Effect of a newly designed observation, response and discharge chart in the Post Anaesthesia Care Unit on patient outcomes: a quasi-expermental study in Australia

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Abstract

Objectives

This study aimed to evaluate whether use of a discharge criteria tool for nursing assessment of patients in Post Anaesthesia Care Unit (PACU) would enhance nurses’ recognition and response to patients at-risk of deterioration and improve patient outcomes.

Methods

A prospective non-randomised pre–post intervention study was conducted in three hospitals in Australia. Participants were adults undergoing elective surgery before (n=723) and after (n=694) implementation of the Post-Anaesthetic Care Tool (PACT).

Results

Nursing response to patients at-risk of deterioration was higher using PACT, with more medical consultations initiated by PACU nurses (19% vs 30%, P<0.001) and more patients with Medical Emergency Team activation criteria modified by an anaesthetist while in PACU (6.5% vs 13.8%, P<0.001). There were higher rates of analgesia administration (37.3% vs 54.2%, P=0.001), nursing assessment of pain and documentation of ongoing analgesia prior to discharge (55% vs 85%, P<0.001). More adverse events were recorded in PACU after introduction of the PACT (8.3% vs 16.7%, P<0.001). The rate of adverse events after discharge from PACU remained constant (16.5%), but the rate of cardiac events (5.1% vs 2.6%, P=0.021) and clinical deterioration (8.7% vs 4.3%, P=0.001) following PACU discharge significantly decreased, using the PACT. Despite the increased number of patients with adverse events in phase 2, healthcare costs did not increase significantly. Length of stay in PACU and length of hospital admission for those patients who had an adverse event in PACU were significantly reduced after implementation of the PACT.

Conclusion

This study found that using a structured discharge criteria tool, the PACT, enhanced nurses’ recognition and response to patients who experienced clinical deterioration, reduced length of stay for patients who experienced an adverse event in PACU and was cost-effective.

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Most cited references 26

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Effect of a comprehensive surgical safety system on patient outcomes.

Eefje N de Vries, Hubert A Prins, Rogier Crolla … (2010)

Adverse events in patients who have undergone surgery constitute a large proportion of iatrogenic illnesses. Most surgical safety interventions have focused on the operating room. Since more than half of all surgical errors occur outside the operating room, it is likely that a more substantial improvement in outcomes can be achieved by targeting the entire surgical pathway. We examined the effects on patient outcomes of a comprehensive, multidisciplinary surgical safety checklist, including items such as medication, marking of the operative side, and use of postoperative instructions. The checklist was implemented in six hospitals with high standards of care. All complications occurring during admission were documented prospectively. We compared the rate of complications during a baseline period of 3 months with the rate during a 3-month period after implementation of the checklist, while accounting for potential confounders. Similar data were collected from a control group of five hospitals. In a comparison of 3760 patients observed before implementation of the checklist with 3820 patients observed after implementation, the total number of complications per 100 patients decreased from 27.3 (95% confidence interval [CI], 25.9 to 28.7) to 16.7 (95% CI, 15.6 to 17.9), for an absolute risk reduction of 10.6 (95% CI, 8.7 to 12.4). The proportion of patients with one or more complications decreased from 15.4% to 10.6% (P<0.001). In-hospital mortality decreased from 1.5% (95% CI, 1.2 to 2.0) to 0.8% (95% CI, 0.6 to 1.1), for an absolute risk reduction of 0.7 percentage points (95% CI, 0.2 to 1.2). Outcomes did not change in the control hospitals. Implementation of this comprehensive checklist was associated with a reduction in surgical complications and mortality in hospitals with a high standard of care. (Netherlands Trial Register number, NTR1943.).

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The incidence and nature of surgical adverse events in Colorado and Utah in 1992.

Atul A Gawande, Eric Thomas, Michael Zinner … (1999)

Despite more than three decades of research on iatrogenesis, surgical adverse events have not been subjected to detailed study to identify their characteristics. This information could be invaluable, however, for guiding quality assurance and research efforts aimed at reducing the occurrence of surgical adverse events. Thus we conducted a retrospective chart review of 15,000 randomly selected admissions to Colorado and Utah hospitals during 1992 to identify and analyze these events. We selected a representative sample of hospitals from Utah and Colorado and then randomly sampled 15,000 nonpsychiatric discharges from 1992. With use of a 2-stage record-review process modeled on previous adverse event studies, we estimated the incidence, morbidity, and preventability of surgical adverse events that caused death, disability at the time of discharge, or prolonged hospital stay. We characterized their distribution by type of injury and by physician specialty and determined incidence rates by procedure. Adverse events were no more likely in surgical care than in nonsurgical care. Nonetheless, 66% of all adverse events were surgical, and the annual incidence among hospitalized patients who underwent an operation or child delivery was 3.0% (confidence interval 2.7% to 3.4%). Among surgical adverse events 54% (confidence interval 48.9% to 58.9%) were preventable. We identified 12 common operations with significantly elevated adverse event incidence rates that ranged from 4.4% for hysterectomy (confidence interval 2.9% to 6.8%) to 18.9% for abdominal aortic aneurysm repair (confidence interval 8.3% to 37.5%). Eight operations also carried a significantly higher risk of a preventable adverse event: lower extremity bypass graft (11.0%), abdominal aortic aneurysm repair (8.1%), colon resection (5.9%), coronary artery bypass graft/cardiac valve surgery (4.7%), transurethral resection of the prostate or of a bladder tumor (3.9%), cholecystectomy (3.0%), hysterectomy (2.8%), and appendectomy (1.5%). Among all surgical adverse events, 5.6% (confidence interval 3.7% to 8.3%) resulted in death, accounting for 12.2% (confidence interval 6.9% to 21.4%) of all hospital deaths in Utah and Colorado. Technique-related complications, wound infections, and postoperative bleeding produced nearly half of all surgical adverse events. These findings provide direction for research to identify the causes of surgical adverse events and for targeted quality improvement efforts.

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Adverse events in surgical patients in Australia.

A. KABLE, R. W. GIBBERD, A D Spigelman (2002)

To determine the adverse event (AE) rate for surgical patients in Australia. A two-stage retrospective medical record review was conducted to determine the occurrence of AEs in hospital admissions. Medical records were screened for 18 criteria and positive records were reviewed by two medical officers using a structured questionnaire. Admissions in 1992 to 28 randomly selected hospitals in Australia. Five hundred and twenty eligible admissions were randomly selected from in-patient database in each hospital. A total of 14,179 medical records were reviewed, with 8747 medical and 5432 surgical admissions. Measures included the rate of AEs in surgical and medical admissions, the proportion resulting in permanent disability and death, the proportion determined to be highly preventable, and the identification of risk factors associated with AEs. The AE rate for surgical admissions was 21.9%. Disability that was resolved within 12 months occurred in 83%, 13% had permanent disability, and 4% resulted in death. Reviewers found that 48% of AEs were highly preventable. The risk of an AE depended on the procedure and increased with age and length of stay. The high AE rate for surgical procedures supports the need for monitoring and intervention strategies. The 18 screening criteria provide a tool to identify admissions with a greater risk of a surgical AE. Risk factors for an AE were age and procedure, and these should be assessed prior to surgery. Prophylactic interventions for infection and deep vein thrombosis could reduce the occurrence of AEs in hospitals.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2017

Publication date (Electronic): 3 December 2017

Volume: 7

Issue: 12

Electronic Location Identifier: e015149

Affiliations

[1 ] School of Nursing and Midwifery, Deakin University , Geelong, Australia

[2 ] Eastern Health-Deakin University Nursing and Midwifery Research Centre , Box Hill, Australia

[3 ] departmentQuality and Patient Safety Research Centre , Deakin University , Burwood, Australia

[4 ] departmentBiostatistics Unit, Faculty of Health , Deakin University , Geelong, Australia

[5 ] School of Nursing and Midwifery, University of Plymouth , Plymouth, UK

Author notes

[Correspondence to ] Dr Maryann Street; maryann.street@ 123456deakin.edu.au

Author information

Maryann Street http://orcid.org/0000-0002-5615-141X

Article

Publisher ID: bmjopen-2016-015149

DOI: 10.1136/bmjopen-2016-015149

PMC ID: 5778298

PubMed ID: 29203501

SO-VID: f49bec52-eb66-438f-8045-d341b39fa761

License:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

History

Date received : 12 November 2016

Date revision received : 15 August 2017

Date accepted : 06 October 2017

Funding

Funded by: HCF Medical Research Foundation;

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ScienceOpen disciplines: Medicine

Keywords: surgery,health economics

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ScienceOpen disciplines: Medicine

Keywords: surgery, health economics

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Effect of a newly designed observation, response and discharge chart in the Post Anaesthesia Care Unit on patient outcomes: a quasi-expermental study in Australia

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Abstract

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SICOT-J (Orthopedic surgery and traumatology)

Most cited references 26

Effect of a comprehensive surgical safety system on patient outcomes.

The incidence and nature of surgical adverse events in Colorado and Utah in 1992.

Adverse events in surgical patients in Australia.

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