Using an International Clinical Registry of Regional Anesthesia to Identify Targets for Quality Improvement

Abstract

Background Despite the widespread use of regional anesthesia, limited information on clinical performance exists. Institutions, therefore, have little knowledge of how they are performing in regards to both safety and effectiveness. In this study, we demonstrate how a medical institution (or physician/physician group) may use data from a multi-center clinical registry of regional anesthesia to inform quality improvement strategies. Methods We analyzed data from the International Registry of Regional Anesthesia that includes prospective data on peripheral regional anesthesia procedures from 19 centers located around the world. Using data from the clinical registry, we present summary statistics of the overall safety and effectiveness of regional anesthesia. Furthermore, we demonstrate, using a variety of performance measures, how these data can be used by hospitals to identify areas for quality improvement. To do so, we compare the performance of one member institution (a United States medical center in New Hampshire) to that of the other 18 member institutions of the clinical registry. Results The clinical registry contained information on 23,271 blocks that were performed between June 1, 2011, and May 1, 2014, on 16,725 patients. The overall success rate was 96.7%, immediate complication rate was 2.2%, and the all-cause 60-day rate of neurological sequelae was 8.3 (95% CI, 7.2–9.7) per 10,000. Registry wide major hospital events included 7 wrong site blocks, 3 seizures, 1 complete heart block, 1 retroperitoneal hematoma, and 3 pneumothoraces. For our reference medical center, we identified areas meriting quality improvement. Specifically, after accounting for differences in the age, sex, and health status of patient populations, the reference medical center appeared to rely more heavily on opioids for post procedure management, had higher patient pain scores, and experienced delayed discharge when compared with other member institutions. Conclusions To our knowledge, this is the first large-scale effort to use a clinical registry to provide comparative outcome rates representing the safety and effectiveness of regional anesthesia. These results can be used to help inform quality improvement strategies.

Evidence Basis for Ultrasound Guidance for Lower-Extremity Peripheral Nerve Block

“…75,76 However, outcome data regarding complications comparing different ultrasound-guided techniques are limited and need to be investigated by quality prospective observational studies in large databases, in addition to the limited number of small RCTs published to date. 77 In summary, USG has clearly become the dominant peripheral nerve localization technique. Since the initial grade A recommendation based on level Ib evidence provided by 11 RCTs that USG decreased BOT, BPT, local anesthetic requirements, only 6 additional RCTs directly comparing USG with a PNS technique 10,44-48 and 5 additional RCTs (3 of them volunteer studies) directly comparing USG with landmark-based field block techniques 31,62-64,66 have been conducted.…”

Wrong-site regional anesthesia

“…The incidence of wrong-site block has been estimated as: 3.63 (95% confidence interval 1.46-7.48) per 10,000 (seven events from Australia and New Zealand in approximately 19 268 procedures) [5], 2.59 (95% confidence interval 1.12-5.10) per 10 000 (eight events from 30 887 procedures in the International Registry of Regional Anesthesia between 1st June 2011 and 30th June 2015) [6] and 1.28 (95% confidence interval 0.43-2.13) per 10 000 in Pennsylvania [7 & ]. The incidence of wrong-site pain procedures is estimated to be 2.66 per (95% confidence interval 1.41-4.54) per 10 000 (13 events in 48,941 procedures) [8].…”

We Should Fear the Reaper

“…An existing registry, the International Registry of Regional Anesthesia (IRORA) has already been established to report on the quality and safety of PNB. 6 The IRORA has many of the attributes required of a registry, including defined inclusion criteria, ease of entry to an online interface, carefully chosen and defined data elements, mandatory fields, data security, preservation of patient and clinical anonymity, automated reports, the ability to benchmark outcomes, and appropriate clinical governance. The IRORA is supported by a research grant funded by the Australian and New Zealand College of Anaesthetists.…”

“…This spinal catheter set has certainly improved over previous designs. 5,6 Unless, the above questions are answered, and further evidence through research is available, it would be unfair to blame the Wiley spinal catheter set, which might then suffer the same fate as the microcatheter in 1992.…”