Raising the Standards

1 Raising the Standards :RCoA quality improvement compendium4th edition, September 2020 Editors Dr Maria Chereshneva, Dr Carolyn Johnston, Dr John R Colvin and Professor Carol J PedenCopyrightISBN: 978-1-5272-6522-6 The Royal College of Anaesthetists 2020 Design and layout by the Royal College of document will be reviewed within five years of part of this document may be produced without written permission of the Royal College of the Royal College of Anaesthetists has endeavoured to ensure that this document is as current as possible at the time it was published, it can take no responsibility for matters arising from circumstances which may have changed, or information which may become available queries in regard to this document should be addressed to the Clinical Quality and Research Directorate at.

2 The Royal College of Anaesthetists Churchill House 35 Red Lion Square London WC1R 4SG020 7092 1692 Charity No: 1013887 VAT Registration No: GB 927 2364 18 Registered Charity in Scotland No: SCO377372 | Raising the Standards : RCoA quality improvement compendiumAcknowledgements 6 Foreword 8 Introduction 10 The patient s perspective 14A Quality improvement in anaesthesia 16A1 Getting started on your quality improvement project: important things to consider 18A2 The science and history of improvement 20A3 Making improvement happen 22A4 Improvement basics: Lean and process maps 26A5 Improvement basics: driver diagrams 28A6 Improvement basics: bundles to improve reliable delivery of care 30A7 Improvement basics: Pareto charts 32A8 Studying patient harm and death to improve care: structured mortality review, global trigger tool and root cause analysis 34A9 How do you know a change is an improvement?

3 Using run charts 36A10 Statistical process control charts 40A11 Performance polygons for representing multidimensional data 42A12 Checklists 46A13 From audit to action: the power of trainee networks 48A14 Co-design and working with patients 50A15 Changing behaviour 52A16 Habits of an improver 54A17 Spread and sustainability: how to spread effective ideas and plan for sustained improvement 56A18 Publishing your quality improvement work 58B Recipes for continuous quality improvement in anaesthesia 61B1 Preoperative care Patient information for anaesthesia Perioperative risk prediction Prehabilitation before surgery Consent in anaesthesia Shared decision making in perioperative care Preoperative fasting Perioperative management of surgery for patients with diabetes Managing frailty in the perioperative period Management of preoperative anaemia Patient blood management in perioperative care Perioperative neurocognitive

4 Disorders Management of obesity in the perioperative period Enhanced recovery after surgery: a narrative review Individualised perioperative pain management Patient experience and outcome measures 98B2 Intraoperative care World Health Organization surgical checklist Conduct of regional anaesthesia Management of the difficult airway Anaesthetic record keeping Awareness under anaesthesia Perioperative temperature management TIVA/TCI training for anaesthesia and intensive care trainees Practical use of total intravenous anaesthesia and target-controlled infusions Intraoperative blood management strategies Think kidneys Management of elective abdominal aortic aneurysm surgery Intraoperative

5 Patient handover Management of death in the operating theatre 128B3 Postoperative care Recovery room staffing and monitoring provision Patient handover in the post-anaesthesia care unit Postoperative nausea and vomiting beyond recovery Record keeping in recovery Postoperative visiting Drinking, eating and mobilising after surgery Recovery discharge protocols Patient satisfaction: a quality improvement project worked example Unplanned critical care admission after elective surgery 1524th Edition.

6 September 2020 | | 3 ContentsB4 Emergency anaesthesia Risk assessment and preparation for emergency surgery Theatre provision for emergency surgery Emergency laparotomy Emergency anaesthesia for the elderly patient Anaesthesia for fractured neck of femur surgery Major lower limb amputation Transfer of the critically ill patient Initial management of the adult patient with major trauma Rib fracture analgesia pathway Prevention of unexpected cardiac arrest Admission to high dependency and intensive care after emergency surgery Structured morbidity and mortality reviews 184B5 Day surgery services Optimising your daycase rates Day surgery cancellations/failure to attend Day surgery within the main theatre setting Performing emergency ambulatory surgery How effective is your daycase spinal service?

7 Pain relief after day surgery The need for a carer at home after day surgery Unplanned hospital admission after day surgery Evaluating your day surgery pathway 206B6 Anaesthesia and sedation outside theatre Anaesthesia in the accident and emergency department Remote site anaesthesia Sedation competency Sedation and anaesthesia in endoscopy Use of capnography outside operating theatres Anaesthesia and sedation in the radiology department Cardioversion Provision of anaesthesia in magnetic resonance imaging Provision of anaesthesia for cardiac catheterisation 236B7 Obstetric practice Information for mothers about analgesia and anaesthesia during delivery Anaesthetic care for women who are obese during pregnancy Response times for the provision of intrapartum analgesia and anaesthesia Regional analgesia during labour Airway and intubation problems during obstetric general anaesthesia

8 Caesarean section anaesthesia: technique and failure rate Pain relief after caesarean section Monitoring of obstetric patients in recovery and receiving enhanced maternity care Timely anaesthetic involvement in the care of high-risk and critically ill women Postnatal obstetric anaesthetic adverse effects and complications Using patient experience-based co-design to improve services 266B8 Paediatrics Preoperative information for children and their families Premedication and anxiolysis in children Paediatric sedation Perioperative temperature control in children Postoperative vomiting in children Implementing

9 Thromboprophylaxis in paediatric surgical patients Postoperative pain management in children 284B9 Intensive care medicine Delirium assessment and management for critical care Venous thromboprophylaxis on the critical care unit Glycaemic control in critical illness Management of acute respiratory distress syndrome in adults Monitoring and targeting mean arterial pressure 2964 | Raising the Standards : RCoA quality improvement Monitoring of oxygen therapy and physiological targets Renal replacement therapy in critical care Sedation, scoring and management on critical care Performance and management of tracheostomies on the critical care unit Transfusion threshold in the intensive care unit End of life care 308B10 Pain medicine Assessment and documentation in acute pain management The use of gabapentinoids in the perioperative period Non-medical prescribing for pain management Managing epidural analgesia Opioid use in chronic pain Intrathecal drug delivery in the management of cancer-related pain Audit of pain

10 Management programmes Continuing professional development and practice improvement for pain medicine anaesthetists Medial branch block and radiofrequency denervation for lumbar facet joint pain 330B11 Delivery of services Focus on sustainability: reducing our carbon footprint through inhalational agents Focus on sustainability: are you wasting your waste? Theatre use and efficiency Cancellation of surgery Sharing, improving and learning from critical incidents Training on, maintenance and purchase of anaesthetic equipment Availability of ultrasound equipment in anaesthetic areas Check and challenge: severe local anaesthetic systemic toxicity Anaphylaxis and the anaesthetist The Cappuccini test: effective clinical supervision to ensure safe delivery of anaesthetic services Prevention and control of healthcare-associated infection in anaesthesia Professional compliance analysis tool for improving the working environment a