Non-Obstetric Safety of Epidurals (NOSE)

Abstract

Epidurals are a useful perioperative procedure for effective analgesia that allow early mobilisation after major surgery and help to minimise postoperative pulmonary, cardiovascular and thromboembolic complications. However, there are potential rare but life-changing complications such as an epidural haematoma. These require a high standard of post-epidural care for prompt recognition and prevention of permanent paralysis. Following a local critical incident of delayed diagnosis of an epidural haematoma in a patient after epidural catheter removal, a multidisciplinary team undertook a Quality Improvement (QI) project to improve epidural safety. To achieve this aim, it is essential that healthcare staff are aware of the early signs of neurological complications during and after epidurals and of what action to take in the event of a developing complication. The application of robust QI methodology has contributed to a sustained improvement in the healthcare staff competence (as measured using a pulse survey) at managing patients who have received perioperative epidurals. This increased from a baseline mean survey score of 38% on three surgical step down wards (general surgery, vascular and gynaecology) to 68% (averaged over the most recent 3 months of the project time frame). Educational interventions alone rarely lead to meaningful and lasting impact for all healthcare staff, due to high turnover of staff and shift working patterns. However, with multiple plan, do, study, act cycles, and a robust QI approach, there was also sustained improvement in process measures, including the occurrence of written handover from high dependency to the step down wards (baseline 33%-71%), ensuring the application of yellow epidural alert wristbands to make these patients readily identifiable (56%-86%), and early signs in improvement in reliability of motor block checks for 24 hours' post-catheter removal (47%-69%).

Keywords: adverse events; anaesthesia; critical care; epidemiology and detection; patient safety; surgery.

Figure 1

Poster to improve epidural safety by promoting the epidural alert wristbands and ease of patient identification.

Figure 2

Aggregated mean pulse survey score for managing patients who have had a perioperative epidural.

Figure 3

Process measure run chart: compliance with written handover.

Figure 4

Process measure run chart: application of epidural alert wristbands.

Figure 5

Process measure run chart: compliance with motor block checks.