Automated feedback modestly improves perioperative treatment adherence of postoperative nausea and vomiting

Highlights

• Audit and feedback, combined with a clinical decision support tool, modestly improves compliance with PONV recommendations.

• Audit and feedback, combined with a clinical decision support tool, did not reduce the prevalence of PONV in the PACU.

• Audit and feedback, alone, do not improve compliance with PONV prophylaxis recommendations.

• Compliance with PONV recommendations improved by 5.5%; there was an 8.7% reduction in rescue medication use in the PACU.

Abstract

Study objective

Extensive evidence demonstrates that medical record modernization and a vast amount of available data have not overcome the gap between recommended and delivered care. This study aimed to evaluate the use of clinical decision support (CDS) in conjunction with feedback (post-hoc reporting) to improve PONV medication administration compliance and postoperative nausea and vomiting (PONV) outcomes.

Design

Single center, prospective observational study between January 1, 2015, and June 30, 2017.

Setting

Perioperative care at a university-affiliated tertiary care center.

Patients

57,401 adult patients who received general anesthesia in a non-emergency setting.

Intervention

A multi-phased intervention that consisted of post-hoc reporting for individual providers by email about PONV occurrences in their patients, followed by directive CDS through preoperative daily case emails that provided therapeutic PONV prophylaxis recommendations based on patients' PONV risk scores.

Measurement

Compliance with PONV medication recommendations, as well as hospital rates of PONV were measured.

Main result

Over the study period, there was a 5.5% (95% CI, 4.2% to 6.4%; p < 0.001) improvement in the compliance of PONV medication administration along with an 8.7% (95% CI, 7.1% to 10.2%, p < 0.001) reduction in PONV rescue medication administration in the PACU. However, there was no statistically or clinically significant reduction in the prevalence of PONV in the PACU. The prevalence of PONV rescue medication administration decreased during the Intervention Rollout Period (odds ratio 0.95 [per month]; 95% CI, 0.91 to 0.99; p = 0.017), and during the Feedback with CDS Recommendation Period (odds ratio, 0.96 [per month]; 95% CI, 0.94 to 0.99; p = 0.013).

Conclusion

PONV medication administration compliance modestly improves with CDS in conjunction with post-hoc reporting; however, no improvement in PACU rates of PONV occurred.

Introduction

There are two main health informatics intervention categories: (1) clinical decision support (CDS) and (2) post-hoc reporting. CDS targets improved decision making during clinical encounters, while post-hoc reporting provides population-level performance summaries that allow health professionals to assess their decision processes outside of a clinical encounter and adjust their performance. CDS and post-hoc reporting only moderately effect clinical care when implemented individually [1,2]. Combining these interventions may improve clinician practice, with CDS targeting the decision in real-time and post-hoc reporting providing feedback on how successfully the CDS was used in practice. Such a feedback loop would create an ongoing learning environment for health professionals and generate new hypotheses about intervention targets. This reiterative process is the basis of a learning healthcare system [[2], [3], [4]].

Anesthesia providers have a critical role in the perioperative period. Intraoperative management is associated with numerous outcomes that include postoperative nausea vomiting (PONV) [5]. The prevalence of PONV is 30% and 40% and varies between institutions based on case mix, opioid use, and patient characteristics [6,7]. Historically, CDS PONV prediction model implementation has not decreased the prevalence of PONV in study populations [8]. CDS PONV prediction model implementation, used in conjunction with prescriptive medication recommendations based on the patient's risk profile, has modestly decreased the prevalence of PONV [5,9]. The most successful studies with multimodal PONV prophylaxis interventions have shown a 10% reduction in the PONV rate, suggesting this as a reasonable initial target [9]. A recent trial suggests that CDS with feedback (post-hoc reporting) integration might be synergetic when combined [10]. Other research on the effect of pragmatic CDS, in conjunction with support systems (e.g. feedback), on clinical care remains sparse at best [4,[11], [12], [13]].

One possible explanation for only modest improvement is that anesthesia providers are not aware of the magnitude of the problem [14]. There is currently a lack of feedback opportunities from post-operative outcomes including patient reported experience measures (PREMs) and patient reported outcomes measures (PROMs) for anesthesiologists [15,16]. Patient outcomes typically occur hours after anesthesia providers have concluded their care. It is uncommon that anesthesia providers perform regular, rigorous, active surveillance of all their patients. Previous work by Frenzel and colleagues showed that nausea and vomiting protocol adherence improved with post-hoc data reporting [ 17]. However, the study did not combine feedback with decision support and provided feedback quarterly rather than weekly. Additionally, a key difference to prior research is that we are feeding back to providers the outcomes that their patients are experiencing rather that compliance with a protocol. Studies to date have not employed post-hoc reporting to systematically report postoperative outcomes back to anesthesia personnel. Therefore, we hypothesized that the current level of awareness of postoperative outcomes is low among anesthesia providers and that CDS for risk-based PONV prophylaxis combined with automated emails containing summaries of patient outcomes would improve adherence to published guidelines for PONV prophylaxis and significantly improve clinical outcomes.