absence of specific recommendations on weaning regimen, length of stay, continued weaning at discharge, discharge location, absence of discharge instructions on weaning regimen or iatrogenic withdrawal syndrome (IWS), discharge within 72 hours of stopping weaning, and readmission.
The postweaning and post-EHR groups were similar in age (20.5 months [95% CI, 11.92-29.15] vs 26.5 months [95% CI, 17.68-35.40]), as well as male sex (11 of 13 [85%] vs 10 of 11 [91%]), respectively. In the post-EHR group, the standardized sedation wean document was missing from 9 of 11 (82%) medical records. However, the primary outcome measure, length of sedation weaning, remained stable at 9.45 (95% CI, 7.62-11.29) days in the post-EHR group compared with 9.08 (95% CI, 7.00-11.18) days in the postweaning group. In addition, only 5 of 11 (46%) of discharges in the post-EHR group had specific guidance on weaning since the standardized template was no longer in use. As a result, in the post-EHR group, patients were 15.2 (95% CI, 0.46-242.34) times as likely to lack discharge instructions on weaning or IWS.
Quality improvement is meant to be a continuous process in which reevaluation of care practices are regularly performed. System-wide redesign can be achieved using a formal methodological approach. Moving forward, notable QI opportunities for our institution included the development of a flexible sedation weaning template, as well as enhancements to discharge instructions to include IWS diagnosis and treatment.
医疗保健组织是复杂且不断发展的系统。迄今为止，耳鼻喉科学文献中缺乏对质量改进（QI）计划可持续性的纵向评估。我们试图重新评估喉气管重建的围手术期管理，这需要充分的镇静。
使用持续 QI 的原则，本研究的目的是（1）描述维持 QI 工作的逐步方法，（2）重新审视一系列我们在实施新电子病历（EHR）后用于镇静戒断管理的过程、结果和平衡措施。
设计、地点和参与者：之前已经制定并于 2013 年 2 月实施了标准化镇静戒断协议。为了解决医疗系统的变化，采用了 7 步式医疗保健改善研究所方法，重新评估了一系列措施，比较了之前的戒断后组（2013-2014 年；13 例患者）和当前的 EHR 后组（2016 年；11 例患者）。我们对这 24 名患者进行了焦点小组审查。
主要结果测量是镇静戒断的时间长度。次要结果、过程和平衡措施包括镇静总时间、无标准化戒断文件、无具体戒断方案建议、住院时间、出院时继续戒断、出院地点、无戒断方案或医源性戒断综合征（IWS）出院说明、停止戒断后 72 小时内出院和再入院。
戒断后组和 EHR 后组在年龄（20.5 个月[95%CI，11.92-29.15] vs 26.5 个月[95%CI，17.68-35.40]）和男性比例（11 例[85%] vs 10 例[91%]）方面相似。在 EHR 后组中，9 例[82%]的病历中缺少标准化镇静戒断文件。然而，EHR 后组的主要结果测量，镇静戒断的时间，仍保持稳定，为 9.45（95%CI，7.62-11.29）天，与戒断后组的 9.08（95%CI，7.00-11.18）天相比。此外，EHR 后组中只有 5 例（46%）出院患者有具体的戒断指导，因为标准化模板不再使用。因此，在 EHR 后组中，患者缺乏戒断或 IWS 说明的可能性是 15.2（95%CI，0.46-242.34）倍。
质量改进是一个持续的过程，应该定期对护理实践进行重新评估。可以使用正式的方法学方法实现全系统重新设计。对我们机构而言，今后的质量改进机会包括制定灵活的镇静戒断模板，以及改进出院说明，以纳入 IWS 诊断和治疗。
