Issa Mirmehdi, MD1, Bruce Ramshaw, MD2. 1Halifax Health, 2Surgical Momentum
Various attempts have been made to improve post-operative pain in patients undergoing laparoscopic ventral hernia repair. Despite these attempts, this operation can be very painful and require several days in the hospital.
Clinical Quality Improvement (CQI) was implemented for a hernia program and included defining dynamic care processes based on the entire cycle of care for patients undergoing laparoscopic ventral hernia repair. We also defined outcome measures that determined the value of care. For this attempted process improvement, the two objective outcome measures that were collected were the length of hospital stay and the requirements for post-operative IV and PO narcotic analgesics. The subjective variable was post-operative pain. 85 consecutive patients undergoing laparoscopic ventral hernia repair were included in this process improvement attempt.
Analysis of data revealed that post-operative pain was the primary factor contributing to prolonged hospital stay and the requirement for a significant amount of narcotic analgesics. An evidence-based process improvement attempt was initiated after the 54th patient. The process improvement attempt included performing a pre-operative transversus abdominis plane (TAP) block to attempt to anesthetize the abdominal wall and help to control post-operative pain. The pre-operative TAP block was performed in 31 patients. Comparing the pre- and post- TAP block groups, the length of hospital stay decreased by 24% and total narcotic analgesics requirements decreased by 44%.
Implementing the principles of CQI can improve the value of care. In this example, length of stay and post-operative narcotic analgesic requirements were decreased after initiating a pre-operative TAP block. More examples of process improvement attempts using the principles of CQI will help demonstrate the validity of this approach.