Chapter 31: Quality Indicators

BACKGROUND

“No monitoring, no improvement.” Measuring quality indicators is necessary for improving patient safety and quality of care. To assess quality of care, effective and meaningful indicators must be defined, monitored, and reported. Unfortunately, consensus indicators are lacking at a national level.

Some of the organizations that define quality in healthcare are:

• CMS—Centers for Medicare & Medicaid Services

• TJC—The Joint Commission

• CDC—Centers for Disease Control and Prevention

Initiatives to improve quality in anesthesia will continue to significantly impact and shape practice. The Anesthesia Quality Institute (AQI) was established in 2008. The AQI created the National Anesthesia Clinical Outcomes Registry (NACOR) in 2010. The vision of the AQI is as follows:

• Improve quality care of patients.

• Lower anesthesia mortality.

• Lower anesthesia adverse incidents.

Similar initiatives at the subspecialty level led the Society for Obstetric Anesthesia and Perinatology (SOAP) to create the Serious Complication Repository (SCORE) in 2004. This data collection captured the incidence of serious obstetric anesthesia–related complications,¹ including:

• Maternal death

• Cardiac arrest

• Myocardial infarction

• Epidural abscess/meningitis

• Epidural hematoma

• Serious neurologic injury

• Aspiration

• Failed intubation

• High neuraxial block

• Anaphylaxis

• Respiratory arrest in labor suite

• Unrecognized spinal catheter

NUMBERS AND VOLUME

Obstetric anesthesia service should, at a minimum, be able to report the monthly and yearly number of procedures.

Labor Analgesia

• Combined spinal and epidural (CSE)

• Epidural

• Dural puncture epidural (DPE)

• Intrathecal catheters

• Epidural replacement (second neuraxial procedure)

• Patient-controlled analgesia (PCA)

Cesarean Delivery and Other Operative Procedures

• Labor converted to cesarean delivery (CD)

• Failed labor epidural conversion to anesthesia for cesarean (requiring either endotracheal tube or laryngeal mask airway [LMA] after neuraxial)

• Scheduled cesarean delivery (cesarean no labor analgesia)

• External cephalic version (ECV)

• Dilation and curettage (D&C)

• Tubal ligation

• Postpartum hemorrhage

• Cardioversion

Type of anesthesia for Cesarean Delivery

• CSE

• Epidural

• Spinal

• DPE

• Intrathecal catheters

• General anesthesia (GA)

• Monitored anesthesia care (MAC)

Other Parameters

• Number of patients with vaginal delivery

• Number of patients with neuraxial analgesia for vaginal delivery

• Peripheral nerve blocks

• Arterial line

• Central line

• Blood transfusion and products

• ICU admission

OBSTETRIC ANESTHESIA QUALITY INDICATORS (TABLE 31-1)