Original ContributionAutomated feedback modestly improves perioperative treatment adherence of postoperative nausea and vomiting
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.
Section snippets
Materials and methods
Institutional Review Board approval with a waiver of consent was granted by Vanderbilt University Medical Center (VUMC, Nashville, TN; PRO140659). This manuscript adheres to the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [18].
Results
A total of 57,401 anesthetics met inclusion criteria were identified from the Vanderbilt University Medical Center Perioperative Data Warehouse database (Fig. 1). Specifically, the Baseline period included 12,211 cases; the Intervention Rollout period included 12,293 cases; the Feedback Implementation period included 13,660 cases; and the Feedback & CDS recommendation period included 19,237 cases. Patients had a mean age of 52.4 (SD = 16.8) years. Meanwhile, there were 15,247 personalized
Discussion
A post-hoc reporting intervention that automatically identifies important postoperative patient outcomes and connects them to clinicians who cared for those patients is technically feasible. There was a modest impact on preemptive PONV medication management when this post-hoc reporting was combined with a CDS system that provided risk-based PONV prophylaxis medication recommendations. Over the study period, there was a 5.5% improvement in the compliance of PONV medication administration along
Author contributions
Calvin Gruss: This author helped with data collection, data analysis and manuscript writeup.
Teus Kappen: This author helped with project creation, project execution, data collection, data analysis, and manuscript writeup.
Leslie Fowler: This author helped with project creation, project execution, and manuscript writeup.
Gen Li: This author helped with data collection, data analysis and manuscript writeup.
Robert Freundlich: This author helped with project creation, project execution and manuscript
Financial disclosures
Gen Li and Robert E. Freundlich receive funding from NIH-NHLBI K23HL148640.
Declaration of Competing Interest
None; the authors of this manuscript have no conflicts of interest.
Acknowledgement
None.
References (26)
- et al.
Automated reminders decrease postoperative nausea and vomiting incidence in a general surgical population
Br J Anaesth
(2012) - et al.
Simplified algorithm for the prevention of postoperative nausea and vomiting: a before-and-after study
Br J Anaesth
(2018) - et al.
Barriers and facilitators perceived by physicians when using prediction models in practice
J Clin Epidemiol
(2016) - et al.
Patient-reported outcome measures and patient-reported experience measures, BJA
Education
(2017) - et al.
STROBE initiative: the strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies
Lancet.
(2007) Risk-tailored prophylaxis for postoperative nausea and vomiting: has the big little problem gotten any smaller?
Br J Anaesth
(2018)- et al.
A systematic review of trials evaluating success factors of interventions with computerised clinical decision support
Implement Sci
(2018) - et al.
The case for conceptual and computable cross-fertilization between audit and feedback and clinical decision support
Stud Health Technol Inform
(2015) - et al.
Integration of clinical decision support and electronic clinical quality measurement: domain expert insights and implications for future direction
AMIA Annu Symp Proc
(2018) - et al.
Using audit and feedback to health professionals to improve the quality and safety of health care
Fourth consensus guidelines for the Management of Postoperative Nausea and Vomiting
Anesth Analg
Prevalence of postoperative nausea and vomiting: a systematic review and meta-analysis
Saudi J Anaesth
Impact of risk assessments on prophylactic antiemetic prescription and the incidence of postoperative nausea and vomiting: a cluster-randomized trial
Anesthesiology.
Cited by (1)
"people, We Have a Problem"
2023, Anesthesiology