Nudge theory in anesthesiology clinical practice

Influences of Software Changes on Oxycodone Prescribing at an Australian Tertiary Emergency Department: A Retrospective Review

Opioid prescribing and dispensing from emergency departments is a noteworthy issue given widespread opioid misuse and diversion in many countries, contributing both physical and economic harm to the population. High patient numbers and the stochastic nature of acute emergency presentations to emergency departments (EDs) introduce challenges for prescribers who are considering opioid stewardship principles. This study investigated the effect of changes to electronic prescribing software on prescriptions with an auto-populated quantity of oxycodone immediate release (IR) from an Australian tertiary emergency department following the implementation of national recommendations for reduced pack sizes. A retrospective review of oxycodone IR prescriptions over two six-month periods between 2019 and 2021 was undertaken, either side of a software adjustment to reduce the default quantities of tablets prescribed from 20 to 10. Patient demographic details were collected, and prescriber years of practice calculated for inclusion in linear mixed effects regression modelling. A reduction in the median number of tablets prescribed per prescription following the software changes (13.5 to 10.0, p < 0.001) with little change in the underlying characteristics of the patient or prescriber populations was observed, as well as an 11.65% reduction in the total number of tablets prescribed. The prescriber's years of practice, patient age and patient sex were found to influence increased prescription sizes. Reduced quantity of oxycodone tablets prescribed was achieved by alteration of prescribing software prefill parameters, providing further evidence to support systems-based policy interventions to influence health care providers behaviour and to act as a forcing function for prescribers to consider opioid stewardship principles.

Effect of an electronic medical record nudge to improve quality improvement program tracking of neuraxial catheter replacements in obstetric patients

BACKGROUND

Monitoring complications associated with medical procedures requires reliable and accurate record keeping. Nudge reminders executed by way of electronic medical record (EMR) alerts influence clinician behaviour. We hypothesised that the introduction of an EMR nudge would improve documentation of replaced neuraxial blocks by obstetric anaesthesiologists at our institution.

METHODS

We developed an EMR nudge that would alert the physician to a replaced neuraxial block if two or more neuraxial procedure notes in a single patient encounter were detected. The nudge encouraged physicians to document neuraxial block replacements in our institution's quality improvement database. We assessed the rate of physician adherence to replaced neuraxial block charting prior to the introduction of the nudge (January 2019-September 2019) and after the implementation (October 2019-December 2020).

RESULTS

494 encounters during the chart review period, January 2019-December 2020, required a neuraxial block replacement, representing an actual neuraxial replacement rate of 6.3% prior to the introduction of the nudge in October 2019. This rate was largely unchanged (6.2%) after the introduction of the nudge (0.1% difference, 95% CI: -0.0119 to 0.0099). Prior to the introduction of the nudge, the proportion of correctly charted failed/replaced blocks in our quality improvement database was 80.0%, and after nudge introduction, the rate was 96.2% (p value <0.00001, OR=6.32, 95% CI: 3.15 to 12.66). A p-chart of the monthly adherence rate demonstrated sustained improvement over time.

CONCLUSIONS

EMR nudge technology significantly improved adherence with quality metric monitoring of neuraxial catheter replacement in obstetric patients. The results imply that data collection for quality metric databases of neuraxial block failures and replacements that rely on clinician memory without a nudge are likely under-reporting neuraxial block failures and replacements. This study supports widespread implementation of nudges in EMRs to improve quality metric reporting.

Evaluation of a behavioural intervention to reduce perioperative midazolam administration to older adults

Background

Older patients commonly receive benzodiazepines during anaesthesia despite guidelines recommending avoidance. Interventions to reduce perioperative benzodiazepine use are not well studied. We hypothesized an automated electronic medical record alert targeting anaesthesia providers would reduce administration of benzodiazepines to older adults undergoing general anaesthesia.

Methods

We conducted a retrospective study of adults who underwent surgery at 5 hospitals within one US academic health system. One of the hospitals received an intervention consisting of provider education and an automated electronic medical record alert discouraging benzodiazepine administration to patients aged 70 years or older. We used difference-in-differences analysis to compare patterns of midazolam use 12-months before and after intervention at the intervention hospital, using the 4 non-intervention hospitals as contemporaneous comparators.

Results

The primary analysis sample included 20,347 cases among patients aged 70 and older. At the intervention hospital, midazolam was administered in 454/4,240 (10.7%) cases pre-alert versus 250/3,750 (6.7%) post-alert (p<0.001). At comparator hospitals, respective rates were 3,186/6,366 (50.0%) versus 2,935/5,991 (49.0%) (p=0.24). After adjustment, the intervention was associated with a 3.2 percentage point (p.p.) reduction in the percentage of cases with midazolam administration (95% CI: (-5.2, -1.1); p=0.002). Midazolam dose was unaffected (adjusted mean difference -0.01 mg, 95% CI: (-0.20, 0.18); p=0.90). In 76,735 cases among patients aged 18-69, the percentage of cases with midazolam administration decreased by 6.9 p. p. (95% CI: (-8.0, -5.7); p<0.001).

Conclusion

Provider-facing alerts in the intraoperative electronic medical record, coupled with education, can reduce midazolam administration to older patients presenting for surgery but may affect care of younger patients.

Comparison of the needle tip location with the operator's position during ultrasound-guided internal jugular vein catheterization: A randomized controlled study

OBJECTIVE

We hypothesized that when a right-handed operator catheterizes the left internal jugular vein (IJV), the tip of the needle might be positioned closer to the center of the vessel after puncture if the operator is standing in the patient's left axillary line, rather than standing cephalad to the patient.

METHODS

The study randomly allocated 44 patients undergoing elective surgery under general anesthesia with planned left central venous catheterization to either conventional (operator stood cephalad to the patient) or intervention (operator stood in the patient's axillary line) groups. The left IJV was catheterized by 18 anesthesiologists. The distance between the center of the vessel and the needle tip, first-attempt success rate, and procedure time were compared.

RESULTS

The distance from the needle tip to the center of the IJV after needle puncture was 3.5 (1.9-5.5) and 3.2 (1.7-4.9) cm in the conventional and intervention groups, respectively (P = .47). The first-attempt success rate was significantly higher in the intervention group (100% vs 68.2%, P = .01). Overall time to successful guidewire insertion was faster in the intervention group (P = .007).

CONCLUSIONS

There was no significant difference in needle tip position when the right-handed operator was standing in the patient's left axillary line compared to standing cephalad to the patient during left IJV catheterization. However, it increased the first-attempt success rate and reduced the overall time for guidewire insertion.