Implementation of a new strategy to improve the peri‐operative management of neuromuscular blockade and its effects on postoperative pulmonary complications

Abstract

Inappropriate dosing of neostigmine for antagonism of neuromuscular blockade has been associated with postoperative pulmonary complications. We evaluated the effects of a quality improvement initiative tailored to optimise the use of neostigmine in antagonising neuromuscular blockade on postoperative pulmonary complications, costs and duration of hospital stay. The quality improvement initiative consisted of: a reduction in available neostigmine aliquot sizes; a cognitive aid; an educational component; and a financial incentive for the intra-operative documentation of train-of-four measurement before administration of neostigmine. We conducted a pre-specified analysis of data obtained in our quality improvement study. Additional analyses were conducted in a propensity-matched cohort. An interrupted time series design was used to discriminate between the intervention and a counterfactual scenario. We analysed 12,025 consecutive surgical cases performed in 2015. Postoperative pulmonary complications occurred in 220 (7.5%) of 2937 cases pre-intervention and 568 (6.3%) of 9088 cases post-intervention. Adjusted regression analyses showed significantly a lower risk of postoperative pulmonary complications (OR 0.73 (95%CI 0.61-0.88); p = 0.001), lower costs (incidence rate ratio 0.95 (95%CI 0.93-0.97); p < 0.001) and shorter duration of hospital stay (incidence rate ratio 0.91 (95%CI 0.87-0.94); p < 0.001) after implementation of the quality improvement initiative. Analyses in a propensity-matched sample (n = 2936 per group) and interrupted time series analysis (n = 27,202 cases) confirmed the findings. Our data show that a local, multifaceted quality improvement initiative can enhance the quality of intra-operative neuromuscular blocking agent utilisation, thereby reducing the incidence of postoperative pulmonary complications.

Quality improvement studies – pitfalls of the before and after study design

“…Figure is a reproduction of Fig. 4a in the current study , with the added counterfactual line, showing the expected trend of mean neostigmine use had the intervention not taken place. As can be seen, the counterfactual line does not intersect with the post‐intervention line, showing that post‐intervention use of neostigmine did indeed decrease .…”

“…Some clinicians may even be inherently sceptical as to whether TOF monitoring can actually predict and/or prevent postoperative pulmonary complications. It is against this background that Rudolph et al conducted their study to improve the peri‐operative management of neuromuscular blockade and to evaluate its effects on postoperative pulmonary complications.…”

“…This current study is a prospective observational study comparing the incidence of major postoperative pulmonary complications before and after implementation of a quality improvement initiative. The primary outcome was a dichotomised composite measure of pneumonia, respiratory failure, pulmonary oedema and/or tracheal intubation.…”

“…When applying the principles of interrupted time series, it is important to remember that it would only be relevant if the intervention was not introduced gradually. The current study did not strictly adhere to this requirement, because the change in neostigmine vial size was instituted 3 months before the department‐wide educational activities and distribution of cognitive aids. As can be seen in Fig.…”

“…A reproduction of Fig. 4a in . The red dotted line shows the counterfactual scenario, depicting a decreasing baseline trend in neostigmine dose used.…”