Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
ValueCare Programme Office, Centre of Performance Excellence, Changi General Hospital, Singapore.
BMJ Open Qual. 2022 Aug;11(3). doi: 10.1136/bmjoq-2021-001738.
Surgery is recommended within 48 hours of hip fractures for better perioperative outcomes. Yet, such targets still commonly remain a challenge. Our institution is no exception.As part of a hospital-wide initiative, our anaesthesia department focused on improving perioperative processes with aims to reduce the time to first anaesthesia consult and surgery for hip fracture patients. Acknowledging multiple causes for surgical delay, we decided first to address anaesthesia-specific factors-(a) first anaesthetist contact usually happens after surgery is offered which leaves a short runway for preoptimisation, (b) this is compounded by varying degrees of anaesthetist involvement for follow-up thereafter. (c) There is a need to calibrate our perioperative care standards and (d) enforce more consistent auditing in quality assurance. This project was conducted in a 1000-bed hospital serving eastern Singapore.
We created an integrated anaesthesia consultant-led outreach service for hip fracture patients, based on a perioperative workflow system to provide proactive anaesthetist consults within 24 hours of admission in advance of surgical decision. This was streamlined with a coordinated follow-up system for preoptimisation until surgery.
Our quality improvement project applied the iterative Plan-Do-Study-Act model from pilot to sustainability stage. We collected data at baseline followed by 6-monthly audits from electronic databases.Primary outcomes measured were time to first anaesthesia consult and surgery. Secondary outcomes included rate of critical care reviews and admission, mortality rate, length of stay and time to nerve blocks.
Post implementation, our service reviewed >600 hip fracture patients. Median time to anaesthesia consult reduced significantly from 35.3 hours (2019) to 21.5 hours (2021) (p=0.029). Median time to surgery was reduced from 61.5 hours (2019) to 50 hours (2021) (p=0.897) with a 13.6% increase in patients operated <48 hours. Critical care admissions, 6-monthly and 12-monthly mortality rates and time to nerve block were reduced with a greater percentage of patients discharged within 10 days.
Our project focused on improving anaesthesia perioperative processes to address surgical delays in hip fracture patients. Our consultant-led anaesthesia service ensured that proactive anaesthesia care was delivered to provide sufficient time for preoptimisation with greater standardisation to follow-up, better communication and quality assurance.
髋部骨折患者建议在 48 小时内进行手术，以获得更好的围手术期结果。然而，这样的目标仍然是一个挑战。我们医院也不例外。作为全院范围内的一项举措，我们的麻醉科专注于改进围手术期流程，旨在减少髋部骨折患者首次麻醉咨询和手术的时间。鉴于手术延迟的多种原因，我们首先决定解决麻醉相关因素-(a) 首次麻醉师接触通常发生在提供手术之后，这使得优化的时间很短，(b) 此后麻醉师的参与程度不同会使情况更加复杂。(c) 需要校准我们的围手术期护理标准，(d) 在质量保证方面加强更一致的审核。该项目在一家服务于新加坡东部的 1000 床位医院进行。
我们创建了一个由麻醉顾问主导的综合服务，为髋部骨折患者提供服务，该服务基于围手术期工作流程，在做出手术决策之前，提前在入院后 24 小时内提供主动麻醉师咨询。这与优化直至手术的协调后续系统相结合。
我们的质量改进项目应用了从试点到可持续性阶段的迭代计划-执行-研究-行动模型。我们在基线时收集数据，然后从电子数据库进行 6 个月的审核。主要结果测量是首次麻醉咨询和手术的时间。次要结果包括重症监护审查和入院率、死亡率、住院时间和神经阻滞时间。
实施后，我们的服务审查了超过 600 名髋部骨折患者。麻醉咨询的中位时间从 35.3 小时(2019 年)显著减少到 21.5 小时(2021 年)(p=0.029)。手术的中位时间从 61.5 小时(2019 年)减少到 50 小时(2021 年)(p=0.897)，48 小时内手术的患者增加了 13.6%。重症监护病房入院、6 个月和 12 个月的死亡率以及神经阻滞时间都有所降低，出院时间在 10 天内的患者比例也有所增加。
我们的项目专注于改进髋部骨折患者的麻醉围手术期流程，以解决手术延迟问题。我们的顾问主导的麻醉服务确保提供积极的麻醉护理，以提供足够的时间进行优化，并遵循更标准化的后续措施、更好的沟通和质量保证。
