Related Editorial:
Ludbrook G, et al. Improving safety and outcomes in perioperative care: does implementation matter? Brit J Anaesth 2022;128:747-751. DOI: https://doi.org/10.1016/j.bja.2022.01.026
National patient safety guidelines were developed in the Netherlands to “improve suboptimal perioperative care.” A complex multifaceted program (“IMPROVE”) to implement the guidelines was developed and employed. It consisted of “educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities,” all of which are extensively described. In 9 hospitals, before and after the implementation program, for a total of 1934 major (non-cardiac) surgery patients, observational measurements were made of adherence to the timely administration of antibiotics and the perioperative checklist, as well as 7 “stop moment” process markers over the hospital stay. The implementation program significantly improved (by 16%) one of the process markers, di scharge from the PACU. Regarding outcome parameters, this one improvement was related to a modest (3 to 8%) decrease in: perioperative mortality, overall “complications,” and unscheduled ICU admission. For the other outcome measures: wound infection, length of stay, reoperation, and readmission, there was no improvement after the implementation program. The journal editor’s summary points suggested: “Most structure [process] indicators had very modest or no improvement over the study period.” And, “There were generally positive associations between guideline adherence and patient outcomes.”
Editorial comment referenced the successful impact of the previous WHO Safe Surgery Checklist and also the Surgical Patient Safety System for perioperative care, but emphasized that simply creating evidence-based safety guidelines was insufficient – implementing them is the issue. The Dutch study is cited as showing “relatively modest compliance with the guidelines and there was substantial inter-hospital variation.” The low degree (3.5 on a scale of a possible 11) of engagement with the implementation program is prominently noted. The editorial questions in general how performance can best be measured, how to implement improvement strategies, and how to measure the resulting impact – all central traditional issues in healthcare quality and safety. It is suggested that process measurements, such as handwashing compliance, be de-emphasized and outcomes “that matter,” such as days confined at home after surgery, be stressed. Though the hugely complex interactions of all the multiple factors that impact outcomes can be exceedingly difficult to sort out, aiming for consistency and reliability of care processes from the improvement implementation is critical. Careful review of the Dutch IMPROVE study suggested that the involved teams did not have enough time or resources to implement the improvements and study their impact, thus allowing relatively obvious suggestions for future efforts, including multiple varied incentives for the caregivers. The study highlights the great challenges of quality improvement efforts and, of course, points the way to further studies.