Methods
We used Plan, Do, Study, Act methodology in this project with ethics exemption (EX/2023/MNHA/92598).
The RBWH Department of Anaesthesia and Perioperative Medicine used local ABS data to evaluate patient satisfaction with epidural pain relief in labour. Satisfaction data were prospectively gathered by the Acute Pain Service on the first day following delivery
and rated on a five point scale 1 – 5, where 1 is very satisfied and 5 is very dissatisfied.
Our audit aimed to determine if our department met the Royal College of Anaesthetists’ satisfaction benchmark for epidural analgesia (>98% of patients satisfied).[1]
In January 2022 we implemented a flow-chart to standardize the collection of patient satisfaction data and patient follow-up when patients reported satisfaction scores of 3-5. Reasons for dissatisfaction were recorded and these patients were debriefed by an anaesthetist. We identified the common factors for dissatisfaction with labour epidural care and these were categorised. We identified 10 reasons for dissatisfaction. The top three reasons were: inadequate analgesia (90%); failure to re-site an ineffective
epidural (37%), and the requirement for multiple reinsertions after epidural failure (18%). In some cases, there was more than one reason for dissatisfaction. In response to these findings our recommendations included: clarifying patient expectations prior
to insertion of a labour epidural; regular review of the epidural and offering reinsertion if analgesia cannot be achieved by troubleshooting the epidural.
Intervention: In the secure obstetric anaesthesia working area close to birth suite, a whiteboard was converted into an epidural tracking board. Patient initials, epidural insertion time, any high risk features and the designated time for epidural review were recorded. Access to the birth suite electronic tracking board was provided by installation of a co-located and networked screen. Review of the epidural is recommended one to two hours post-insertion and then very four hours after that, unless interventions are required. Review may be performed by the epidural proceduralist or another member of the anaesthesia team.
Review:
Following a 12-month period using this system, clinicians using the tracking board were surveyed and 100% agreed that regular review of epidurals was important. Feedback was sought on potential ways to encourage clinicians to regularly review epidurals following
insertion. We are currently facilitating the incorporation of anaesthesia epidural review information into the electronic tracking board used in birth suite. This will facilitate regular review of epidurals and enhance interdisciplinary communication regarding
individual patient care.
Discussion
This project was only made possible due to our departmental participation in the Statewide Anaesthesia Benchmarking System and therefore to the contributions of:
1. The RBWH anaesthetists who enter data into the database on a daily basis, resulting in over 10 000 individual labour epidural entries from RBWH since 2019.
2. The RBWH Acute Pain Service
nurses who complete the Day 1 follow-up data, which includes patient satisfaction
3. The RBWH ABS Quality Improvement Group who provided input and support to the project.
4. Statewide Anaesthesia and Perioperative Care Clinical Network (SWAPNet), Dr Guy Godsall and the Healthcare Improvement Unit for ongoing curation of the ABS database.
Tertiary hospital maternity care is a 24 hour a day service and obstetric anaesthetists are an integral part of the service at RBWH. Providing labour epidurals, as well anaesthesia for planned and emergency cesarean deliveries, we work closely with obstetricians and midwives to provide the highest standard of care possible. Because of the unplanned and emergent nature of most of the work, planning structured and regular review of epidurals can be challenging, particularly in after-hours shifts.
Important considerations in implementing the tracking board included:
- Ensuring that the task of recording epidurals on the tracking board was not overly burdensome to clinicians particularly in after-hours shifts
- Ensuring confidentiality of patient information
- Publicising, educating and encouraging use of the tracking board in a department with over 100 specialist anaesthetists and over 50 rotating trainees
We have received queries from another Queensland Hospital and an interstate tertiary hospital who are also seeking to implement and encourage regular review of labour epidurals, which is considered a benchmark for excellence in obstetric anaesthesia care. Implementation at other Queensland Health institutions is possible and should incorporate evaluation of patient satisfaction using ABS data, consultation with key stakeholders in individual anaesthesia departments and consideration of site-specific requirements such as location of birth suites, operating theatres and anaesthesia departments.
